Seeking help in times of economic hardship: access, experiences of services and unmet need

BACKGROUND

Economic recessions are often accompanied by increased levels of psychological distress and suicidal behaviour in affected populations. Little is known about the experiences of people seeking help for employment, financial and benefit-related difficulties during recessions. We investigated the experiences of people struggling financially in the aftermath of the Great Recession (2008-9) - including some who had self-harmed - and of the frontline support staff providing assistance.

METHODS

Interviews were conducted with three groups of people in two cities: i) people who had self-harmed due to employment, financial or benefit concerns (n = 19) ('self-harm'); ii) people who were struggling financially drawn from the community (n = 22), including one focus group) ('community'); iii) and frontline staff from voluntary and statutory sector organisations (e.g., Job Centres, Debt Advice and counselling agencies) providing support services to the groups (n = 25, including 2 focus groups) ('service providers'). Data were analysed using the constant comparison method.

RESULTS

Service provision was described by people as confusing and difficult to access. The community sample reported considerably more knowledge and access to debt advice than the participants who had self-harmed - although both groups sought similar types of help. The self-harm group exhibited greater expectation that they should be self-reliant and also reported lower levels of informal networks and support from friends and relatives. They had also experienced more difficult circumstances such as benefit sanctions, and most had pre-existing mental health problems. Both self-harm and community groups indicated that practical help for debt and benefit issues would be the most useful - a view supported by service providers - and would have particularly helped those who self-harmed.

CONCLUSION

Interventions to identify those in need and aid them to access practical, reliable and free advice from support agencies could help mitigate the impact on mental health of benefit, debt and employment difficulties for vulnerable sections of society.

Suicide risk linked with clinical consultation frequency, psychiatric diagnoses and psychotropic medication prescribing in a national study of primary-care patients

BACKGROUND

Little is known about the precursors of suicide risk among primary-care patients. This study aimed to examine suicide risk in relation to patterns of clinical consultation, psychotropic drug prescribing, and psychiatric diagnoses.

METHOD

Nested case-control study in the Clinical Practice Research Datalink (CPRD), England. Patients aged ⩾16 years who died by suicide during 2002-2011 (N = 2384) were matched on gender, age and practice with up to 20 living control patients (N = 46 899).

RESULTS

Risk was raised among non-consulting patients, and increased sharply with rising number of consultations in the preceding year [⩾12 consultations v. 1: unadjusted odds ratio (OR) 6.0, 95% confidence interval (CI) 4.9-7.3]. Markedly elevated risk was also associated with the prescribing of multiple psychotropic medication types (⩾5 types v. 0: OR 62.6, CI 44.3-88.4) and with having several psychiatric diagnoses (⩾4 diagnoses v. 0: OR 31.1, CI 19.3-50.1). Risk was also raised among patients living in more socially deprived localities. The confounding effect of multiple psychotropic drug types largely accounted for the rising risk gradient observed with increasing consultation frequency.

CONCLUSIONS

A greater proportion of patients with several psychiatric diagnoses, those prescribed multiple psychotropic medication types, and those who consult at very high frequency might be considered for referral to mental health services by their general practitioners. Non-consulters are also at increased risk, which suggests that conventional models of primary care may not be effective in meeting the needs of all people in the community experiencing major psychosocial difficulties.

A Straightforward Electrochemical Approach to Imine- and Amine-bisphenolate Metal Complexes with Facile Control Over Metal Oxidation State

Synthetic methods to prepare organometallic and coordination compounds such as Schiff-base complexes are diverse, with the route chosen being dependent upon many factors such as metal-ligand combination and metal oxidation state. In this work we have shown that electrochemical methodology can be employed to synthesize a variety of metal-salen/salan complexes which comprise diverse metal-ligand combinations and oxidation states. Broad application has been demonstrated through the preparation of 34 complexes under mild and ambient conditions. Unprecedented control over metal oxidation state (M(II/III/IV) where M=Fe, Mn) is presented by simple modification of reaction conditions. Along this route, a general protocol-switch is described which allows access to analytically pure Fe(II/III)-salen complexes. Tuning electrochemical potential, selective metalation of a Mn/Ni alloy is also presented which exclusively delivers Mn(II/IV)-salen complexes in high yield.

