Treatment as usual (TAU) as a control condition in trials of cognitive behavioural-based psychotherapy for self-harm: Impact of content and quality on outcomes in a systematic review

Katrina Witt; Daniela Pache de Moraes; Tatiana Taylor Salisbury; Ella Arensman; David Gunnell; Philip Hazell; Ellen Townsend; Kees van Heeringen; Keith Hawton

doi:10.1016/j.jad.2018.04.025

Treatment as usual (TAU) as a control condition in trials of cognitive behavioural-based psychotherapy for self-harm: Impact of content and quality on outcomes in a systematic review

J Affect Disord. 2018 Aug 1:235:434-447. doi: 10.1016/j.jad.2018.04.025. Epub 2018 Apr 4.

Authors

Katrina Witt¹, Daniela Pache de Moraes², Tatiana Taylor Salisbury³, Ella Arensman⁴, David Gunnell⁵, Philip Hazell⁶, Ellen Townsend⁷, Kees van Heeringen⁸, Keith Hawton⁹

Affiliations

¹ Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK.
² Discipline of Medicine, Pontifícia Universidade Católica do Paraná, Brazil.
³ Institute of Psychiatry, Psychology and Neurology, King's College London, London, UK; Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
⁴ National Suicide Research Foundation and School of Public Health, University College Cork, Republic of Ireland.
⁵ School of Social and Community Medicine, University of Bristol, Bristol, UK.
⁶ Discipline of Psychiatry, Sydney Medical School, Sydney, Australia.
⁷ Self-Harm Research Group, School of Psychology, University of Nottingham, Nottingham, UK.
⁸ Unit for Suicide Research, Department of Psychiatry and Medical Psychology, Gent University, Gent, Belgium.
⁹ Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK. Electronic address: keith.hawton@psych.ox.ac.uk.

PMID: 29679896
DOI: 10.1016/j.jad.2018.04.025

Abstract

Background: Randomized controlled trials (RCTs) are the mainstay of evaluations of the efficacy of psychosocial interventions. In a recent Cochrane systematic review we analysed the efficacy of cognitive behavioural-based psychotherapies compared to treatment as usual (TAU) in adults who self-harm. In this study we examine the content and reporting quality of TAU in these trials and their relationship to outcomes.

Methods: Five electronic databases (CCDANCTR-Studies and References, CENTRAL, MEDLINE, EMBASE, and PsycINFO) were searched for RCTs, indexed between 1 January 1998 and 30 April 2015, of cognitive-behavioural interventions compared to TAU for adults following a recent (within six months) episode of self-harm. Comparisons were made between outcomes for trials which included different categories of TAU, which were grouped as: multidisciplinary treatment, psychotherapy only, pharmacotherapy only, treatment by primary care physician, minimal contact, or unclear.

Results: 18 trials involving 2433 participants were included. The content and reporting quality of TAU varied considerably between trials. The apparent effectiveness of cognitive behavioural psychotherapy varied according to TAU reporting quality and content. Specifically, effects in favour of cognitive-behavioural psychotherapy were strongest in trials in which TAU content was not clearly described (Odds Ratio: 0.29, 95% Confidence Interval 0.15-0.62; three trials) compared to those in which TAU comprised multidisciplinary treatment (Odds Ratio: 0.79, 95% CI 0.63 to 0.97; 12 trials).

Limitations: The included trials had high risk of bias with respect to participant and clinical personnel blinding, and unclear risk of bias for selective outcome reporting.

Conclusions: TAU content and quality represents an important source of heterogeneity between trials of psychotherapeutic interventions for prevention of self-harm. Before clinical trials begin, researchers should plan to carefully describe both aspects of TAU to improve the overall quality of investigations.

Keywords: Clinical trials; Methodology; Self-harm; Suicide; Treatment as usual.

Publication types

Systematic Review

MeSH terms

Cognitive Behavioral Therapy / methods*
Databases, Factual
Evidence-Based Medicine
Humans
Psychotherapy / methods
Randomized Controlled Trials as Topic
Self-Injurious Behavior / psychology
Self-Injurious Behavior / therapy*