Six year follow-up of a clinical sample of self-harm patients

Randomised controlled trial of a psychotherapeutic intervention to improve quality of life and other outcomes in people who repeatedly self-harm: FReSH START study protocol

BACKGROUND

Self-harm is a major public health challenge, and repeated self-harm is common in those attending hospital following an episode. Evidence suggests psychological interventions could help people who self-harm, but few definitive studies have assessed their clinical and cost-effectiveness. Repeated self-harm is associated with poor quality of life, depression, suicide and increased health service costs which justify the development of psychotherapeutic interventions tailored for people with repeated self-harm.

METHODS

FReSH START is a multicentre individually 1:1 randomised controlled trial evaluating the clinical and cost-effectiveness of standard care plus psychological therapy or standard care alone for adults (≥ 18 years) presenting at an emergency department (ED) with repeated self-harm. Recruiting 630 participants, it includes an internal pilot, economic evaluation and process evaluation. The intervention will be delivered by mental health staff working in acute settings, with experience of assessing and managing risk in people presenting to emergency services with self-harm. Staff will be trained and supervised to deliver one of three specially adapted therapies: psychodynamic interpersonal therapy, cognitive behavioural therapy or acceptance and commitment therapy. Participants allocated to the intervention will receive one of the adapted therapies according to therapist allocation for up to 6 months via 12 weekly, one to one, 45-50-min sessions. The primary outcome is quality of life measured by the Clinical Outcomes in Routine Evaluation Outcome Measure at 12 months post-randomisation. Secondary outcomes include suicidal intent, depression and cost-effectiveness. Data are collected using hospital attendance records and online/postal/telephone questionnaires at 6 and 12 months post-randomisation, with resource use additionally collected at 3 and 9 months.

DISCUSSION

This protocol outlines a randomised controlled trial to investigate whether modified therapies are cost-effective and improve quality of life for people who repeatedly self-harm. Few interventions are proven to be deliverable in the NHS for this population. This study is strengthened by the involvement of qualified mental health workers experienced in managing risk as therapists.

TRIAL REGISTRATION

Registered on August 03, 2021. IRAS number: 297939. ISRCTN: https://doi.org/10.1186/ISRCTN73357210 . REC reference: 21/EE/0145.

SPONSOR

University of Leeds.

Nonsuicidal self-injury as the gateway and consequence of suicidal ideation among adolescents: a cross-lagged regression analysis

Background

There is a consensus that both nonsuicidal self-injury (NSSI) and suicidal ideation as risk factors for suicidal behavior have a strong connection. However, a lack of longitudinal information has limited the clarification of the concrete relationship between them.

Aims

This study aimed to examine the specific mechanism between NSSI and suicidal ideation over time, during adolescence.

Method

A longitudinal study was conducted with 193 Chinese adolescents. NSSI and suicidal ideations were examined over the course of a 1year followed-up, and three waves of data were collected.

Results

The NSSI at time T1 significantly positively predicted suicidal ideation at time T2; Suicidal ideation at time T2 also significantly positively predicted NSSI at time T3.

Limitations

Given that the small number of participants with suicidal ideation and NSSI, the findings of the study should be interpreted with caution and a lager sample is needed in the future.

Conclusion

It was suggested that NSSI may occur before suicidal ideation, which in turn would strengthen NSSI, so interventions should be carried out from two aspects (behaviors and thoughts) to improve adolescents' mental health.

Clinical characteristics and 6-month follow-up of adults with and without alcohol use disorder who self-harm

Background

Alcohol use disorder (AUD) is associated with suicidal behavior, but prospective clinical studies are lacking.

Aim

To compare clinical characteristics and 6-month outcomes in persons with and without AUD who self-harm.

Methods

804 adults (mean age 33, age range 18-95, 541 women and 263 men, 666 with suicide attempts and 138 with non-suicidal self-injuries at index) at three Swedish university hospitals took part in a research interview that included the Mini International Neuropsychiatric Interview (MINI). Subsequent non-fatal suicidal behavior within six months was identified by record review; suicides were identified by national register.

Results

At index, 39% of the men and 29% of the women had AUD. Over two thirds of these cases (69%) were identified by the MINI, but not by clinical AUD diagnosis. While trait impulsivity was more common among persons with AUD than those without (56% vs 36%, P adj = <.001), impulsivity in connection with the index attempt was noted in half of the participants in each group (48% vs 52%, P adj = 1). Subsequent suicidal behavior (fatal/non-fatal) occurred in 67 persons with AUD (26%) and in 98 without AUD (18%), a 60% higher risk among persons with AUD (OR = 1.60, 95% [CI 1.13-2.28], P = .009). Four persons with AUD (2%) and six without (1%) died by suicide within 6 months.

Conclusion

Almost a third of patients presenting at psychiatric emergency settings after self-harm fulfilled criteria for AUD, but clinicians often missed this diagnosis. Risk for subsequent suicidal behavior was elevated in patients with AUD. Educational interventions to improve recognition of alcohol use disorder may aid clinicians in the assessment and management of patients who present with self-harm.

Does the need for uniqueness lead to non-suicidal self-injury? The mediation of depression and the moderation of gender

Objective

Based on the integrated theoretical model of the development and maintenance of non-suicidal self-injury (NSSI) and gender role theory, this study investigated the longitudinal impact of the need for uniqueness on NSSI among adolescents, and the mediating role of depression and the moderating role of gender.

Participants

A total of 1,166 middle school students (Mean age = 13.04, SDage = 0.78, range = 11-16) from a city in central China was recruited to complete the Need for Uniqueness Scale, Depression Scale, and Adolescent Self-Injury Questionnaire at two waves. The participants included 475 boys and 457 girls.

Methods

Convenience sampling was used, and a longitudinal study (2 time points with a 6-month interval) was conducted to test our hypotheses. SPSS 25.0 was used to evaluate reliability, and to calculate descriptive statistics and Pearson correlation. PROCESS version 3 was used to test longitudinal relationships among the need for uniqueness, depression and NSSI, and construct a moderated mediation model.

Results

Results revealed that T1 need for uniqueness in adolescents was significantly positively associated with T2 NSSI and T2 depression, and T2 depression was significantly positively associated with T2 NSSI. After controlling for gender, T1 need for uniqueness positively predicted T2 NSSI. Furthermore, the mediation analysis demonstrated that the pathway linking T1 need for uniqueness to T2 NSSI through T2 depression was statistically significant. Moreover, gender moderated the indirect effect from T2 depression to T2 NSSI in the association between T1 need for uniqueness and T2 NSSI. Compared to boys in the same situation, girls who are susceptible to depression were more likely to commit NSSI.

Conclusion

This study demonstrated that the need for uniqueness in adolescents longitudinally predicts NSSI through the mediating role of depression and gender moderates the indirect effect from depression to NSSI. The current study not only suggests that the need for uniqueness is a risk factor for NSSI among adolescents, but also provides an empirical basis for the prevention and intervention of NSSI.