Peptide:glycosaminoglycan hybrid hydrogels as an injectable intervention for spinal disc degeneration

Degeneration of the spinal discs is a major cause of back pain. During the degeneration process, there is a loss of glycosaminoglycans (GAGs) from the proteoglycan-rich gel in the disc's nucleus, which adversely alters biomechanical performance. Current surgical treatments for back pain are highly invasive and have low success rates; there is an urgent need for minimally-invasive approaches that restore the physiological mechanics of the spine. Here we present an injectable peptide:GAG hydrogel that rapidly self-assembles in situ and restores the mechanics of denucleated intervertebral discs. It forms a gel with comparable mechanical properties to the native tissue within seconds to minutes depending on the peptide chosen. Unlike other biomaterials that have been proposed for this purpose, these hybrid hydrogels can be injected through a very narrow 25 G gauge needle, minimising damage to the surrounding soft tissue, and they mimic the ability of the natural tissue to draw in water by incorporating GAGs. Furthermore, the GAGs enhance the gelation kinetics and thermodynamic stability of peptide hydrogels, significantly reducing effusion of injected material from the intervertebral disc (GAG leakage of 8 ± 3% after 24 h when peptide present, compared to 39 ± 3% when no peptide present). In an ex vivo model, we demonstrate that the hydrogels can restore the compressive stiffness of denucleated bovine intervertebral discs. Compellingly, this novel biomaterial has the potential to transform the clinical treatment of back pain by resolving current surgical challenges, thus improving patient quality of life.

Detection and quantification of new psychoactive substances (NPSs) within the evolved "legal high" product, NRG-2, using high performance liquid chromatography-amperometric detection (HPLC-AD)

The global increase in the production and abuse of cathinone-derived New Psychoactive Substances (NPSs) has developed the requirement for rapid, selective and sensitive protocols for their separation and detection. Electrochemical sensing of these compounds has been demonstrated to be an effective method for the in-field detection of these substances, either in their pure form or in the presence of common adulterants, however, the technique is limited in its ability to discriminate between structurally related cathinone-derivatives (for example: (±)-4′-methylmethcathinone (4-MMC, 2a) and (±)-4′-methyl-N-ethylmethcathinone (4-MEC, 2b) when they are both present in a mixture. In this paper we demonstrate, for the first time, the combination of HPLC-UV with amperometric detection (HPLC-AD) for the qualitative and quantitative analysis of 4-MMC and 4-MEC using either a commercially available impinging jet (LC-FC-A) or custom-made iCell channel (LC-FC-B) flow-cell system incorporating embedded graphite screen-printed macroelectrodes. The protocol offers a cost-effective, reproducible and reliable sensor platform for the simultaneous HPLC-UV and amperometric detection of the target analytes. The two systems have similar limits of detection, in terms of amperometric detection [LC-FC-A: 14.66 μg mL(-1) (2a) and 9.35 μg mL(-1) (2b); LC-FC-B: 57.92 μg mL(-1) (2a) and 26.91 μg mL(-1) (2b)], to the previously reported oxidative electrochemical protocol [39.8 μg mL(-1) (2a) and 84.2 μg mL(-1) (2b)], for two synthetic cathinones, prevalent on the recreational drugs market. Though not as sensitive as standard HPLC-UV detection, both flow cells show a good agreement, between the quantitative electroanalytical data, thereby making them suitable for the detection and quantification of 4-MMC and 4-MEC, either in their pure form or within complex mixtures. Additionally, the simultaneous HPLC-UV and amperometric detection protocol detailed herein shows a marked improvement and advantage over previously reported electroanalytical methods, which were either unable to selectively discriminate between structurally related synthetic cathinones (e.g. 4-MMC and 4-MEC) or utilised harmful and restrictive materials in their design.

