دانلود رایگان مقاله انگلیسی تاثیر پذیری خانواده درمانی اصولی در برابر درمان همیشگی مردم جوان بعد از خودزنی - الزویر 2018

Summary

Background Self-harm in adolescents is common and repetition occurs in a high proportion of these cases. Scarce evidence exists for effectiveness of interventions to reduce self-harm. Methods This pragmatic, multicentre, randomised, controlled trial of family therapy versus treatment as usual was done at 40 UK Child and Adolescent Mental Health Services (CAMHS) centres. We recruited young people aged 11–17 years who had self-harmed at least twice and presented to CAMHS after self-harm. Participants were randomly assigned (1:1) to receive manualised family therapy delivered by trained and supervised family therapists or treatment as usual by local CAMHS. Participants and therapists were aware of treatment allocation; researchers were masked. The primary outcome was hospital attendance for repetition of self-harm in the 18 months after group assignment. Primary and safety analyses were done in the intention-to-treat population. The trial is registered at the ISRCTN registry, number ISRCTN59793150. Findings Between Nov 23, 2009, and Dec 31, 2013, 3554 young people were screened and 832 eligible young people consented to participation and were randomly assigned to receive family therapy (n=415) or treatment as usual (n=417). Primary outcome data were available for 795 (96%) participants. Numbers of hospital attendances for repeat self-harm events were not significantly different between the groups (118 [28%] in the family therapy group vs 103 [25%] in the treatment as usual group; hazard ratio 1·14 [95% CI 0·87–1·49] p=0·33). Similar numbers of adverse events occurred in both groups (787 in the family therapy group vs 847 in the treatment as usual group). Interpretation For adolescents referred to CAMHS after self-harm, having self-harmed at least once before, our family therapy intervention conferred no benefits over treatment as usual in reducing subsequent hospital attendance for self-harm. Clinicians are therefore still unable to recommend a clear, evidence-based intervention to reduce repeated self-harm in adolescents. Funding National Institute for Health Research Health Technology Assessment programme.

Discussion

In young people who had recently repeatedly selfharmed, we found no clinical or cost benefits for family therapy over treatment as usual in terms of hospital attendance for subsequent repetition of self-harm. For interventions in which the whole family was the subject of the assessment, and more than one person is involved in treatment, methods to assess benefits (and harms) beyond the individual should be considered.30 Our finding that family therapy is cost-effective when considering combined benefits to the young person and caregiver is therefore salient, although it assumes QALYs can be aggregated across individuals as a simple sum. This addition has been done in previous studies of child health,34 but is not part of the NICE reference case and assumes interdependence between utilities (the health state) of the adolescent and caregiver. Our study sample had baseline levels of difficulty at least as severe as the average CAMHS referral.17 The proportion of female participants recruited and the mix of referrals from hospital and community sources are similar to those seen in other studies.4 The treatments given in the treatment as usual group were highly varied, which can be expected from a pragmatic trial, but broadly similar to CAMHS practice in the UK with a mixture of supportive or individual counselling, cognitive behavioural therapy, and family work;17 however, the proportion of patients who received formal family therapy for self-harm (87 [21%] of 417) was much higher than we were expecting. Those in the treatment as usual group who received a version of family therapy did not, however, have significantly better primary outcome results than either those in the family therapy group or those in treatment as usual who only received other interventions.