Self-, other-, and dual-harm during adolescence: a prospective-longitudinal study of childhood risk factors and early adult correlates

BACKGROUND

Little is known about the childhood antecedents and adult correlates of adolescent dual-harm (i.e. co-occurring self- and other-harm). We examine the longitudinal associations between (a) social and psychological risk factors in childhood and adolescent dual-harm and (b) adolescent dual-harm and social and mental health impairments in early adulthood.

METHODS

Participants (N = 1482) are from a prospective longitudinal community-representative study. Dual-, self-, and other-harm were self-reported at ages 13, 15, and 17. Social and psychological risk factors in childhood were assessed between 7 and 11; early adult correlates at age 20. Groups with dual-harm, self-harm only, other-harm only, and no harm were compared.

RESULTS

Between 13 and 17, 7.2% of adolescents reported dual-harm (self-harm only: 16.2%; other-harm only: 13.3%). Some childhood risk factors (e.g. sensation-seeking, parental divorce, victimization by peers) characterized all harm groups; others were common to the dual- and self-harm (anxiety/depressive symptoms, relational aggression) or dual- and other-harm groups only (low self-control, substance use, delinquency). Adolescents with dual-harm had reported more physical aggression and harsh parenting, and lower school bonding in childhood than any other group. In early adulthood, they reported more anxiety/depressive symptoms, psychopathy symptoms, homicidal ideations, delinquency, and victimization experiences than any other group.

CONCLUSIONS

Adolescent dual-harm follows psychological problems and social disconnection in childhood and signals risk of psychopathology and isolation in early adulthood. To curb the burden from dual-harm, interventions must target adolescents, families, peer networks, and school environments. Differentiating youth with dual-harm from those with single-harm is important for developing personalized treatments.

What helps people to reduce or stop self-harm? A systematic review and meta-synthesis of first-hand accounts

BACKGROUND

Self-harm is an important public health problem but therapeutic interventions, particularly for people who have a history of multiple repetition, are not always taken up or effective when they are. The aim of this review is to explore first-hand accounts of what helps outside therapy and identify actions and processes, which can support the reduction or cessation of self-harm.

METHODS

A systematic review and thematic meta-synthesis of the first-person accounts of what has helped to reduce or stop self-harm reported in primary studies.

RESULTS

The meta-synthesis combined 546 participant excerpts from 56 studies. Two over-arching themes were identified: (i) breaking the chain incorporated actions taken to break the link between a person's current psychological or social state and the act of self-harm and (ii) building a new foundation for change captured actions over the longer-term, focusing on practical changes in relationships and in a person's way of life, such as work or living arrangements.

CONCLUSIONS

The results emphasize the importance of interpersonal change in reducing or stopping self-harm. While interpersonal factors are acknowledged as important reasons behind self-harm, they are often under-represented in self-management advice and therapeutic interventions that focus on individual psychopathology.

Risk of repeat self-harm and suicide death following an episode of hospital self-harm presentation among adolescents and young adults

BACKGROUND

Self-harm is a critical issue affecting young people which could result in adverse outcomes including repeat episodes and suicide. In this study, we aimed to estimate the short-term and long-term risk of repeat self-harm and subsequent suicide death following self-harm presentations among adolescents and young adults.

METHODS

Using linked data from the New South Wales (NSW) Emergency Department Data Collection (EDDC), the NSW Admitted Patient Data Collection (APDC), and cause of death unit record file (COD-URF), we collected all self-harm presentations to emergency departments and/or hospitals and suicide deaths between 2012 and 2019 in NSW, Australia. We used survival analysis models to estimate the incidence of repeat self-harm and suicide by time since the index self-harm and relative risks by sex, type of hospital presentation and count of self-harm records.

RESULTS

In total, we identified 81,133 self-harm episodes among 48,547 individuals aged 10-29 years. Of 48,547 individuals who engaged in an index self-harm during the study period, 39.5 % (19,180) were aged between 15 and 19 years. The incidence of both repeat self-harm and suicide were highest in the year following the index self-harm presentation (repeat self-harm: 188.84 per 1000 person-years; suicide: 3.30 per 1000 person-years) and declined to 14.51 and 0.28 per 1000 person-years after five years. Among individuals indexed for self-harm at 15-29 years, males and those who were admitted to hospital for the index self-harm had the highest risk of both subsequent repeat self-harm and suicide death and those with 2 or more self-harm presentation records had the higher risk for subsequent suicide death.

CONCLUSION

Adolescents and young adults with self-harm presentations were at a high risk of subsequent repeat self-harm and suicide death, especially the first year after presentations. Youth-specific early intervention and long-term management should be delivered accordingly, especially for those at early adolescence .

The associations between depressive symptoms, functional impairment, and quality of life, in patients with major depression: undirected and Bayesian network analyses

BACKGROUND

Depressive symptoms, functional impairment, and decreased quality of life (QOL) are three important domains of major depressive disorder (MDD). However, the possible causal relationship between these factors has yet to be elucidated. Moreover, it is not known whether certain symptoms of MDD are more impairing than others. The network approach is a promising solution to these shortfalls.

METHODS

The baseline data of a multicenter prospective project conducted in 11 governances of China were analyzed. In total, 1385 patients with MDD were included. Depressive symptoms, functioning disability, and QOL were evaluated by the 17-item Hamilton Depression Rating Scale (HAMD-17), the Sheehan Disability Scale (SDS), and the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF). The network was estimated through the graphical Least Absolute Shrinkage and Selection Operator (LASSO) technique in combination with the directed acyclic graph.

RESULTS

Three centrality metrics of the graphical LASSO showed that social life dysfunction, QOL, and late insomnia exhibited the highest strength centrality. The network accuracy and stability were estimated to be robust and stable. The Bayesian network indicated that some depressive symptoms were directly associated with QOL, while other depressive symptoms showed an indirect association with QOL mediated by impaired function. Depressed mood was positioned at the highest level in the model and predicted the activation of functional impairment and anxiety.

CONCLUSIONS

Functional disability mediated the relationship between depressive symptoms and QOL. Family functionality and suicidal symptoms were directly related to QOL. Depressed mood played the predominant role in activating both anxiety symptom and functional impairment.

Means restriction for the prevention of suicide on roads

BACKGROUND

Road traffic suicides are common. However, due to the difficulty in distinguishing between motor vehicle crash fatalities and actual suicides, no official figures exist for this method of suicide. Restricting access to means is an important universal or population-based approach to suicide prevention with clear evidence of its effectiveness. However, the evidence with respect to means restriction for the prevention of suicide on roads is not well established. We conducted a systematic review to assess the impact of restrictions on the availability of, or access to, means of suicide on roads.

OBJECTIVES

To evaluate the effectiveness of interventions to restrict the availability of, or access to, means of suicide on roads.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, and the Transport Research International Documentation (TRID) Database from the date of database inception to March 2020. We conducted searches of the World Health Organization International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov to identify unpublished and ongoing studies. We applied no date, language, or publication status restrictions to these searches.

SELECTION CRITERIA

Eligible studies were randomised or quasi-randomised controlled trials, controlled intervention studies without randomisation, before-after studies, or studies using interrupted time series designs, which evaluated interventions to restrict the availability of, or access to, means of suicide on roads.

