Self-harm

Impact of the COVID-19 Pandemic on the Incidence and Characteristics of Patients with Psychiatric Illnesses Visiting Emergency Departments in Korea

The global coronavirus disease 2019 (COVID-19) pandemic has had wide-ranging effects on the mental health of the public. This study aimed to investigate the impact of the COVID-19 pandemic on the characteristics of psychiatric patients who visited emergency departments (ED) during this time. A cross-sectional study was conducted including patients visiting 402 nationwide EDs from 27 January 2020 to 29 June 2020 (22 weeks; during-COVID) and the corresponding period in 2019 (28 January 2019 to 30 June 2019, 22 weeks; before-COVID) to control for seasonal influences. Among the 6,210,613 patients who visited the ED, 88,520 (2.5%) patients who visited before the pandemic and 73,281 (2.7%) patients who visited during the pandemic had some kind of psychiatric illness. The incidence rates of psychiatric self-harm increased from 0.54 before the pandemic to 0.56 during the pandemic per 1,000,000 person-days (p = 0.04). Age- and sex-standardized rates of psychiatric illnesses per 100,000 ED visits increased during the pandemic (rate differences (95% CIs); 45.7 (20.1–71.4) for all psychiatric disorders and 42.2 (36.2–48.3) for psychiatric self-harm). The incidence of psychiatric self-harm and the proportion of psychiatric patients visiting EDs increased during the COVID-19 pandemic.

Hospital presenting suicidal ideation: A systematic review

BACKGROUND

Research indicates that the emergency department is the primary setting for people to present with suicidal ideation. Attempting to provide interventions for this population depends greatly on understanding their needs and life circumstances at the time of presentation to services, therefore enabling more appropriate treatment pathways and services to be provided.

AIM

This review aims to collate, evaluate and synthesize the empirical research focused on the population of people presenting to hospital settings with suicidal ideation.

METHOD

A systematic literature search was performed. Articles that met a specified set of inclusion criteria including participants being over 18, not being admitted to hospital and presenting to an emergency department setting underwent a quality assessment and data analysis. The quality assessment used was the EPHPP Quality Assessment Tool for Quantitative Studies (Thomas et al., 2004).

RESULTS

Twenty-seven articles were included in the review. Studies were quantitative and of reasonable methodological quality (Thomas et al., 2004). The literature was characterized by demographic information, mental health factors associated with the presentation to hospital and treatment pathways or outcomes reported. The reviewed research showed that people presenting to emergency departments with suicidal ideation were varying in age, gender, ethnic background and socio-economic status (SES). Large proportions of studies reported psychosocial factors alongside interpersonal struggles as the main presenting reason. The review highlights large variability across these factors. Mental health diagnosis was common, previous suicide attempt was a risk factor, and treatment pathways were unclear. The review identifies the outstanding gaps and weaknesses in this literature as well as areas in need of future research.

CONCLUSIONS

In conclusion, the review highlights the prevalence of people reporting interpersonal factors as the reason for suicidal ideation and not mental health disorders or diagnosis. Despite this, no mention of trauma or life stories was made in any study assessing this population. Despite a large variation across studies making synthesis difficult, data proves clinically relevant and informative for future practice and guidance on areas needing further research.

Disordered eating and self-harm as risk factors for poorer mental health during the COVID-19 pandemic: a UK-based birth cohort study

BACKGROUND

Young adults and especially those with pre-existing mental health conditions, such as disordered eating and self-harm, appear to be at greater risk of developing metal health problems during the COVID-19 pandemic. However, it is unclear whether this increased risk is affected by any changes in lockdown restrictions, and whether any lifestyle changes could moderate this increased risk.

METHODS

In a longitudinal UK-based birth cohort (The Avon Longitudinal Study of Parents and Children, ALSPAC) we assessed the relationship between pre-pandemic measures of disordered eating and self-harm and mental health during the COVID-19 pandemic in 2657 young adults. Regression models examined the relationship between self-reported disordered eating, self-harm, and both disordered eating and self-harm at age 25 years and depressive symptoms, anxiety symptoms and mental wellbeing during a period of eased restrictions in the COVID-19 pandemic (May-July 2020) when participants were aged 27-29 years. Analyses were adjusted for sex, questionnaire completion date, pre-pandemic socioeconomic disadvantage and pre-pandemic mental health and wellbeing. We also examined whether lifestyle changes (sleep, exercise, alcohol, visiting green space, eating, talking with family/friends, hobbies, relaxation) in the initial UK lockdown (April-May 2020) moderated these associations.

RESULTS

Pre-existing disordered eating, self-harm and comorbid disordered eating and self-harm were all associated with the reporting of a higher frequency of depressive symptoms and anxiety symptoms, and poorer mental wellbeing during the pandemic compared to individuals without disordered eating and self-harm. Associations remained when adjusting for pre-pandemic mental health measures. There was little evidence that interactions between disordered eating and self-harm exposures and lifestyle change moderators affected pandemic mental health and wellbeing.

CONCLUSIONS

Young adults with pre-pandemic disordered eating, self-harm and comorbid disordered eating and self-harm were at increased risk for developing symptoms of depression, anxiety and poor mental wellbeing during the COVID-19 pandemic, even when accounting for pre-pandemic mental health. Lifestyle changes during the pandemic do not appear to alter this risk. A greater focus on rapid and responsive service provision is essential to reduce the impact of the pandemic on the mental health of these already vulnerable individuals. The aim of this project was to explore the mental health of young adults with disordered eating behaviours (such as fasting, vomiting/taking laxatives, binge-eating and excessive exercise) and self-harm during the COVID-19 pandemic. We analysed data from an established study that has followed children from birth (in 1991 and 1992) up to present day, including during the pandemic when participants were 28 years old. We looked at the relationship between disordered eating and/or self-harm behaviours from before the pandemic and mental health problems (symptoms of depression and anxiety) and mental wellbeing during the pandemic. We also explored whether there were any lifestyle changes (such as changes in sleep, exercise, visiting green space) that might be linked to better mental health and wellbeing in young adults with disordered eating and self-harm. We found that young adults with prior disordered eating and/or self-harm had more symptoms of depression and anxiety, and worse mental wellbeing than individuals without prior disordered eating or self-harm. However, lifestyle changes did not appear to affect mental health and wellbeing in these young adults. Our findings suggest that people with a history of disordered eating and/or self-harm were at high risk for developing mental health problems during the pandemic, and they will need help from mental health services.

Two Pathways to Self-Harm in Adolescence

OBJECTIVE

The behavioral and emotional profiles underlying adolescent self-harm, and its developmental risk factors, are relatively unknown. We aimed to identify subgroups of young people who self-harm (YPSH) and longitudinal risk factors leading to self-harm.

METHOD

Participants were from the Millennium Cohort Study (N = 10,827). A clustering algorithm was used to identify subgroups who self-harmed with different behavioral and emotional profiles at age 14 years. We then traced the profiles back in time (ages 5-14 years) and used feature selection analyses to identify concurrent correlates and longitudinal risk factors of self-harming behavior.

RESULTS

There were 2 distinct subgroups at age 14 years: a smaller group (n = 379) who reported a long history of psychopathology, and a second, much larger group (n = 905) without. Notably, both groups could be predicted almost a decade before the reported self-harm. They were similarly characterized by sleep problems and low self-esteem, but there was developmental differentiation. From an early age, the first group had poorer emotion regulation, were bullied, and their caregivers faced emotional challenges. The second group showed less consistency in early childhood, but later reported more willingness to take risks and less security with peers/family.

CONCLUSION

Our results uncover 2 distinct pathways to self-harm: a "psychopathology" pathway, associated with early and persistent emotional difficulties and bullying; and an "adolescent risky behavior" pathway, whereby risk taking and external challenges emerge later into adolescence and are associated with self-harm. At least one of these pathways has a long developmental history, providing an extended window for interventions as well as potential improvements in the identification of children at risk, biopsychosocial causes, and treatment or prevention of self-harm.

Determinants of long-term unplanned readmission and mortality following self-inflicted and non-self-inflicted major injury: a retrospective cohort study

PURPOSE

To describe the characteristics of major injury and identify determinants of long-term unplanned readmission and mortality after self-inflicted and non-self-inflicted injury to inform potential readmission screening.

METHOD

A retrospective cohort study of 11,269 individuals aged ≥ 15 years hospitalised for a major injury during 2013-2017 in New South Wales, Australia. Unplanned readmission and mortality up to 27-month post-injury were examined. Logistic regression was used to examine predictors of unplanned readmission.

RESULTS

During the 27-month follow-up, 2700 (24.8%) individuals with non-self-inflicted and 98 (26.1%) with self-inflicted injuries had an unplanned readmission. Individuals with an anxiety-related disorder and a non-self-inflicted injury who were discharged home were three times more likely (OR: 3.27; 95%CI 2.28-4.69) or if they were discharged to a psychiatric facility were four times more likely (OR: 4.11; 95%CI 1.07-15.80) to be readmitted. Compared to individuals aged 15-24 years, individuals aged ≥ 65 years were 3 times more likely to be readmitted (OR 3.12; 95%CI 2.62-3.70). Individuals with one (OR 1.60; 95%CI 1.39-1.84) or ≥ 2 (OR 1.88; 95%CI 1.52-2.32) comorbidities, or who had a drug-related dependence (OR 1.88; 95%CI 1.52-2.31) were more likely to be readmitted. The post-discharge age-adjusted mortality rate following a self-inflicted injury (35.6%; 95%CI 29.9-41.8) was higher than for individuals with a non-self-inflicted injury (11.0%; 95%CI 10.4-11.8).

