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.

Clinical effectiveness and cost-effectiveness of the Rehabilitation Enablement in Chronic Heart Failure (REACH-HF) facilitated self-care rehabilitation intervention in heart failure patients and caregivers: rationale and protocol for a multicentre randomised controlled trial

INTRODUCTION

The Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) trial is part of a research programme designed to develop and evaluate a health professional facilitated, home-based, self-help rehabilitation intervention to improve self-care and health-related quality of life in people with heart failure and their caregivers. The trial will assess the clinical effectiveness and cost-effectiveness of the REACH-HF intervention in patients with systolic heart failure and impact on the outcomes of their caregivers.

METHODS AND ANALYSIS

A parallel two group randomised controlled trial with 1:1 individual allocation to the REACH-HF intervention plus usual care (intervention group) or usual care alone (control group) in 216 patients with systolic heart failure (ejection fraction <45%) and their caregivers. The intervention comprises a self-help manual delivered by specially trained facilitators over a 12-week period. The primary outcome measure is patients' disease-specific health-related quality of life measured using the Minnesota Living with Heart Failure questionnaire at 12 months' follow-up. Secondary outcomes include survival and heart failure related hospitalisation, blood biomarkers, psychological well-being, exercise capacity, physical activity, other measures of quality of life, patient safety and the quality of life, psychological well-being and perceived burden of caregivers at 4, 6 and 12 months' follow-up. A process evaluation will assess fidelity of intervention delivery and explore potential mediators and moderators of changes in health-related quality of life in intervention and control group patients. Qualitative studies will describe patient and caregiver experiences of the intervention. An economic evaluation will estimate the cost-effectiveness of the REACH-HF intervention plus usual care versus usual care alone in patients with systolic heart failure.

ETHICS AND DISSEMINATION

The study is approved by the North West-Lancaster Research Ethics Committee (ref 14/NW/1351). Findings will be disseminated via journals and presentations to publicise the research to clinicians, commissioners and service users.

TRIAL REGISTRATION NUMBER

ISRCTN86234930; Pre-results.

Management of adrenocortical insufficiency with continuous subcutaneous hydrocortisone infusion: long-term experience in three patients

To assess continuous subcutaneous hydrocortisone infusion (CSHI) in patients with adrenocortical insufficiency (AI) and difficulties with oral replacement. Three patients with AI and frequent hospital admissions attributed to adrenal crises were treated with CSHI, which was delivered via a continuous subcutaneous infusion. All three patients preferred CSHI and remained on it long term, which permitted prolonged follow-up analysis. All three patients reported symptomatic improvement, and in two cases, reduced hospital admission rates and inpatient stay lengths were observed. The cost of hospital admissions and overall treatment was reduced in all cases. CSHI offers a practical and acceptable alternative to oral replacement in a subset of patients with AI. The cost of initiating and maintaining the pump is offset in the long term by reduced frequency and duration of emergency admissions. CSHI can therefore be considered in a select group of patients who are resistant to treatment with conventional oral glucocorticoids.

Neutrophil:lymphocyte ratios and serum cytokine changes after hepatic artery chimeric antigen receptor-modified T-cell infusions for liver metastases

Introduction

Our phase I Hepatic Immunotherapy for Metastases (HITM) trial tested the safety of chimeric antigen receptor modified T cell (CAR-T) hepatic artery infusions (HAI) for unresectable CEA+ liver metastases (LM). High neutrophil:lymphocyte ratios (NLR) predict poor outcome in cancer patients and we hypothesized that NLR changes would correlate with early responses to CAR-T HAI.

Methods

Six patients completed the protocol. Three patients received CAR-T HAI in dose escalation (1 × 10⁸, 1 × 10⁹, and 1 × 10¹⁰cells) and the remainder received 3 doses (1 × 10¹⁰ cells) with IL2 support. Serum cytokines and NLR were measured at multiple time points.

Results

The mean NLR for all patients was 13.9 (range 4.8-38.1). NLR increased in four patients following treatment with a mean fold change of 1.9. Serum IL6 levels and NLR fold-changes demonstrated a trend towards a positive correlation (r=0.77, p=0.10). Patients with poor CEA responses were significantly more likely to have higher NLR level increases (p=0.048).

Conclusions

Increased NLR levels were associated with poor responses following CAR-T HAI. NLR variations and associated cytokine changes may be useful surrogates of response to CAR-T HAI.