DATA COLLECTION AND ANALYSIS

Two review authors screened abstracts and full-text publications against the inclusion criteria. Two review authors planned to independently extract data and assess risk of bias of included studies. However, we identified no studies eligible for inclusion.

MAIN RESULTS

We identified no studies that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

This systematic review highlights the paucity of research around road traffic suicides and the need for future robust studies that aim to investigate the effectiveness of interventions to prevent suicide on roads. Suicide ascertainment is a key issue; therefore, clear objective criteria are necessary in order to scale up and study this method more accurately. In the absence of any substantial evidence, we advocate for more awareness on road traffic suicides and its inclusion in future government suicide prevention policies. Further research exploring effective measures, particularly those that do not require driver compliance, are also needed.

Means restriction for the prevention of suicide by jumping

BACKGROUND

Jumping from a height is an uncommon but lethal means of suicide. Restricting access to means is an important universal or population-based approach to suicide prevention with clear evidence of its effectiveness. However, the evidence with respect to means restriction for the prevention of suicide by jumping is not well established.

OBJECTIVES

To evaluate the effectiveness of interventions to restrict the availability of, or access to, means of suicide by jumping. These include the use of physical barriers, fencing or safety nets at frequently-used jumping sites, or restriction of access to these sites, such as by way of road closures.

SEARCH METHODS

We searched the Cochrane Library, Embase, MEDLINE, PsycINFO, and Web of Science to May 2019. We conducted additional searches of the international trial registries including the World Health Organization International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov, to identify relevant unpublished and ongoing studies. We searched the reference lists of all included studies and relevant systematic reviews to identify additional studies and contacted authors and subject experts for information on unpublished or ongoing studies. We applied no restrictions on date, language or publication status to the searches. Two review authors independently assessed all citations from the searches and identified relevant titles and abstracts. Our main outcomes of interest were suicide, attempted suicide or self-harm, and cost-effectiveness of interventions.

SELECTION CRITERIA

Eligible studies were randomised or quasi-randomised controlled trials, controlled intervention studies without randomisation, before-and-after studies, or studies using interrupted time series designs, which evaluated interventions to restrict the availability of, or access to, means of suicide by jumping.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion and three review authors extracted study data. We pooled studies that evaluated similar interventions and outcomes using a random-effects meta-analysis, and we synthesised data from other studies in a narrative summary. We summarised the quality of the evidence included in this review using the GRADE approach.

MAIN RESULTS

We included 14 studies in this review. Thirteen were before-and-after studies and one was a cost-effectiveness analysis. Three studies each took place in Switzerland and the USA, while two studies each were from the UK, Canada, New Zealand, and Australia respectively. The majority of studies (10/14) assessed jumping means restriction interventions delivered in isolation, half of which were at bridges. Due to the observational nature of included studies, none compared comparator interventions or control conditions. During the pre- and postintervention period among the 13 before-and-after studies, a total of 742.3 suicides (5.5 suicides per year) occurred during the pre-intervention period (134.5 study years), while 70.6 suicides (0.8 suicides per year) occurred during the postintervention period (92.4 study years) - a 91% reduction in suicides. A meta-analysis of all studies assessing jumping means restriction interventions (delivered in isolation or in combination with other interventions) showed a directionality of effect in favour of the interventions, as evidenced by a reduction in the number of suicides at intervention sites (12 studies; incidence rate ratio (IRR) = 0.09, 95% confidence interval (CI) 0.03 to 0.27; P < 0.001; I2 = 88.40%). Similar findings were demonstrated for studies assessing jumping means restriction interventions delivered in isolation (9 studies; IRR = 0.05, 95% CI 0.01 to 0.16; P < 0.001; I2 = 73.67%), studies assessing jumping means restriction interventions delivered in combination with other interventions (3 studies; IRR = 0.54, 95% CI 0.31 to 0.93; P = 0.03; I2 = 40.8%), studies assessing the effectiveness of physical barriers (7 studies; IRR = 0.07, 95% CI 0.02 to 0.24; P < 0.001; I2 = 84.07%), and studies assessing the effectiveness of safety nets (2 studies; IRR = 0.09, 95% CI 0.01 to 1.30; P = 0.07; I2 = 29.3%). Data on suicide attempts were limited and none of the studies used self-harm as an outcome. There was considerable heterogeneity between studies for the primary outcome (suicide) in the majority of the analyses except those relating to jumping means restriction delivered in combination with other interventions, and safety nets. Nevertheless, every study included in the forest plots showed the same directional effects in favour of jumping means restriction. Due to methodological limitations of the included studies, we rated the quality of the evidence from these studies as low. A cost-effectiveness analysis suggested that the construction of a physical barrier on a bridge would be a highly cost-effective project in the long term as a result of overall reduced suicide mortality.

AUTHORS' CONCLUSIONS

The findings from this review suggest that jumping means restriction interventions are capable of reducing the frequency of suicides by jumping. However, due to methodological limitations of included studies, this finding is based on low-quality evidence. Therefore, further well-designed high-quality studies are required to further evaluate the effectiveness of these interventions, as well as other measures at jumping sites. In addition, further research is required to investigate the potential for suicide method substitution and displacement effects in populations exposed to interventions to prevent suicide by jumping.

Self-reported disability and quality of life in an online Australian community sample with suicidal thoughts

BACKGROUND

Limited research has been conducted to quantify the level of disability and health related quality of life (HRQoL) associated with suicidal thoughts and behaviour. The aims of the current study were to (1) describe levels of disability and HRQoL in an Australian sample of adults with suicidal ideation, (2) examine the effect of zero, one, or more than one previous suicide attempt on disability and HRQoL, and (3) describe the demographic and clinical characteristics associated with disability and HRQoL.

METHOD

Data for the current study is drawn from the baseline assessment of the Healthy Thinking trial that evaluated the effectiveness of an online self-help program for suicidal thoughts in an Australian adult community sample (n = 418). Measures of disability, quality of life, clinical symptoms, suicidality and demographic variables were included.

RESULTS

The mean disability score for the overall sample was 19.2 (SD = =8.9), while the mean perceived physical health score was 40.7 (SD = =6.5) and the mean perceived mental health score was 36.1 (SD = =5.9). Higher levels of disability and lower levels of perceived physical health were associated with multiple suicide attempts compared to one or no history of suicide attempt.

LIMITATIONS

Limitations included the limited generalisability of results, the use of self-report to assess suicide attempts, and the use of cross-sectional data.

CONCLUSION

Suicidal thoughts and behaviours are associated with high levels disability and low levels of perceived physical and mental health. Early intervention programs are needed to reduce the high levels of burden associated with suicidality.

Suicide risk, personality disorder and hospital admission after assessment by psychiatric emergency services

BACKGROUND

The main objectives of the mobile Psychiatric Emergency Services (PES) in the Netherlands are to assess the presence of a mental disorder, to estimate risk to self or others, and to initiate continuity of care, including psychiatric hospital admission. The aim of this study was to assess the associations between the level of suicidality and risk of voluntary or involuntary admission in patients with and without a personality disorder who were presented to mobile PES.