CONCLUSIONS

Unplanned readmission after injury is associated with injury intent, age, and comorbid health. Screening for anxiety and drug-related dependence after major injury, accompanied by service referrals and post-discharge follow-up, has potential to prevent readmission.

Disordered eating and self-harm as risk factors for poorer mental health during the COVID-19 pandemic: A UK-based birth cohort study

BACKGROUND

Young adults and especially those with pre-existing mental health conditions, such as disordered eating and self-harm, appear to be at greater risk of developing metal health problems during the COVID-19 pandemic. However, it is unclear whether this increased risk is affected by any changes in lockdown restrictions, and whether any lifestyle changes could moderate this increased risk.

METHODS

In a longitudinal UK-based birth cohort (The Avon Longitudinal Study of Parents and Children, ALSPAC) we assessed the relationship between pre-pandemic measures of disordered eating and self-harm and mental health during the COVID-19 pandemic in 2,657 young adults. Regression models examined the relationship between self-reported disordered eating, self-harm, and both disordered eating and self-harm at age 25 years and depressive symptoms, anxiety symptoms and mental wellbeing during a period of eased restrictions in the COVID-19 pandemic (May-July 2020) when participants were aged 27-29 years. Analyses were adjusted for sex, questionnaire completion date, pre-pandemic socioeconomic disadvantage and pre-pandemic mental health and wellbeing. We also examined whether lifestyle changes (sleep, exercise, alcohol, visiting green space, eating, talking with family/friends, hobbies, relaxation) in the initial UK lockdown (April-May 2020) moderated these associations.

RESULTS

Pre-existing disordered eating, self-harm and comorbid disordered eating and self-harm were all associated with the reporting of a higher frequency of depressive symptoms and anxiety symptoms, and poorer mental wellbeing during the pandemic compared to individuals without disordered eating and self-harm. Associations remained when adjusting for pre-pandemic mental health measures. There was little evidence that interactions between disordered eating and self-harm exposures and lifestyle change moderators affected pandemic mental health and wellbeing.

CONCLUSIONS

Young adults with pre-pandemic disordered eating, self-harm and comorbid disordered eating and self-harm were at increased risk for developing symptoms of depression, anxiety and poor mental wellbeing during the COVID-19 pandemic, even when accounting for pre-pandemic mental health. Lifestyle changes during the pandemic do not appear to alter this risk. A greater focus on rapid and responsive service provision is essential to reduce the impact of the pandemic on the mental health of these already vulnerable individuals.

Hospital and Community Correlates of Recommended Emergency Department Mental Health Care for Patients Presenting With Self-Harm

OBJECTIVE

Emergency departments (EDs) are well positioned to deliver suicide prevention services. This study examined hospital and community correlates of recommended practices.

METHODS

This study examined results from a national survey of ED nursing directors (N=513) focusing on hospital- and community-level variation in the routine provision of four recommended practices: suicide risk screening, access to means assessment, safety planning, and follow-up referrals.

RESULTS

Few significant differences existed between hospitals that routinely provided these practices and hospitals that did not. Routine scheduling of follow-up appointments was associated with presence of formal contractual relationships with outpatient mental health facilities (p=0.005). Routine provision of safety planning was associated with higher levels of psychiatrist or psychologist staffing (p=0.032).

CONCLUSIONS

There were few differences in the hospital and community characteristics between EDs that routinely provided recommended care and those that did not, suggesting few structural barriers to implementation of these recommended services for high-risk ED patients.

Self-harm During Visits to the Emergency Department: A Qualitative Content Analysis

BACKGROUND

Some patients engage in self-harm behaviors while in the emergency department, both suicidal and nonsuicidal self-harm. Little is known about what motivates these behaviors. This gap in the empirical literature limits efforts to develop early identification and risk mitigation strategies.

OBJECTIVE

To describe methods and motivations when patients self-harm in the emergency department.

METHOD

Authors reviewed self-harm incident reports and medical records from two academic urban emergency departments. Event timing and self-harm methods were extracted. Authors performed a qualitative content analysis of self-harm narratives to examine the question, "Which factors motivate patients to engage in deliberate (nonaccidental) self-harm in the emergency department?"

RESULTS

The sample included 184 self-harm incidents involving 118 unique patients. A wide variety of self-harm methods were present in the data. Suicidal intent was present in a minority of incidents. Other motives included psychosis, intoxication, aggression, managing distress, communication, and manipulation.

CONCLUSIONS

Self-harm behaviors in the emergency department encompassed a variety of methods and motivations. These findings suggest risk mitigation strategies that emphasize suicide screening, reducing environmental hazards, and increasing observation are unlikely to achieve the goal of zero harm. Strategies focusing on engagement may create more fruitful opportunities to improve patient safety.

Experiences of Help From the Perspective of Finnish People Who Self-Harmed During Adolescence

Adolescent self-harm is a widespread phenomenon, and a significant problem worldwide. This study describes the experiences of help from the perspective of Finnish people who have suffered self-harm during adolescence. Data were collected from 27 participants as essays and interviews. Participants included both females and males with different backgrounds and treatment experiences. The data were analysed using inductive content analysis. Participants described having received help from other people in informal and formal ways, and they had both positive and negative experiences of help. The results show that several barriers exist for self-harming adolescents to access help, thus improvement in this area are necessary.

Incidence of and Factors Associated With Nonfatal Self-injury After a Cancer Diagnosis in Ontario, Canada

IMPORTANCE

Psychological distress is a key component of patient-centered cancer care. While a greater risk of suicide among patients with cancer has been reported, more frequent consequences of distress, including nonfatal self-injury (NFSI), remain unknown.

OBJECTIVE

To examine the risk of NFSI after a cancer diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

This population-based retrospective cohort study used linked administrative databases to identify adults diagnosed with cancer between 2007 and 2019 in Ontario, Canada.

EXPOSURES

Demographic and clinical factors.

MAIN OUTCOMES AND MEASURES

Cumulative incidence of NFSI, defined as emergency department presentation of self-injury, was computed, accounting for the competing risk of death from all causes. Factors associated with NFSI were assessed using multivariable Fine and Gray models.

RESULTS

In total, 806 910 patients met inclusion criteria. The mean (SD) age was 65.7 (14.3) years, and 405 161 patients (50.2%) were men. Overall, 2482 (0.3%) had NFSI and 182 (<0.1%) died by suicide. The 5-year cumulative incidence of NFSI was 0.27% (95% CI, 0.25%-0.28%). After adjusting for key confounders, prior severe psychiatric illness, whether requiring inpatient care (subdistribution hazard ratio [sHR], 12.6; 95% CI, 10.5-15.2) or outpatient care (sHR, 7.5; 95% CI, 6.5-8.8), and prior self-injury (sHR, 6.6; 95% CI, 5.5-8.0) were associated with increased risk of NFSI. Young adults (age 18-39 years) had the highest NFSI rates relative to individuals aged 70 years or older (sHR, 5.4; 95% CI, 4.5-6.5). The magnitude of association between prior inpatient psychiatric illness and NFSI was greatest for young adults (sHR, 17.6; 95% CI, 12.0-25.8). Certain cancer subsites were also associated with increased risk, including head and neck cancer (sHR, 1.5; 95% CI, 1.2-1.9).

CONCLUSIONS AND RELEVANCE

In this study, patients with cancer had a higher incidence of NFSI than suicide after diagnosis. Younger age, history of severe psychiatric illness, and prior self-injury were independently associated with risk of NFSI. These exposures appeared to act synergistically, placing young adults with a prior mental health history at the greatest risk of NFSI. These factors should be used to identify at-risk patients.

Developing a Natural Language Processing tool to identify perinatal self-harm in electronic healthcare records

BACKGROUND

Self-harm occurring within pregnancy and the postnatal year ("perinatal self-harm") is a clinically important yet under-researched topic. Current research likely under-estimates prevalence due to methodological limitations. Electronic healthcare records (EHRs) provide a source of clinically rich data on perinatal self-harm.

AIMS

(1) To create a Natural Language Processing (NLP) tool that can, with acceptable precision and recall, identify mentions of acts of perinatal self-harm within EHRs. (2) To use this tool to identify service-users who have self-harmed perinatally, based on their EHRs.

METHODS

We used the Clinical Record Interactive Search system to extract de-identified EHRs of secondary mental healthcare service-users at South London and Maudsley NHS Foundation Trust. We developed a tool that applied several layers of linguistic processing based on the spaCy NLP library for Python. We evaluated mention-level performance in the following domains: span, status, temporality and polarity. Evaluation was done against a manually coded reference standard. Mention-level performance was reported as precision, recall, F-score and Cohen's kappa for each domain. Performance was also assessed at 'service-user' level and explored whether a heuristic rule improved this. We report per-class statistics for service-user performance, as well as likelihood ratios and post-test probabilities.

RESULTS

Mention-level performance: micro-averaged F-score, precision and recall for span, polarity and temporality >0.8. Kappa for status 0.68, temporality 0.62, polarity 0.91. Service-user level performance with heuristic: F-score, precision, recall of minority class 0.69, macro-averaged F-score 0.81, positive LR 9.4 (4.8-19), post-test probability 69.0% (53-82%). Considering the task difficulty, the tool performs well, although temporality was the attribute with the lowest level of annotator agreement.

CONCLUSIONS

It is feasible to develop an NLP tool that identifies, with acceptable validity, mentions of perinatal self-harm within EHRs, although with limitations regarding temporality. Using a heuristic rule, it can also function at a service-user-level.

Change in prevalence of self-harm from 2002 to 2018 among Norwegian adolescents

Background

Self-harm is prevalent among adolescents and associated with mental health problems and negative life-events. Few studies have examined changes in its prevalence related to these factors. This study explored whether changes in prevalence of self-harm among adolescents had occurred, and to what extent changes in associated factors may have contributed.

