Deliberate Self-Harm by Burning: A Retrospective Case Controlled Study:

Mental health liaison in a regional burns unit-Past, present and future

OBJECTIVE

To describe the epidemiology of patients assessed by a Psychiatric Liaison Team (PLT) on a Regional Burns Unit in London, UK.

METHOD

A case note review of all patients assessed by the PLT over a 4-year period was carried out. Data were extracted regarding whether the burn was sustained intentionally or non-intentionally, ICD-10 psychiatric diagnosis, alcohol use at the time of injury and mechanism of injury. The independent t-test and chi-squared test were used for data analysis.

RESULTS

The PLT assessed 81 patients in total, 45 (55.6%) of burns were non-intentional, 32 (39.5%) were deliberate, and 4 patients (4.9%) were victims of an assault. The overall ratio of males to females was approximately equal. The mean age of patients with deliberate burns was younger, as compared to non-intentional burns, this difference was statistically significant (p < 0.01). Of the patients in the sample, 95% had a psychiatric diagnosis. We identified a difference in type of psychiatric diagnosis in the non-intentional and intentional burns groups. Alcohol use was linked to 38 (48%) of all patients assessed. Flame injuries were the most common mechanism of injury. Chemical burns, were significantly associated with a diagnosis of personality disorder (p < 0.05, chi-square test).

CONCLUSION

Well-resourced psychiatric liaison teams working collaboratively with burns units are essential to meet the needs of this diverse and complex group of patients.

Burn recidivism: a 10-year retrospective study characterizing patients with repeated burn injuries at a large tertiary referral burn center in the United States

Background

Psychiatric and substance use disorders are common among trauma and burn patients and are known risk factors for repeat episodes of trauma, known as trauma recidivism. The epidemiology of burn recidivism, specifically, has not been described. This study aimed to characterize cases of burn recidivism at a large US tertiary care burn center and compare burn recidivists (RCs) with non-recidivists (NRCs).

Methods

A 10-year retrospective descriptive cohort study of adult burn patients admitted to the North Carolina Jaycee Burn Center was conducted using data from an electronic burn registry and the medical record. Continuous variables were reported using medians and interquartile ranges (IQR). Chi-square and Wilcoxon-Mann-Whitney tests were used to compare demographic, burn, and hospitalization characteristics between NRCs and RCs.

Results

A total of 7134 burn patients were admitted, among which 51 (0.7%) were RCs and accounted for 129 (1.8%) admissions. Of the 51 RCs, 37 had two burn injuries each, totaling 74 admissions as a group, while the remaining 14 RCs had between three and eight burn injuries each, totaling 55 admissions as a group. Compared to NRCs, RCs were younger (median age 36 years vs. 42 years, p = 0.02) and more likely to be white (75% vs. 60%, p = 0.03), uninsured (45% vs. 30%, p = 0.02), have chemical burns (16% vs. 5%, p <  0.0001), and have burns that were ≤ 10% total body surface area (89% vs. 76%, p = 0.001). The mortality rate for RCs vs. NRCs did not differ (0% vs. 1.2%, p = 0.41). Psychiatric and substance use disorders were approximately five times greater among RCs compared to NRCs (75% vs. 15%, p <  0.001). Median total hospital charges per patient were nearly three times higher for RCs vs. NRCs ($85,736 vs. $32,023, p <  0.0001).

Conclusions

Distinct from trauma recidivism, burn recidivism is not associated with more severe injury or increased mortality. Similar to trauma recidivists, but to a greater extent, burn RCs have high rates of comorbid psychiatric and medical conditions that contribute to increased health care utilization and costs. Studies involving larger samples from multiple centers can further clarify whether these findings are generalizable to national burn and trauma populations.

Self-immolation in Iran: Systematic Review and Meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis of self-immolation epidemiology and characteristics in Iran.

METHODS

This was a systematic review and meta-analysis study. PubMed, Scopus, Web of science and Science Direct were searched for English literature and SID and Magiran for Persian in the time period of 2000 to 2016. The retrieved studies were screened and reviewed then quality assessed. Random Effect model was applied for meta-analysis. The qualitative data were analyzed by content analysis method.

RESULTS

After literature screening, 39 studies included in the analysis. Women were subject to self-immolation more than men. The rate of self-immolation estimated to be 4.5 cases in every 100,000 populations and it was the reason of 16% of hospitalized burns. The average length of hospital stay calculated to be 12.24 (95% CI: 8.85-15.59) days. The total burnt surface area was 65.3% (95% CI: 56.71-73.89). Death due to self-immolation was 62.1%. The major risk factors of self-immolation were having mental health issues, family problems and characteristics and problems in relation/communication with spouses.

