Routine hospital management of self-harm and risk of further self-harm: propensity score analysis using record-based cohort data

Healthcare practitioners' views of self-harm management practices in older adults in Ireland: A qualitative study

OBJECTIVES

To explore healthcare practitioners' views on management practices of self-harm in older adults.

METHODS

Semi-structured interviews were conducted with healthcare practitioners, including consultant psychiatrists, general practitioners, clinical psychologists, psychotherapists, clinical nurse specialists and social workers. Purposeful sampling was used to recruit participants in the Republic of Ireland ensuring diverse perspectives of healthcare practitioners were included. Healthcare practitioners were recruited advertising via professional and clinical research networks, social media, and snowballing methods. Interviews were audio-recorded, transcribed verbatim, and analysed using reflexive thematic analysis.

RESULTS

We conducted interviews with 20 healthcare practitioners from April to July 2023. Three main themes were generated: first, a perceived greater risk of suicide, and increased awareness of complexity in older adults' self-harm presentations. Second, integrated care as an avenue for improving the management of self-harm in older adults. Third, the importance of safety planning in risk assessments of older adults.

CONCLUSIONS

Healthcare practitioners viewed self-harm in older adults as complex, challenging, and associated with high suicide risk, approaching patients with care and caution. The need for integrated support and improved collaboration between relevant healthcare practitioners was identified. Suggestions were made for primary care having a lead role in identifying and managing older adults after self-harm. Increased mental health promotion and awareness of mental health and self-harm in this age group would help address current stigma and shame.

Discharged from the emergency department following hospital-presented self-harm: referral patterns and risk of repeated self-harm

BACKGROUND

Presentation to the emergency department (ED) with self-harm provides an important opportunity for intervention.

AIMS

To investigate characteristics and self-harm repetition risk of those discharged from the ED without a referral for mental health-related aftercare.

METHOD

Data on consecutive self-harm presentations to EDs for the years 2013-2019 (n = 55,770) were obtained from the National Self-Harm Registry Ireland. Multilevel Poisson and Cox regression models were estimated.

RESULTS

Half of the self-harm presenters were discharged from the ED (49.8%) and almost half of them did not receive a mental health-related referral (46.8%). Receipt of a psychosocial assessment was associated with a 50% reduced risk of non-referral (IRR 0.54; 95% CI 0.51-0.57). Non-referral was also less likely for young people (< 18 years), presentations involving attempted hanging, persons with previous self-harm presentations, and in the latter half of the study period (2017-2019 vs. 2013-2016), but was more likely for those brought by ambulance, presenting outside 9 am-5 pm and admitted to an ED medical assessment unit. Of those not referred, 19.3% had a repeat presentation within 12 months, compared to 22.4% of those referred. No difference in repetition risk between these two groups was evident in adjusted analyses. Self-harm history had the strongest association with repetition, with highest risk among individuals with four or more previous presentations (HR 9.30, 95% CI 8.14-10.62).

CONCLUSIONS

The findings underline the importance of assessing all individuals who present with self-harm and highlight the need for comprehensively resourced 24hr services providing mental health care in the ED.

Hospital-presenting self-harm among older adults living in Ireland: a 13-year trend analysis from the National Self-Harm Registry Ireland

OBJECTIVES

To examine trends in rates of self-harm among emergency department (ED) presenting older adults in Ireland over a 13-year period.

DESIGN

Population-based study using data from the National Self-Harm Registry Ireland.

SETTING

National hospital EDs.

PARTICIPANTS

Older adults aged 60 years and over presenting with self-harm to hospital EDs in Ireland between January 1, 2007 and December 31, 2019.

MEASUREMENTS

ED self-harm presentations.

RESULTS

Between 2007 and 2019, there were 6931 presentations of self-harm in older adults. The average annual self-harm rate was 57.8 per 100,000 among older adults aged 60 years and over. Female rates were 1.1 times higher compared to their male counterparts (61.4 vs 53.9 per 100,000). Throughout the study time frame, females aged 60-69 years had the highest rates (88.1 per 100,000), while females aged 80 years and over had the lowest rates (18.7 per 100,000). Intentional drug overdose was the most commonly used method (75.5%), and alcohol was involved in 30.3% of presentations. Between the austerity and recession years (2007-2012), self-harm presentations were 7% higher compared to 2013-2019 (incidence rate ratio (IRR): 1.07 95% CI 1.02-1.13, p = 0.01).

CONCLUSIONS

Findings indicate that self-harm in older adults remains a concern with approximately 533 presentations per year in Ireland. While in younger age groups, females report higher rates of self-harm, this gender difference was reversed in the oldest age group (80 years and over), with higher rates of self-harm among males. Austerity/recession years (2007-2012) had significantly higher rates of self-harm compared to subsequent years.

Staff perceptions of barriers to self-harm care in the emergency department: A cross-sectional survey study

BACKGROUND

Emergency departments (EDs) are often the first point of contact for people with self-harm; however, they do not always receive optimal care. The study objective was to examine the perspectives of ED staff who respond to self-harm presentations, perceived barriers to providing optimal, guideline-concordant care, and staff's familiarity with existing guidelines.

METHODS

An online cross-sectional survey comprising purpose-designed questions concerning self-harm in the ED was completed by 131 staff (83.2% nurses) from two hospitals in Victoria, Australia. Survey results were analysed using Stata version 16 and frequencies and percentages were calculated.

RESULTS

Respondents reported knowledge of how to appropriately manage a person presenting with self-harm. However, lack of space (62.3%) and time (78.7%) to conduct the appropriate assessments, lack of self-harm training (71.8%), and limited awareness of or access to guidelines and recommendations for self-harm management within the ED (63.6%), were identified as primary barriers to their ability to appropriately manage these presenters.

CONCLUSIONS

Improvements to the ED environment and processes, as well as the provision of regular self-harm specific education and training for all ED staff are needed. Implementation of best-practice standards should prioritise guideline-concordant care, with a particular focus on the education needs of nursing staff.

