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

• Published in: Journal of affective disorders 2018-08, Vol.235, p.434-447
• Main Authors: Witt, Katrina, de Moraes, Daniela Pache, Salisbury, Tatiana Taylor, Arensman, Ella, Gunnell, David, Hazell, Philip, Townsend, Ellen, van Heeringen, Kees, Hawton, Keith
• Format: Article
• Language: English
• Subjects: Clinical trials; Cognitive Behavioral Therapy - methods; Databases, Factual; Evidence-Based Medicine; Humans; Methodology; Psychotherapy - methods; Randomized Controlled Trials as Topic; Self-harm; Self-Injurious Behavior - psychology; Self-Injurious Behavior - therapy; Suicide; Treatment as usual
• ISSN: 0165-0327; 1573-2517
• DOI: 10.1016/j.jad.2018.04.025

•Although CBT-based psychotherapy was strongly associated with a significant treatment effect for repetition of self-harm when compared to an unclear TAU condition, the effect size was reduced when compared to multidisciplinary TAU.•No significant subgroup differences as a result of TAU content or reporting quality were observed for the secondary outcome measures of depression, hopelessness, and suicidal ideation.•In few trials were details provided of the treatment components offered to participants allocated to the TAU condition. In fewer still was the number of treatment sessions attended by control participants reported. Additionally, and particularly importantly, no author provided a detailed break-down of the treatments actually received by participants in the TAU condition.•In order to improve the overall quality of trials of psychological interventions researchers should carefully describe both the nature of TAU and what participants in this condition actually receive. 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. 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. 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: 0.7