Understanding vulnerability to self-harm in times of economic hardship and austerity: a qualitative study

OBJECTIVE

Self-harm and suicide increase in times of economic recession, but little is known about why people self-harm when in financial difficulty, and in what circumstances self-harm occurs. This study aimed to understand events and experiences leading to the episode of self-harm and to identify opportunities for prevention or mitigation of distress.

SETTING

Participants' homes or university rooms.

PARTICIPANTS

19 people who had attended hospital following self-harm in two UK cities and who specifically cited job loss, economic hardship or the impact of austerity measures as a causal or contributory factor.

PRIMARY AND SECONDARY OUTCOME MEASURES

Semistructured, in-depth interviews. Interviews were audio recorded, transcribed and analysed cross-sectionally and as case studies.

RESULTS

Study participants described experiences of severe economic hardship; being unable to find employment or losing jobs, debt, housing problems and benefit sanctions. In many cases problems accumulated and felt unresolvable. For others an event, such as a call from a debt collector or benefit change triggered the self-harm. Participants also reported other current or past difficulties, including abuse, neglect, bullying, domestic violence, mental health problems, relationship difficulties, bereavements and low self-esteem. These contributed to their sense of despair and worthlessness and increased their vulnerability to self-harm. Participants struggled to gain the practical help they felt they needed for their economic difficulties or therapeutic support that might have helped with their other co-existing or historically damaging experiences.

CONCLUSIONS

Economic hardships resulting from the recession and austerity measures accumulated or acted as a 'final straw' to trigger self-harm, often in the context of co-existing or historically damaging life-experiences. Interventions to mitigate these effects should include providing practical advice about economic issues before difficulties become insurmountable and providing appropriate psychosocial support for vulnerable individuals.

Which are the most useful scales for predicting repeat self-harm? A systematic review evaluating risk scales using measures of diagnostic accuracy

OBJECTIVES

The aims of this review were to calculate the diagnostic accuracy statistics of risk scales following self-harm and consider which might be the most useful scales in clinical practice.

DESIGN

Systematic review.

METHODS

We based our search terms on those used in the systematic reviews carried out for the National Institute for Health and Care Excellence self-harm guidelines (2012) and evidence update (2013), and updated the searches through to February 2015 (CINAHL, EMBASE, MEDLINE, and PsychINFO). Methodological quality was assessed and three reviewers extracted data independently. We limited our analysis to cohort studies in adults using the outcome of repeat self-harm or attempted suicide. We calculated diagnostic accuracy statistics including measures of global accuracy. Statistical pooling was not possible due to heterogeneity.

RESULTS

The eight papers included in the final analysis varied widely according to methodological quality and the content of scales employed. Overall, sensitivity of scales ranged from 6% (95% CI 5% to 6%) to 97% (CI 95% 94% to 98%). The positive predictive value (PPV) ranged from 5% (95% CI 3% to 9%) to 84% (95% CI 80% to 87%). The diagnostic OR ranged from 1.01 (95% CI 0.434 to 2.5) to 16.3 (95%CI 12.5 to 21.4). Scales with high sensitivity tended to have low PPVs.

CONCLUSIONS

It is difficult to be certain which, if any, are the most useful scales for self-harm risk assessment. No scales perform sufficiently well so as to be recommended for routine clinical use. Further robust prospective studies are warranted to evaluate risk scales following an episode of self-harm. Diagnostic accuracy statistics should be considered in relation to the specific service needs, and scales should only be used as an adjunct to assessment.

Neurosurgical patties: adhesion and damage mitigation

OBJECT

Neurosurgical patties are textile pads used during most neurosurgical operations to protect tissues, manage the fluid environment, control hemostasis, and aid tissue manipulation. Recent research has suggested that, contrary to their aim, patties adhere to brain tissue and cause damage during removal. This study aimed to characterize and quantify the degree of and consequences resulting from adhesion between neurosurgical patties and brain tissue.

