title: Pharmacological interventions for self-harm in adults.
abstract: BACKGROUND
  Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self harm.
  
  
  OBJECTIVE
  To identify all randomised controlled trials of pharmacological agents or natural products for SH in adults, and to conduct meta-analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., placebo/alternative pharmacological treatment) for SH patients.
  
  
  METHODS
  For this update the Cochrane Depression, Anxiety and Neurosis Review Group (CCDAN) Trials Search Co-ordinator searched the CCDAN Specialised Register (September 2014). Additional searches of MEDLINE, EMBASE, PsycINFO, and CENTRAL were conducted to October 2013.
  
  
  METHODS
  We included randomised controlled trials comparing pharmacological treatments or natural products with placebo/alternative pharmacological treatment in individuals with a recent (within six months) episode of SH resulting in presentation to clinical services.
  
  
  METHODS
  We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratios (ORs) and their 95% confidence intervals (CIs). For continuous outcomes we calculated the mean difference (MD) and 95% CI. Meta-analysis was only possible for one intervention (i.e. newer generation antidepressants) on repetition of SH at last follow-up. For this analysis, we pooled data using a random-effects model. The overall quality of evidence for the primary outcome was appraised for each intervention using the GRADE approach.
  
  
  RESULTS
  We included seven trials with a total of 546 patients. The largest trial included 167 participants. We found no significant treatment effect on repetition of SH for newer generation antidepressants (n = 243; k = 3; OR 0.76, 95% CI 0.42 to 1.36; GRADE: low quality of evidence), low-dose fluphenazine (n = 53; k = 1; OR 1.51, 95% CI 0.50 to 4.58; GRADE: very low quality of evidence), mood stabilisers (n = 167; k = 1; OR 0.99, 95% CI 0.33 to 2.95; GRADE: low quality of evidence), or natural products (n = 49; k = 1; OR 1.33, 95% CI 0.38 to 4.62; GRADE: low quality of evidence). A significant reduction in SH repetition was found in a single trial of the antipsychotic flupenthixol (n = 30; k = 1; OR 0.09, 95% CI 0.02 to 0.50), although the quality of evidence for this trial, according to the GRADE criteria, was very low. No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported.
  
  
  CONCLUSIONS
  Given the low or very low quality of the available evidence, and the small number of trials identified, it is not possible to make firm conclusions regarding pharmacological interventions in SH patients. More and larger trials of pharmacotherapy are required. In view of an indication of positive benefit for flupenthixol in an early small trial of low quality, these might include evaluation of newer atypical antipsychotics. Further work should include evaluation of adverse effects of pharmacological agents. Other research could include evaluation of combined pharmacotherapy and psychological treatment.
authors.affiliation: Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK, OX3 7JX.
authors.forename: Keith
authors.initials: K
authors.lastname: Hawton
authors.forename: Katrina G
authors.initials: KG
authors.lastname: Witt
authors.forename: Tatiana L
authors.initials: TL
authors.lastname: Taylor Salisbury
authors.forename: Ella
authors.initials: E
authors.lastname: Arensman
authors.forename: David
authors.initials: D
authors.lastname: Gunnell
authors.forename: Philip
authors.initials: P
authors.lastname: Hazell
authors.forename: Ellen
authors.initials: E
authors.lastname: Townsend
authors.forename: Kees
authors.initials: K
authors.lastname: van Heeringen
mesh_terms: D000328:Adult; D000927:Anticonvulsants / Q000627:therapeutic use; D000928:Antidepressive Agents / Q000627:therapeutic use*; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D005260:Female; D005476:Fluphenazine / Q000627:therapeutic use; D006801:Humans; D018020:Lithium Compounds / Q000627:therapeutic use; D008297:Male; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D016728:Self-Injurious Behavior / Q000188:drug therapy*
chemical_list: D000927:Anticonvulsants; D000928:Antidepressive Agents; D014150:Antipsychotic Agents; D018020:Lithium Compounds; D005476:Fluphenazine