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Reducing risk following self-harm: the need for careful prescribing. Br J Gen Pract 2019; 69:224-225. [PMID: 31023669 DOI: 10.3399/bjgp19x702317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Mahar AL, Cramm H, Aiken AB, Whitehead M, Tien H, Fear NT, Kurdyak P. A retrospective cohort study comparing non-fatal self-harm emergency department visits between Canadian veterans living in Ontario and matched civilians. Int Rev Psychiatry 2019; 31:25-33. [PMID: 30994372 DOI: 10.1080/09540261.2019.1580685] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This was a retrospective cohort study linking provincial administrative databases to compare rates of non-fatal self-harm between CAF and RCMP veterans living in Ontario and age-matched civilians. This study included male veterans who registered for provincial health insurance between 2002 and 2013. A civilian comparator group was matched 4:1 on age and sex. Self-harm emergency department (ED) visits were identified from provincial ED admission records until death or December 31, 2015. Multivariable Poisson regression compared the risk of self-harm. Analyses adjusted for age, geography, income, rurality, and major physical and mental comorbidities. In total, 9514 male veterans and 38,042 age- and sex-matched civilians were included. Overall, 0.55% of veterans had at least one non-fatal self-harm ED visit, compared with 0.81% of civilians. The rate of ED self-harm visits was 40% lower in the veteran population, compared to the civilian population (RR = 0.60; 95% CI = 0.41-0.87). In both groups, psychosocial and physical comorbidities, and death by suicide were more common in those who self-harmed than those who did not. A better understanding of why veterans have a lower rate of self-harm emergency department visits and how it is related to the number of completed suicides is an important area for future consideration.
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Affiliation(s)
- Alyson L Mahar
- a Department of Community Health Sciences , University of Manitoba , Winnipeg , Canada
| | - Heidi Cramm
- b School of Rehabilitation Therapy , Queen's University , Kingston , Canada
| | | | | | - Homer Tien
- e Canadian Armed Forces , Ottawa , Canada
| | - Nicola T Fear
- f Psychological Medicine , Kings College London , London , UK
| | - Paul Kurdyak
- d IC/ES , Toronto , Canada.,g Centre for Addiction and Mental Health , Toronto , Canada
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Self-harm in a primary care cohort of older people: incidence, clinical management, and risk of suicide and other causes of death. Lancet Psychiatry 2018; 5:905-912. [PMID: 30337211 PMCID: PMC6203699 DOI: 10.1016/s2215-0366(18)30348-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 08/31/2018] [Accepted: 09/03/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND Self-harm is a major risk factor for suicide, with older adults (older than 65 years) having reportedly greater suicidal intent than any other age group. With the aging population rising and paucity of research focus in this age group, the extent of the problem of self-harm needs to be established. In a primary care cohort of older adults we aimed to investigate the incidence of self-harm, subsequent clinical management, prevalence of mental and physical diagnoses, and unnatural-cause mortality risk, including suicide. METHODS The UK Clinical Practice Research Datalink contains anonymised patient records from general practice that routinely capture clinical information pertaining to both primary and secondary care services. We identified 4124 adults aged 65 years and older with a self-harm episode ascertained from Read codes recorded during 2001-14. We calculated standardised incidence and in 2854 adults with at least 12 months follow-up examined the frequency of psychiatric referrals and prescription of psychotropic medication after self-harm. We estimated prevalence of mental and physical illness diagnoses before and after self-harm and, using Cox regression in a matched cohort, we examined cause-specific mortality risks. FINDINGS Overall incidence of self-harm in older adults aged 65 years and older was 4·1 per 10 000 person-years with stable gender-specific rates observed over the 13-year period. After self-harm, 335 (11·7%) of 2854 adults were referred to mental health services, 1692 (59·3%) were prescribed an antidepressant, and 336 (11·8%) were prescribed a tricyclic antidepressant (TCA). Having a diagnosed previous mental illness was twice as prevalent in the self-harm cohort as in the comparison cohort (prevalence ratio 2·10 [95% CI 2·03-2·17]) and with a previous physical health condition prevalence was 20% higher in the self-harm cohort compared to the comparison cohort (1·20 [1·17-1·23]). Adults from the self-harm cohort (n=2454) died from unnatural causes an estimated 20 times more frequently than the comparison cohort (n=48 921) during the first year. A markedly elevated risk of suicide (hazard ratio 145·4 [95% CI 53·9-392·3]) was observed in the self-harm cohort. INTERPRETATION Within primary care, we have identified a group of older adults at high risk from unnatural death, particularly within the first year of self-harm. We have highlighted a high frequency of prescription of TCAs, known to be potentially fatally toxic in overdose. We emphasise the need for early intervention, careful alternative prescribing, and increased support when older adults consult after an episode of self-harm and with other health conditions. FUNDING National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre.