Estimated Average Treatment Effect of Psychiatric Hospitalization in Patients With Suicidal Behaviors: A Precision Treatment Analysis

Importance

Psychiatric hospitalization is the standard of care for patients presenting to an emergency department (ED) or urgent care (UC) with high suicide risk. However, the effect of hospitalization in reducing subsequent suicidal behaviors is poorly understood and likely heterogeneous.

Objectives

To estimate the association of psychiatric hospitalization with subsequent suicidal behaviors using observational data and develop a preliminary predictive analytics individualized treatment rule accounting for heterogeneity in this association across patients.

Design, Setting, and Participants

A machine learning analysis of retrospective data was conducted. All veterans presenting with suicidal ideation (SI) or suicide attempt (SA) from January 1, 2010, to December 31, 2015, were included. Data were analyzed from September 1, 2022, to March 10, 2023. Subgroups were defined by primary psychiatric diagnosis (nonaffective psychosis, bipolar disorder, major depressive disorder, and other) and suicidality (SI only, SA in past 2-7 days, and SA in past day). Models were trained in 70.0% of the training samples and tested in the remaining 30.0%.

Exposures

Psychiatric hospitalization vs nonhospitalization.

Main Outcomes and Measures

Fatal and nonfatal SAs within 12 months of ED/UC visits were identified in administrative records and the National Death Index. Baseline covariates were drawn from electronic health records and geospatial databases.

Results

Of 196 610 visits (90.3% men; median [IQR] age, 53 [41-59] years), 71.5% resulted in hospitalization. The 12-month SA risk was 11.9% with hospitalization and 12.0% with nonhospitalization (difference, -0.1%; 95% CI, -0.4% to 0.2%). In patients with SI only or SA in the past 2 to 7 days, most hospitalization was not associated with subsequent SAs. For patients with SA in the past day, hospitalization was associated with risk reductions ranging from -6.9% to -9.6% across diagnoses. Accounting for heterogeneity, hospitalization was associated with reduced risk of subsequent SAs in 28.1% of the patients and increased risk in 24.0%. An individualized treatment rule based on these associations may reduce SAs by 16.0% and hospitalizations by 13.0% compared with current rates.

Conclusions and Relevance

The findings of this study suggest that psychiatric hospitalization is associated with reduced average SA risk in the immediate aftermath of an SA but not after other recent SAs or SI only. Substantial heterogeneity exists in these associations across patients. An individualized treatment rule accounting for this heterogeneity could both reduce SAs and avert hospitalizations.

An Ideal-Type Analysis of People's Perspectives on Care Plans Received from the Emergency Department following a Self-Harm or Suicidal Crisis

People presenting to Emergency Departments (EDs) in a self-harm/suicidal crisis in England receive a psychosocial assessment and care plan. We aimed to construct a typology of peoples' perspectives on crisis care plans to explore the range of experiences of care plans. Thirty-two semi-structured interviews with people who presented to EDs following a self-harm/suicidal crisis in England were analysed using an ideal-type analysis. Cases were systematically compared to form clusters of cases with similar experiences of care plans. People's perspectives on care plans fitted into three types: (1) personalised care plans (n = 13), consisting of advice or referrals perceived as helpful; (2) generic care plans (n = 13), consisting of generic advice that the person already knew about or had already tried; and (3) did not receive a care plan (n = 6) for those who reported not receiving a care plan, or who were only provided with emergency contacts. Care planning in the ED following a suicidal/self-harm crisis was perceived as supportive if it provided realistic and personalised advice, based on what had/had not worked previously. However, many people reported not receiving a helpful care plan, as it was ill-fitted to their needs or was not considered sufficient to keep them safe, which may mean that these patients are at increased risk of repeat self-harm.

Secondary mental health service utilisation following emergency department contact for suicidal behaviour: A systematic review

OBJECTIVE

Engagement with secondary mental health services after an emergency department presentation with suicidal behaviours may be an important strategy for reducing the risk of repeat attempts. Our aim was to examine secondary mental health service contact following a presentation to emergency department with suicidal behaviours.

METHODS

A systematic review of papers published between 2000 and 2020 was undertaken. This identified 56 papers relating to 47 primary studies. Data were extracted and summarised separately by age group: (1) young people, (2) older adults and (3) adults and studies with participants of 'all ages'.

RESULTS

Studies in young people (n = 13) showed, on average, 44.8% were referred and 33.7% had contact with secondary mental health services within 4 weeks of emergency department discharge. In comparison, in adult/all ages studies (n = 34), on average, 27.1% were referred to and 26.2% had mental health service contact within 4 weeks. Only three studies presented data on contact with mental health services for older adults, and proportions ranged from 49.0% to 86.0%.

CONCLUSION

This review highlights poor utilisation of secondary mental health service following emergency department presentation for suicidal behaviours, and further research is needed to identify the reasons for this. Crucially, this information could assist in the allocation of resources to facilitate the timely implementation of suicide prevention services.

Psychiatric admissions after hospital presented deliberate self-harm in the young: A national study

Follow-up psychiatric care is crucial for young adults presenting to hospitals because of deliberate self-harm (DSH). However, who receives such care is not sufficiently understood. We therefore investigated the clinical and sociodemographic correlates of admissions to psychiatric inpatient treatment immediately following general hospital treatment of DSH in this age band. All episodes of hospital presented DSH among patients aged 18-35 years during the period 2008-2018 were identified from the Norwegian Patient Register. The outcome was admissions to psychiatric inpatient treatment immediately after discharge from the general hospital. The correlates of such admissions were calculated using binomial generalized estimating equation. Of 26.166 identified DSH episodes, 21.4% were admitted to psychiatric inpatient treatment. Admissions were most common for patients with a history of psychiatric treatment and a recorded diagnosis of psychosis-, mood- or personality disorders. Adjusted for other psychiatric factors, alcohol- or substance misuse diagnoses and repeated presentations of DSH were inversely associated with admissions to psychiatric inpatient treatment. Young adults admitted to psychiatric inpatient treatment following DSH have a high burden of psychiatric morbidity and risk factors for suicide. However, the inverse association seen for two important risk factors for suicide, alcohol- or substance misuse and repeated DSH, warrants further attention.