METHODS

Observational data were obtained in three areas of the Netherlands from 2007 to 2016. In total, we included 71,707 contacts of patients aged 18 to 65 years. The outcome variable was voluntary or involuntary psychiatric admission. Suicide risk and personality disorder were assessed by PES-clinicians. Multivariable regression analysis was used to explore associations between suicide risk, personality disorder, and voluntary or involuntary admission.

RESULTS

Independently of the level of suicide risk, suicidal patients diagnosed with personality disorder were less likely to be admitted voluntarily than those without such a diagnosis (admission rate .37 versus .46 respectively). However, when the level of suicide risk was moderate or high, those with a personality disorder who were admitted involuntarily had the same probability of involuntary admission as those without such a disorder.

CONCLUSIONS

While the probability of voluntary admission was lower in those diagnosed with a personality disorder, independent of the level of suicidality, the probability of involuntary admission was only lower in those whose risk of suicide was low. Future longitudinal studies should investigate the associations between (involuntary) admission and course of suicidality in personality disorder.

Meta-analysis of suicide rates among people discharged from non-psychiatric settings after presentation with suicidal thoughts or behaviours

OBJECTIVE

To quantify the suicide rate among people discharged from non-psychiatric settings after presentations with suicidal thoughts or behaviours.

METHOD

Meta-analysis of studies reporting suicide deaths among people with suicidal thoughts or behaviours after discharge from emergency departments or the medical or surgical wards of general hospitals.

RESULTS

A total of 115 studies reported 167 cohorts and 3747 suicide deaths among 248 005 patients during 1 263 727 person-years. The pooled suicide rate postdischarge was 483 suicide deaths per 100 000 person-years (95% confidence interval (CI) 445-520, prediction interval (PI) 200-770) with high between-sample heterogeneity (I²  = 92). The suicide rate was highest in the first year postdischarge (851 per 100 000 person-years) but remained elevated in the long term. Suicide rates were elevated among samples of men (716 per 100 000 person-years) and older people (799 per 100 000 person-years) but were lower in samples of younger people (107 per 100 000 person-years) and among studies published between 2010 and 2018 (329 per 100 000 person-years).

CONCLUSIONS

People with suicidal thoughts or behaviours who are discharged from non-psychiatric settings have highly elevated rates of suicide despite a clinically meaningful decline in these suicide rates in recent decades.

Alexithymia and Its Associations With Depression, Suicidality, and Aggression: An Overview of the Literature

Depression affects around 4-10% of the general population in England. Depression can often lead to behaviors and thoughts related to suicide and aggression, which have a social and economic burden to the United Kingdom. One construct that has been theorized as having an association with these behaviors is alexithymia. People with alexithymia have difficulties identifying and describing their emotional experiences. To date, there is no consensus on types or causes of alexithymia. Whilst the literature evidences a strong relationship between alexithymia and suicidality and aggression, little is known about the nature of this relationship. The present article will attempt to describe the extant literature on this relationship, drawing out some of the contentions and unanswered questions.

Retention strategies in longitudinal cohort studies: a systematic review and meta-analysis

BACKGROUND

Participant retention strategies that minimise attrition in longitudinal cohort studies have evolved considerably in recent years. This study aimed to assess, via systematic review and meta-analysis, the effectiveness of both traditional strategies and contemporary innovations for retention adopted by longitudinal cohort studies in the past decade.

METHODS

Health research databases were searched for retention strategies used within longitudinal cohort studies published in the 10-years prior, with 143 eligible longitudinal cohort studies identified (141 articles; sample size range: 30 to 61,895). Details on retention strategies and rates, research designs, and participant demographics were extracted. Meta-analyses of retained proportions were performed to examine the association between cohort retention rate and individual and thematically grouped retention strategies.

RESULTS

Results identified 95 retention strategies, broadly classed as either: barrier-reduction, community-building, follow-up/reminder, or tracing strategies. Forty-four of these strategies had not been identified in previous reviews. Meta-regressions indicated that studies using barrier-reduction strategies retained 10% more of their sample (95%CI [0.13 to 1.08]; p = .01); however, studies using follow-up/reminder strategies lost an additional 10% of their sample (95%CI [- 1.19 to - 0.21]; p = .02). The overall number of strategies employed was not associated with retention.

CONCLUSIONS

Employing a larger number of retention strategies may not be associated with improved retention in longitudinal cohort studies, contrary to earlier narrative reviews. Results suggest that strategies that aim to reduce participant burden (e.g., flexibility in data collection methods) might be most effective in maximising cohort retention.

School- and class-level variation in self-harm, suicide ideation and suicide attempts in Danish high schools

Aim: Strong associations have been found between being exposed to self-harm in family and friends and own self-harm in adolescence. Therefore, self-harm and suicide behaviour might tend to cluster within school and school classes. The aim of this study was to describe the prevalence, frequency and type of self-harm, suicide ideation and suicide attempts within Danish high schools and to test whether self-harm and suicide behaviour cluster in schools and school classes. Methods: Data came from the Danish National Youth Study 2014, a national survey. The respective study included 66,284 high-school students nested in 117 schools and 3146 school classes. The prevalence and clustering of self-harm behaviour, ever and within the last year, type of self-harm (e.g. cutting, burning, scratching and hitting) and suicide ideation and suicide attempts were investigated. Multi-level logistic regression was applied to quantify clustering among participants within the same class and school. Results: In total, 12,960 (20%) reported self-harm ever and 5706 (8.6%) within the last year. Prevalence was higher among girls than boys. Among girls, cutting (15%) and scratching (13%) was the most common type of self-harm, whereas among boys, hitting (6.7%) was most prevalent. The degree of clustering of self-harm and suicide behaviour was low, with school-level intra-class correlation coefficients (ICC) ranging from 0.8–1.8% and school class level ICC’s from 4.3–6.8%. Conclusions: This study shows that self-harm was common, especially in girls. The degree of clustering of self-harm and suicide behaviour in school and school classes was low.

Self-injury and suicide behavior among young people with perceived parental alcohol problems in Denmark: a school-based survey

The aim of this study was to test the hypothesis that young people who perceive their parents to have alcohol problems are more likely to self-injure, have suicide ideation, and to attempt suicide than young people without parental alcohol problems. We also tested whether the association between parental alcohol problems and self-injury, suicide ideation, and suicide attempt among young people differed depending on the gender of the child and the parent. Data came from the Danish National Youth Study 2014, a web-based national survey. A total of 75,853 high school and vocational school students participated. Self-injury, suicidal ideation, and suicide attempts were outcomes and the main exposure variables were perceived parental alcohol problems, gender of the parent with alcohol problems, cohabitation with a parent with alcohol problems, and severity of the parents' alcohol problems. Young people with parental alcohol problems had higher odds of self-injury [boys: OR = 1.59 (95% CI 1.40-1.82); girls: OR = 1.84 (95% CI 1.69-1.99)], suicidal ideation [boys: OR = 1.81 (95% CI 1.59-2.06); girls: OR 1.74 (95% CI 1.59-1.89)], and suicide attempt [boys: OR = 2.10 (95% CI 1.63-2.71); girls: OR = 2.09 (95% CI 1.80-2.42)] compared to young people without parental alcohol problems. Girls with parental alcohol problems had higher odds of self-injury than boys with parental alcohol problems, whereas no gender differences were found for suicidal ideation and suicide attempts. Also no differences were found depending on the gender of the parent with alcohol problems. This study shows that young people with parental alcohol problems have higher odds of self-injury, suicide ideation, and suicide attempts.