METHODS

Using a customized peel apparatus, the authors performed 90° peel tests on 5 patty products: Policot, Telfa, Americot, Delicot, and Ray-Cot (n = 247) from American Surgical Company. They tested 4 conditions: wet patty on glass (control), wet patty on wet brain peeled at 5 mm/sec (wet), dry patty on wet brain peeled at 5 mm/sec (dry), and wet patty on wet brain peeled at 20 mm/sec (speed). The interaction between patty and tissue was analyzed using peel-force traces and pre-peel histological analysis.

RESULTS

Adhesion strength differed between patty products (p < 0.001) and conditions (p < 0.001). Adhesion strength was greatest for Delicot patties under wet (2.22 mN/mm) and dry (9.88 mN/mm) conditions. For all patties, damage at the patty-tissue interface was proportional to the degree of fiber contact. When patties were irrigated, mechanical adhesion was reduced by up to 550% compared with dry usage.

CONCLUSIONS

For all patty products, mechanical (destructive) and liquid-mediated (nondestructive) adhesion caused damage to neural tissue. The greatest adhesion occurred with Delicot patties. To mitigate patty adhesion and neural tissue damage, surgeons should consider regular irrigation to be essential during neurosurgical procedures.

Suicide by gases in England and Wales 2001-2011: evidence of the emergence of new methods of suicide

BACKGROUND

Increases in suicide deaths by gassing, particularly carbon monoxide poisoning from burning barbecue charcoal, have occurred in many parts of East Asia and resulted in rises in overall suicide rates in some countries. Recent trends in gas poisoning suicides outside Asia have received little attention.

METHODS

We analysed suicides by gassing in England and Wales (2001-2011) using national suicide mortality data enhanced by free text searching of information sent by coroners to the Office for National Statistics (ONS). We conducted specific searches for suicides involving barbecue charcoal gas, helium, and hydrogen sulphide. We analysed coroners' records of eight people who used helium as a method of suicide, identified from systematic searches of the records of four coroners.

RESULTS

Gassing accounted for 5.2% of suicide deaths in England and Wales during 2001-2011. The number of gas suicides declined from 368 in 2001 to 174 by 2011 (a 53% reduction). The fall was due to a decline in deaths involving car exhaust and other sources of carbon monoxide. There was a rapid rise in deaths due to helium inhalation over the period, from five deaths in the two year period 2001-2002 to 89 in 2010-2011 (a 17-fold increase). There were small rises in deaths involving hydrogen sulphide (0 cases in 2001-2002 versus 14 cases in 2010-2011) and barbecue charcoal gas (1 case in 2001-2002 versus 11 cases in 2010-2011). Compared to individuals using other methods, those suicides adopting new types of gas for suicide were generally younger and from more affluent socioeconomic groups. The corones' records of four of the eight individuals dying by helium inhalation whose records were reviewed showed evidence of Internet involvement in their choice of method.

LIMITATIONS

We were not able to identify the source of carbon monoxide (car exhaust or barbecue charcoal) for over 50% of cases.

CONCLUSION

Increases in helium inhalation as a method of suicide have partially offset recent decreases in suicide by the use of car exhaust. Public health measures are urgently needed to prevent a potential epidemic rise in the use of helium similar to the recent rises in charcoal burning suicides in East Asia.

Electrochemical flow-reactor for expedient synthesis of copper–N-heterocyclic carbene complexes

An electrochemical flow-cell has been developed for the highly efficient and selective generation of organometallic Cu^I–N-heterocyclic carbene complexes under neutral and ambient conditions.

Dynamics of interpedicular widening in spinal burst fractures: an in vitro investigation

BACKGROUND CONTEXT

Spinal burst fractures are a significant cause of spinal instability and neurologic impairment. Although evidence suggests that the neurologic trauma arises during the dynamic phase of fracture, the biomechanics underpinning the phenomenon has yet to be fully explained. Interpedicular widening (IPW) is a distinctive feature of the fracture but, despite the association with the occurrence of neurologic deficit, little is known about its biomechanics.

PURPOSE

To provide a comprehensive in vitro study on spinal burst fracture, with special attention on the dynamics of IPW.