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54
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Mitchell R. Self-harm in older adults: room to improve clinical care. Lancet Psychiatry 2018; 5:859-860. [PMID: 30337212 DOI: 10.1016/s2215-0366(18)30358-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 09/11/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Rebecca Mitchell
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW 2109, Australia.
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55
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Risk factors for self-harm in people with epilepsy. J Neurol 2018; 265:3009-3016. [PMID: 30357466 PMCID: PMC6244650 DOI: 10.1007/s00415-018-9094-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To estimate the risk of self-harm in people with epilepsy and identify factors which influence this risk. METHODS We identified people with incident epilepsy in the Clinical Practice Research Datalink, linked to hospitalization and mortality data, in England (01/01/1998-03/31/2014). In Phase 1, we estimated risk of self-harm among people with epilepsy, versus those without, in a matched cohort study using a stratified Cox proportional hazards model. In Phase 2, we delineated a nested case-control study from the incident epilepsy cohort. People who had self-harmed (cases) were matched with up to 20 controls. From conditional logistic regression models, we estimated relative risk of self-harm associated with mental and physical illness comorbidity, contact with healthcare services and antiepileptic drug (AED) use. RESULTS Phase 1 included 11,690 people with epilepsy and 215,569 individuals without. We observed an adjusted hazard ratio of 5.31 (95% CI 4.08-6.89) for self-harm in the first year following epilepsy diagnosis and 3.31 (95% CI 2.85-3.84) in subsequent years. In Phase 2, there were 273 cases and 3790 controls. Elevated self-harm risk was associated with mental illness (OR 4.08, 95% CI 3.06-5.42), multiple general practitioner consultations, treatment with two AEDs versus monotherapy (OR 1.84, 95% CI 1.33-2.55) and AED treatment augmentation (OR 2.12, 95% CI 1.38-3.26). CONCLUSION People with epilepsy have elevated self-harm risk, especially in the first year following diagnosis. Clinicians should adequately monitor these individuals and be especially vigilant to self-harm risk in people with epilepsy and comorbid mental illness, frequent healthcare service contact, those taking multiple AEDs and during treatment augmentation.
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56
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Parisi R, Webb RT, Kleyn CE, Carr MJ, Kapur N, Griffiths CEM, Ashcroft DM. Psychiatric morbidity and suicidal behaviour in psoriasis: a primary care cohort study. Br J Dermatol 2018; 180:108-115. [PMID: 30007069 DOI: 10.1111/bjd.17004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND Psychological distress among people with psoriasis may lead to elevated risks of suicide and nonfatal self-harm. OBJECTIVES To investigate psychiatric comorbidity, psychotropic medication prescribing and risk of suicidality in people with psoriasis. METHODS A cohort of patients with psoriasis (1998-2014) was delineated using the Clinical Practice Research Datalink, with linkage to Hospital Episode Statistics and Office for National Statistics mortality records. Each patient with psoriasis was matched with up to 20 patients without psoriasis on age, sex and general practice. A stratified Cox regression model was used to estimate the hazard ratios (HRs) for suicide or nonfatal self-harm risks adjusted for socioeconomic status. RESULTS At baseline, among 56 961 and 876 919 patients with and without psoriasis, higher prevalence for histories of alcohol misuse, bipolar disorder, depression, anxiety disorders, self-harm and psychotropic drug prescription were observed. The deprivation-adjusted HR indicated lower suicide risk in people with psoriasis [HR 0·59, 95% confidence interval (CI) 0·41-0·85]. The risk of suicide varied according to age: it was lower in people with psoriasis diagnosed at ≥ 40 years (HR 0·38, 95% CI 0·21-0·66), whereas there was no difference in risk of suicide in people with psoriasis diagnosed before age 40 years (HR 0·92, 95% CI 0·58-1·46). Conversely, there was a small increased risk for self-harm (HR 1·15, 95% CI 1·04-1·27) associated with psoriasis. CONCLUSIONS The prevalence of mental illness was raised in people with psoriasis, and this may lead to a greater risk of self-harm. Nevertheless, having psoriasis does not appear to be associated with an increased risk of suicide. Healthcare professionals caring for patients with psoriasis should continue to monitor and tackle effectively the psychological needs of these individuals.