Surviving moment to moment: The experience of living in a state of ambivalence for those with recurrent suicide attempts

OBJECTIVE

This qualitative study aimed to capture the experience of living in the ambivalent space between life and death for adults with recurrent suicide attempts (RSA). It sought to expand upon an earlier study that explored the processes involved in transitioning away from RSA among adults, which revealed that occupying this ambivalent space is a crucial part of this process.

DESIGN

Interpretive phenomenological analysis (IPA) was used. This methodology was designed to explore the lived experiences and meaning making and enabled interpretation of the multidimensional subjective experiences of RSA participants.

METHODS

In-depth semi-structured interviews were conducted with eight adult women with a history of RSA who had participated in a therapeutic intervention at the research site (Skills for Safer Living: A Psychosocial/Psychoeducational Intervention for People with Recurrent Suicide Attempts [SfSL/PISA]). The six stages of IPA were followed to analyse the interview data.

RESULTS

Analysis revealed the superordinate theme, 'surviving moment to moment', which refers to a precarious state of making decisions about one's life and destiny on a moment-to-moment basis without clear commitment to either life or death. Two subordinate themes were identified: 'deciding not to die in the moment' when the participants were more invested in dying than living and 'deciding to live in the moment' when they were more invested in living than dying.

CONCLUSION

The study illuminated the complex process of making decisions about ones' destiny on a moment-to-moment basis. It revealed the torment experienced when occupying this state, while paradoxically, also revealing how indecision about life and death provided a lifeline opportunity for those with RSA. Clinicians who recognize the subtle distinctions associated with this in-between state can tailor their interventions accordingly.

PRACTITIONER POINTS

Surviving moment to moment is characterized by a state of emotional flux and uncertainty about one's destiny, where the person has not fully committed to either life or death. Within this state, there are two interlinked subprocesses, whereby the person is leaning more towards death or life. A critical feature in working with this client group is to recognize their ambiguity and the fragility and temporality of their decisions about their destiny. The practitioner has an opportunity to be a catalyst in the momentum towards life by demonstrating understanding of this survival struggle and tailoring intervention to fit with the nuanced processes within this state.

Mortality, functional and return to work outcomes of major trauma patients injured from deliberate self-harm

BACKGROUND

Self-harm and intentional injuries represent a significant public health concern. People who survive serious injury from self-harm can experience poor outcomes that negatively impact on their daily life. The aim of this study was to investigate a cohort of major trauma patients hospitalised for self-harm in Victoria, and to identify risk factors for longer term mortality, functional recovery and return to work.

METHOD

482 adult major trauma patients who were injured due to self-harm and survived to hospital discharge, and were captured by the population-based Victorian State Trauma Registry (VSTR), were included. For those with a date of injury from January 1, 2007 to December 31, 2013, demographics and injury event data, Glasgow Outcome Scale Extended (GOS-E) and return to work (RTW) outcomes at 6, 12 and 24 months post-injury were extracted from the registry. Post-discharge mortality was identified through the Victorian Registry of Births, Deaths and Marriages (BDM). Multivariable logistic regression was used to determine predictors of the GOS-E and RTW and survival analysis was used to identify predictors of mortality.

RESULTS

A total of 37 (7.7%) deaths occurred post-discharge. There were no clear predictors of all-cause mortality. Overall, 36% of patients reported making a good recovery at 24 months. Older age (p=0.01), transport-related methods of self-harm (p=0.02), higher Injury Severity Score (p<0.001) and having a Charlson Comorbidity Index weighting of one or more (p=0.02) were predictive of poorer functional recovery. Of patients who were working or studying prior to injury, 54% reported returning to work by 24 months post-injury. Higher Injury Severity Score was an important predictor of not returning to work (p=0.002).

CONCLUSION

The vast majority of major trauma patients who self-harmed and survived to hospital discharge were alive at two years post-injury, yet only half of this cohort returned to work and just over a third of patients experienced a good recovery.

[Self-injury in hospitalized patients: Concerning 19 cases]

INTRODUCTION

Self-mutilating behaviour is expanding, especially among adolescents and patients with a psychiatric disorder.

CLINICAL MATERIAL

We have tried to describe the self-mutilating behaviour in Moroccan inpatients of the psychiatric department of Mohammed V Military Hospital of Rabat, through a prospective and descriptive longitudinal study over a period of four months, based on a questionnaire prepared according to the literature data to allow discussing its results.

RESULTS

The rate of participation was 90.4%, or 19 patients. All patients were male. The age of onset of self-injury was between 14 and 62 years with an average of 26.3 years. Only two patients had an age of onset in adolescence, before age 20, the majority (57.8%) in a young adult age. Eight patients (42.1%) report having experienced physical abuse while only four patients were sexually abused, especially by relatives. The number of episodes varied from one episode in twelve cases (63.15%), to seven cases (37%) with repetitive self-mutilation. The most common type of self-injury was cuts (16 cases), twelve patients inflicted burns, and two patients inflicted fist blows. The forearm was the most common location. All patients were unable to resist the pressing need to self-harm after various reasons, often in a relational or professional frustration state. The use of concomitant substances to self-mutilation was reported in nine episodes, alcohol in seven episodes (24.1%) and cannabis in three episodes (10.3%). Only five patients reported receiving medical care for physical consequences of self-harm. Only two patients underwent a psychiatric care following their self-mutilation and admitted to our service. Personality disorders was the psychiatric disorder most diagnosed in our sample, followed by mood disorders. Borderline personality disorder was the pathological personality disorder most commonly diagnosed in our study with nearly two thirds of cases, followed by antisocial personality.

DISCUSSION

The size of our population and the prevalence of self-harm are comparable to most studies on self-mutilation in clinical populations. The low prevalence of patients beginning this behaviour early was low in our population, explained by the pre-commitment visits, which limit their integration into the military body. The role of physical and sexual abuse in childhood in the development of self-harm behaviour in adolescence is still a subject of discussion, but shame and fear of the breakdown of the family union have significantly limited the mention of such a history by our patients. The use of self-harm to relieve an intolerable anger thus the absence of suicidal intent, confirms the difference between self-harm and suicide. The intolerant nature of the military environment to self-behaviour limits its repetition and allows their early management. The high frequency of personality disorders in our sample is consistent with studies indicating high levels in patients who self-harm, including borderline personality, and supports that the DSM-IV considers self-harm to be a diagnostic criterion of this personality disorder.

CONCLUSION

Self-injury is a common pathological behaviour and serious in its relational impact. Our present data collected mainly similarities with that of the literature. For cultural reasons, the self-mutilation in our sample is more linked to an impulse control problem than to childhood abuse. So the establishment of a system of care adapted to preserve the privacy of patients, understanding of self-harm, informing the general public and the early treatment of victims of abusive families seems essential to reduce expansion of this behaviour.