Methods

Two cross-sectional school-based surveys among adolescents (grades 8–10) in Norway were conducted in 2002 (N = 5842) and in 2017/18 (N = 29 063). Past year prevalence of self-harm and identical variables on risk factors was analyzed in hierarchical logistic regression to examine whether and to what extent changes in self-harm correlates could explain periodical change in prevalence of self-harm.

Results

An increase from 4.1% to 16.2% in self-harm prevalence was observed from 2002 to 2017/18. The increase was relatively larger among girls compared to boys and among 8th graders compared to 10th graders. Among the assessed risk factors for self-harm, depressive symptoms increased, while anti-social behavior, exposure to violent acts and drinking to intoxication decreased. The increase in depressive symptoms contributed to explain increase in self-harm. This contribution was outweighed by the decrease in other risk factors.

Conclusions

Self-harm prevalence increased 4-fold among Norwegian adolescents over a 15-year period. While exposure to several risk factors for self-harm changed substantially in this period, these risk factors could in sum not explain any of the increase in self-harm.

Trajectories of antidepressant use before and after a suicide attempt among refugees and Swedish-born individuals: a cohort study

Background

To identify key information regarding potential treatment differences in refugees and the host population, we aimed to investigate patterns (trajectories) of antidepressant use during 3 years before and after a suicide attempt in refugees, compared with Swedish-born. Association of the identified trajectory groups with individual characteristics were also investigated.

Methods

All 20–64-years-old refugees and Swedish-born individuals having specialised healthcare for suicide attempt during 2009–2015 (n = 62,442, 5.6% refugees) were followed 3 years before and after the index attempt. Trajectories of annual defined daily doses (DDDs) of antidepressants were analysed using group-based trajectory models. Associations between the identified trajectory groups and different covariates were estimated by chi²-tests and multinomial logistic regression.

Results

Among the four identified trajectory groups, antidepressant use was constantly low (≤15 DDDs) for 64.9% of refugees. A ‘low increasing’ group comprised 5.9% of refugees (60–260 annual DDDs before and 510–685 DDDs after index attempt). Two other trajectory groups had constant use at medium (110–190 DDDs) and high (630–765 DDDs) levels (22.5 and 6.6% of refugees, respectively). Method of suicide attempt and any use of psychotropic drugs during the year before index attempt discriminated between refugees’ trajectory groups. The patterns and composition of the trajectory groups and their association, discriminated with different covariates, were fairly similar among refugees and Swedish-born, with the exception of previous hypnotic and sedative drug use being more important in refugees.

Conclusions

Despite previous reports on refugees being undertreated regarding psychiatric healthcare, no major differences in antidepressant treatment between refugees and Swedish-born suicide attempters were found.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01460-z.

Non-suicidal self-injury (NSSI) among emerging adults: Sub-group profiles and their clinical relevance

BACKGROUND

High prevalence rates and variations in patterns of non-suicidal self-injury (NSSI) necessitate the identification of profiles of distinct sub-groups of self-injurers.

AIM

To identify homogenous sub-groups of NSSI in a community-based sample of emerging adults.

METHOD

Data was collected using a cross-sectional survey design from a sample of 1,574 emerging adults aged 18-25 years, via multi-stage sampling. Cluster analysis using the k-medoid partitioning method was used to identify homogenous sub-groups in the sub-sample of 353 self-injurers. Follow-up analysis was conducted on measures of self-criticism, brooding-rumination, emotion regulation difficulties, experiential avoidance, psychological distress, attachment style and perceived social support to explore the validity of the clusters.

RESULTS

Five homogenous sub-groups were identified; Multimethod, Exclusively Severe, Female Minor, Male Minor and Experimental NSSI. The sub-groups showed distinct patterns of NSSI behaviour, differing on the basis of gender, severity, frequency, diversification, age of onset and functions of NSSI. The Multimethod and Exclusively severe NSSI group members showed significantly higher psychological distress and emotion regulation difficulties.

CONCLUSION

Identification of distinct sub-groups highlights the heterogeneity in NSSI behaviour. This has implications for comprehensive assessment frameworks, early identification of more vulnerable groups of self-injurers, and planning of targeted interventions.

Strategies to Care for Patients Being Treated in the Emergency Department After Self-harm: Perspectives of Frontline Staff

INTRODUCTION

Every year, approximately 500 000 patients in the United States present to emergency departments for treatment after an episode of self-harm. Evidence-based practices such as designing safer ED environments, safety planning, and discharge planning are effective for improving the care of these patients but are not always implemented with fidelity because of resource constraints. The aim of this study was to provide insight into how ED staff innovate processes of care and services by leveraging what is available on-site or in their communities.

METHODS

A total of 34 semi-structured qualitative phone interviews were conducted with 12 nursing directors, 11 medical directors, and 11 social workers from 17 emergency departments. Respondents comprised a purposive stratified sample recruited from a large national survey in the US. Interview transcripts were coded and analyzed using a directed content analysis approach to identify categories of strategies used by ED staff to care for patients being treated after self-harm.

RESULTS

Although respondents characterized the emergency department as an environment that was not well-suited to meet patient mental health needs, they nevertheless described 4 categories of strategies to improve the care of patients seen in the emergency department after an episode of self-harm. These included: adapting the ED environment, improving efficiencies to provide mental health care, supporting the staff who provide direct care for patients, and leveraging community resources to improve access to mental health resources postdischarge.

DISCUSSION

Despite significant challenges in meeting the mental health needs of patients treated in the emergency department after self-harm, the staff identified opportunities to provide mental health care and services within the emergency department and leverage community resources to support patients after discharge.

Mental health presentations to the paediatric emergency department: A retrospective study

AIM

To describe a cohort of patients aged 7-17 years presenting with mental health (MH) problems to an Australian tertiary paediatric emergency department (ED), in order to identify: (i) predictors of admission; and (ii) prolonged length of stay (LOS); (iii) reasons for ED presentation based on diagnosis and (iv) differences between major diagnostic groups.

METHODS

Data for all presentations from 1 January 2018 to 31 December 2018 were extracted and analysed from the hospital's electronic medical record system. MH presentations were identified though rule-based coding and manual file review.

RESULTS

In this 12-month period, 1071 children had 1690 emergency MH presentations constituting 6.7% of all ED presentations for children aged 7-17 years. Collectively, the leading cause for presentations was suicidal ideation, self-harm or drug overdose (55%). Compared to discharged patients, admitted patients were more likely to be female (odds ratio (OR) 1.82, confidence interval (CI) 1.41-2.35), aged over 14-years (OR 2.50, CI 1.98-3.15), triaged with high acuity (OR 2.70, CI 2.00-3.65) and arrive by ambulance or police (OR 1.31, CI 1.04-1.64). The highest risk diagnosis associated with admission was eating disorders (OR 9.19, CI 5.48-15.40). Patients with a prolonged LOS (>8 h) were more likely to need admission (OR 5.38, CI 3.81-7.61) and be diagnosed with drug overdose (OR 2.39, CI 1.51-3.80) or acute behavioural disturbance (OR 1.61, CI 1.09-2.39).

CONCLUSION

Mental health presentations constitute a large proportion of ED presentations. Suicidal behaviour and self-harm account for half of them. We have identified patients at increased risk of admission and prolonged ED LOS.

Suicide, self-harm and thoughts of suicide or self-harm in infectious disease epidemics: a systematic review and meta-analysis

AIMS

Suicide accounts for 2.2% of all years of life lost worldwide. We aimed to establish whether infectious epidemics are associated with any changes in the incidence of suicide or the period prevalence of self-harm, or thoughts of suicide or self-harm, with a secondary objective of establishing the frequency of these outcomes.

METHODS

In this systematic review and meta-analysis, MEDLINE, Embase, PsycINFO and AMED were searched from inception to 9 September 2020. Studies of infectious epidemics reporting outcomes of (a) death by suicide, (b) self-harm or (c) thoughts of suicide or self-harm were identified. A random-effects model meta-analysis for the period prevalence of thoughts of suicide or self-harm was conducted.

RESULTS

In total, 1354 studies were screened with 57 meeting eligibility criteria, of which 7 described death by suicide, 9 by self-harm, and 45 thoughts of suicide or self-harm. The observation period ranged from 1910 to 2020 and included epidemics of Spanish Flu, severe acute respiratory syndrome, human monkeypox, Ebola virus disease and coronavirus disease 2019 (COVID-19). Regarding death by suicide, data with a clear longitudinal comparison group were available for only two epidemics: SARS in Hong Kong, finding an increase in suicides among the elderly, and COVID-19 in Japan, finding no change in suicides among children and adolescents. In terms of self-harm, five studies examined emergency department attendances in epidemic and non-epidemic periods, of which four found no difference and one showed a reduction during the epidemic. In studies of thoughts of suicide or self-harm, one large survey showed a substantial increase in period prevalence compared to non-epidemic periods, but smaller studies showed no difference. As a secondary objective, a meta-analysis of thoughts of suicide and self-harm found that the pooled prevalence was 8.0% overall (95% confidence interval (CI) 5.2-12.0%; 14 820 of 99 238 cases in 24 studies) over a time period of between seven days and six months. The quality assessment found 42 studies were of high quality, nine of moderate quality and six of high quality.

CONCLUSIONS

There is little robust evidence on the association of infectious epidemics with suicide, self-harm and thoughts of suicide or self-harm. There was an increase in suicides among the elderly in Hong Kong during SARS and no change in suicides among young people in Japan during COVID-19, but it is unclear how far these findings may be generalised. The development of up-to-date self-harm and suicide statistics to monitor the effect of the current pandemic is an urgent priority.