Association of Psychiatric Services Referral and Attendance Following Treatment for Deliberate Self-harm With Prospective Mortality in Norwegian Patients

IMPORTANCE

Psychiatric care following somatic treatment for deliberate self-harm (DSH) is pivotal in patients' lives both in the short and long term, but evidence to guide such care is limited.

OBJECTIVE

To examine follow-up psychiatric care for patients treated for DSH (ie, intentional self-injury or self-poisoning, irrespective of motivation) at hospital emergency departments and to assess the association of psychiatric referral and treatment attendance with risk of subsequent mortality in these patients.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective data from several Norwegian registries were interlinked to follow up a national cohort of all patients with hospital-treated DSH for up to 11 years from 2008 through 2018. Data were analyzed from March to October 2021.

EXPOSURES

Socioeconomic characteristics, psychiatric history, and clinical features of DSH.

MAIN OUTCOMES AND MEASURES

Referral to psychiatric services, attendance in psychiatric treatment, and prospective mortality were the 3-stage outcomes during follow-up. Logistic regression with odds ratios and cause-specific survival analysis with hazard ratios were used to examine associations between exposures and outcomes.

RESULTS

The study identified 43 153 patients (24 286 [56.3%] female; median [IQR] age at index DSH, 39.0 [23.0-56.0] years) involving 69 569 DSH episodes. Of these patients, 6762 (15.7%) were referred to psychiatric services after somatic treatment for DSH, and 22 008 patients (51.0%) attended psychiatric treatment within 3 months of discharge following somatic treatment for DSH. Prior psychiatric history and psychiatric disorders comorbid with DSH were associated with both referral to and attendance in psychiatric care. During follow-up, 7041 patients died by suicide (n = 911) or other causes (n = 6130). While suicide risk was associated with male sex, age 35 to 64 years, and particularly prior and coexisting psychopathologies, other-cause mortality was associated with age 65 years and older and socioeconomic disadvantage. Patients with psychiatric referrals generally had an increased risk of suicide, but the risk was particularly high among patients who received a referral but did not subsequently attend psychiatric treatment (adjusted hazard ratio, 3.07; 95% CI, 2.28-4.12). The observed association was more pronounced during the first years of follow-up and in patients aged 10 to 34 years or 35 to 64 years and those with a clear intent of self-harm.

CONCLUSIONS AND RELEVANCE

This national cohort study found an association between psychiatric care attendance following treatment for DSH and prospective mortality, highlighting the importance of patient engagement in psychiatric treatment.

Suicide and self-harm

Suicide and self-harm are major health and societal issues worldwide, but the greatest burden of both behaviours occurs in low-income and middle-income countries. Although rates of suicide are higher in male than in female individuals, self-harm is more common in female individuals. Rather than having a single cause, suicide and self-harm are the result of a complex interplay of several factors that occur throughout the life course, and vary by gender, age, ethnicity, and geography. Several clinical and public health interventions show promise, although our understanding of their effectiveness has largely originated from high-income countries. Attempting to predict suicide is unlikely to be helpful. Intervention and prevention must include both a clinical and community focus, and every health professional has a crucial part to play.

Suicide Risk Among Hospitalized Versus Discharged Deliberate Self-Harm Patients: Generalized Random Forest Analysis Using a Large Claims Data Set

INTRODUCTION

Suicide rates are extremely high among emergency department patients seen for deliberate self-harm. Inpatient hospitalization is often recommended for these patients, but evidence on the suicide prevention impacts of hospitalization is scarce. Confounding by indication and challenges to implementing randomized designs are barriers to advances in this field.

METHODS

Investigators used 2009-2012 statewide data on 57,312 self-harm emergency department patients from California, linked to mortality records. Naive 12-month and 30-day suicide risks were estimated among patients who were hospitalized versus those who were discharged. Then, generalized random forest methods were applied to estimate the average treatment impacts of hospitalization on suicide, conditioning on observable covariates. Associations were calculated separately for sex- and age-specific subgroups. Analyses were conducted in February 2019-August 2021.

RESULTS

In naive analyses, suicide risk was significantly higher in hospitalized than in discharged patients in each subgroup. In 12-month models accounting for the observed covariates through generalized random forest methods, hospitalized male patients had 5.4 more suicides per 1,000 patients (95% CI=3.0, 7.8), hospitalized patients aged 10-29 years had 2.4 more suicides per 1,000 (95% CI=1.1, 3.6), and those aged ≥50 years had 5.8 more suicides per 1,000 (95% CI=0.5, 11.2) than corresponding discharged patients. Hospitalization was not significantly associated with suicide among female patients or patients aged 30-49 years in generalized random forest analyses. Patterns were similar in 30-day generalized random forest models.

CONCLUSIONS

Emergency department personnel intend to hospitalize self-harm patients with high suicide risk; this study suggests that this goal is largely realized. Analyses that control for confounding by observable covariates did not find clear evidence that hospitalization reduces suicide risk and could not rule out the possibility of iatrogenic effects.

Evaluation of the impact and implementation of a national clinical programme for the management of self-harm in hospital emergency departments: study protocol for a natural experiment

BACKGROUND

A National Clinical Programme for the Management of Hospital-Presenting Self-Harm (NCP-SH) was introduced in Ireland in 2014. This involved the development of a model of care to standardise the management of self-harm in emergency departments, to be delivered by dedicated clinical nurse specialists. The core components of the programme were to: ensure an empathic and timely response, conduct a biopsychosocial assessment, involve family members in assessment and discharge planning, and provide a bridge to next care. The overall aim of the programme was to reduce the rate of repeat self-harm. This multistage study will evaluate the impact of the NCP-SH on hospital-presenting self-harm and to identify determinants influencing its implementation.

