Self-harm induced somatic admission after discharge from psychiatric hospital – a prospective cohort study

Risk factors for mortality in patients admitted to a psychiatric acute ward: A prospective cohort study

INTRODUCTION

Associations between psychiatric disorders and mortality have been extensively studied, but limited evidence exists regarding influence of clinical characteristics on mortality risk, at the time of acute psychiatric hospitalization.

METHODS

A prospective total-cohort study included all patients consecutively admitted to Haukeland University Hospital's psychiatric acute ward in Bergen, Norway between 2005 and 2014 (n = 6125). Clinical interviews were conducted at the first admission within the study period, and patients were subsequently followed for up to 15 years in the Norwegian Cause of Death Registry. Competing risks regression models were used to investigate associations between clinical characteristics at first admission and the risk of natural and unnatural death during follow-up.

RESULTS

The mean age at first admission and at time of death was 42.5 and 62.8 years, respectively, and the proportion of women in the sample was 47.2%. A total of 1381 deaths were registered during follow-up, of which 65.5% had natural, 30.4% unnatural, and 4.1% unknown causes. Higher age, male sex, unemployment, cognitive deficits, and physical illness were associated with increased risk of natural death. Male sex, having no partner, physical illness, suicide attempts, and excessive use of alcohol and illicit substances were associated with increased risk of unnatural death.

CONCLUSION

Psychiatric symptoms, except suicide attempts, were unrelated to increased mortality risk. In the endeavor to reduce the increased mortality risk in people with mental disorders, focus should be on addressing modifiable risk factors linked to physical health and excessive use of alcohol and illicit substances.

Absolute risks of self-harm and interpersonal violence by diagnostic category following first discharge from inpatient psychiatric care

BACKGROUND

Persons discharged from inpatient psychiatric services are at greatly elevated risk of harming themselves or inflicting violence on others, but no studies have reported gender-specific absolute risks for these two outcomes across the spectrum of psychiatric diagnoses. We aimed to estimate absolute risks for self-harm and interpersonal violence post-discharge according to gender and diagnostic category.

METHODS

Danish national registry data were utilized to investigate 62,922 discharged inpatients, born 1967-2000. An age and gender matched cohort study was conducted to examine risks for self-harm and interpersonal violence at 1 year and at 10 years post-discharge. Absolute risks were estimated as cumulative incidence percentage values.

RESULTS

Patients diagnosed with substance misuse disorders were at especially elevated risk, with the absolute risks for either self-harm or interpersonal violence being 15.6% (95% CI 14.9, 16.3%) of males and 16.8% (15.6, 18.1%) of females at 1 year post-discharge, rising to 45.7% (44.5, 46.8%) and 39.0% (37.1, 40.8%), respectively, within 10 years. Diagnoses of personality disorders and early onset behavioral and emotional disorders were also associated with particularly high absolute risks, whilst risks linked with schizophrenia and related disorders, mood disorders, and anxiety/somatoform disorders, were considerably lower.

CONCLUSIONS

Patients diagnosed with substance misuse disorders, personality disorders and early onset behavioral and emotional disorders are at especially high risk for internally and externally directed violence. It is crucial, however, that these already marginalized individuals are not further stigmatized. Enhanced care at discharge and during the challenging transition back to life in the community is needed.

Borderline Personality Disorder: What Predicts Acute Psychiatric Readmissions?

Individuals diagnosed with borderline personality disorder (BPD) often struggle with chronic suicidal thoughts and behaviors and have frequent acute psychiatric admissions. Prevention of serial admissions and disruptions in long-term treatment strategies is needed. This study explored predictors of how frequently and how quickly patients diagnosed with BPD are readmitted after an index psychiatric admission. The authors identified self-harming behavior as a predictor of readmission frequency, whereas depression and hallucinations and delusions predicted time elapsed between the index admission and the first readmission. The authors recommend that predictors of readmissions should be carefully monitored and treated following index admission.

Suicidal and violent ideation in acute psychiatric inpatients: prevalence, co-occurrence, and associated characteristics

OBJECTIVE

We studied the point prevalence of suicidal and violent ideation, as well as their co-occurrence and associated characteristics in inpatients with mental health disorders.

METHODS

Data on suicidal and violent ideation, and sociodemographic and clinical information, were gathered from 1,737 patients when admitted to the acute psychiatric ward.

RESULTS

The point prevalence was 51.9% for suicidal ideation and 19.8% for violent ideation. The point prevalence of co-occurring suicidal and violent ideation was 12.3%, which was significantly greater than expected by chance. Logistic regression analyses indicated that both suicidal and violent ideation were associated with young age and the absence of diagnoses of psychotic disorders; in addition, suicidal ideation was associated with female gender, violent ideation, and diagnoses of mood- neurotic and personality disorders, whereas violent ideation was associated with male gender, suicidal ideation, and diagnoses of mood and neurotic disorders.