An interpretative phenomenological analysis of the experience of self-harm repetition and recovery in young adults

Six young adults (aged 19-21 years) with repeat self-harm for over 5 years were interviewed about their self-harm, why they continued and what factors might help them to stop. Interpretative phenomenological analysis identified six themes: keeping self-harm private and hidden; self-harm as self-punishment; self-harm provides relief and comfort; habituation and escalation of self-harm; emotional gains and practical costs of cutting, and not believing they will stop completely. Young adults presented self-harm as an ingrained and purposeful behaviour which they could not stop, despite the costs and risks in early adulthood. Support strategies focused on coping skills, not just eradicating self-harm, are required.

Young people who self-harm: a prospective 1-year follow-up study

PURPOSE

To explore repetition, service provision and service engagement following presentation of young people to emergency services with self-harm.

METHODS

969 patients who presented to accident and emergency services after self-harm were followed up prospectively for a period of 1 year. Data on rates, method, clinical history, initial service provision, engagement and repetition (defined as re-presenting to emergency services with further self-harm) were gathered from comprehensive electronic records.

RESULTS

Young people were less likely to repeat self-harm compared to those aged 25 and above. A psychiatric history and a history of childhood trauma were significant predictors of repetition. Young people were more likely to receive self-help as their initial service provision, and less likely to receive acute psychiatric care or a hospital admission. There were no differences in engagement with services between young people and those aged 25 and above.

CONCLUSION

Younger individuals may be less vulnerable to repetition, and are less likely to represent to services with repeated self-harm. All young people who present with self-harm should be screened for mental illness and asked about childhood trauma. Whilst young people are less likely to be referred to psychiatric services, they do attend when referred. This may indicate missed opportunity for intervention.

Direct and indirect effects of maltreatment typologies on suicidality in a representative Northern Irish sample: Psychopathology only partially mediates the relationship

There has been a rise in suicide rates among men who grew up during the 1970's in Northern Ireland (NI). Conflict exposures (CEs) have been linked with suicide ideation but not attempts. Civil conflict has also been linked with aggressive parenting which is associated with the development of aggressive drives, psychopathology and suicidality. This study investigated (1) cohort specific associations between latent classes (LCs) of maltreatment and (2) associations between LCs, CEs, psychopathology and suicidality. Data were from NI Study of Health and Stress (N = 1986). Maltreatment and suicidality were queried using validated measures. Psychiatric assessments were based on DSM-IV criteria. Logistic regression, latent class analysis, chi square tests and mediation analyses were conducted. Two at risk LCs were identified, entitled "family violence exposure" (FVE, 10.4%; Male, 55.4%) and "family violence and sexual abuse exposure" (FVSAE, 1.2%; Female, 90.5%). Both were more likely to have experienced CEs (FVE = 71%; FVSAE = 77.5%) than the low risk class. The FVE were more likely to be male; aged 35-49 and to suffer from a mental disorder. The FVSAE class all endorsed rape, were more likely to be separated and to suffer from a mental disorder. CEs uniquely predicted ideation but not enactment. Psychopathology partially mediated the relationship between LCs and suicidality. FVE and FVSAE directly increased the odds of enactment. These findings are original and highly pertinent and they should be used to inform any strategy for addressing the cohort specific and trauma related rise in suicide rates in NI.

Suicidality among adolescents engaging in nonsuicidal self-injury (NSSI) and firesetting: the role of psychosocial characteristics and reasons for living

BACKGROUND

Co-occurrence of problem behaviors, particularly across internalizing and externalizing spectra, increases the risk of suicidality (i.e., suicidal ideation and attempt) among youth.

METHODS

We examined differences in psychosocial risk factors across levels of suicidality in a sample of 77 school-based adolescents engaging in both nonsuicidal self-injury (NSSI) and repeated firesetting. Participants completed questionnaires assessing engagement in problem behaviors, mental health difficulties, negative life events, poor coping, impulsivity, and suicidality.

RESULTS

Adolescents endorsing suicidal ideation reported greater psychological distress, physical and sexual abuse, and less problem solving/goal pursuit than those with no history of suicidality; adolescents who had attempted suicide reported more severe NSSI, higher rates of victimization and exposure to suicide, relative to those with suicidal ideation but no history of attempt. Additional analyses suggested the importance of coping beliefs in protecting against suicidality.

CONCLUSIONS

Clinical implications and suggestions for future research relating to suicide prevention are discussed.

The situation of former adolescent self-injurers as young adults: a follow-up study

BACKGROUND

Nonsuicidal self-injury (NSSI) in adolescence has been described as comorbid condition in affective or anxiety disorders, as well as borderline personality disorder (BPD) and is a risk factor for later suicide attempts. Prevalence rates of NSSI decline steeply from adolescence to young adulthood. Yet, to the best of our knowledge, the longitudinal development of adolescent psychiatric patients with NSSI into their young adulthood has not been investigated. The aim of this study was to assess current NSSI and psychological impairment of young adults, who had been in treatment for NSSI in their adolescence.

METHODS

Former patients of the departments of child and adolescent psychiatry and psychotherapy in Ulm and Ravensburg, Germany (N = 52), who presented with NSSI in their adolescence, were recruited (average age: 21.5 years (SD = 2.6)). Data was assessed using questionnaires and structured clinical interviews. Two groups of participants with prevailing NSSI and ceased NSSI were compared concerning their current psychological impairment, history of NSSI, suicide attempts, and BPD diagnosis.

RESULTS

Around half of all participants had engaged in NSSI within the last year, and around half met diagnostic criteria for BPD. Although there was no significant association between current NSSI and BPD, an earlier age of onset of NSSI and a longer duration of NSSI during adolescence was significantly predictive of adult BPD. Two thirds of participants still met criteria of an axis 1 psychiatric disorder. Suicide attempts were reported by 53.8 % of all participants. Participants with current NSSI were more likely to meet criteria for a current axis 1 disorder, had engaged in NSSI more often in their lifetime, and reported more suicide attempts.

CONCLUSIONS

Reduction of NSSI from adolescence to young adulthood was lower than described in previous community samples. This may be due to the initial high psychiatric impairment of this sample in adolescence. Early onset of NSSI seemed to be a risk factor for a longer duration of NSSI during adolescence but not for NSSI prevailing into adulthood. However, it was a risk factor for adult BPD. Furthermore, the occurrence of suicidal thoughts and behaviors and prevailing NSSI was highly associated.

The longitudinal course of non-suicidal self-injury and deliberate self-harm: a systematic review of the literature

Non-suicidal self-injury (NSSI) has been proposed as diagnostic entity and was added to the section 3 of the DSM 5. Nevertheless, little is known about the long-term course of this disorder and many studies have pointed to the fact that NSSI seems to be volatile over time. We aimed to assemble studies providing longitudinal data about NSSI and furthermore included studies using the definition of deliberate self-harm (DSH) to broaden the epidemiological picture. Using a systematic search strategy, we were able to retrieve 32 studies reporting longitudinal data about NSSI and DSH. We furthermore aimed to describe predictors for the occurrence of NSSI and DSH that were identified in these longitudinal studies. Taken together, there is evidence for an increase in rates of NSSI and DSH in adolescence with a decline in young adulthood. With regards to predictors, rates of depressive symptoms and female gender were often reported as predictor for both NSSI and DSH.