METHODS

Employing a sequential mixed methods design, the first stage will use data from the National Self-Harm Registry Ireland to examine the impact of the NCP-SH on self-harm repetition, along with other aspects of care, including provision of psychosocial assessments and changes in admissions and postdischarge referrals. A cost-effectiveness analysis will assess the cost per repeat self-harm attendance avoided as a result of the NCP-SH. The second stage will identify the influences of implementation fidelity-adherence to the programme's core components-using a combination of document analysis and semistructured interviews with staff of the programme, guided by the Consolidated Framework for Implementation Research.

ETHICS AND DISSEMINATION

This study has received full ethical approval and will run until August 2023. This study is novel in that it will identify important factors influencing successful implementation of complex programmes. It is expected that the findings will provide important learnings for the integration of mental health services in general hospital settings and will be disseminated via peer-review publications along with reports for clinicians and policy-makers.

Factors associated with psychiatric admission and subsequent self-harm repetition: a cohort study of high-risk hospital-presenting self-harm

BACKGROUND

Individuals presenting to hospital with self-harm of high lethality or high suicidal intent are at high risk of subsequent suicide.

AIM

To examine factors associated with psychiatric admission and self-harm repetition following high-risk self-harm (HRSH).

METHOD

A cohort study of 324 consecutive HRSH patients was conducted across three urban hospitals (December 2014-February 2018). Information on self-harm repetition was extracted from the National Self-harm Registry Ireland. Logistic regression models examined predictors of psychiatric admission and self-harm repetition. Propensity score (PS) methods were used to address confounding.

RESULTS

Forty percent of the cohort were admitted to a psychiatric inpatient setting. Factors associated with admission were living alone, depression, previous psychiatric admission, suicide note and uncommon self-harm methods. History of emotional, physical or sexual abuse was associated with not being admitted. Twelve-month self-harm repetition occurred in 17.3% of cases. Following inverse probability weighting according to the PS, psychiatric admission following HRSH was not associated with repetition. Predictors of repetition were recent self-harm history, young age (18-24 years) and previous psychiatric admission.

CONCLUSION(S)

Findings indicate that psychiatric admission following HRSH is not associated with repeated self-harm and reaffirms the consistent finding that history of self-harm and psychiatric treatment are strong predictors of repetition.

Temporal trends in primary care-recorded self-harm during and beyond the first year of the COVID-19 pandemic: Time series analysis of electronic healthcare records for 2.8 million patients in the Greater Manchester Care Record

BACKGROUND

Surveillance of temporal trends in clinically treated self-harm is an important component of suicide prevention in the dynamic context of COVID-19. There is little evidence beyond the initial months following the onset of the pandemic, despite national and regional restrictions persisting to mid-2021.

METHODS

Descriptive time series analysis utilizing de-identified, primary care health records of 2.8 million patients from the Greater Manchester Care Record. Frequencies of self-harm episodes between 1st January 2019 and 31st May 2021 were examined, including stratification by sex, age group, ethnicity, and index of multiple deprivation quintile.

FINDINGS

There were 33,444 episodes of self-harm by 13,148 individuals recorded during the study period. Frequency ratios of incident and all episodes of self-harm were 0.59 (95% CI 0.51 to 0.69) and 0.69 (CI 0.63 to 0.75) respectively in April 2020 compared to February 2020. Between August 2020 and May 2021 frequency ratios were 0.92 (CI 0.88 to 0.96) for incident episodes and 0.86 (CI 0.84 to 0.88) for all episodes compared to the same months in 2019. Reductions were largest among men and people living in the most deprived neighbourhoods, while an increase in all-episode self-harm was observed for adolescents aged 10-17.

INTERPRETATION

Reductions in primary care-recorded self-harm persisted to May 2021, though they were less marked than in April 2020 during the first national lockdown. The observed reductions could represent longer term reluctance to seek help from health services. Our findings have implications for the ability for services to offer recommended care for patients who have harmed themselves.

Study designs and outcomes used in evaluation studies of hospital-presenting self-harm: protocol for a methodological systematic review

INTRODUCTION

Self-harm is the most common risk factor for suicide, and so those who present to hospital following self-harm provide an opportunity for targeted clinical care interventions. Observational studies evaluating such interventions may be useful in overcoming limitations of controlled trials, but study design, statistical analyses and outcomes used must be appropriate. This methodological systematic review will describe, categorise, synthesise and compare the methodological aspects of studies evaluating interventions and aspects of clinical management following hospital-presenting self-harm in both observational and experimental (ie, controlled trials or quasi-experimental studies) study designs.

METHODS AND ANALYSIS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Protocol guidelines were followed in drafting this protocol. Search terms were developed (related to self-harm, hospital presentation and evaluation studies) and adapted for MEDLINE, PsycINFO, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and grey literature databases. Two reviewers will independently screen 100 titles/abstracts until consensus is reached, with the remaining screened by one reviewer. Full-text screening will be conducted independently by two reviewers. Data will be extracted by one reviewer, and a second will check all data extracted. Validated risk of bias tools will be used. Data synthesis will focus on the heterogeneity of outcomes used in individual studies. Descriptive summary statistics of the data (eg, key study characteristics, type and frequency of outcomes) will be provided in categorical format, using frequencies and percentages. Outcomes will be reported separately for trials (both randomised and non-randomised trials), observational and quasi-experimental studies. Categorisation of outcomes will be guided by Cochrane Effective Practice and Organisation of Care resources for reviews of health systems interventions.

ETHICS AND DISSEMINATION

Results will be disseminated at national and international conferences and published in a peer-reviewed journal. Findings will be used to inform future studies in the area of hospital-presenting self-harm. Ethical approval is not required for this review.

PROSPERO REGISTRATION NUMBER

CRD42020208714.

Investigating the relationship between childhood sexual abuse, self-harm repetition and suicidal intent: mixed-methods study

BACKGROUND

Research into the association between childhood sexual abuse (CSA) and self-harm repetition is limited.