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Affiliation(s)
- R Parisi
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K
| | - R T Webb
- Centre for Mental Health and Safety, School of Health Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K
| | - C E Kleyn
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K.,NIHR Manchester Biomedical Research Centre, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K
| | - M J Carr
- Centre for Mental Health and Safety, School of Health Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K
| | - N Kapur
- Centre for Mental Health and Safety, School of Health Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K
| | - C E M Griffiths
- Dermatology Centre, Salford Royal NHS Foundation Trust, The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K.,NIHR Manchester Biomedical Research Centre, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K
| | - D M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, U.K.,NIHR Manchester Biomedical Research Centre, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K
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Griffin E, McMahon E, McNicholas F, Corcoran P, Perry IJ, Arensman E. Increasing rates of self-harm among children, adolescents and young adults: a 10-year national registry study 2007-2016. Soc Psychiatry Psychiatr Epidemiol 2018; 53:663-671. [PMID: 29721594 DOI: 10.1007/s00127-018-1522-1] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/25/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Rates of hospital-treated self-harm are highest among young people. The current study examined trends in rates of self-harm among young people in Ireland over a 10-year period, as well as trends in self-harm methods. METHODS Data from the National Self-Harm Registry Ireland on presentations to hospital emergency departments (EDs) following self-harm by those aged 10-24 years during the period 2007-2016 were included. We calculated annual self-harm rates per 100,000 by age, gender and method of self-harm. Poisson regression models were used to examine trends in rates of self-harm. RESULTS The average person-based rate of self-harm among 10-24-year-olds was 318 per 100,000. Peak rates were observed among 15-19-year-old females (564 per 100,000) and 20-24-year-old males (448 per 100,000). Between 2007 and 2016, rates of self-harm increased by 22%, with increases most pronounced for females and those aged 10-14 years. There were marked increases in specific methods of self-harm, including those associated with high lethality. CONCLUSIONS The findings indicate that the age of onset of self-harm is decreasing. Increasing rates of self-harm, along with increases in highly lethal methods, indicate that targeted interventions in key transition stages for young people are warranted.
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Affiliation(s)
- Eve Griffin
- National Suicide Research Foundation, 4.28 Western Gateway Building, University College Cork, Cork, Ireland.
| | - Elaine McMahon
- National Suicide Research Foundation, 4.28 Western Gateway Building, University College Cork, Cork, Ireland
| | - Fiona McNicholas
- Department of Child and Adolescent Psychiatry, Our Lady's Children's Hospital, Dublin, Ireland.,School of Medicine, University College Dublin, Dublin, Ireland.,Lucena Clinic, Rathgar, Dublin 6, Ireland
| | - Paul Corcoran
- National Suicide Research Foundation, 4.28 Western Gateway Building, University College Cork, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
| | - Ivan J Perry
- School of Public Health, University College Cork, Cork, Ireland
| | - Ella Arensman
- National Suicide Research Foundation, 4.28 Western Gateway Building, University College Cork, Cork, Ireland.,School of Public Health, University College Cork, Cork, Ireland
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DelPozo-Banos M, John A, Petkov N, Berridge DM, Southern K, LLoyd K, Jones C, Spencer S, Travieso CM. Using Neural Networks with Routine Health Records to Identify Suicide Risk: Feasibility Study. JMIR Ment Health 2018; 5:e10144. [PMID: 29934287 PMCID: PMC6035342 DOI: 10.2196/10144] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 04/10/2018] [Accepted: 04/29/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Each year, approximately 800,000 people die by suicide worldwide, accounting for 1-2 in every 100 deaths. It is always a tragic event with a huge impact on family, friends, the community and health professionals. Unfortunately, suicide prevention and the development of risk assessment tools have been hindered by the complexity of the underlying mechanisms and the dynamic nature of a person's motivation and intent. Many of those who die by suicide had contact with health services in the preceding year but identifying those most at risk remains a challenge. OBJECTIVE To explore the feasibility of using artificial neural networks with routinely collected electronic health records to support the identification of those at high risk of suicide when in contact with health services. METHODS Using the Secure Anonymised Information Linkage Databank UK, we extracted the data of those who died by suicide between 2001 and 2015 and paired controls. Looking at primary (general practice) and secondary (hospital admissions) electronic health records, we built a binary feature vector coding the presence of risk factors at different times prior to death. Risk factors included: general practice contact and hospital admission; diagnosis of mental health issues; injury and poisoning; substance misuse; maltreatment; sleep disorders; and the prescription of opiates and psychotropics. Basic artificial neural