The iceberg of suicide and self-harm in Irish adolescents: a population-based study

PURPOSE

Suicide is a leading cause of death among adolescents. Self-harm is the most important risk factor for suicide, yet the majority of self-harm does not come to the attention of health services. The purpose of this study was to establish the relative incidence of adolescent suicide, hospital-treated self-harm and self-harm in the community.

METHODS

Annual suicide rates were calculated for 15-17 year-old in the Cork and Kerry region in Ireland based on data from the Central Statistics Office. Rates of hospital-treated self-harm were collected by the Irish National Registry of Deliberate Self-Harm. Rates of self-harm in the community were assessed using a survey of 3,881 adolescents, the Child and Adolescent Self-harm in Europe study.

RESULTS

The annual suicide rate was 10/100,000. Suicide was six times more common among boys than girls. The annual incidence rate of hospital-treated self-harm was approximately 344/100,000, with the female rate almost twice the male rate. The rate of self-harm in the community was 5,551/100,000, and girls were almost four times more likely to report self-harm. For every boy who died by suicide, 16 presented to hospital with self-harm and 146 reported self-harm in the community. For every female suicide, 162 girls presented to hospital with self-harm and 3,296 reported self-harm.

CONCLUSIONS

Gender differences in relative rates of self-harm and suicide are very large, with boys who have harmed themselves at particularly high risk of suicide. Knowledge of the relative incidence of self-harm and suicide in adolescents can inform prevention programmes and services.

Emergency Department Admission and Mortality Rate for Suicidal Behavior

Background: The international literature reports that for every completed suicide there are between 8 and 22 visits to an Emergency Department (ED) for attempted suicide/suicidal behavior. Aims: To describe the characteristics of admission to emergency departments (EDs) for suicide-related presenting complaints in the metropolitan area of Bologna; to estimate the risk for all-cause mortality and for suicide; to identify the profiles of subjects most at risk. Method: Follow-up of patients admitted to the EDs of the metropolitan area of Bologna between January 2004 and December 2010 for attempted suicide. A Cox model was used to evaluate the association between sociodemographic variables and the general mortality risk. Results: We identified 505 cases of attempted suicide, which were more frequent for female subjects, over the weekend, and at night (8:00 p.m./8:00 a.m.). The most used suicide methods were psychotropic drugs, sharp or blunt objects, and jumping from high places. In this cohort, 3.6% of subjects completed suicide (4.5% of males vs. 2.9% of females), 2.3% within 1 year of the start of follow-up. The most common causes of death were drug use and hanging. In the multivariate analysis, those who used illicit drugs 24 hr prior to admission to the ED (hazard ratio [HR] = 3.46, 95% CI = 1.23–9.73) and patients who refused the treatment (HR = 6.74, 95% CI = 1.86–24.40) showed an increased mortality risk for suicide. Conclusion: Deliberate self-harm patients presenting to the ED who refuse treatment represent a specific target group for setting up dedicated prevention schemes.

Investigating the role of executive attentional control to self-harm in a non-clinical cohort with borderline personality features

Self-injurious behavior (or self-harm) is a frequently reported maladaptive behavior in the general population and a key feature of borderline personality disorder (BPD). Poor affect regulation is strongly linked to a propensity to self-harm, is a core component of BPD, and is linked with reduced attentional control abilities. The idea that attentional control difficulties may provide a link between BPD, negative affect and self-harm has yet to be established, however. The present study explored the putative relationship between levels of BPD features, three aspects of attentional/executive control, affect, and self-harm history in a sample of 340 non-clinical participants recruited online from self-harm forums and social networking sites. Analyses showed that self-reported levels of BPD features and attentional focusing predicted self-harm incidence, and high attentional focusing increased the likelihood of a prior self-harm history in those with high BPD features. Ability to shift attention was associated with a reduced likelihood of self-harm, suggesting that good attentional switching ability may provide a protective buffer against self-harm behavior for some individuals. These attentional control differences mediated the association between negative affect and self-harm, but the relationship between BPD and self-harm appears independent.

Can early follow-up after deliberate self-harm reduce repetition? A prospective study of 325 patients

BACKGROUND

Patients who deliberately harm themselves often repeat their self-destructive acts. The objective of this study was to assess whether a follow-up visit within 10 days to a psychiatric consultant could reduce the frequency of repeated deliberate self-harm (DSH).

METHODS

A cohort of 325 consecutive DSH patients attending two large emergency departments in Stockholm, Sweden, were included and followed for 6 months. Any visit to a psychiatric consultant within 10 days was registered as an early follow-up. Repeated DSH episode within 6 months among the 325 patients was detected via nationwide registers.

MAIN OUTCOME MEASURE

Repeated DSH within 6 months.

RESULTS

At 6 months follow-up 22 (24%) of 92 patients with an early follow-up had repeated their DSH acts compared to 58 (25%) of 233 patients without an early follow-up (OR 1.06 (95% CI: 0.60-1.85) p-value 0.85). After adjustment for possible confounders, multivariable analysis showed an OR of 1.22 (95% CI: 0.62-2.38, p-value 0.56).

LIMITATIONS

Early follow-up was registered as any visit to a psychiatric consultant and no information regarding actions taken at the visit were obtained.

CONCLUSION

After adjusting for other factors associated with repetition there was an association of patients who were offered and thereafter attended an early follow-up visit and a decreased risk of repeated DSH.

The cessation of deliberate self-harm in a university sample: the reasons, barriers, and strategies involved

Information on how individuals cease deliberate self-harm behaviors, and what they experience as helpful and hindering to this process, was sought in order to optimize and inform treatment. University students (N = 54) with a past history of self-harm were queried about their experience with DSH cessation. Qualitative analysis revealed 6 themes of reasons for DSH cessation, 5 themes of strategies used to cease DSH behaviors, and 4 themes of barriers to cessation. Treatment can be informed by the motivations, strategies, and barriers that individuals experience during the cessation process. The positive strategies that individuals naturally use to cease DSH should be capitalized on in treatment, and the negative strategies should be minimized.

Alcohol and Repeated Deliberate Self-Harm

Background: Repeated episode(s) of deliberate self-harm (RDSH) is a major risk factor for suicide. Aims: To identify specific risk factors for RDSH among patients admitted following an episode of deliberate self-harm (DSH) through acute intoxication. Methods: A prospective 6-month study was conducted with 184 patients (71% female) admitted to the emergency room (ER) as a result of self-poisoning (SP). Results: Rate of RDSH stood at 18% after 6 months. The sociodemographic variables associated with repeated deliberate self-harm were to have no principal activity, consultation with a medical professional during the 6 months preceding the self-poisoning, and referral to psychiatric services upon release from the ER. The clinical variable associated with RDSH was alcohol addiction (OR = 2.7; IC 95% = 1.2–6.1, p < .05) as assessed at the time of the initial ER admission. Conclusions: When patients are initially admitted to the ER as a result of self-poisoning, it is important to evaluate specific factors, particularly alcohol use, that could subsequently lead to repeated deliberate self-harm. The goal is to improve the targeting and referral of patients toward structures that can best respond to their needs.