STUDY DESIGN

Experimental measurements in combination with computed tomography scanning were used to quantitatively investigate the biomechanics of burst fracture in a cadaveric model.

METHODS

Twelve human three-adjacent-vertebra segments were tested to induce burst fracture. Impact was delivered through a drop-weight tower, whereas IPW was continuously recorded by two displacement transducers. Computed tomography scanning aided quantifying canal occlusion (CO) and evaluating sample anatomy and fracture appearance. Two levels of energy were delivered to two groups: high energy (HE) and low energy (LE).

RESULTS

No difference was found between HE and LE in terms of the residual IPW (ie, post-fracture), maximum IPW, or CO (median 20.2%). Whereas IPW was not found to be correlated with CO, a moderate correlation was found between the maximum and the residual IPW. At the fracture onset, IPW reached a maximum median value of 15.8% in approximately 20 to 25 milliseconds. After the transient phase, the pedicles were recoiled to a median residual IPW of 4.9%.

CONCLUSIONS

Our study provides for the first time insight on how IPW actually evolves during the fracture onset. In addition, our results may help shedding more light on the mechanical initiation of the fracture.

Assessing cement injection behaviour in cancellous bone: An in vitro study using flow models

Understanding the cement injection behaviour during vertebroplasty and accurately predicting the cement placement within the vertebral body is extremely challenging. As there is no standardized methodology, we propose a novel method using reproducible and pathologically representative flow models to study the influence of cement properties on injection behaviour. The models, confined between an upper glass window and a lower aluminium plate, were filled with bone marrow substitute and then injected (4, 6 and 8 min after cement mixing) with commercially available bone cements (SimplexP, Opacity+, OsteopalV and Parallax) at a constant flow rate (3 mL/min). A load cell was used to measure the force applied on the syringe plunger and calculate the peak pressure. A camera was used to monitor the cement flow during injection and calculate the following parameters when the cement had reached the boundary of the models: the time to reach the boundary, the filled area and the roundness. The peak pressure was comparable to that reported during clinical vertebroplasty and showed a similar increase with injection time. The study highlighted the influence of cement formulations and model structure on the injection behaviour and showed that cements with similar composition/particle size had similar flow behaviour, while the introduction of defects reduced the time to reach the boundary, the filled area and the roundness. The proposed method provides a novel tool for quick, robust differentiation between various cement formulations through the visualization and quantitative analysis of the cement spreading at various time intervals.

Scales for predicting risk following self-harm: an observational study in 32 hospitals in England

OBJECTIVE

To investigate the extent to which risk scales were used for the assessment of self-harm by emergency department clinicians and mental health staff, and to examine the association between the use of a risk scale and measures of service quality and repeat self-harm within 6 months.

DESIGN

Observational study.

SETTING

A stratified random sample of 32 hospitals in England.

PARTICIPANTS

6442 individuals presenting with self-harm to 32 hospital services during a 3-month period between 2010 and 2011.

OUTCOMES

21-item measure of service quality, repeat self-harm within 6 months.

RESULTS

A variety of different risk assessment tools were in use. Unvalidated locally developed proformas were the most commonly used instruments (reported in n=22 (68.8%) mental health services). Risk assessment scales were used in one-third of services, with the SAD PERSONS being the single most commonly used scale. There were no differences in service quality score between hospitals which did and did not use scales as a component of risk assessment (median service quality score (IQR): 14.5 (12.8, 16.4) vs 14.5 (11.4, 16.0), U=121.0, p=0.90), but hospitals which used scales had a lower median rate of repeat self-harm within 6 months (median repeat rate (IQR): 18.5% vs 22.7%, p=0.008, IRR (95% CI) 1.18 (1.00 to 1.37). When adjusted for differences in casemix, this association was attenuated (IRR=1.13, 95% CI (0.98 to 1.3)).

CONCLUSIONS

There is little consensus over the best instruments for risk assessment following self-harm. Further research to evaluate the impact of scales following an episode of self-harm is warranted using prospective designs. Until then, it is likely that the indiscriminant use of risk scales in clinical services will continue.