Long-term outcomes of patients admitted to an intensive care unit with intentional self-harm

Self-harm is one of the most common reasons for admission to an intensive care unit (ICU). While most patients with self-harm survive the ICU admission, little is known about their outcomes after hospital discharge. We conducted a retrospective cohort study of patients in the Barwon region in Victoria admitted to the ICU with self-harm (between 1998 and 2018) who survived to hospital discharge. The primary objective was to determine mortality after hospital discharge, and secondarily estimate relative survival, years of potential life lost, cause of death and factors associated with death. Over the 20-year study period, there were 710 patients in the cohort. The median patient age was 37 years (interquartile range (IQR) 26-48 years). A total of 406 (57%) were female, and 527 (74%) had a prior psychiatric diagnosis. The incidence of ICU admission increased over time (incidence rate ratio 1.05; 95% confidence interval (CI) 1.03-1.06 per annum). There were 105 (15%) patients who died after hospital discharge. Relative survival decreased each year after discharge, with the greatest decrement during the first 12 months. At ten years, relative survival was 0.85 (95% CI 0.81-0.88). The median years of potential life lost was 35 (IQR 22-45). Cause of death was self-harm in 27%, possible self-harm in 32% and medical disease in 41%. The only factors associated with mortality were male sex, older age and re-admission to ICU with self-harm. Further population studies are required to confirm these findings, and to understand what interventions may improve long-term survival in this relatively young group of critically ill patients.

Negative life events and self-harm among the elderly: Result from a survey of 7070 people aged≥60 in China

PURPOSES

Negative life events have been reported as a risk factor for elderly self-harm. The aim of this study was to examine the relationship between negative life events and self-harm in a large sample of people aged 60 and older, and explore the role of some previously identified influential factors in this relationship.

METHODS

Multi-stage stratified sampling method was used to select the elderly people over 60 years old in Shandong, China. Information were collected through face-to-face interviews. Univariate and multivariable logistic regression were used for initial analysis. Karlson-Holm-Breen (KHB) method was used for mediating effect analysis.

RESULTS

A total of 7070 participants were included in the study, 160 reported they had a history of self-harm (2.3%), 756 reported they had negative life event experience (10.7%). After model adjustment, the association between negative life events, loneliness, economic status and self-harm was still statistically significant. Mediation analysis showed that the association is explained by loneliness (proportion of mediation 48.86%), self-rated economic status (16.13%).

CONCLUSIONS

Negative life events, loneliness and economic status were associated with self-harm among the older adults. Loneliness and economic status may play an intermediary role in the relationship between negative life events and self-harm, especially loneliness. More psychological and social functions intervention strategies and prevention measures on the self-harm of the elderly should be provided for the elderly who have experienced negative life events.

COVID-19 pandemic: demographic and clinical correlates of passive death wish and thoughts of self-harm among Canadians

BACKGROUND

Suicidal ideation can be triggered or exacerbated by psychosocial stressors including natural disasters and pandemics.

AIMS

This study investigated prevalence rates and demographic and clinical correlates of self-reported passive death wishes and thoughts of self-harm among Canadians subscribing to Text4Hope; a daily supportive text message program.

METHODS

A survey link was sent out to Text4Hope subscribers. Demographic information was captured and clinical data collected using the Perceived Stress Scale (PSS), Generalized Anxiety Disorder-7-item (GAD-7) scale, and Patient Health Questionnaire-9 (PHQ-9). Data were analysed with descriptive analysis, the chi-square test, and logistic regression.

RESULTS

Responders showed an increase in prevalence rates for passive death wish and thoughts of self-harm compared to baseline Canadian statistics on suicidality. Responders aged ⩽25years, Indigenous, had less than high school education, unemployed, single, living with family, with increased anxiety, disordered sleep, and recent concerns about germs and contamination were at greatest risk.

CONCLUSIONS

Our results indicate that suicidal thoughts may have increased in the general population as a result of COVID-19 and signals an urgent need for public education on appropriate health seeking methods and increased access to mental and social support especially during the COVID-19 pandemic and its immediate aftermath.

Factors Associated With Hospital Presentation of Self-Harm Among Older Canadians in Long-Term Care: A 12-Year Cohort Study

OBJECTIVES

This study aimed to examine the incidence of, and factors associated with, hospital presentation for self-harm among older Canadians in long-term care (LTC).

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

The LTC data were collected using Resident Assessment Instrument-Minimum Data Set (RAI-MDS) and Resident Assessment Instrument-Home Care (RAI-HC), and linked to the Discharge Abstract Database (DAD) with hospital records of self-harm diagnosis. Adults aged 60+ at first assessment between April 1, 2003, and March 31, 2015, were included.

METHODS

Adjusted hazard ratios (HRs) of self-harm for potentially relevant factors, including demographic, clinical, and psychosocial characteristics, were calculated using Fine & Gray competing risk models.

RESULTS

Records were collated of 465,870 people in long-term care facilities (LTCF), and 773,855 people receiving home care (HC). Self-harm incidence per 100,000 person-years was 20.76 [95% confidence interval (CI) 20.31-25.40] for LTCF and 46.64 (44.24-49.12) for HC. In LTCF, the strongest risks were younger age (60-74 years vs 90+: HR, 6.00; 95% CI, 3.24-11.12), psychiatric disorders (bipolar disorder: 3.46; 2.32-5.16; schizophrenia: 2.31; 1.47-3.62; depression: 2.29; 1.80-2.92), daily severe pain (2.01; 1.30-3.11), and daily tobacco consumption (1.78; 1.29-2.45). For those receiving HC, the strongest risk factors were younger age (60-74 years vs 90+: 2.54; 1.97-3.28), psychiatric disorders (2.20; 1.93-2.50), daily tobacco consumption (2.08; 1.81-2.39), and frequent falls (1.98; 1.46-2.68). All model interactions between setting and factors were significant.

CONCLUSIONS AND IMPLICATIONS

There was lower incidence of hospital presentation for self-harm for LTCF residents than HC recipients. We found sizable risks of self-harm associated with several modifiable risk factors, some of which can be directly addressed by better treatment and care (psychiatric disorders and pain), whereas others require through more complex interventions that target underlying factors and causes (tobacco and falls). The findings highlight a need for setting- and risk-specific prevention strategies to address self-harm in the older populations.

A look at the global impact of SARS CoV-2 on orthopedic services

BACKGROUND

The COVID-19 pandemic profoundly impacted healthcare institutions worldwide. Particularly, orthopedic departments had to adapt their operational models.

PURPOSE

This review aimed to quantify the reduction in surgical and outpatient caseloads, identify other significant trends and ascertain the impact of these trends on orthopedic residency training programs.

METHODS

Medline and Embase were searched for articles describing case load for surgeries, outpatient clinic attendance, or emergency department (ED) visits. Statistical analysis of quantitative data was performed after a Freeman-Tukey double arcsine transformation. Results were pooled with random effects by DerSimonian and Laird model. When insufficient data was available, a systematic approach was used to present the results instead.

RESULTS

A total of 23 studies were included in this study. The number of elective surgeries, trauma procedures and outpatient attendance decreased by 80% (2013/17400, 0.20, CI: 0.12 to 0.29), 47% (3887/17561, 0.53, CI: 0.37 to 0.69) and 63% (84174/123967, 0.37, CI: 0.24 to 0.51) respectively. During the pandemic, domestic injuries and polytrauma increased. Residency training was disrupted due to diminished clinical exposure and changing teaching methodologies. Additionally, residents had more duties which contributed to a lower quality of life.

CONCLUSIONS

The COVID-19 pandemic has made an unprecedented impact on orthopedics departments worldwide. The slow return of orthopedic departments to normalcy and the compromised training of residents due to the pandemic points to an uncertain future for healthcare institutions worldwide, wherein the impact of this pandemic may yet still be felt far in the future.

Clinicians' Perspectives on Self-Harm in Pakistan: A Qualitative Study

Background: Suicide is a serious public health problem, ranked amongst the leading causes of death worldwide. There are no official data on self-harm and suicide in Pakistan; both are illegal acts, and are socially and religiously condemned. This study explored the views of clinicians, including general practitioners (GPs) and hospital physicians (HPs) on self-harm, about their management of people who self-harm and what interventions might be appropriate in Pakistan. Methods: This qualitative study, generating data using semi-structured interviews, was nested within a Randomized Controlled Trial (RCT) of a psychosocial intervention for people following self-harm. Clinicians (n = 18) with experience of treating people who self-harm were recruited from public hospitals and general practices. Results: Face-to-face interviews were conducted in Urdu and digitally recorded with consent, transcribed and translated into English. Transcripts were checked for cultural and interpretive interpretations by the research team, then analyzed thematically using the principles of constant comparison. The following themes will be presented: encountering people with self-harming behaviors; challenges encountered in managing people who self-harm; barriers to accessing care, and what ideal care might look like. Participants identified their lack of training and expertise in the management of people with self-harm behavior. Conclusions: This is the first study to explore clinicians' perspectives on self-harm in Pakistan. The study highlighted the need for training for doctors in the identification and management of mental health problems, including the management of people who self-harm.

The Correlation between Oral Self-Harm and Ethnicity in Institutionalized Children

Oral self-harm was described in institutionalized children who share a lack of emotional attention; frequently these children experience feelings such as neglect, loneliness, isolation or lack of connection with the world. The aim of our paper was to conduct a cross-sectional study in order to assess the prevalence of this behavior and its correlation with ethnicity among children from three institutions located in the central part of Romania. We examined 116 children from three ethnic groups, Romanians, Hungarians and local Roma population aged between 10–14 years old. The oral soft tissues were evaluated by one dentist who recorded the lesions of lips, buccal mucosa, commissures and tongue; data were statistically analyzed at a level of significance of p < 0.05. We found oral self-harm lesions in 18.1% participants, with statistically significant higher odds in girls (p = 0.03). The results showed an association between ethnicity and the development of these lesions (Chi-square p = 0.04). The most frequent lesions were located at oral commissures (35.48%), buccal mucosa (29.03%) and upper lip (19.36%). Oral self-harm lesions have a high incidence among institutionalized children in Romania. Identification of these cases in early stages is important, as these conditions are known to be aggravated during adolescence and adulthood.