CONCLUSION

Despite the low rate of self-immolation in Iran, it comprises one sixth of the hospitalized burns. The mortality rate of self-immolation also is high and this highlights the importance of providing special care. Psychological consultations and mental health screening in the primary health care would help to prevent the self-immolation.

Epidemiology and financial implications of self-inflicted burns

INTRODUCTION

The cost of the treatment of burns is high especially in self-inflicted burns with prolonged treatment. We performed a retrospective review of the self-inflicted burns at our regional burns centre to determine the costs incurred in their management and to identify factors which could reduce the financial burden in the future.

METHODS

The data was collected retrospectively of all the inpatient and outpatient self-inflicted burns presenting to our regional burns centre in the year 2011.

RESULTS

Twenty one patients (out of a total of 870 patients) presented with self-inflicted burns to our centre in 2011. Five (23.8%) were major burns with an average of 53.2% Total Body Surface Area (TBSA) and 16 (76.2%) were minor burns with an average of 0.5% TBSA. 11 (52.4%) patients had flame burns including 4 self-immolation burns. The mortality rate was 4.8% (n=1). Five (23.8%) patients underwent surgical treatment. Seven (33.3%) patients were treated in intensive care and with average stay of 46.85 days. Critical care and theatre attendances made up most of the costs with average ICU stay per patient calculated at £313,131/day. The total cost of all 21 patients was £1,581,856.

CONCLUSION

Burns are preventable injuries, early detection and intervention in patients with propensity to self-inflict burns can possibly reduce the costs of treatment in the future.

Intentional burns in Nepal: a comparative study

AIMS

Intentional burns injuries are associated with high mortality rates, and for survivors, high levels of physical and psychological morbidity. This study provides a comprehensive assessment of intentional burn admissions to the adult Burns Unit at Bir Hospital, Kathmandu, Nepal, during the period 2002-2013.

METHODS

A secondary data analysis of de-identified data of patients hospitalized at Bir Hospital, Kathmandu, with a burn during the period of 1 January 2002 to 31 August 2013. Socio-demographic, injury and psychosocial factors of patients with intentional and unintentional burns are described and compared. Chi-square tests, Fisher's exact test and Wilcoxon rank sum tests were used to determine statistical significance.

RESULTS

There were a total of 1148 burn admissions of which 329 (29%) were for intentional burn, 293 (26%) were self-inflicted and 36 (3%) were due to assault. Mortality rates for intentional burns were approximately three times those for unintentional burns (60 vs. 22%). When compared to unintentional burns, patients with intentional burns were more likely to be female (79 vs. 48%), married (84 vs. 67%), younger (25 vs. 30 years), have more extensive burns (total body surface area, %: 55 vs. 25) and higher mortality (60 vs. 22%). Intentional burns were more likely to occur at home (95 vs. 67%), be caused by fire (96 vs. 77%), and kerosene was the most common accelerant (91 vs. 31%). A primary psychosocial risk factor was identified in the majority of intentional burn cases, with 60% experiencing adjustment problems/interpersonal conflict and 32% with evidence of a pre-existing psychological condition. A record of alcohol/substance abuse related to the patient or other was associated with a greater proportion of intentional burns when compared with unintentional burns (17 vs. 4%).

CONCLUSIONS

The majority of intentional burn patients were female. Almost all intentional burns occurred in the home and were caused by fire, with kerosene the most common accelerant used. Underlying psychosocial risk factors were identified in most cases. Intentional burns resulted in severe burns with high mortality. Intentional burns are not only a serious medical issue; they represent significant public health and gender issues in Nepal.

Self-immolation and its adverse life-events risk factors: results from an Iranian population

Background:

Despite considerable loss of life by deliberate self-burning in low and middle-income countries, few scholars have examined psychiatric factors such as adverse life events that may be related to self-immolation.

Methods:

This case-control study investigated adverse life-events as risk factors for self-immolation patients admitted to a burn center serving the western region of Iran. Variables investigated included the following adverse life-events: unplanned pregnancy, infertility, homelessness, financial hardship, problems with friends, intimate relationship break-up , school or university failure, anxiety about school/university performance, problems at work, personal history of suicide attempts, family history of suicide attempts, individual history of mental disorders, and malignant disease.

Results:

Financial hardship (OR=3.35, 95% CI=1.19-9.90), intimate relationship break-up (OR=5.45, 95% CI=1.20-11.99), and personal history of suicide attempts (OR=7.00, 95% CI=1.38-35.48) were associated with increased risk of self-immolation.

Conclusions:

This study suggests that financial hardship, intimate relationship break-ups, and personal history of suicide attempts are risk factors for self-immolation. Other variables studied did not play a role as individually protective or risk factors for self-immolation.