AIMS

We aimed to examine the association between self-harm repetition, mental health conditions, suicidal intent and CSA experiences among people who frequently self-harm.

METHOD

A mixed-methods study was conducted including consecutive patients aged ≥18 years, with five or more self-harm presentations, in three Irish hospitals. Information was extracted from psychiatric records and patients were invited to participate in a semi-structured interview. Data was collected and analysed with a mixed-methods, convergent parallel design. In tandem, the association between CSA and self-harm repetition, suicidal intent and mental health conditions was examined with logistic regression models and independent sample t-test, with psychiatric records data. Thematic analysis was conducted with interview data, to explore CSA experiences and self-harm repetition.

RESULTS

Between March 2016 and July 2019, information was obtained on 188 consecutive participants, with 36 participants completing an interview. CSA was recorded in 42% of the total sample and 72.2% of those interviewed. CSA was positively associated with self-harm repetition (odds ratio 6.26, 95% CI 3.94-9.94, P = 0.00). Three themes emerged when exploring participants' CSA experiences: CSA as a precipitating factor for self-harm, secrecy of CSA accentuating shame, and loss experiences linked to CSA and self-harm.

CONCLUSIONS

CSA was frequently reported among people who frequently self-harm, and associated with self-harm repetition. Identification of patients at risk of repetition is key for suicide prevention. This is an at-risk group with particular characteristics that must be considered; comprehensive patient histories can help inform and tailor treatment pathways.

'Relieved to be seen'-patient and carer experiences of psychosocial assessment in the emergency department following self-harm: qualitative analysis of 102 free-text survey responses

OBJECTIVES

We sought to explore patient and carer experiences of psychosocial assessments following presentations to hospital after self-harm.

DESIGN

Thematic analysis of free-text responses to an open-ended online survey.

SETTING

Between March and November 2019, we recruited 88 patients (82% women) and 14 carers aged ≥18 years from 16 English mental health trusts, community organisations, and via social media.

RESULTS

Psychosocial assessments were experienced as helpful on some occasions but harmful on others. Participants felt better, less suicidal and less likely to repeat self-harm after good-quality compassionate and supportive assessments. However, negative experiences during the assessment pathway were common and, in some cases, contributed to greater distress, less engagement and further self-harm. Participants reported receiving negative and stigmatising comments about their injuries. Others reported that they were refused medical care or an anaesthetic. Stigmatising attitudes among some mental health staff centred on preconceived ideas over self-harm as a 'behavioural issue', inappropriate use of services and psychiatric diagnosis.

CONCLUSION

Our findings highlight important patient experiences that can inform service provision and they demonstrate the value of involving patients/carers throughout the research process. Psychosocial assessments can be beneficial when empathetic and collaborative but less helpful when overly standardised, lacking in compassion and waiting times are unduly long. Patient views are essential to inform practice, particularly given the rapidly changing service context during and after the COVID-19 emergency.

Accuracy of individual and combined risk-scale items in the prediction of repetition of self-harm: multicentre prospective cohort study

BACKGROUND

Individuals attending emergency departments following self-harm have increased risks of future self-harm. Despite the common use of risk scales in self-harm assessment, there is growing evidence that combinations of risk factors do not accurately identify those at greatest risk of further self-harm and suicide.

AIMS

To evaluate and compare predictive accuracy in prediction of repeat self-harm from clinician and patient ratings of risk, individual risk-scale items and a scale constructed with top-performing items.

METHOD

We conducted secondary analysis of data from a five-hospital multicentre prospective cohort study of participants referred to psychiatric liaison services following self-harm. We tested predictive utility of items from five risk scales: Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS, Modified SAD PERSONS, Barratt Impulsiveness Scale and clinician and patient risk estimates. Area under the curve (AUC), sensitivity, specificity, predictive values and likelihood ratios were used to evaluate predictive accuracy, with sensitivity analyses using classification-tree regression.

RESULTS

A total of 483 self-harm episodes were included, and 145 (30%) were followed by a repeat presentation within 6 months. AUC of individual items ranged from 0.43-0.65. Combining best performing items resulted in an AUC of 0.56. Some individual items outperformed the scale they originated from; no items were superior to clinician or patient risk estimations.

CONCLUSIONS

No individual or combination of items outperformed patients' or clinicians' ratings. This suggests there are limitations to combining risk factors to predict risk of self-harm repetition. Risk scales should have little role in the management of people who have self-harmed.

Health Care Management Models for the Evolution of Hospitalization in Acute Inpatient Psychiatry Units: Comparative Quantitative Study

BACKGROUND

Mental health disorders are a problem that affects patients, their families, and the professionals who treat them. Hospital admissions play an important role in caring for people with these diseases due to their effect on quality of life and the high associated costs. In Spain, at the Healthcare Complex of Zamora, a new disease management model is being implemented, consisting of not admitting patients with mental diseases to the hospital. Instead, they are supervised in sheltered apartments or centers for patients with these types of disorders.

OBJECTIVE

The main goal of this research is to evaluate the evolution of hospital days of stay of patients with mental disorders in different hospitals in a region of Spain, to analyze the impact of the new hospital management model.

METHODS

For the development of this study, a database of patients with mental disorders was used, taking into account the acute inpatient psychiatry unit of 11 hospitals in a region of Spain. SPSS Statistics for Windows, version 23.0 (IBM Corp), was used to calculate statistical values related to hospital days of stay of patients. The data included are from the periods of 2005-2011 and 2012-2015.

RESULTS

After analyzing the results, regarding the days of stay in the different health care complexes for the period between 2005 and 2015, we observed that since 2012 at the Healthcare Complex of Zamora, the total number of days of stay were reduced by 64.69%. This trend is due to the implementation of a new hospital management model in this health complex.

CONCLUSIONS

With the application of a new hospital management model at the Healthcare Complex of Zamora, the number of days of stay of patients with mental diseases as well as the associated hospital costs were considerably reduced.

