Repeat self-harm: an 18-month follow-up

Self-harm hospitalised morbidity and mortality risk using a matched population-based cohort design

OBJECTIVE

Prior and repeated self-harm hospitalisations are common risk factors for suicide. However, few studies have accounted for pre-existing comorbidities and prior hospital use when quantifying the burden of self-harm. The aim is to quantify hospitalisation in the 12 months preceding and re-hospitalisation and mortality risk in the 12 months post a self-harm hospitalisation.

METHOD

A population-based matched cohort using linked hospital and mortality data for individuals ⩾18 years from four Australian jurisdictions. A non-injured comparison cohort was matched on age, gender and residential postcode. Twelve-month pre- and post-index self-harm hospitalisations and mortality were examined.

RESULTS

The 11,597 individuals who were hospitalised following self-harm in 2009 experienced 21% higher health service use in the 12 months pre and post the index admission and a higher mortality rate (2.9% vs 0.3%) than their matched counterparts. There were 133 (39.0%) deaths within 2 weeks of hospital discharge and 342 deaths within 12 months of the index hospitalisation in the self-harm cohort. Adjusted rate ratios for hospital readmission were highest for females (2.86; 95% confidence interval: [2.33, 2.52]) and individuals aged 55-64 years (3.96; 95% confidence interval: [2.79, 5.64]).

CONCLUSION

Improved quantification of the burden of self-harm-related hospital use can inform resource allocation for intervention and after-care services for individuals at risk of repeated self-harm. Better assessment of at-risk self-harm behaviour, appropriate referrals and improved post-discharge care, focusing on care continuity, are needed.

Repetition of deliberate self-harm: a study of the characteristics and subsequent deaths in patients presenting to a general hospital according to extent of repetition

Repetition of deliberate self-harm (DSH) is common. Some patients repeat multiple times. We have investigated the characteristics of repeaters, and mortality in three groups of DSH patients by repetition status. Data collected by the Oxford Monitoring System for Attempted Suicide were used to examine the pattern of repetition of DSH patients presenting to a general hospital between 1990 and 1997. Each patient was tracked through the monitoring system with regard to repetition. Patients traceable through National Death Registers were followed up until 2000 with respect to mortality. A total of 4,167 patients were studied of which 1,022 (24.5%) repeated at least once during follow-up. Using multinomial regression, past history of DSH was the variable most strongly associated with frequent (4+) and less frequent (1-3) repetitions. Risk of suicide was significantly increased in females with frequent repetition (7.7% dying by suicide), compared with both those with 1-3 repetitions (2.3%) and those not repeating (1.0%). The analyses were repeated for the 2,167 patients with no past history of DSH at their first presentation. Using multinomial regression, personality disorder was the only variable that was associated with 4+ repetitions compared with no repetitions, although a number of variables distinguished between patients with 1-3 repetitions and no repeat episodes. For clinicians assessing DSH patients, past history of DSH is the best predictor of infrequent and frequent repetition. In patients with no past history of DSH the presence of personality disorder increases the risk of frequent repetition of DSH.

Does availability of mental health resources prevent recurrent suicidal behavior? An ecological analysis

This study examines whether availability of mental health resources in the county of residence is associated with subsequent suicidal behavior after a previous suicide attempt. Among 10,922 individuals who attempted suicide in Colorado between 1998 and 2002, residence in a county that offered a minimum safety-net of mental health services significantly reduced the risk of suicidal behavior for at least 1 year after the index attempt. Safety-net services included mental health treatment, crisis treatment, and case management. These results suggest one strategy for prevention of suicidal behavior that could inform state-level health policy development and resource allocation.

Prediction of repeated parasuicide after 1-12 months

To investigate predictors for repetition of suicide attempts 1-12 months after a suicide attempt.

SUBJECTS AND METHODS

Two hundred and sixteen patients who had made a suicide attempt were investigated after 1 month, and 178 were followed up again after 12 months.

RESULTS

During 1-12 months after the suicide attempt, 30 patients reattempted suicide (repeaters). During 0-1 month 13 patients had reattempted suicide (early repeaters), and nine of them also repeated between 1 and 12 months. Repeaters had more often made three or more attempts before index attempt, they more often were in treatment at the index attempt and at 1 month they had lower global functioning and higher suicide ideation. In a Cox Regression analysis two predictors for repetition between 1 and 12 months remained significant; early repetition (OR 6.7, 95% CI, 3.0-14.9) and having GAF-scores below 49 (median cut-off) (OR 3.4 (95% CI, 1.5-7.5).

CONCLUSION

Our findings suggest that repetitive behaviour in itself is a strong predictor of future attempts. Strategies focusing on the repetitive behaviour are warranted.

Repetition of deliberate self-harm as seen in Uganda

Described is the presentation of repetition of deliberate self-harm (DSH) as seen in an African population in urban Uganda. A Luganda version (local language in study area) of the modified European Parasuicide Interview Schedule I (EPSIS I) was used to collect the data. An univariate analysis was conducted. Results indicated that repeaters of DSH differed significantly from non-repeaters on several dimensions. The factors included were: more often single, less often had children, staying alone or with their parents, reported sexual problems as a precipitant of current DSH event, more negative life events in childhood and less negative life events in the last year. Furthermore, a multivariate analysis was conducted resulting in only sexual problems and the psychological factor of trait anger, which retained statistical significance. The significance of these findings is discussed.