networks were trained to differentiate between the suicide cases and paired controls. We interpreted the output score as the estimated suicide risk. System performance was assessed with 10x10-fold repeated cross-validation, and its behavior was studied by representing the distribution of estimated risk across the cases and controls, and the distribution of factors across estimated risks. RESULTS We extracted a total of 2604 suicide cases and 20 paired controls per case. Our best system attained a mean error rate of 26.78% (SD 1.46; 64.57% of sensitivity and 81.86% of specificity). While the distribution of controls was concentrated around estimated risks < 0.5, cases were almost uniformly distributed between 0 and 1. Prescription of psychotropics, depression and anxiety, and self-harm increased the estimated risk by ~0.4. At least 95% of those presenting these factors were identified as suicide cases. CONCLUSIONS Despite the simplicity of the implemented system, the proposed methodology obtained an accuracy like other published methods based on specialized questionnaire generated data. Most of the errors came from the heterogeneity of patterns shown by suicide cases, some of which were identical to those of the paired controls. Prescription of psychotropics, depression and anxiety, and self-harm were strongly linked with higher estimated risk scores, followed by hospital admission and long-term drug and alcohol misuse. Other risk factors like sleep disorders and maltreatment had more complex effects.
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Affiliation(s)
| | - Ann John
- Swansea University, Swansea University Medical School, Swansea, United Kingdom
| | - Nicolai Petkov
- Division of Intelligent Systems, Department of Computer Science, Bernoulli Institute of Mathematics, Computer Science and Artificial Intelligence, Faculty of Science and Engineering, University of Groningen, Groningen, Netherlands
| | - Damon Mark Berridge
- Swansea University, Swansea University Medical School, Swansea, United Kingdom
| | - Kate Southern
- Cardiff Adult Self Injury Project, Cardiff, United Kingdom
| | - Keith LLoyd
- Swansea University, Swansea University Medical School, Swansea, United Kingdom
| | - Caroline Jones
- Hillary Rodham Clinton School of Law, Swansea University, Swansea, United Kingdom
| | - Sarah Spencer
- Princess of Wales Hospital, Bridgend, ABMU Health Board, Swansea, United Kingdom
| | - Carlos Manuel Travieso
- Signals and Communications Department, IDeTIC, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
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Morgan C, Webb RT, Carr MJ, Kontopantelis E, Green J, Chew-Graham CA, Kapur N, Ashcroft DM. Incidence, clinical management, and mortality risk following self harm among children and adolescents: cohort study in primary care. BMJ 2017; 359:j4351. [PMID: 29046278 PMCID: PMC5641980 DOI: 10.1136/bmj.j4351] [Citation(s) in RCA: 182] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives To examine temporal trends in sex and age specific incidence of self harm in children and adolescents, clinical management patterns, and risk of cause specific mortality following an index self harm episode at a young age.Design Population based cohort study.Setting UK Clinical Practice Research Datalink-electronic health records from 647 general practices, with practice level deprivation measured ecologically using the index of multiple deprivation. Patients from eligible English practices were linked to hospital episode statistics (HES) and Office for National Statistics (ONS) mortality records.Participants For the descriptive analytical phases we examined data pertaining to 16 912 patients aged 10-19 who harmed themselves during 2001-14. For analysis of cause specific mortality following self harm, 8638 patients eligible for HES and ONS linkage were matched by age, sex, and general practice with up to 20 unaffected children and adolescents (n=170 274).Main outcome measures In the first phase, temporal trends in sex and age specific annual incidence were examined. In the second phase, clinical management was assessed according to the likelihood of referral to mental health services and psychotropic drug prescribing. In the third phase, relative risks of all cause mortality, unnatural death (including suicide and accidental death), and fatal acute alcohol or drug poisoning were estimated as hazard ratios derived from stratified Cox proportional hazards models for the self harm cohort versus the matched unaffected comparison cohort.Results The annual incidence of self harm was observed to increase in girls (37.4 per 10 000) compared with boys (12.3 per 10 000), and a sharp 68% increase occurred among girls aged 13-16, from 45.9 per 10 000 in 2011 to 77.0 per 10 000 in 2014. Referrals within 12 months of the index self harm episode were 23% less likely for young patients registered at the most socially deprived practices, even though incidences were considerably higher in these localities. Children and adolescents who harmed themselves were approximately nine times more likely to die unnaturally during follow-up, with especially noticeable increases in risks of suicide (deprivation adjusted hazard ratio 17.5, 95% confidence interval 7.6 to 40.5) and fatal acute alcohol or drug poisoning (34.3, 10.2 to 115.7).Conclusions Gaining a better understanding of the mechanisms responsible for the recent apparent increase in the incidence of self harm among early-mid teenage girls, and coordinated initiatives to tackle health inequalities in the provision of services to distressed children and adolescents, represent urgent priorities for multiple public agencies.