Barium aspiration in an infant: a case report and review of management

We describe a case of bilateral inhalation of barium in an infant following a barium swallow for investigation of dusky spells associated with feeds. A bronchoscopy subsequently revealed the presence of a mid-tracheal tracheo-esophageal cleft. To date, little has been reported on barium aspiration in children and there is no consensus for management. We review the literature on barium aspiration, its consequences, and make recommendations for management.

Suicide in bipolar disorder in a national English sample, 1996-2009: frequency, trends and characteristics

BACKGROUND

Bipolar disorder (BD) has been reported to be associated with high risk of suicide. We aimed to investigate the frequency and characteristics of suicide in people with BD in a national sample.

METHOD

Suicide in BD in England from 1996 to 2009 was explored using descriptive statistics on data collected by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI). Suicide cases with a primary diagnosis of BD were compared to suicide cases with any other primary diagnosis.

RESULTS

During the study period 1489 individuals with BD died by suicide, an average of 116 cases/year. Compared to other primary diagnosis suicides, those with BD were more likely to be female, more than 5 years post-diagnosis, current/recent in-patients, to have more than five in-patient admissions, and to have depressive symptoms. In BD suicides the most common co-morbid diagnoses were personality disorder and alcohol dependence. Approximately 40% were not prescribed mood stabilizers at the time of death. More than 60% of BD suicides were in contact with services the week prior to suicide but were assessed as low risk.

CONCLUSIONS

Given the high rate of suicide in BD and the low estimates of risk, it is important that health professionals can accurately identify patients most likely to experience poor outcomes. Factors such as alcohol dependence/misuse, personality disorder, depressive illness and current/recent in-patient admission could characterize a high-risk group. Future studies need to operationalize clinically useful indicators of suicide risk in BD.

Are hospital services for self-harm getting better? An observational study examining management, service provision and temporal trends in England

OBJECTIVES

To describe the characteristics and management of individuals attending hospital with self-harm and assess changes in management and service quality since an earlier study in 2001, a period in which national guidance has been available.

DESIGN

Observational study.

SETTING

A stratified random sample of 32 hospitals in England, UK.

PARTICIPANTS

6442 individuals presenting with 7689 episodes of self-harm during a 3-month audit period between 2010 and 2011.

OUTCOME

Self-harm episodes, key aspects of individual management relating to psychosocial assessment and follow-up, and a 21-item measure of service quality.

RESULTS

Overall, 56% (3583/6442) of individuals were women and 51% (3274/6442) were aged under 35 years. Hospitals varied markedly in their management. The proportion of episodes that received a psychosocial assessment by a mental health professional ranged from 22% to 88% (median 58%, IQR 48-70%); the proportion of episodes resulting in admission to general hospitals varied from 22% to 85% (median 54%, IQR 41-63%); a referral for specialist mental health follow-up was made in 11-64% of episodes (median 28%, IQR 22-38%); a referral to non-statutory services was made in 4-62% of episodes (median 15%, IQR 8-23%); 0-21% of episodes resulted in psychiatric admission (median 7%, QR 4-12%). The specialist assessment rate varied by method of harm; the median rate for self-cutting was 45% (IQR 28-63%) vs 58% (IQR 48-73%) for self-poisoning. Compared with the 2001 study, there was little difference in the proportion of episodes receiving specialist assessment; there was a significant increase in general hospital admission but a decrease in referrals for specialist mental health follow-up. However, scores on the service quality scale had increased from a median of 11.5-14.5 (a 26% increase).

CONCLUSIONS

Services for the hospital management of self-harm remain variable despite national guidelines and policy initiatives. We found no evidence for increasing levels of assessment over time but markers of service quality may have improved. This paper forms part of the study 'Variations in self-harm service delivery: an observational study examining outcomes and temporal trends'. The National Institute for Health Research Clinical Research Network (NIHR CRN) Portfolio database registration number: HOMASH 2 (7333). The NIHR Coordinated System for gaining NHS Permission (CSP) registration number: 23226.