Gender differences in self-harm and drinking behaviors among high school students in Beijing, China

BACKGROUND

Self-harm and drinking are both serious problems in adolescents and many studies presented evidence of their association. However, gender differences in this association are seldom deeply discussed. Our study aimed to evaluate the prevalence of self-harm and explore its association with drinking behaviors by gender and investigate the extent to which the gender differences exist in the association between self-harm and drinking.

METHODS

A total of 32,362 students in grades 7 to 12 in Beijing, China were anonymously surveyed and included in our study using two-stage, stratified probability proportion sampling. Self-harm, drinking behaviors and other basic information were obtained from an anonymous questionnaire. Demographic variables, self-harm and drinking behaviors were analyzed using the Chi-square test and the Gamma test between genders and the gender differences in this association were analyzed by Log-binomial regression.

RESULTS

The total prevalence of self-harm was 13.7% with no significant gender difference (χ² =0.352, P = 0.553). The prevalence of self-harm in girls decreased with age (G = -0.163, P < 0.001). Self-harm was associated with drinking behaviors in both boys and girls. The Log-binomial regression demonstrated that girls in the 16-19 years old group were at lower risk of self-harm than girls in the 12-15 years old group while this association was weaker in boys (1.493 vs 1.128). The higher OR for self-harm was found among girls with early drinking experiences compared with boys (2.565 vs 1.863). Girls who had previously drunk (i.e. drunk at least once) (2.211 vs 1.636), were currently drinking (3.400 vs 2.122) and performed binge drinking (6.357 vs 3.924) were at greater risk of self-harm than boys.

CONCLUSION

Among high school students, self-harm has a significant positive association with drinking and girls with drinking behaviors are at higher risk of suffering self-harm. Identifying adolescents' drinking behaviors is of vital importance to self-harm prevention and special attention should be focused on younger girls.

Predicting post-discharge self-harm incidents using disease comorbidity networks: A retrospective machine learning study

BACKGROUND

Self-harm is preventable if the risk can be identified early. The co-occurrence of multiple diseases is related to self-harm risk. This study develops a comorbidity network-based deep learning framework to improve the prediction of individual self-harm.

METHODS

Between 01/01/2007-12/31/2010, we obtained 2,323 patients with self-harm records and 46,460 randomly sampled controls from 1,764,094 inpatients across 44 public hospitals in Hong Kong. 80% of the samples were randomly selected for model training, and the remaining 20% were set aside for model testing. We propose a novel patient embedding method, namely Dx2Vec (Diagnoses to Vector), based on the comorbidity network constructed by all historical diagnoses. Dx2Vec represents the comorbidity patterns among diseases and temporal patterns of historical admissions for each patient.

RESULTS

Experiments demonstrate that the Dx2Vec-based model outperforms the baseline deep learning model in identifying patients who would self-harm within 12 months (C-statistic: 0.89). The precision is 0.54 for positive cases and 0.98 for negative cases, whilst the recall is 0.72 for positive cases and 0.96 for negative cases. The model extracted the most predictive diagnoses, and pairwise comorbid diagnoses to help medical professionals identify patients with risk.

LIMITATIONS

The inpatient data does not contain lab test information.

CONCLUSIONS

Incorporation of a disease comorbidity network can significantly improve self-harm prediction performance, indicating that it is critical to consider comorbidity patterns in self-harm screening and prevention programs. The findings have the potential to be translated into effective self-harm screening systems.

Childhood adversity and self-poisoning: A hospital case control study in Sri Lanka

INTRODUCTION

Adverse childhood experiences (ACE) have been recognized as an important risk factor for suicidal behaviour among adults, but evidence from low and middle-income countries is lacking. This study explored associations between ACE and hospital admission due to non-fatal self-poisoning in Sri Lanka.

METHODS

This was a case-control study. Adults admitted to a tertiary care hospital for medical management of self-poisoning were included as cases, and age and sex matched controls were recruited from the outpatient department. ACE were measured using the World Health Organization's Childhood Adversity Scale. Logistic regression models adjusting for age, sex, ethnicity, and religion were used to quantify the association between ACE and self-poisoning.

RESULTS

The study included 235 cases and 451 controls. Cases were 2.5 times (95% CI 1.8, 3.6) more likely to report an ACE than controls and had higher ACE scores. Childhood physical abuse (OR 4.7, 95% CI 1.2, 19.0) and emotional abuse or neglect (OR 3.7, 95% CI 1.3, 10.1, and 3.7, 95% CI 2.3, 6.0 respectively), increased the risk of self-poisoning in adulthood, as did witnessing household violence (OR 2.2, 95% CI 1.4, 3.4), growing up in a household with a mentally ill or suicidal household member (OR 2.1, 95% CI 1.2, 3.4), and experiencing parental death/separation/divorce (OR 3.1, 95% CI 2.0, 4.9) as a child.

CONCLUSIONS

Reducing exposures to ACEs should be a priority for prevention of suicide and self-harm in Sri Lanka. Innovative methods to increase support for children facing adversity should be explored.

Prescribers aware: a cross-sectional study from New Zealand emergency departments on the substances used in intentional self-poisoning and their sources

INTRODUCTION Intentional self-poisoning or self-harm through poisoning, is a common cause of presentations to emergency departments (EDs). National datasets do not allow identification of the substances most commonly used in hospital-treated intentional self-poisoning in New Zealand, nor do they capture sources of these substances. AIM To investigate the specific substances used in intentional self-poisoning and the sources from which they are obtained. METHODS In this cross-sectional study, information about the demographics and presentation particulars of intentional self-poisoning patients aged ≥16 years, presenting to three public EDs, as well as the substances they used in the self-poisoning event and the sources of these agents, were collected prospectively. RESULTS A total of 102 patients were recruited from the potentially eligible 1137 intentional self-poisoning patients presenting to the three EDs during the study period. Seventy per cent used their own prescription medications and 24% used medicines they purchased themselves. Paracetamol and ethanol were most commonly encountered substances. Patients presented a median of 1.9h after exposure (interquartile range 1.0-3.3h), 62% self-referred, 60% presented to the ED in the evening or at night and 66% were triaged into Australasian Triage Scale 3 (to be seen within 30min). Two-thirds were referred to emergency psychiatric services. DISCUSSION Collecting specific substance information, such as from this study, can assist in planning specific activities to prevent intentional self-poisoning. As most people used their prescribed medicines, the findings can inform and assist doctors in their prescribing practices when they manage patients at risk of self-poisoning.

Prevalence and risk factors for repetition of non-fatal self-harm in Hong Kong, 2002-2016: A population-based cohort study

Background

A history of self-harm is strongly associated with future self-harm attempts. Large-scale Asian cohort studies examining risk factors for repeated self-harm are lacking. This paper reports on annual prevalence, cumulative risk, annual risk of non-fatal self-harm repetition, and risk factors among Hong Kong patients with a history of self-harm.

Methods

The Hong Kong Clinical Data Analysis and Reporting System (CDARS) provided all accident & emergency department and inpatient self-harm records between Jan 1, 2002 and Dec 31, 2016. Demographic and clinical characteristics were extracted. Annual prevalence, over-time cumulative and annual risks of non-fatal self-harm repetition were estimated, and the adjusted hazard ratios (HR; plus 95% CIs) of putative risk factors associated with repetition were estimated using Wei-Lin-Weissfeld (WLW) generalization of the Cox model for recurrent event analysis.

Findings

There were 127,801 self-harm episodes by 99,116 individuals. Annual prevalence of repeated self-harm, of all self-harms, ranged from 7•36% to 28•71% during the study period. Risk of self-harm repetition within one year of the index event was 14•25% (95% CI, 14•04%-14•46%). People with four or more previous self-harm episodes carried the highest risk of self-harm repetition (adjusted HR 4•81 [95% CI 4•46-5•18]). Significant risk factors for non-fatal self-harm repetition included male gender (1•08 [1•05-1•11]), older age (65+ years) (1•07 [1•01-1•13]), social welfare for payment (1•30 [1•27-1•34]), psychiatric admission (1•60 [1•50-1•72]), self-injury only (1•19 [1•15-1•23]), self-injury combined with self-poisoning (1•38 [1•24-1•53]), depression and bipolar disorders (1•09 [1•04-1•14]), personality disorders (1•18 [1•06-1•32]), substance misuse (1•31 [1•27-1•36]), and asthma (1•18 [1•02-1•36]).

Interpretation

Hong Kong self-harm patients with non-fatal self-harm events should be supported by effective, timely and ongoing aftercare plans based on their risk profiles, to reduce risk of self-harm reoccurrence.

Funding

Research Grants Council, General Research Funding: 17611619.

Impact of Around-the-Clock Mental Health Staffing on Emergency Department Management of Patients Who Deliberately Self-Harm

OBJECTIVE

Emergency departments (EDs) offer opportunities to deliver critical frontline suicide prevention services via assessment, safety planning, and linkages with community-based mental health care after discharge. Because mental health crises can occur at any time, this study sought to evaluate whether around-the-clock mental health staffing in the ED influences the likelihood of providing these evidence-based mental health services.

METHODS

ED nursing leadership from a national sample of 406 hospitals completed a survey on the ED management of patients who deliberately self-harm, including availability of mental health staff (psychiatrists, psychiatric nurses, psychologists, social workers, other mental health professionals). Analyses examined whether around-the-clock mental health staffing was associated with provision of key assessments, safety planning, and discharge practices, controlling for hospital characteristics.