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Affiliation(s)
- Catharine Morgan
- Centre for Pharmacoepidemiology and Drug Safety, NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, Division of Pharmacy and Optometry, University of Manchester, Manchester, UK
| | - Roger T Webb
- Centre for Mental Health & Risk, NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Matthew J Carr
- Centre for Mental Health & Risk, NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Health Informatics, Manchester Academic Health Science Centre (MAHSC), Division of Informatics, Imaging and Data sciences, University of Manchester, Manchester, UK
| | - Jonathan Green
- Manchester Academic Health Science Centre, Division of Neuroscience and Experimental Psychology, University of Manchester, Manchester, UK; Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Carolyn A Chew-Graham
- Research Institute for Primary Care and Health Sciences, West Midlands Collaboration for Leadership in Applied Health Research and Care, Keele University, Staffordshire, UK
| | - Nav Kapur
- Centre for Suicide Prevention, NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, Division of Psychology and Mental Health, University of Manchester, Manchester, UK; Greater Manchester Mental Health NHS Foundation Trust, Prestwich Hospital, Prestwich, Manchester, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, Division of Pharmacy and Optometry, University of Manchester, Manchester, UK
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Saunders NR, Lebenbaum M, Stukel TA, Lu H, Urquia ML, Kurdyak P, Guttmann A. Suicide and self-harm trends in recent immigrant youth in Ontario, 1996-2012: a population-based longitudinal cohort study. BMJ Open 2017; 7:e014863. [PMID: 28864687 PMCID: PMC5589002 DOI: 10.1136/bmjopen-2016-014863] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To describe the trends in suicide and emergency department (ED) visits for self-harm in youth by immigration status and immigrant characteristics. DESIGN Population-based longitudinal cohort study from 1996 to 2012 using linked health and administrative datasets. SETTING Ontario, Canada. PARTICIPANTS Youth 10 to 24 years, living in Ontario, Canada. EXPOSURE The main exposure was immigrant status (recent immigrant (RI) versus long-term residents (LTR)). Secondary exposures included region of birth, duration or residence, and refugee status. MAIN OUTCOME MEASURE Trends over time in suicide and ED self-harm were modelled within consecutive 3-year time periods. Rate ratios were estimated using Poisson regression models. RESULTS 2.5 to 2.9 million individuals were included per cohort period. LTR suicide rates ranged from 7.4 to 9.4/100 000 male person-years versus 2.2-3.4/100 000 females. RI's suicide rates were 2.7-7.2/100,000 male versus 1.9-2.7/100 000 female person-years. Suicide rates were lower among RI compared with LTR (adjusted relative rate (aRR)=0.70, 95% CI=0.57 to 0.85) with different mechanisms of suicide. No significant time trend in suicide rates was observed (p=0.40). ED self-harm rates for LTR and RI were highest in females (2.6-3.4/1000 LTR females versus 1.1-1.5/1000 males, 1.2-1.8/1000 RI females versus 0.4-0.6/1000 males). RI had lower rates of self-harm compared with LTR (aRR=0.60, 95% CI=0.56 to 0.65). Stratum-specific rates showed a steeper decline per period in RI compared with LTR (RI: aRR=0.85, 95% CI=0.81 to 0.89; LTR: aRR=0.91, 95% CI=0.90 to 0.93). Observed trends were not universal across region of origin and by refugee status. INTERPRETATION Suicide rates have been stable and ED self-harm rates are declining over time among RI youth. These trends by important subgroups should continue to be monitored to allow for early identification of subpopulations of immigrant youth in need of targeted and culturally appropriate public health interventions.