Atmospheric pressure and suicide attempts in Helsinki, Finland

The influence of weather on mood and mental health is commonly debated. Furthermore, studies concerning weather and suicidal behavior have given inconsistent results. Our aim was to see if daily weather changes associate with the number of suicide attempts in Finland. All suicide attempts treated in the hospitals in Helsinki, Finland, during two separate periods, 8 years apart, were included. Altogether, 3,945 suicide attempts were compared with daily weather parameters and analyzed with a Poisson regression. We found that daily atmospheric pressure correlated statistically significantly with the number of suicide attempts, and for men the correlation was negative. Taking into account the seasonal normal value during the period 1971-2000, daily temperature, global solar radiation and precipitation did not associate with the number of suicide attempts on a statistically significant level in our study. We concluded that daily atmospheric pressure may have an impact on suicidal behavior, especially on suicide attempts of men by violent methods (P < 0.001), and may explain the clustering of suicide attempts. Men seem to be more vulnerable to attempt suicide under low atmospheric pressure and women under high atmospheric pressure. We show only statistical correlations, which leaves the exact mechanisms of interaction between weather and suicidal behavior open. However, suicidal behavior should be assessed from the point of view of weather in addition to psychiatric and social aspects.

Examining the link between nonsuicidal self-injury and suicidal behavior: a review of the literature and an integrated model

Self-injurious behaviors (SIB) refer to behaviors that cause direct and deliberate harm to oneself, including nonsuicidal self-injury (NSSI), suicidal behaviors, and suicide. Although in recent research, NSSI and suicidal behavior have been differentiated by intention, frequency, and lethality of behavior, researchers have also shown that these two types of self-injurious behavior often co-occur. Despite the co-occurrence of NSSI and suicidal behavior, however, little attention has been given as to why these self-injurious behaviors may be linked. Several authors have suggested that NSSI is a risk factor for suicidal behavior, but no comprehensive review of the literature on NSSI and suicidal behavior has been provided. To address this gap in the literature, we conducted an extensive review of the research on NSSI and suicidal behavior among adolescents and adults. First, we summarize several studies that specifically examined the association between NSSI and suicidal behavior. Next, three theories that have been proposed to account for the link between NSSI and suicidal behavior are described, and the empirical support for each theory is critically examined. Finally, an integrated model is introduced and several recommendations for future research are provided to extend theory development.

Disability weights for suicidal thoughts and non-fatal suicide attempts

BACKGROUND

Although there are disability weights available for a wide range of health states, these do not include suicidality. This makes it difficult to evaluate the severity of suicidality in comparison with other health states. The aim of this study therefore is to estimate disability weights for suicidal thoughts and for mental distress involved in non-fatal suicide attempts.

METHODS

A Dutch expert panel of sixteen medical practitioners who were knowledgeable about suicidality estimated disability weights (DWs) for twelve health states by interpolating them on a calibrated Visual Analogue Scale. The DWs for ten of these health states had been estimated in previous studies and were used to determine the external consistency of the panel. The other two concerned health states for suicidal thoughts and non-fatal suicide attempts. The resulting DWs could vary between 0 (best imaginable health state) and 1 (worst imaginable health state).

RESULTS

Both internal (Cronbach's α = 0.98) and external consistency of the panel were satisfactory. The DWs for suicidal thoughts and non-fatal suicide attempts were estimated to be 0.36 and 0.46 respectively.

LIMITATIONS

The panel was relatively small, which resulted in broad confidence intervals.

CONCLUSIONS

Suicidal thoughts are considered to be as disabling as alcohol dependence and severe asthma. The mental distress involved in non-fatal suicide attempts is thought to be comparable in disability to heroin dependence and initial stage Parkinson's. These results demonstrate the severity of suicidality.

Prevalence and correlates of lifetime deliberate self-harm and suicidal ideation in naturalistic outpatients: the Leiden Routine Outcome Monitoring study

BACKGROUND

Deliberate self-harm and suicidal ideation (DSHI) are common phenomena in general and mental health populations. Identifying factors associated with DSHI may contribute to the early identification, prevention and treatment of DSHI. Aims of the study are to determine the prevalence and correlates of lifetime DSHI in a naturalistic sample of psychiatric outpatients with mood, anxiety or somatoform (MAS) disorders.

METHODS

Of 3798 consecutive patients from January 2004 to December 2006, 2844 (74.9%) patients were analyzed (mean age=37.5, SD=12.0; age range: 18-65; 62.7% women). Lifetime DSHI was assessed with routine outcome monitoring (ROM), including demographic parameters, DSM-IV diagnosis, depressive symptoms, symptoms of anxiety, general psychopathology and personality traits.

RESULTS

Of the 2844 subjects, 55% reported lifetime DSHI. In multivariable logistic regression analysis, the most important factors associated with lifetime DSHI were being unmarried, low education, high number of psychiatric diagnoses, lower anxiety scores, higher depression scores and the personality trait of emotional dysregulation.

LIMITATIONS

Deliberate self-harm may have been under-reported in self-report questionnaires; The assessment of personality traits may have been influenced by state psychopathology; traumatic events were not assessed.

CONCLUSIONS

The findings suggest that DSHI is common among psychiatric outpatients with MAS disorders and that current symptoms and underlying personality vulnerabilities were independently involved in DSHI. Whether symptoms of somatic anxiety are protective should be confirmed in subsequent studies. These findings may help clinicians in identifying patients at risk for deliberate self-harm and suicide.

Healthcare and social services resource use and costs of self-harm patients

BACKGROUND

Patients who have self-harmed have increased morbidity across a wide range of health outcomes, but there is no evidence on their pattern of health and social service use, and its relationship with repetition of self-harm. Previous studies have shown that resource use and costs in the short-term hospital management of self-harm is associated with certain patient and service characteristics but their impact in the longer term has not been demonstrated. The aim of this study is to test the association between changing levels of costs of health and social care with further episodes of self-harm and to identify the clinical and social factors associated with this.

METHOD

This was a cost-analysis incidence study of a sample of patients from a cohort of self-harm patients who remained within one region over the course of their follow-up. Resource use was retrospectively observed from their first episode of self-harm (dating back on some occasions to the 1970's), and costs applied. Panel data analyses were used to identify factors associated with observed costs over time.

RESULTS

Patients with five or more episodes of self-harm had the highest levels of resource costs. Health and social care costs reduced with time from last episode of self-harm. In the year following the first episode of self-harm, psychiatric care accounted for 69% and psychotropic drug prescriptions 1% of the mean resource costs.

CONCLUSIONS

The management of self-harm occurs within a complex system of health and social care. Major self-harm repeaters place the greatest cost burden on the system. Better understanding of the impact of risk assessment models and consequent service provision on clinical outcome may help in the design of effective services for this patient group.