RESULTS

There were no significant differences in the extent to which EDs with and without around-the-clock mental health staff routinely completed recommended assessment practices (71% and 70%, respectively). EDs with around-the-clock mental health staff were more likely than their counterparts to routinely provide two recommended safety planning practices (59% vs. 27%, p<0.001; adjusted odds ratio [AOR]=3.76) and were more likely to routinely schedule follow-up outpatient care (44% vs. 21%, p=0.002; AOR=3.26).

CONCLUSIONS

Around-the-clock mental health coverage in the ED is associated with routine provision of key safety planning and discharge practices. EDs should have consistent access to staff either in person or remotely to facilitate the delivery of evidence-based mental health practices.

Emotion-Oriented Coping Style Predicts Self-Harm in Response to Acute Psychiatric Hospitalization

Psychiatric hospitalization can cause significant distress for patients. Research has shown that to cope with the stress, patients sometimes resort to self-harm. Given the paucity of research on self-harm among psychiatric inpatients, a better understanding of transdiagnostic processes as predictors of self-harm during psychiatric hospitalization is needed. The current study examined whether coping styles predicted self-harm after controlling for commonly associated factors, such as age, gender, and borderline personality disorder. Participants were 72 patients (mean age = 39.32 years, SD = 12.29, 64% male) admitted for inpatient treatment at a public psychiatric hospital in Sydney, Australia. Participants completed self-report measures of coping styles and ward-specific coping behaviors, including self-harm, in relation to coping with the stress of acute hospitalization. Results showed that younger age, diagnosis of borderline personality disorder, and higher emotion-oriented coping were associated with self-harm. After controlling for age and borderline personality disorder, higher levels of emotion-oriented coping were found to be a significant predictor of self-harm. Findings were partially consistent with hypotheses; emotion-oriented but not avoidance-oriented coping significantly predicted self-harm. This finding may help to identify and provide psychiatric inpatients who are at risk of self-harm with appropriate therapeutic interventions.

Effects of Omega 3 Fatty Acids on Main Dimensions of Psychopathology

The usefulness of polyunsaturated fatty acids on inflammatory, cardiovascular, and the nervous system was studied in the last decades, but the mechanisms underlying their benefic properties are still partially unknown. These agents seem to express their action on the membrane phospholipid composition and permeability and modulation of second messenger cascades. In psychiatry, the efficacy and tolerability of omega-3 fatty acids were investigated in several psychiatric disorders, including major depression, bipolar disorder, personality disorders, high-risk conditions to develop psychosis, attention-deficit hyperactivity disorder, and autism spectrum disorders. Initial findings in this field are promising, and some relevant questions need to be addressed. In particular, the effects of these agents on the main symptom dimensions have to be investigated in a trans-diagnostic perspective. The present systematic review is aimed to examine the available data on the efficacy of omega-3 fatty acids on domains of psychotic symptoms, affective symptoms, impulsivity, and aggressiveness, and harmful behaviors, and suicide risk.

Characteristics and risk of repeat suicidal ideation and self-harm in patients who present to emergency departments with suicidal ideation or self-harm: A prospective cohort study

BACKGROUND

Characteristics and outcomes of patients presenting to Emergency Departments (EDs) have been under-examined. This paper describes the characteristics and risk of repeat suicidality amongst patients presenting to EDs with (1) suicidal ideation and (2) self-harm, compared to (3) controls in mental health crisis.

METHODS

The Clinical Record Interactive Search tool identified 2211 patients who presented to three London EDs with suicidal ideation or self-harm, and 1108 control patients. All patients received a full psychosocial assessment. Chi-squared tests examined group characteristics. Cox regression models assessed the risk of re-presentation with suicidal ideation or self-harm within one year.

RESULTS

There were a higher proportion of females and individuals under the age of 25 in the self-harm group. Patients presenting with suicidal ideation or self-harm were more likely to be white, live in more deprived areas, and less likely to receive a psychiatric diagnosis within one year compared to controls. Risk of repeat suicidality within one year was 3-4 times higher in those with baseline suicidal ideation (adjusted HR = 3.66, 95% CI 2.44-5.48) or self-harm (HR = 3.53 95% CI 2.47-5.04) compared to controls.

LIMITATIONS

To be included patients needed to have a full psychosocial assessment. Incomplete records meant 21.4% of the sample was excluded. This will have introduced bias which might confound observed associations.

CONCLUSION

Individuals presenting with either suicidal ideation or self-harm have similar risk for re-presentation within one year. Both groups would benefit from personalised risk management plans and active follow-up to reduce the risk of repeat suicidal behaviour.

How Individuals Who Self-Harm Manage Their Own Risk-'I Cope Because I Self-Harm, and I Can Cope with my Self-Harm'

Self-harm is a complex and idiosyncratic behaviour. This article focuses on how those who self-harm manage their own risk. Utilising opportunity sampling, ten members of a self-harm support group were interviewed about how they risk manage their self-harm and the data analysed using interpretative phenomenological analysis. The analysis showed that all participants were actively involved in risk management of their self-harm. Through a process of managing consequences, exercising control in the process, and an awareness of the social context. It is posited that people who self-harm should be viewed as actively engaging with the risks of self-harm whilst it is a coping mechanism, as opposed to passive or ignoring. This understanding can be integrated into current risk management plans within services and invites a more dynamic conversation of self-harm between services users and services. Effective risk management involves good relationships between individuals who self-harm and clinicians, services which promote positive risk taking as opposed to defensive practice, and true collaboration between services and service users.

Nonsuicidal Self-Injury Among African American and Hispanic Adolescents and Young Adults: a Systematic Review

While African American and Hispanic adolescents and young adults living in the USA are exposed to myriad stressors that may increase their risk for mental health difficulties, few studies have examined nonsuicidal self-injury (NSSI) among these youth. The purpose of this systematic review was to critically examine and synthesize current literature on NSSI among these understudied youth. Using multiple search terms related to NSSI, race/ethnicity, and developmental stage, electronic literature searches of PubMed, PsychINFO, and Google Scholar databases retrieved 3036 relevant articles published in the English language between 2000 and 2018; manual reference checks yielded an additional 17 articles. Ultimately, a total of 52 full-text studies were assessed for eligibility, and 15 articles were included in the present review. Although the majority of studies reported higher prevalence of NSSI among non-Hispanic White youth, evidence suggests that African American males are also at high risk of engaging in self-harm. Emotional dysregulation emerged as a common risk factor, while social support and feelings of connection were protective for some African American and Hispanic youth. Although racism and discrimination were not linked to NSSI in the reviewed studies, this remains an important area of future research for prevention and intervention efforts.

Effect of Pokémon Go on Self-Harm Using Population-Based Interrupted Time-Series Analysis: Quasi-Experimental Study

BACKGROUND

Pokémon Go is a very popular location-based augmented reality game with widespread influences over the world. An emerging body of research demonstrates that playing Pokémon Go can lead to improvements in physical activity and psychosocial well-being; however, whether Pokémon Go reduces self-harm incidence at the population-level is still questionable.

OBJECTIVE

This study aimed to quantify how the launch of Pokémon Go in Hong Kong affected the incidence of self-harm using a quasi-experimental design.

METHODS

An interrupted time-series design with Poisson segmented regression adjusted for time and seasonality trends was used on data from 2012 to 2018 to detect any changes in the number of accident and emergency attendances due to self-harm, after Pokémon Go was launched. The findings were validated using a baseline control period and using other intentional injuries and minor noninjuries as control outcomes. We also assessed intervention effects by age group.

RESULTS

From January 1, 2012 to July 31, 2018, there were 13,463 accident and emergency attendances due to self-harm in Hong Kong. During the period after launching Pokémon Go, self-harm attendances dropped by 34% (adjusted incidence rate ratio: 0.66, 95% CI 0.61-0.73). When analyzed by age group, a reduction in self-harm incidence was only apparent in adults (18 to 24 years of age: adjusted incidence rate ratio: 0.78, P=.02; 25 to 39 years of age: adjusted incidence rate ratio: 0.75, P<.001; 40 years of age and older: adjusted incidence rate ratio: 0.57, P<.001).

CONCLUSIONS

Self-harm incidence in the population, particularly in adults, showed a significant decline in the period after Pokémon Go was launched. Augmented reality games such as Pokémon Go show great promise as a tool to enhance psychosocial well-being and improve mental health.

Pacemaker implantation in patients with major depression, should it be of concern? A case report and literature review

Background

Psychological adaptation after cardiac pacemaker implantation is a challenge for patients with mental illness.

Case presentation

Here we report a self-harming patient with a psychiatric disorder. A 73-year-old female patient with 16-year coronary heart disease and a 4-year depression was admitted to our hospital for a coma. Two months earlier, the local hospital confirmed that the patient had a second-degree sinoatrial (SA) block (type 2) as well as basal septal hypertrophy with the left ventricular outflow obstruction. Therefore, metoprolol sustained-release tablets 95 mg QD and diltiazem sustained-release tablets 90 mg QD was given as treatment after a pacemaker was implanted. However, the patient had continued complaining about discomfort due to the pacemaker implanted after being discharged from the hospital. Two months later, she attempted to commit suicide by removing her pacemaker and taking 80 sleeping pills. After a series of treatments, the patient improved and was discharged without a pacemaker re-implantation. With continued anti-depression treatment and strengthen family supervision, the patient’s condition is stable now.

Conclusions

A suicide attempt by intentionally removing the permanent pacemaker system was rarely reported. In bradycardia patients with a history of psychological or psychiatric disease, careful evaluation should be done before and after implantation of the pacemaker.