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Affiliation(s)
- Natasha Ruth Saunders
- Division of Pediatric Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Child Health Evaluative Sciences, Sickkids Research Institute, Toronto, Canada
| | | | - Therese A Stukel
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Hong Lu
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Marcelo L Urquia
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Manitoba Centre for Health Policy, Department of Community Health Services, Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Paul Kurdyak
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Centre for Addiction and Mental Health, Toronto, Canada
| | - Astrid Guttmann
- Division of Pediatric Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, University of Toronto, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
- Child Health Evaluative Sciences, Sickkids Research Institute, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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61
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Carr MJ, Ashcroft DM, Kontopantelis E, While D, Awenat Y, Cooper J, Chew-Graham C, Kapur N, Webb RT. Premature Death Among Primary Care Patients With a History of Self-Harm. Ann Fam Med 2017; 15:246-254. [PMID: 28483890 PMCID: PMC5422086 DOI: 10.1370/afm.2054] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/16/2016] [Accepted: 12/30/2016] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Self-harm is a public health problem that requires a better understanding of mortality risk. We undertook a study to examine premature mortality in a nationally representative cohort of primary care patients who had harmed themselves. METHODS During 2001-2013, a total of 385 general practices in England contributed data to the Clinical Practice Research Datalink with linkage to Office for National Statistics mortality records. We identified 30,017 persons aged 15 to 64 years with a recorded episode of self-harm. We estimated the relative risks of all-cause and cause-specific natural and unnatural mortality using a comparison cohort of 600,258 individuals matched on age, sex, and general practice. RESULTS We found an elevated risk of dying prematurely from any cause among the self-harm cohort, especially in the first year of follow-up (adjusted hazard ratio for that year, 3.6; 95% CI, 3.1-4.2). In particular, suicide risk was especially high during the first year (adjusted hazard ratio, 54.4; 95% CI, 34.3-86.3); although it declined sharply, it remained much higher than that in the comparison cohort. Large elevations of risk throughout the follow-up period were also observed for accidental, alcohol-related, and drug poisoning deaths. At 10 years of follow-up, cumulative incidence values were 6.5% (95% CI, 6.0%-7.1%) for all-cause mortality and 1.3% (95% CI, 1.2%-1.5%) for suicide. CONCLUSIONS Primary care patients who have harmed themselves are at greatly increased risk of dying prematurely by natural and unnatural causes, and especially within a year of a first episode. These individuals visit clinicians at a relatively high frequency, which presents a clear opportunity for preventive action. Primary care patients with myriad comorbidities, including self-harming behavior, mental disorder, addictions, and physical illnesses, will require concerted, multipronged, multidisciplinary collaborative care approaches.
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Affiliation(s)
- Matthew J Carr
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Carr, While, Awenat, Cooper, Kapur, Webb); Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Ashcroft); NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester M13 9PL, UK (Ashcroft); Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Kontopantelis); Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire ST5 5BG, UK (Chew-Graham); West Midlands NIHR Collaborative Leadership in Applied Health Research and Care (CLAHRC), Birmingham, UK (Chew-Graham).
