Interventions for self-harm are less effective for men

Researchers at City St George’s, University of London have found that psychological interventions for self-harm appear to be more effective for females than males, raising concerns about how well current treatments meet the needs of men at high risk of suicide.

In a systematic review and meta-analysis published in The Lancet Regional Health – Europe, the team analysed 46 randomised controlled trials involving over 15,000 participants. The study is the first to specifically compare the effectiveness of psychosocial interventions (PSIs) for self-harm in males and females across both clinical and non-clinical settings. Psychosocial interventions involve mostly talking therapies (such as cognitive behaviour therapy) or presenting information and support.

Self-harm is the biggest risk factor for death by suicide. Although females are around 1.5 times more likely to report self-harm globally and in England, males are at least twice as likely to die by suicide worldwide and more than three times as likely in the UK. In England, males presenting to the hospital with self-harm are three times more likely to die by suicide than females. Men are also more than four times more likely to die by suicide than women following their first suicide attempt.

Against this backdrop, the researchers set out to examine whether commonly used psychosocial treatments are equally effective for both sexes.

The team, which was led by Professor Rose McCabe, Professor of Clinical Communication at City St George’s, drew on trials identified in two Cochrane reviews published in 2021 and updated the searches through to May 2024. Eligible studies included participants who had self-harmed within the past six months, included at least one male and one female in the intervention arm, evaluated a psychosocial intervention, and reported outcomes such as repetition of self-harm.

Of 108 eligible trials identified, outcome data by sex was obtained for 46 trials. This included 11,723 females (76.1 per cent of participants) and the primary outcome was repetition of self-harm after treatment.

Across the 34 trials reporting the primary outcome, males in the intervention arms were more likely to repeat self-harm than females in the intervention arms. Among 6,228 participants analysed, 14.6 per cent of males (301 out of 2,062) who had received an intervention repeated self-harm post-treatment compared with 14.4 per cent of females (599 out of 4,166).

When comparing intervention groups with comparator groups, a clearer difference emerged. Males receiving psychosocial interventions were as likely as comparator males to have repeated self-harm. In contrast, females receiving interventions were significantly less likely to repeat self-harm than females in comparator groups. However, there were no significant differences between males and females in the intervention arms when the researchers looked at secondary outcomes, such as the frequency of self-harm, treatment adherence, depression, hopelessness, suicidal ideation and/or suicide.

The study also examined a wide range of psychosocial interventions, including cognitive behavioural therapy (CBT)-based psychotherapy, dialectical behaviour therapy (DBT), mentalisation-based therapy (MBT), psychodynamic psychotherapy, case management, family therapy, structured GP follow-up and remote contact interventions such as letters or text messages. Intervention durations ranged from 30 minutes to 24 months.

Subgroup analyses found that the sex difference in repetition of self-harm was present in trials involving adults but not in those involving adolescents. And there were no sex differences for any of the outcomes when trials were analysed by type of psychosocial intervention.

Lead author Oliver Matias said:

“Our findings suggest that psychosocial interventions for self-harm appear to be more effective for females than for males. Given that men are significantly more likely to die by suicide, this gap is concerning. It highlights an urgent need to better understand why men self-harm, and we need to design and deliver interventions that better address the needs of men who self-harm.”

Professor McCabe said:

“Men account for the majority of deaths by suicide, yet our findings suggest current interventions are not reducing self-harm in males. Addressing this gap should be a public health priority. To address the specific needs of males in improving support for self-harm, we need to ensure that there are more male representatives in patient and public involvement. Promising approaches include non-talking therapy options, group and community approaches (e.g. Men's Sheds, barbers/hairdressers, sports clubs, men's support groups, fathers' support groups, employment support groups, male-friendly helplines); action-orientated approaches (e.g. sports, working on a project together); coaching and mentoring approaches”.

The researchers also highlight the need to consider gender-diverse individuals, who may be at higher risk of self-harm.

The study was funded by City St George’s, University of London and the National Institute for Health and Care Research ARC North Thames.

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