Factors explaining variation in recommended care pathways following hospital-presenting self-harm: a multilevel national registry study

BACKGROUND

People who present to hospital following self-harm are at high risk of suicide. Despite this, there are considerable variations in the management of this group across hospitals and the factors influencing such variations are not well understood.

AIMS

The aim of this study was to identify the specific hospital and individual factors associated with care pathways following hospital-presenting self-harm.

METHOD

Data on presentations to hospitals by those aged 18 years and over were obtained from the National Self-Harm Registry Ireland for 2017 and 2018. Factors associated with four common outcomes following self-harm (self-discharge, medical and psychiatric admission and psychosocial assessment before discharge) were examined using multilevel Poisson regression models.

RESULTS

Care pathways following self-harm varied across hospitals and were influenced by both hospital and individual factors. Individual factors were primarily associated with self-discharge (including male gender, younger age and alcohol involvement), medical admission (older age, drug overdose as a sole method and ambulance presentations) and psychiatric admission (male gender, methods associated with greater lethality and older age). The hospital admission rate for self-harm was the only factor associated with all outcomes examined. The availability of psychiatric in-patient facilities and specialist mental health staff contributed to variation in psychiatric admissions and psychosocial assessments prior to discharge. Hospital factors explained the majority of observed variation in the provision of psychosocial assessments.

CONCLUSIONS

Characteristics of the presenting hospital and hospital admission rates influence the recommended care pathways following self-harm. Provision of onsite mental health facilities and specialist mental health staff has a strong impact on psychiatric care of these patients.

Healthcare professionals' implementation of national guidelines with patients who self-harm

BACKGROUND

National guidelines for the short-term management of self-harm are aimed at healthcare professionals who may be involved in the care of people who have self-harmed. However, evidence from small-scale studies globally suggest there is a lack of awareness of such guidelines among some groups of healthcare professionals. For the first time in a large representative sample of patient-facing healthcare professionals, we aimed to identify: (a) which healthcare professionals are aware of guidelines for the management of self-harm; (b) the perceived availability of training; (c) the use of risk screening tools; and (d) the extent to which healthcare professionals implement guidelines for the management of self-harm.

METHODS

1020 UK healthcare professionals completed a cross-sectional survey online.

RESULTS

85.6% (873/1020) of the sample had heard of the national guidelines, but only 24.3% (248/1020) knew "a fair amount" or more about them. Of the respondents who had previously encountered a patient who had self-harmed or was at risk of repeat self-harm, the guidelines were implemented in fewer than 50% (M = 43.89%, SD = 38.79) of encounters. 31% (312/1020) of the sample had received training in managing self-harm and, contrary to guidelines, 2.25% (23/1020) of the sample had used self-harm risk screening tools.

CONCLUSIONS

Our findings highlight a need to improve knowledge of self-harm management guidelines, and identifies professional groups where awareness and knowledge is currently low. Further work is required to develop interventions to change healthcare professional practice with respect to the implementation of self-harm management guidelines.

Risk factors of hospitalization for any medical condition among patients with prior emergency department visits for mental health conditions

BACKGROUND

This longitudinal study identified risk factors for frequency of hospitalization among patients with any medical condition who had previously visited one of six Quebec (Canada) emergency departments (ED) at least once for mental health (MH) conditions as the primary diagnosis.

METHODS

Records of n = 11,367 patients were investigated using administrative databanks (2012-13/2014-15). Hospitalization rates in the 12 months after a first ED visit in 2014-15 were categorized as no hospitalizations (0 times), moderate hospitalizations (1-2 times), and frequent hospitalizations (3+ times). Based on the Andersen Behavioral Model, data on risk factors were gathered for the 2 years prior to the first visit in 2014-15, and were identified as predisposing, enabling or needs factors. They were tested using a hierarchical multinomial logistic regression according to the three groups of hospitalization rate.

RESULTS

Enabling factors accounted for the largest percentage of total variance explained in the study model, followed by needs and predisposing factors. Co-occurring mental disorders (MD)/substance-related disorders (SRD), alcohol-related disorders, depressive disorders, frequency of consultations with outpatient psychiatrists, prior ED visits for any medical condition and number of physicians consulted in specialized care, were risk factors for both moderate and frequent hospitalizations. Schizophrenia spectrum and other psychotic disorders, bipolar disorders, and age (except 12-17 years) were risk factors for moderate hospitalizations, while higher numbers (4+) of overall interventions in local community health service centers were a risk factor for frequent hospitalizations only. Patients with personality disorders, drug-related disorders, suicidal behaviors, and those who visited a psychiatric ED integrated with a general ED in a separate site, or who visited a general ED without psychiatric services were also less likely to be hospitalized. Less urgent and non-urgent illness acuity prevented moderate hospitalizations only.

CONCLUSIONS

Patients with severe and complex health conditions, and higher numbers of both prior outpatient psychiatrist consultations and ED visits for medical conditions had more moderate and frequent hospitalizations as compared with non-hospitalized patients. Patients at risk for frequent hospitalizations were more vulnerable overall and had important biopsychosocial problems. Improved primary care and integrated outpatient services may prevent post-ED hospitalization.

Comparing short-term risk of repeat self-harm after psychosocial assessment of patients who self-harm by psychiatrists or psychiatric nurses in a general hospital: Cohort study

BACKGROUND

There is mixed evidence for whether psychosocial assessment following hospital presentation for self-harm reduces self-harm repetition. A possible reason is the differences in professional background of assessors (primarily psychiatrists and psychiatric nurses) due to variability in training and therapist style.

METHODS

Using data from the Oxford Monitoring System for Self-harm, we analysed data on patients making their first emergency department (ED) presentation for self-harm between 2000 and 2014, followed-up until 2015. Using logistic regression, we estimated the probability of repeat self-harm within 12 months, comparing: (i) patients receiving psychosocial assessment versus none, adjusting for age, gender, self-harm method, past self-harm presentation, and general hospital admission; and (ii) patients assessed by a psychiatric nurse versus those assessed by a psychiatrist, adjusting for age, self-harm method, time and year of presentation.