Recurrence of suicidal thoughts and behaviors during one year of follow-up: An exploratory study

Suicidal thoughts and behaviors (STB) include suicidal ideation (SI), suicide attempt (SA) and completed suicide. We aimed to identify recurrence predictors of any type of STB, and separately for SA and SI, and to analyze the time until event. A 108-subject cohort presenting at Emergencies with STB was followed during one year. Recurrence risk factors were investigated by multiple Cox survival regressions. Within one year, 31.5%, 23.1% and 9.3% patients recurred with any STB, SA, and SI respectively. Most recurrences (~70%) occurred within the first 6 months. Seeking emergency psychiatric assistance for problems other than STB during follow-up was a common predictor for recurrence of any STB, and SA and SI specifically. Previous SA history and contact with psychiatry outpatient units during follow-up predicted both STB in general and SA in particular. A specific predictor for SA was hospitalization at index, while SI recurrence was associated to SI at index. These results highlight the importance of early intervention and multidisciplinary follow-up considering concurrent psychosocial or adaptive problems. A careful exploration at Emergencies is needed to target potential predictors.

Congenital Heart Disease and Risk of Suicide and Self-Harm: A Danish Nationwide Cohort Study

Background

In this nationwide study, we used the unique Danish registries to estimate the risk of suicide and deliberate self‐harm in patients with congenital heart disease (CHD).

Methods and Results

We identified all Danish citizens receiving a diagnosis of CHD between 1977 and 2007. As a reference cohort, we randomly selected 10 citizens for each patient, matched by sex and birth year. Using the Fine and Gray competing risk regression, we estimated the cumulative incidences of suicide and self‐harm, and Cox proportional regression analysis was used to compare the risk of suicide and deliberate self‐harm in patients with CHD with the reference cohort. We identified 14 433 patients with CHD. Mean follow‐up was 21.3 years, with a maximum follow‐up of 42 years. Since the time of diagnosis, 2659 patients had died, with a median age of death of 23 years. A total of 15 patients had died by suicide, compared with 232 suicides in the reference cohort. Patients with CHD had a low and similar risk of dying by suicide when compared with the reference cohort (cause‐specific hazard ratio, 0.81; 95% CI, 0.48–1.37; and subhazard ratio, 0.68; 95% CI, 0.41–1.16). We identified 336 events of self‐harm among patients with CHD, and 3484 events in the reference group. The overall risk of deliberate self‐harm was not increased in patients with CHD when compared with the reference group (subhazard ratio, 0.95; 95% CI, 0.85–1.06).

Conclusions

This is the first study to estimate the risk of suicide and deliberate self‐harm in patients with CHD. We found that patients with CHD do not have an increased risk of suicide or deliberate self‐harm when compared with a large reference cohort.

Previous suicide attempt and subsequent risk of re-attempt and suicide: Are there differences in immigrant subgroups compared to Swedish-born individuals?

BACKGROUND

Studies investigating how suicide attempting refugees and non-refugee migrants differ from Swedish-born individuals in terms of re-attempts and suicide are missing. It remains unknown how mental disorders and labour market marginalization (LMM) impact on these associations.

METHODS

This longitudinal cohort study included Swedish residents aged 20-64 with suicide attempt in 2004-2012. In total, 42,684 individuals including 2017 refugees, and 2544 non-refugee migrants were included and followed until December 31, 2016. Risks of re-attempt and suicide were calculated as hazard ratios (HR) with 95% confidence intervals (CI), and adjusted for important confounders. Stratified analyses were to assess if mental disorders or LMM modified these associations.

RESULTS

In the adjusted models, refugees had an adjusted HR (aHR) of suicide re-attempt of 0.74 (CI: 0.67-0.81), and an aHR of 0.67 (CI: 0.53-0.86) for suicide death. These estimates were very similar to those of non-refugee migrants. Refugees and non-refugee migrants with suicide attempt had a lower prevalence of specialised health care due to mental disorders compared to Swedish-born attempters (48%, 44% and 61%, respectively). Mental disorders and LMM in terms of long-term sickness absence and disability pension increased the risk of re-attempt and suicide in all three groups.

LIMITATIONS

Only suicide attempts and mental disorders resulting in specialized in-and outpatient care were registered.

CONCLUSION

Migrants show considerably lower risks of re-attempt and suicide than Swedish-born individuals, with no differences between migrant groups. Despite vast differences in the prevalence of specific mental disorders, the role of mental disorders in the pathways to re-attempt and suicide does not appear to differ considerably between these groups.

Risk of self-harm after the diagnosis of psychiatric disorders in Hong Kong, 2000-10: a nested case-control study

BACKGROUND

Psychiatric disorders are established risk factors for self-harm. However, variation in the risk of self-harm by specific psychiatric disorder and stratified by gender and age is rarely examined in population-representative samples. This study aimed to investigate the risk of self-harm following diagnosis of different psychiatric disorders in an Asian population, through a review of inpatient records retrieved from the Hong Kong Clinical Data Analysis and Reporting System (CDARS).

METHODS

For this nested case-control study, the inpatient data of people admitted for any reason to Hong Kong public hospitals, between Jan 1, 2000, and Dec 31, 2010, were extracted from CDARS. Cases were people aged 10 years or older who had been admitted to inpatient care with a first-listed record of psychiatric disorder during the study period. The seven psychiatric disorders of interest were: depression, alcohol misuse or dependence, personality disorders, bipolar disorders, anxiety disorders, schizophrenia, and substance misuse or dependence. Two control patients were matched per case from a subsample of all individuals with the same gender, age, and admission time (ie, same calendar year and month), who did not have any record of the psychiatric disorders of interest. Any patients with a history of self-harm diagnosis before, or at the same time as, the first diagnosis of psychiatric disorder (cases) or admission (controls), were excluded. For each diagnostic category, a Cox proportional hazard regression model was fitted to estimate the adjusted hazard ratio (HR; plus 95% CIs) of associated self-harm, adjusting for gender, age, control-matched admission time, 20 districts of residence, physical comorbidities established as risk factors for self-harm (diabetes, asthma, migraine, epilepsy, HIV, and cancer), and presence of the six other psychiatric disorders. We repeated this analysis in subgroups stratified by gender (male and female) and by age (adolescent, 10-24 years; young adult, 25-44 years; middle-aged, 45-64 years; and older people, ≥65 years).

FINDINGS

Between 2000 and 2010, we followed up a cohort of 86 353 people with a first-recorded diagnosis of a psychiatric disorder of interest, and 134 857 matched controls. The highest risk of self-harm was observed in patients with substance misuse or dependence (adjusted HR vs matched controls, 9·6 [95% CI 8·4-11·0]), followed by those with personality disorders (3·7 [2·8-4·9]) and alcohol misuse or dependence (3·2 [2·9-3·7]). When stratified by gender and age, the highest risk of self-harm behaviour was found in the substance misuse or dependence group for both genders (for female patients: adjusted HR vs matched controls, 7·7 [6·0-9·8]; and for male patients, 10·5 [8·9-12·4]), and for all age groups (adolescent: 9·6 [7·2-12·7]; young adults: 10·2 [8·4-12·3]; middle-aged: 11·2 [8·0-15·6], and older people: 3·2 [1·7-6·1]).

INTERPRETATION

First-recorded diagnoses of psychiatric disorders were significantly associated with an elevated risk of subsequent self-harm. The associations varied considerably by diagnostic categories across gender and age subgroups. Our findings highlight the need to develop more efficient and targeted preventive measures in psychiatric care management, with specific attention to demographic characteristics linked to increased risk within the same diagnostic category.

FUNDING

None.

“The pen is the blade, my skin the paper”: risk factors for self-injury in adolescents

ABSTRACT Objective: to describe the risk factors that influence the self-injury behavior of adolescents assisted at a Psychosocial Care Center for Children and Adolescents, according to subjects’ own perceptions. Method: a descriptive, exploratory, qualitative study carried out through medical records and a focus group with 07 adolescents. The statements were submitted to thematic content analysis. Results: in the risk factors category, four subcategories emerged: Family adversity factors; Social contagion; Adverse life events; Personal characteristics. Conflicts, lack of support, drug use in the family, meeting someone who cuts themselves, social networks, religiosity, history of sexual violence and bullying were identified as risk factors that influence self-injury. Final Considerations: adolescents pointed out the need for prejudice-free dialogues in schools, in health and family devices, configuring protective factors to avoid this practice that comes from several negative events throughout life.

Suicide attempt following sickness absence and disability pension due to common mental disorders: a prospective Swedish twin study

PURPOSE

The aim of this study was to investigate if sickness absence and disability pension (SA/DP) in general and due to specific common mental disorders (CMDs) are associated with subsequent suicide attempt among women and men by taking familial factors (genetics and shared environment) into consideration.

METHODS

This register-based cohort study includes 4871 twin pairs 18-65 years of age discordant for SA/DP due to CMDs 2005-2010. Twins were followed up for suicide attempt from inpatient and specialised outpatient care until December 2012. Conditional Cox proportional hazards regression models, adjusting for familial factors, were used to calculate hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

SA/DP due to CMDs was associated with a higher risk of suicide attempt (HR 3.14, CI 2.51-3.93). The risk of suicide attempt was five times higher among men and three times higher among women, compared to the SA/DP unaffected co-twins. In the diagnosis-specific analysis, SA/DP due to anxiety disorders resulted in the highest HR (4.09, CI 2.37-7.06) for suicide attempt, followed by depressive disorders (HR 3.70, CI 2.66-5.14) and stress-related disorders (HR 1.96, CI 1.35-2.84). The stratified analysis on zygosity indicates that there seems to be a genetic influence on the associations between SA/DP due to CMDs and suicide attempt, particularly among women and among those with SA/DP due to depressive disorders.