Further study is needed to substantiate findings of this study and direct research toward tailoring culturally sensitive, empirically-supported interventions for prevention of self-immolation.

A case-control study of psychosocial risk and protective factors of self-immolation in Iran

Self-immolation is the third leading cause of years of life lost (YLL) among women in Iran. The aim of this study is to investigate self-immolation-related risk and protective factors in the western region of Iran, a province with the highest prevalent of self-immolation in the country. Using a case-control design, we compared 151 cases of self-immolation attempters who were admitted to a burn center in Kermanshah with 302-matched control group from the same community/locality between March 21st, 2009, and March 20th, 2012. We conducted descriptive, bivariate, and multivariate analysis to examine the associations of self-immolation with demographic and familial risk factors, adverse life events, mental disorders, as well as potential protective factors. According to our findings, the highest percentage of self-immolation was in the 16-25 year-old age group (60%) and in females (76%). Of the potential risk factors in the study, major depression, adjustment disorders, individual history of suicide attempts and opium dependence, were statistically significant predictors of self-immolation. Suggestions for translating the local picture of self-immolation portrayed by our findings, into meaningful prevention strategies that have a good fit with the social and interpersonal context within which self-immolation takes place are discussed.

Self-inflicted burn injuries in the Australian context

OBJECTIVE

The primary objective was to calculate the number of self-inflicted burn injuries of all admissions in an Australian hospital burns unit. The secondary objectives included examining the demographic profile, length of stay and co-morbidity of mental illness in these cases compared with the total admissions to the burns unit.

METHODS

A retrospective study of medical records was conducted at a tertiary burns unit over a 5-year period.

RESULTS

A total of 33 self-inflicted burn injury cases were identified which represented 2.2% of all burns unit admissions. These patients were 70% male, the average age was 36.1 years and 11 were born overseas, which was similar to the profile of all admissions. Twenty-four (73%) patients were diagnosed with a mental illness, compared with 14% for all admissions. The average length of stay was 52 days, compared with the burns unit average of 12 days.

CONCLUSIONS

While the percentage of self-inflicted burn cases of all burns unit admissions was low, these cases have a greater burden of care due to their longer admission time and higher frequency of co-morbid mental illness. This finding supports the need for close involvement of consultation liaison psychiatry teams within a burns unit.

Epidemiology of burns throughout the World. Part II: intentional burns in adults

A significant number of burns and deaths from fire are intentionally wrought. Rates of intentional burns are unevenly distributed throughout the world; India has a particularly high rate in young women whereas in Europe rates are higher in men in mid-life. Data from hospitalized burn patients worldwide reveal incidence rates for assault by fire and scalds ranging from 3% to 10%. The average proportion of the body surface area burned in an assault by fire or scalds is approximately 20%. In different parts of the world, attempted burning of others or oneself can be attributed to different motives. Circumstances under which assaults occur fall largely into the categories of interpersonal conflict, including spousal abuse, elder abuse, or interactions over contentious business transactions. Contributing social factors to assaults by burning include drug and alcohol abuse, non-constructive use of leisure time, non-participation in religious and community activities, unstable relationships, and extramarital affairs. Although the incidence of self-mutilation and suicide attempts by burning are relatively low, deliberate self-harm carries a significant risk of death, with an overall mortality rate of 65% worldwide. In those who resort to self-immolation, circumstantial themes reflect domestic discord, family dysfunction, and the social ramifications of unemployment. Preventing injurious burn-related violence requires a multifaceted approach, including legislation and enforcement, education, and advocacy. Better standardized assessment tools are needed to screen for risks of abuse and for psychiatric disorders in perpetrators.

Psychiatric disorders (Axis I and Axis II) and self-immolation: a case-control study from Iran

The objective of this study was to investigate preexisting psychiatric disorders in self-immolation patients. In a case-control study, 30 consecutive cases of deliberate self-inflicted burns, admitted to the regional burn center, were compared with 30 controls. Mental disorders were assessed via detailed clinical interview. Descriptive data revealed that 67% of self-immolation patients had adjustment disorder (all female), 10% drug and alcohol abuse/dependence (all male), 7% dysthymia, 3% major depression, 3% anorexia nervosa, 3% primary insomnia, 7% borderline personality disorder (50% male), 7% depressive personality disorder (100% female), and 3% antisocial personality disorder. In bivariate comparisons, adjustment disorders emerged as related to risk of self-immolation (odds ratio = 13.00). This study suggests that adjustment disorder is a risk factor for self-immolation. As a result, it has been suggested that increasing education about problem-solving approaches, and coping skills for females and at-risk groups are appropriate prevention programs and strategies in Iranian communities.