RESULTS

The 12,652 patients who had an index ED presentation for self-harm during the study period accounted for 24,450 presentations, in 17,303 (71%) of which a psychosocial assessment was conducted; in 9318 (54%) by a psychiatric nurse and in 7692 (45%) by a psychiatrist. We found a reduced probability of repeat self-harm presentation among patients receiving psychosocial assessment versus none (adjusted odds ratio [AOR] = 0.70; 95% CI = 0.65-0.75; p < 0.001), but no differences between patients assessed by a psychiatric nurse or a psychiatrist (AOR = 1.05; 95% CI = 0.98-1.13; p = 0.129).

LIMITATIONS

Findings from a single hospital may not be generalizable to other settings.

CONCLUSIONS

Short-term risk of repeat self-harm after psychosocial assessment for self-harm may not differ by the assessor's professional background.

Study protocol for the implementation and evaluation of the Self-harm Assessment and Management for General Hospitals programme in Ireland (SAMAGH)

BACKGROUND

Previous self-harm is one of the strongest predictors of future self-harm and suicide. Increased risk of repeated self-harm and suicide exists amongst patients presenting to hospital with high-risk self-harm and major self-harm repeaters. However, so far evidence-based training in the management of self-harm for mental health professionals is limited. Within this context, we aim to develop, implement and evaluate a training programme, SAMAGH, Self-harm Assessment and Management Programme for General Hospitals in Ireland. SAMAGH aims to (a) reduce hospital-based self-harm repetition rates and (b) increase rates of mental health assessments being conducted with self-harm patients. We also aim to evaluate the training on self-harm knowledge, attitudes, and skills related outcomes of healthcare professionals involved in the training.

METHODS/DESIGN

The study will be conducted in three phases. First, the SAMAGH Training Programme has been developed, which comprises two parts: 1) E-learning Programme and 2) Simulation Training. Second, SAMAGH will be delivered to healthcare professionals from general hospitals in Ireland. Third, an outcome and process evaluation will be conducted using a pre-post design. The outcome evaluation will be conducted using aggregated data from the National Self-Harm Registry Ireland (NSHRI) on self-harm repetition rates from all 27 public hospitals in Ireland. Aggregated data based on the 3-year average (2016, 2017, 2018) self-harm repetition rates prior to the implementation of the SAMAGH will be used as baseline data, and NSHRI data from 6 and 12 months after the implementation of SAMAGH will be used as follow-up. For the process evaluation, questionnaires and focus groups will be administered and conducted with healthcare professionals who completed the training.

DISCUSSION

This study will contribute to the evidence base regarding the effectiveness of an evidence informed training programme that aims to reduce repeated hospital self-harm presentations and to improve compliance with self-harm assessment and management. This study is also expected to contribute to self-harm and suicide training with the possibility of being translated to other settings. Its feasibility will be evaluated through a process evaluation.

Suicide and all-cause mortality in a high-risk cohort: A latent class approach

OBJECTIVE

To use latent class analysis to group patients consulted to an emergency psychiatry consultation service and assess occurrence of suicide attempts and all-cause mortality across groups.

METHOD

Latent class analysis was used to classify individuals assessed by psychiatry in the emergency department of the two teaching hospitals in Winnipeg, Canada. A second latent class analysis was done on individuals presenting with a suicide attempt. Indicators variables included a variety of clinically assessed factors, such as presentation suicidality and occurrence of anxiety/depression/psychosis, and prior medical treatment. Two post-treatment indicators were used; suicide attempt hospitalizations and all-cause mortality within 12 months of assessment.

RESULTS

Latent class analysis identified 8 classes for all presentations (n = 5292) and 3 classes for the attempter subgroup (n = 730). Although there is considerable overlap in indicators among the classes certain indicators differentiated between the groups: suicide attempt presentation, prior psychiatric treatment, psychotropic medication polypharmacy, childhood abuse, and addictions. Although the presence of deaths and future attempts varied between the identified groups, there were no groups with a >10% proportion of individuals with either of these outcomes.

CONCLUSIONS

Potential exists for latent class-based assessments, but additional samples with better indicators are needed.

Using Administrative Data to Predict Suicide After Psychiatric Hospitalization in the Veterans Health Administration System

There is a very high suicide rate in the year after psychiatric hospital discharge. Intensive postdischarge case management programs can address this problem but are not cost-effective for all patients. This issue can be addressed by developing a risk model to predict which inpatients might need such a program. We developed such a model for the 391,018 short-term psychiatric hospital admissions of US veterans in Veterans Health Administration (VHA) hospitals 2010-2013. Records were linked with the National Death Index to determine suicide within 12 months of hospital discharge (n=771). The Super Learner ensemble machine learning method was used to predict these suicides for time horizon between 1 week and 12 months after discharge in a 70% training sample. Accuracy was validated in the remaining 30% holdout sample. Predictors included VHA administrative variables and small area geocode data linked to patient home addresses. The models had AUC=.79-.82 for time horizons between 1 week and 6 months and AUC=.74 for 12 months. An analysis of operating characteristics showed that 22.4%-32.2% of patients who died by suicide would have been reached if intensive case management was provided to the 5% of patients with highest predicted suicide risk. Positive predictive value (PPV) at this higher threshold ranged from 1.2% over 12 months to 3.8% per case manager year over 1 week. Focusing on the low end of the risk spectrum, the 40% of patients classified as having lowest risk account for 0%-9.7% of suicides across time horizons. Variable importance analysis shows that 51.1% of model performance is due to psychopathological risk factors accounted, 26.2% to social determinants of health, 14.8% to prior history of suicidal behaviors, and 6.6% to physical disorders. The paper closes with a discussion of next steps in refining the model and prospects for developing a parallel precision treatment model.