CONCLUSIONS

Overall, the findings highlight the need for further research on suicidal and violent ideation in people with mental health problems including, but not limited to, their association with adverse behavioral outcomes, as well as the need to routinely assess both suicidal and violent ideation in clinical practice.

Disease Trajectories for Hidradenitis Suppurativa in the Danish Population

Importance

Hidradenitis suppurativa (HS) is a chronic skin disease characterized by recurrent inflamed nodular lesions and is associated with multiple comorbidities; previous studies have been of cross-sectional design, and the temporal association of HS with multiple comorbidities remains undetermined.

Objective

To evaluate and characterize disease trajectories in patients with HS using population-wide disease registry data.

Design, Setting, and Participants

This retrospective registry-based cohort study included the entire Danish population alive between January 1, 1994, and April 10, 2018 (7 191 519 unique individuals). Among these, 14 488 Danish inhabitants were diagnosed with HS or fulfilled diagnostic criteria identified through surgical procedure codes.

Exposures

Citizens of Denmark with a diagnosis code of HS as defined by International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) or as identified through surgical procedures.

Main Outcomes and Measures

Disease trajectories experienced more frequently by patients with HS than by the overall Danish population. Strength of associations between disease co-occurrences was evaluated using relative risk (RR). All significant disease pairs were tested for directionality using a binomial test, and pairs with directionality were merged into disease trajectories of 3 consecutive diseases. Numerous disease trajectories were combined into a disease progression network showing the most frequent disease paths over time for patients with HS.

Results

A total of 11 929 individuals were identified by ICD-10 diagnosis codes (8392 [70.3%] female; mean [SD] age, 37.72 [13.01] years), and 2791 were identified by procedural codes (1686 [60.4%] female; mean [SD] age, 37.38 [15.83]). The set of most common temporal disease trajectories included 25 diagnoses and had a characteristic appearance in which genitourinary, respiratory, or mental and behavioral disorders preceded the diagnosis of HS and chronic obstructive pulmonary disease (604 cases [4.2%]; RR, 1.57; 95% CI, 1.55-1.59; P < .001), pneumonia (827 [5.7%]; RR, 1.18; 95% CI, 1.15-1.20; P < .001), and acute myocardial infarction (293 [2.0%]; RR, 1.37; 95% CI, 1.35-1.39; P < .001) developed after the diagnosis.

Conclusions and Relevance

The findings suggest that patients with newly diagnosed HS may have a high frequency of manifest type 1 diabetes and subsequent high risk of acute myocardial infarction, pneumonia, and chronic obstructive pulmonary disease.

Elderly patients with no previous psychiatric history: suicidality and other factors relating to psychiatric acute admissions

BACKGROUND

The common recommendation that adults with onset of mental illness after the age of 65 should receive specialised psychogeriatric treatment is based on limited evidence.

AIMS

To compare factors related to psychiatric acute admission in older adults who have no previous psychiatric history (NPH) with that of those who have a previous psychiatric history (PPH).

METHOD

Cross-sectional cohort study of 918 patients aged ≥65 years consecutively admitted to a general adult psychiatric acute unit from 2005 to 2014.

RESULTS

Patients in the NPH group (n = 526) were significantly older than those in the PPH group (n = 391) (77.6 v. 70.9 years P < 0.001), more likely to be men, married or widowed and admitted involuntarily. Diagnostic prevalence in the NPH and PPH groups were 49.0% v. 8.4% (P < 0.001) for organic mental disorders, 14.6% v. 30.4% (P < 0.001) for psychotic disorders, 30.2% v. 55.5% (P < 0.001) for affective disorders and 20.7% v. 13.3% (P = 0.003) for somatic disorders. The NPH group scored significantly higher on the Health of the Nation Outcome Scale (HoNOS) items agitated behaviour; cognitive problems; physical illness or disability and problems with activities of daily living, whereas those in the PPH group scored significantly higher on depressed mood. Although the PPH group were more likely to report suicidal ideation, those in the NPH group were more likely to have made a suicide attempt before the admission.

CONCLUSIONS

Among psychiatric patients >65 years, the subgroup with NPH were characterised by more physical frailty, somatic comorbidity and functional and cognitive impairment as well as higher rates of preadmission suicide attempts. Admitting facilities should be appropriately suited to manage their needs.

Is the reported increase in young female hospital-treated intentional self-harm real or artefactual?

BACKGROUND

The Australian Institute of Health and Welfare has reported an increased rate of hospital-treated intentional self-harm in young females (2000-2012) in Australia. These reported increases arise from institutional data that are acknowledged to underestimate the true rate, although the degree of underestimation is not known.