| | - Darren M Ashcroft
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Carr, While, Awenat, Cooper, Kapur, Webb); Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Ashcroft); NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester M13 9PL, UK (Ashcroft); Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Kontopantelis); Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire ST5 5BG, UK (Chew-Graham); West Midlands NIHR Collaborative Leadership in Applied Health Research and Care (CLAHRC), Birmingham, UK (Chew-Graham)
| | - Evangelos Kontopantelis
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Carr, While, Awenat, Cooper, Kapur, Webb); Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Ashcroft); NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester M13 9PL, UK (Ashcroft); Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Kontopantelis); Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire ST5 5BG, UK (Chew-Graham); West Midlands NIHR Collaborative Leadership in Applied Health Research and Care (CLAHRC), Birmingham, UK (Chew-Graham)
| | - David While
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Carr, While, Awenat, Cooper, Kapur, Webb); Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Ashcroft); NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester M13 9PL, UK (Ashcroft); Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Kontopantelis); Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire ST5 5BG, UK (Chew-Graham); West Midlands NIHR Collaborative Leadership in Applied Health Research and Care (CLAHRC), Birmingham, UK (Chew-Graham)
| | - Yvonne Awenat
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Carr, While, Awenat, Cooper, Kapur, Webb); Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Ashcroft); NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester M13 9PL, UK (Ashcroft); Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Kontopantelis); Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire ST5 5BG, UK (Chew-Graham); West Midlands NIHR Collaborative Leadership in Applied Health Research and Care (CLAHRC), Birmingham, UK (Chew-Graham)
| | - Jayne Cooper
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Carr, While, Awenat, Cooper, Kapur, Webb); Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Ashcroft); NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester M13 9PL, UK (Ashcroft); Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Kontopantelis); Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire ST5 5BG, UK (Chew-Graham); West Midlands NIHR Collaborative Leadership in Applied Health Research and Care (CLAHRC), Birmingham, UK (Chew-Graham)
| | - Carolyn Chew-Graham
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Carr, While, Awenat, Cooper, Kapur, Webb); Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Ashcroft); NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester M13 9PL, UK (Ashcroft); Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Kontopantelis); Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire ST5 5BG, UK (Chew-Graham); West Midlands NIHR Collaborative Leadership in Applied Health Research and Care (CLAHRC), Birmingham, UK (Chew-Graham)
| | - Nav Kapur
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Carr, While, Awenat, Cooper, Kapur, Webb); Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Ashcroft); NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester M13 9PL, UK (Ashcroft); Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Kontopantelis); Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire ST5 5BG, UK (Chew-Graham); West Midlands NIHR Collaborative Leadership in Applied Health Research and Care (CLAHRC), Birmingham, UK (Chew-Graham)
| | - Roger T Webb
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Carr, While, Awenat, Cooper, Kapur, Webb); Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Ashcroft); NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester M13 9PL, UK (Ashcroft); Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK (Kontopantelis); Research Institute of Primary Care and Health Sciences, Keele University, Staffordshire ST5 5BG, UK (Chew-Graham); West Midlands NIHR Collaborative Leadership in Applied Health Research and Care (CLAHRC), Birmingham, UK (Chew-Graham)
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Epidemiology of alcohol dependence in UK primary care: Results from a large observational study using the Clinical Practice Research Datalink. PLoS One 2017; 12:e0174818. [PMID: 28362848 PMCID: PMC5376077 DOI: 10.1371/journal.pone.0174818] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 03/15/2017] [Indexed: 12/17/2022] Open
Abstract
This study aims to investigate the incidence and annual presentation rates of alcohol dependence in general practice in the UK, and examine age-, gender-, socioeconomic-, and region-specific variation. We conducted a retrospective 'open' cohort study using the Clinical Practice Research Datalink (CPRD), an anonymised primary care database. Prior to data extraction, a case definition for alcohol dependence in CPRD was established using 47 Read codes, which included primary alcohol dependence and consequences of alcohol dependence. Directly standardised rates for incidence and annual presentation were calculated for each year between 1990 and 2013. Rates were compared by gender, age, UK home nation, and practice-level Index of Multiple Deprivation. The directly standardised annual incidence rates were 8.3 and 3.7 per 10,000 male and female patients, respectively. The estimated annual rates of presentation per 10,000 were 17.1 for males and 7.6 for females. Female to male rate ratios were: 0.40 (95% CI: 0.39-0.41) for incident cases; and 0.37 (95% CI: 0.36-0.39) for annual presentation. Rates were highest in those aged 35-54 for both measures and across genders, and lowest in those aged over 75 years. With England as the reference nation, Northern Ireland and Scotland had significantly higher rates for both measures. Patients from the most deprived areas had the highest incidence and annual presentation rates. There is unequal distribution of patients with severe alcohol dependence across population subgroups in general practice. Given the health and economic burden associated with dependent drinking, these data will be useful in informing future public health initiatives.