Comparative Effectiveness of Inpatient Rehabilitation Interventions for Traumatic Brain Injury: Introduction

The Comparative Effectiveness of Inpatient Rehabilitation Interventions for Traumatic Brain Injury (TBI-CER) project used causal inference methods as an alternative to randomized controlled trials to evaluate rehabilitation practices. The TBI practice-based evidence dataset afforded the opportunity to compare the outcomes of different rehabilitation approaches while controlling for a large set of potential confounders using propensity score methods (PSMs). PSMs rely on 4 assumptions: positivity, exchangeability, consistency, and correct specification of the propensity score model. When these assumptions are met, PSMs provide a transparent means for evaluating potential causal relations between interventions and outcomes using observational data. In combination, the series of studies resulting from the TBI-CER project suggested that the content and approach used in treatment have a stronger effect on outcomes than the amount of time spent in treatment. Further, engagement of the patient and family in treatment is key to optimizing outcomes up to 9 months postdischarge from rehabilitation.

Development of best practice guidelines for suicide-related crisis response and aftercare in the emergency department or other acute settings: a Delphi expert consensus study

BACKGROUND

For those who have experienced suicidal behaviour, discharge from the hospital emergency department and other acute settings represents a period of heightened vulnerability for future suicide risk. Current guidelines for suicide response in acute settings often fail to fully address the barriers faced by emergency department personnel who have contact with a person who presents for suicidal behaviour, and have been developed largely without the input of consumers or service users. The aim of the study was to use the Delphi expert consensus method to develop guidelines for staff responding to suicidal presentations in acute settings.

METHODS

Systematic searches of academic and grey literature and interviews with key informants were conducted in order to develop a 525-item questionnaire, which comprised actions staff can take when responding to suicide-related presentations in acute settings. This was administered over three rounds to two panels consisting of Australian experts (39 health professionals, 50 consumers with lived experience). Items that reached consensus by at least 80% across both panels were included in the guidelines.

RESULTS

A total of 420 items were rated as essential or important by at least 80% of both panels. The items included strategies that covered initial contact, assessment, referral, discharge and follow-up, staff training, and linkage with community aftercare services. Participation rate across all three rounds was 67.4% (78% consumers, 53.8% professionals).

CONCLUSION

The guidelines include strategies for responding to suicidal behaviour in acute settings. These guidelines can be used to inform policy development and address barriers to best practice for those working in the area. Future research should investigate ways to optimise implementation of these guidelines in order to improve equal access to quality care for who present to acute settings for suicidal behaviour.

Suicide and all-cause mortality following routine hospital management of self-harm: Propensity score analysis using multicentre cohort data

BACKGROUND

Observational studies are suited to examining links between the routine hospital management of self-harm and future suicide and all-cause mortality due to their large scale. However, care must be taken when attempting to infer causal associations in non-experimental settings.

METHODS

Data from the Multicentre Study of Self-Harm in England were used to examine associations between four types of hospital management (specialist psychosocial assessment, general hospital admission, psychiatric outpatient referral and psychiatric admission) following self-harm and risks of suicide and all-cause mortality in the subsequent 12 months. Missing data were handled by multiple imputation and propensity score (PS) methods were used to address observed differences between patients at baseline. Unadjusted, PS stratified and PS matched risk ratios (RRs) were calculated.

RESULTS

The PSs balanced the majority of baseline differences between treatment groups. Unadjusted RRs showed that all four treatment types were associated with either increased risks or no change in risks of suicide and all-cause mortality within a year. None of the four types of hospital management were associated with lowered risks of suicide or all-cause mortality following propensity score stratification (psychosocial assessment and medical admission) and propensity score matching (psychiatric outpatient referral and psychiatric admission), though there was no longer an increased risk among people admitted to a psychiatric bed. Individuals who self-cut were at an increased risk of death from any cause following psychosocial assessment and medical admission. Medical admission appeared to be associated with reduced risk of suicide in individuals already receiving outpatient or GP treatment for a psychiatric disorder.

CONCLUSIONS

More intensive forms of hospital management following self-harm appeared to be appropriately allocated to individuals with highest risks of suicide and all-cause mortality. PS adjustment appeared to attenuate only some of the observed increased risks, suggesting that either differences between treatment groups remained, or that some treatments had little impact on reducing subsequent suicide or all-cause mortality risk. These findings are in contrast to some previous studies that have suggested psychosocial assessment by a mental health specialist reduces risk of repeat self-harm. Future observational self-harm studies should consider increasing the number of potential confounding variables collected.

Accuracy of risk scales for predicting repeat self-harm and suicide: a multicentre, population-level cohort study using routine clinical data

BACKGROUND

Risk scales are used widely in the management of patients presenting to hospital following self-harm. However, there is evidence that their diagnostic accuracy in predicting repeat self-harm is limited. Their predictive accuracy in population settings, and in identifying those at highest risk of suicide is not known.

METHOD

We compared the predictive accuracy of the Manchester Self-Harm Rule (MSHR), ReACT Self-Harm Rule (ReACT), SAD PERSONS Scale (SPS) and Modified SAD PERSONS Scale (MSPS) in an unselected sample of patients attending hospital following self-harm. Data on 4000 episodes of self-harm presenting to Emergency Departments (ED) between 2010 and 2012 were obtained from four established monitoring systems in England. Episodes were assigned a risk category for each scale and followed up for 6 months.

RESULTS

The episode-based repeat rate was 28% (1133/4000) and the incidence of suicide was 0.5% (18/3962). The MSHR and ReACT performed with high sensitivity (98% and 94% respectively) and low specificity (15% and 23%). The SPS and the MSPS performed with relatively low sensitivity (24-29% and 9-12% respectively) and high specificity (76-77% and 90%). The area under the curve was 71% for both MSHR and ReACT, 51% for SPS and 49% for MSPS. Differences in predictive accuracy by subgroup were small. The scales were less accurate at predicting suicide than repeat self-harm.

CONCLUSIONS

The scales failed to accurately predict repeat self-harm and suicide. The findings support existing clinical guidance not to use risk classification scales alone to determine treatment or predict future risk.