OBJECTIVE

To consider whether the reported increase in young females' hospital-treated intentional self-harm is real or artefactual and specify the degree of institutional underestimation.

METHODS

Averages for age- and gender-standardised event rates for hospital-treated intentional self-harm (national: Australian Institute of Health and Welfare; state: New South Wales Ministry of Health) were compared with sentinel hospital event rates for intentional self-poisoning (Hunter Area Toxicology Service, Calvary Mater Newcastle) in young people (15-24 years) for the period 2000-2012. A time series analysis of the event rates for the sentinel hospital was conducted.

RESULTS

The sentinel hospital event rates for young females of 444 per 100,000 were higher than the state (378 per 100,000) and national (331 per 100,000) rates. There was little difference in young male event rates - sentinel unit: 166; state: 166 and national: 153 per 100,000. The sentinel hospital rates showed no change over time for either gender.

CONCLUSION

There was no indication from the sentinel unit data of any increase in rates of intentional self-poisoning for young females. The sentinel and state rates were higher than the national rates, demonstrating the possible magnitude of underestimation of the national data. The reported increases in national rates of hospital-treated self-harm among young females might be due to artefactual factors, such as changes in clinical practice (greater proportion admitted), improved administrative coding of suicidal behaviours or possibly increased hospital presentations of community self-injury cases, but not intentional self-poisoning. A national system of sentinel units is needed for the accurate and timely monitoring of all hospital-treated self-harm.

Multiple adverse outcomes following first discharge from inpatient psychiatric care: a national cohort study

BACKGROUND

Discharged psychiatric inpatients are at elevated risk of serious adverse outcomes, but no previous study has comprehensively examined an array of multiple risks in a single cohort.

METHODS

We used data from the Danish Civil Registration System to delineate a cohort of all individuals born in Denmark in 1967-2000, who were alive and residing in Denmark on their 15th birthday, and who had been discharged from their first inpatient psychiatric episode at age 15 years or older. Each individual in the discharged cohort was matched on age and sex with 25 comparators without a history of psychiatric admission. Data linked to each individual were also obtained from the Psychiatric Central Research Register, Register of Causes of Death, National Patient Register, and the National Crime Register. We used survival analysis techniques to estimate absolute and relative risks of all-cause mortality, suicide, accidental death, homicide victimisation, homicide perpetration, non-fatal self-harm, violent criminality, and hospitalisation following violence, until Dec 31, 2015.

FINDINGS

We included 62 922 individuals in the discharged cohort, and 1 573 050 matched comparators. Risks for each of all eight outcomes examined were markedly elevated in the discharged cohort relative to the comparators. Within 10 years of first discharge, the cumulative incidence of death, self-harm, committing a violent crime, or hospitalisation due to interpersonal violence was 32·0% (95% CI 31·6-32·5) in the discharged cohort (37·1% [36·5-37·8] in men and 27·2% [26·7-27·8] in women). Absolute risk of at least one adverse outcome occurring within this timeframe were highest in people diagnosed with a psychoactive substance use disorder at first discharge (cumulative incidence 49·4% [48·4-50·4]), and lowest in those diagnosed with a mood disorder (24·4% [23·6-25·2]). For suicide and non-fatal self-harm, risks were especially high during the first 3 months post-discharge, whereas risks for accidental death, violent criminality, and hospitalisation due to violence were more constant throughout the 10-year follow-up.

INTERPRETATION

People discharged from inpatient psychiatric care are at higher risk than the rest of the population for a range of serious fatal and non-fatal adverse outcomes. Improved inter-agency liaison, intensive follow-up immediately after discharge, and longer-term social support are indicated.

FUNDING

Medical Research Council, European Research Council, and Wellcome Trust.

Extreme challenges: psychiatric inpatients with severe self-harming behavior in Norway: a national screening investigation

BACKGROUND

Extreme self-harming behavior is a major challenge for patients and health services. Nevertheless, this patient population is poorly described in research literature.

AIMS

The aim of this study was to assess the volume of patients with extensive psychiatric hospitalization due to extreme self-harming behaviors, the extent of severe medical sequelae, and collaboration problems within health services.

METHODS

In a national screening investigation, department managers in 83 adult psychiatric inpatient institutions across all health regions in Norway were invited to participate in a brief, prepared, telephone interview.

RESULTS

Sixty-one interviews were completed. Extensive hospitalization (prolonged or multiple) due to extreme self-harm was reported for the last year in all health regions and in 427 individual cases. Mean number of cases did not differ by region. Psychiatric hospitalizations were more frequent in hospital units than mental health centers. In 109 of the cases, self-harming behavior had severe medical consequences, including five deaths. In 122 of the cases, substantial collaboration problems within the health services were reported (disagreements on diagnosis, treatment needs and resources). Extensive (long-term) hospitalization was particularly associated with the combination of severe medical sequelae and collaboration problems.