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Prevalence and Correlates of Self-Harm in the German General Population. PLoS One 2016; 11:e0157928. [PMID: 27362348 PMCID: PMC4928828 DOI: 10.1371/journal.pone.0157928] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 06/07/2016] [Indexed: 11/23/2022] Open
Abstract
The study aimed at evaluating the psychometric properties of the German version of the Self- Harm Inventory (SHI) and examining the lifetime prevalence and correlates of self-harm in a representative German population sample (N = 2,507; age mean = 48.79, SD = 18.11; range 14 to 94 years; 55.5% women) using the SHI. All participants answered the German SHI, the short form of the Barratt Impulsiveness Scale (BIS-15), the ultra-brief Patient Health Questionnaire for Depression and Anxiety (PHQ-4), and provided sociodemographic information. The one-factorial structure of the SHI was replicated using a confirmatory factor analysis. Internal consistency coefficients were sufficient and in line with previous studies. Almost half of the sample (49%) acknowledged at least one self-harming behavior over the life-span, most frequently indirect forms of self-harm. The rate of participants who engaged in at least one SHI behavior was higher among men than women (51.6% vs. 46.9%, respectively, χ2= 5.38, p = 0.020). Higher SHI scores were related to younger age, male gender, living alone, more symptoms of anxiety and depression (PHQ-4), higher impulsivity scores (BIS-15), and suffering from obesity grade 2. Women engaged more often in discreet forms of self-harm than men, e.g., preventing wounds from healing, exercising an injury, starving, and abusing laxatives. In terms of other indirect self-harming behaviors, men admitted more often driving recklessly, being promiscuous and losing a job on purpose, while women reported more frequently engaging in emotionally abusive relationships. With respect to direct self-harm, women were more likely to endorse suicide attempts and cutting, while men admitted more often head-banging. The findings suggest that self-harm constitutes a common problem. Future longitudinal studies are required to examine the natural course, sociodemographic and psychopathological risk factors, as well as possible time-trends of self-harming behaviors in more depth.
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Carr MJ, Ashcroft DM, Kontopantelis E, While D, Awenat Y, Cooper J, Chew-Graham C, Kapur N, Webb RT. Clinical management following self-harm in a UK-wide primary care cohort. J Affect Disord 2016; 197:182-8. [PMID: 26994436 PMCID: PMC4870375 DOI: 10.1016/j.jad.2016.03.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 02/19/2016] [Accepted: 03/07/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Little is known about the clinical management of patients in primary care following self-harm. METHODS A descriptive cohort study using data from 684 UK general practices that contributed to the Clinical Practice Research Datalink (CPRD) during 2001-2013. We identified 49,970 patients with a self-harm episode, 41,500 of whom had one complete year of follow-up. RESULTS Among those with complete follow-up, 26,065 (62.8%, 62.3-63.3) were prescribed psychotropic medication and 6318 (15.2%, 14.9-15.6) were referred to mental health services; 4105 (9.9%, CI 9.6-10.2) were medicated without an antecedent psychiatric diagnosis or referral, and 4,506 (10.9%, CI 10.6-11.2) had a diagnosis but were not subsequently medicated or referred. Patients registered at practices in the most deprived localities were 27.1% (CI 21.5-32.2) less likely to be referred than those in the least deprived. Despite a specifically flagged NICE 'Do not do' recommendation in 2011 against prescribing tricyclic antidepressants following self-harm because of their potentially lethal toxicity in overdose, 8.8% (CI 7.8-9.8) of individuals were issued a prescription in the subsequent year. The percentage prescribed Citalopram, an SSRI antidepressant with higher toxicity in overdose, fell sharply during 2012/2013 in the aftermath of a Medicines and Healthcare products Regulatory Agency (MHRA) safety alert issued in 2011. CONCLUSIONS A relatively small percentage of these vulnerable patients are referred to mental health services, and reduced likelihood of referral in more deprived localities reflects a marked health inequality. National clinical guidelines have not yet been effective in reducing rates of tricyclic antidepressant prescribing for this high-risk group.
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Affiliation(s)
- Matthew J Carr
- Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, UK.
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, UK; NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, UK
| | - Evangelos Kontopantelis
- Centre for Health Informatics, Institute of Population Health, University of Manchester, UK; NIHR School for Primary Care Research, University of Manchester, UK
| | - David While
- Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, UK
| | - Yvonne Awenat
- School of Psychological Sciences, University of Manchester, UK
| | - Jayne Cooper
- Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, UK
| | - Carolyn Chew-Graham
- Research Institute of Primary Care and Health Sciences, Keele University, UK
| | - Nav Kapur
- Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, UK; Manchester Mental Health and Social Care Trust, UK
| | - Roger T Webb
- Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, UK
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