CONCLUSIONS

SA/DP due to CMDs was a risk factor for suicide attempt among women and men. Genetic factors might explain part of the associations for women and for those with SA/DP due to depressive disorders.

Identifying typologies among persons admitted to hospital for non-fatal intentional self-harm in Victoria, Australia

PURPOSE

The aim of this study was to determine whether people who have been hospitalised as the result of non-fatal self-harm form meaningful groups based on mechanism of injury, and demographic and mental health-related factors.

METHODS

A retrospective analysis of 18,103 hospital admissions for self-harm in Victoria, Australia over the 3-year period 2014/2015-2016/2017 recorded on the Victorian Admitted Episodes Dataset (VAED). The VAED records all hospital admissions in public and private hospitals in Victoria. The primary analysis used a two-step method of cluster analysis. Initial analysis determined two distinct groups, one composed of individuals who had a recorded mental illness diagnosis and one composed of individuals with no recorded mental illness diagnosis. Subsequent cluster analysis identified four subgroups within each of the initial two groups.

RESULTS

Within the diagnosed mental illness subgroups, each subgroup was characterised by a particular mental disorder or a combination of disorders. Within the no diagnosis of mental illness groups, the youngest group was also the most homogenous (all females who self-poisoned), the oldest group had a high proportion of rural/regional residents, the group with the highest proportion of males also had the highest proportion of people who used cutting as the method of self-harm, and the group with the highest proportion of metropolitan residents also had the highest proportion of people who were married.

CONCLUSIONS

Preventative interventions need to take into account that those who are admitted to hospital for self-harm are a heterogeneous group.

Development and Factorial Validation of the Inventory of Deliberate Self-Harm Behaviours for Portuguese Adolescents

Deliberate self-harm (DSH) is a public health problem that mainly affects adolescents and young adults. Evidence suggests that multiple methods are used with a self-aggressive intent. The present article focuses on the development and factorial validation of the Inventory of Deliberate Self-harm Behaviours for Portuguese adolescents. This instrument assesses the lifetime frequency of 13 DSH methods, with and without suicidal intent. Study 1 consisted of an exploratory factor analysis with a sample of 131 adolescents with a reported history of DSH. Results revealed a three-factor structure with acceptable internal consistency: High Severity DSH, Mild Severity DSH, and Substance Use DSH. After item reduction, this structure was tested in Study 2 through a confirmatory factor analysis with an independent sample of 109 adolescents also with a history of DSH. Results showed an acceptable model fit. This instrument presents a solid structure and acceptable psychometric properties, allowing its use in further research.

Pre-conception self-harm, maternal mental health and mother-infant bonding problems: a 20-year prospective cohort study

BACKGROUND

Self-harm in young people is associated with later problems in social and emotional development. However, it is unknown whether self-harm in young women continues to be a marker of vulnerability on becoming a parent. This study prospectively describes the associations between pre-conception self-harm, maternal depressive symptoms and mother-infant bonding problems.

METHODS

The Victorian Intergenerational Health Cohort Study (VIHCS) is a follow-up to the Victorian Adolescent Health Cohort Study (VAHCS) in Australia. Socio-demographic and health variables were assessed at 10 time-points (waves) from ages 14 to 35, including self-reported self-harm at waves 3-9. VIHCS enrolment began in 2006 (when participants were aged 28-29 years), by contacting VAHCS women every 6 months to identify pregnancies over a 7-year period. Perinatal depressive symptoms were assessed with the Edinburgh Postnatal Depression Scale during the third trimester, and 2 and 12 months postpartum. Mother-infant bonding problems were assessed with the Postpartum Bonding Questionnaire at 2 and 12 months postpartum.

RESULTS

Five hundred sixty-four pregnancies from 384 women were included. One in 10 women (9.7%) reported pre-conception self-harm. Women who reported self-harming in young adulthood (ages 20-29) reported higher levels of perinatal depressive symptoms and mother-infant bonding problems at all perinatal time points [perinatal depressive symptoms adjusted β = 5.40, 95% confidence interval (CI) 3.42-7.39; mother-infant bonding problems adjusted β = 7.51, 95% CI 3.09-11.92]. There was no evidence that self-harm in adolescence (ages 15-17) was associated with either perinatal outcome.

CONCLUSIONS

Self-harm during young adulthood may be an indicator of future vulnerability to perinatal mental health and mother-infant bonding problems.

Examining risk factors for self-harm and suicide in LGBTQ+ young people: a systematic review protocol

INTRODUCTION

Young people who identify as Lesbian, Gay, Bisexual, Transgender, Queer or Questioning (LGBTQ+) are at increased risk for self-harm, suicide ideation and behaviours. However, there has yet to be a comprehensive understanding of what risk factors influence these behaviours within LGBTQ+ young people as a whole. The purpose of this systematic review is to examine risk factors associated with self-harm, suicidal ideation and behaviour in LGBTQ+) young people.

METHODS AND ANALYSIS

A systematic review will be conducted, conforming to the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. Electronic databases (MEDLINE, Scopus, EMBASE, PsycINFO and Web of Science) will be systematically searched for cross-sectional, prospective, longitudinal, cohort and case-control designs which examine risk factors for self-harm and/or suicidal ideation and behaviour in LGBTQ+ young people (aged 12-25 years). Only studies published in English will be included. No date restrictions will be applied. Study quality assessment will be conducted using the original and modified Newcastle-Ottawa Scales. Meta-analysis or narrative synthesis will be used, dependent on findings.

ETHICS AND DISSEMINATION

This is a systematic review of published literature and thereby ethical approval was not sought. The review will be submitted to a peer-reviewed journal, be publicly disseminated at conferences focusing on mental health, self-harm and suicide prevention. The findings will also be shared through public engagement and involvement, particularly those related to young LGBTQ+ individuals.

PROSPERO REGISTRATION NUMBER

CRD42019130037.

Suicide and Self-Harm in Recent Immigrants in Ontario, Canada: A Population-Based Study

OBJECTIVE

To estimate the rates of suicide and self-harm among recent immigrants and to determine which immigrant-specific risk factors are associated with these outcomes.

METHODS

Population-based cohort study using linked health administrative data sets (2003 to 2017) in Ontario, Canada which included adults ≥18 years, living in Ontario (N = 9,055,079). The main exposure was immigrant status (long-term resident vs. recent immigrant). Immigrant-specific exposures included visa class and country of origin. Outcome measures were death by suicide or emergency department visit for self-harm. Cox proportional hazards estimated adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs).

RESULTS

We included 590,289 recent immigrants and 8,464,790 long-term residents. Suicide rates were lower among immigrants (n = 130 suicides, 3.3/100,000) than long-term residents (n = 6,354 suicides, 11.8/100,000) with aHR 0.3, 95% CI, 0.2 to 0.3. Male-female ratios in suicide rates were attenuated in immigrants. Refugees had 2.1 (95% CI, 1.3 to 3.6; rate 6.1/100,000) and 2.8 (95% CI, 2.5 to 3.2) times the likelihood of suicide and self-harm, respectively, compared with nonrefugee immigrants. Self-harm rate was lower among immigrants (n = 2,256 events, 4.4/10,000) than long-term residents (n = 68,039 events, 9.7/10,000 person-years; aHR 0.3; 95% CI, 0.3 to 0.3). Unlike long-term residents, where low income was associated with high suicide rates, income was not associated with suicide among immigrants and there was an attenuated income gradient for self-harm. Country of origin-specific analyses showed wide ranges in suicide rates (1.4 to 9.9/100,000) and self-harm (1.8 to 14.9/10,000).

CONCLUSION

Recent immigrants have lower rates of suicide and self-harm and different sociodemographic predictors compared with long-term residents. Analysis of contextual factors including immigrant class, origin, and destination should be considered for all immigrant suicide risk assessment.

Associations between Chinese adolescents subjected to traditional and cyber bullying and suicidal ideation, self-harm and suicide attempts

BACKGROUND

The incidence of bullying is high among adolescents. Adolescents who were victims of bullying have a higher risk of self-harm and suicidal behavior than adolescents who were non-victims. However, research on suicide and both traditional and cyber bullying was limited in China. Therefore, this study examined the associations between Chinese adolescents who were the victims of traditional and cyber bullying and the prevalence of suicidal ideation, self-harm and suicide attempts.

METHODS

This was a population-based study of 2647 students (51.2% girls) with a mean age of 13.6 ± 1.1 years from 10 junior high schools in Shantou, China. Information on bullying victimization, suicidal ideation, self-harm and suicide attempts were collected using a self-administered questionnaire and the psychopathology of the students was assessed using the Strengths and Difficulties Questionnaire (SDQ). The associations were examined with multinomial logistic regression, adjusted for covariates.

RESULTS

Traditional bullying victimization was reported by 16.7% of the adolescents, cyber bullying victimization by 9.0% and both by 3.5%. The prevalence of suicidal ideation was 23.5%, self-harm was 6.2% and suicide attempts was 4.2%. Psychopathology symptoms were risk factors for suicide ideation only, ideation plus self-harm, self-harm only and suicide attempts. Victims of both traditional and cyber bullying had the highest risk of suicidal ideation only, ideation plus self-harm and suicide attempts, compared to those reporting one form of bullying. Victims of cyber bullying only had the second highest risk of suicidal ideation only and suicidal ideation plus self-harm compared to non-victims.

CONCLUSIONS

Adolescents who were victims of both traditional and cyber bullying had greater risks of adverse outcomes of suicidal ideation only, suicidal ideation plus self-harm and suicide attempts. The results of the current study suggest that those exposed to both forms of bullying should be routinely screened for suicidal risk. In addition, school-based anti-bully interventions should also target cyber bullying.