CONCLUSION

This investigation confirms a noteworthy, nationwide, population of severely self-harming inpatients with extensive health service use, prevalent severe medical complications, and unsatisfactory collaboration within health services. These preliminary results are alarming, and indicate a need for more profound understanding of highly complex and severe cases.

Injuries prior and subsequent to index poisoning with medication among adolescents: a national study based on Norwegian patient registry

BACKGROUND

Adolescents treated for self-poisoning with medication have a high prevalence of mental health problems and constitute a high-risk population for self-harm repetition. However, little is known about whether this population is also prone to injuries of other forms.

METHODS

Data were extracted from the Norwegian Patient Registry to include all incidents of treated injuries in adolescents aged 10-19 years who were treated for self-poisoning with medication during 2008-2011. This longitudinal approach allowed for the inclusion of injuries of various forms both before and after the index poisoning with medication. Gender differences and associations of injuries with recorded deliberate self-harm or psychiatric comorbidity at index poisoning were analysed. Forms of injury and psychiatric illnesses were coded according to the ICD-10 system.

RESULTS

1497 adolescents treated for self-poisoning with medication were identified from the source database, including 1144 (76.4%) girls and 353 (23.6%) boys. For these 1497 adolescents a total of 2545 injury incidents were recorded in addition to the index poisoning incidents, consisting of 778 injury incidents taking place before the index poisoning and 1767 incidents taking place subsequently. Altogether 830 subjects (55.4%) had an injury treated either before or after the index poisoning. Injuries to the hand and wrist as well as injuries to the head, neck and throat were predominant in males. Females were more likely to repeat poisoning with medication, particularly those with psychiatric disorders.

CONCLUSION

Adolescents treated for poisoning with medication represent a high-risk population prone to both prior and subsequent injuries of other forms, and should be assessed for suicidal intent and psychiatric illness.

Overdoses with Aripiprazole: Signs, Symptoms and Outcome in 239 Exposures Reported to the Danish Poison Information Centre

The aim of this study was to characterize the clinical signs and symptoms of exposures to aripiprazole overdoses. We retrospectively identified all aripiprazole exposures reported to the Danish Poison Information Centre (DPIC) from June 2007 to May 2015. Information concerning demographics, ingested dose and symptoms was extracted from the DPIC database and medical records. Information on death and admission to hospital was obtained from Danish national registers. We analysed 239 cases, 86 concerning single-drug exposures to aripiprazole, and 153 cases where aripiprazole had been taken with at least one other substance (mixed-drug). The median ingested aripiprazole dose was 105 mg (IQR: 50-1680 mg) in the single-drug exposure group and 120 mg (IQR: 60-225 mg) in the mixed-drug exposure group. The most commonly reported symptom was light sedation, reported in 63% of the single-drug group and 50% of the mixed-drug exposure group. There were no malignant arrhythmias or ECG abnormalities after single-drug exposures. No deaths were recorded in relation to the intake. We found a long-term mortality rate of 13 deaths per 1000 person-years (95% CI: 7; 23 per 1000 person-years), which is significantly higher than in an age- and gender-matched background population. In conclusion, we found that aripiprazole overdoses had few and mild symptoms predominantly related to the sedative properties. We detected a benign cardiovascular safety profile and no new safety concerns. Our findings may support an increased threshold of 300 mg for hospital admission after a single-drug exposure with aripiprazole and symptoms not worse than light sedation.

Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm

OBJECTIVE

To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations.

METHOD

Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm.

RESULTS

The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care.

CONCLUSION

The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.

Borderline Personality Disorder and Posttraumatic Stress Disorder at Psychiatric Discharge Predict General Hospital Admission for Self-Harm

We investigated whether posttraumatic stress disorder (PTSD) was predictor of suicidal behavior even when adjusting for comorbid borderline personality disorder (BPD) and other salient risk factors. To study this, we randomly selected 308 patients admitted to a psychiatric hospital because of suicide risk. Baseline interviews were performed within the first days of the stay. Information concerning the number of self-harm admissions to general hospitals over the subsequent 6 months was retrieved through linkage with the regional hospital registers. A censored regression analysis of hospital admissions for self-harm indicated significant associations with both PTSD (β = .21, p < .001) and BPD (β = .27, p < .001). A structural model comprising two latent BPD factors, dysregulation and relationship problems, as well as PTSD and several other variables, demonstrated that PTSD was an important predictor of the number of self-harm admissions to general hospitals(B = 1.52, p < .01). Dysregulation predicted self-harm directly (B = 0.28, p < .05), and also through PTSD [corrected]. These results suggested that PTSD and related dysregulation problems could be important treatment targets for a reduction in the risk of severe self-harm in high-risk psychiatric patients.