A follow-up study of adolescent attempted suicide in Israel

OBJECTIVES

(1) To compare the outcome of adolescent subjects who have made a suicide attempt with the outcome of matched controls, using their psychological and psychometric screening tests for military service at age 16.5 years. Their subsequent performance during military service between ages 18 and 21 was also evaluated. (2) To compare the prognosis of those attempters who received intensive psychiatric inpatient evaluation in a general hospital with the prognosis of those who received emergency room treatment only.

METHOD

The computerized military records of 216 adolescents, who had been treated between 1987 and 1988 for attempted suicide in a general hospital emergency room, prior to their induction into the army, were evaluated. They were rated on the following tests: cognitive/educational performance and psychosocial adaptation, psychiatric and psychological health diagnoses, and performance during their military service between 1989 and 1992.

RESULTS

Although the female attempters had slightly more problems in the military than the controls, their overall prognosis was surprisingly good. The male suicide attempters did very poorly in their subsequent military service. There was no long-term advantage in having had a psychiatric evaluation performed in a hospital over a brief emergency room evaluation. Most differences between attempters and controls were in service performance, rather than in cognitive and psychometric tests.

CONCLUSIONS

There may be marked differences between the sexes in the significance of attempted suicide and in the indications for intervention. The policy of mandatory general hospitalization for suicide attempters may need reevaluation.

Fatal and non-fatal repetition of self-harm. Systematic review

BACKGROUND

Non-fatal self-harm frequently leads to non-fatal repetition and sometimes to suicide. We need to quantify these two outcomes of self-harm to help us to develop and test effective interventions.

AIMS

To estimate rates of fatal and non-fatal repetition of self-harm.

METHOD

A systematic review of published follow-up data, from observational and experimental studies. Four electronic databases were searched and 90 studies met the inclusion criteria.

RESULTS

Eighty per cent of studies found were undertaken in Europe, over one-third in the UK. Median proportions for repetition 1 year later were: 16% non-fatal and 2% fatal; after more than 9 years, around 7% of patients had died by suicide. The UK studies found particularly low rates of subsequent suicide.

CONCLUSIONS

After 1 year, non-fatal repetition rates are around 15%. The strong connection between self-harm and later suicide lies somewhere between 0.5% and 2% after 1 year and above 5% after 9 years. Suicide risk among self-harm patients is hundreds of times higher than in the general population.

Attempted suicide: repetition and survival--findings of a follow-up study

OBJECTIVE

This was a prospective follow-up study of suicidal patients to assess the influence over time of different risk factors, whether on completed suicides or reattempts. Survival analysis makes it possible to weigh the influence of variables that increase or decrease a patient's life span or that make reattempts less likely.

METHOD

A cohort of 150 patients admitted to a psychiatric department after a suicide attempt was followed up over 10 years. The study protocol used standardized criteria, and periodic controls were carried out in all patients.

RESULTS

In total, 12% of patients completed suicide, 10% died from natural causes, 75% were still alive and 25% reattempted. In the survival analysis the risk for completed suicide or reattempting was highest during the first 2 years after the index attempt admission. Global Assessment of Functioning (GAF) was the factor that most increased survival time. The number of previous attempts decreased survival time and increased the risk of reattempts.

CONCLUSION

Since suicidal risk varied over time, intensifying contact with patients during periods of psychopathological change or life events could prolong their survival.

Repetition of deliberate self-poisoning in an Australian hospital-treated population

OBJECTIVES

To describe the hospital-treated prevalences for repeat deliberate self-poisoning (RDSP) and the demographic characteristics of the RDSP group, and to compare the RDSP and non-RDSP groups.

DESIGN

Prospective longitudinal cohort study, with a one- to four-year follow-up.

SETTING

The Hunter Area Toxicology Service (HATS), a regional toxicology treatment centre in New South Wales.

SUBJECTS

1238 consecutive DSP patients referred to hospital, 1992-1994, with follow-up through 1995.

OUTCOME MEASURES

Deliberate self-poisoning (DSP) admissions within one year (RDSP-1), within six months (RDSP-6m), and within 28 days (RDSP-28d) of any other DSP admission by the same patient; length of stay; demographic characteristics; and drugs ingested.

RESULTS

175 patients (14.1%) repeated DSP during the study; 165 (13.3%) were classified as RDSP-1, giving a patient prevalence of hospitalisation in the range of 14.6 to 20.7 per 100,000 per year. Fifty-six RDSP-28d patients (33.9% of RDSP-1) accounted for 49.8% of the RDSP-1 admissions, and 123 RDSP-6m patients (74.5% of RDSP-1) accounted for 83.5% of RDSP-1 admissions. For RDSP-1, the male:female ratio was 1:1.9, with 35.7% unemployed, 29.1% pensioners and 15.8% married or in de facto relationships. RDSP-1 patients had a shorter length of stay (3 h), which was not clinically important. RDSP was more likely for the 25-34 years age group (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.17-4.29) and the 35-44 years age group (OR, 2.12; 95% CI, 1.02-4.39) than the 10-18 years group, and more likely for women than men (OR, 1.69; 95% CI, 1.17-2.46). Being married/de facto reduced the risk for repetition (OR, 0.55; 95% CI, 0.31-0.96) compared with being single. Medications indicated for psychiatric illness were most commonly used for DSP.

CONCLUSIONS

Many patients who repeat DSP do so after a very brief interval and account for a disproportionate number of hospitalisations. Availability of psychiatric medications for DSP patients is a possible area of intervention.

Research methods in clinical investigation: a case study analysis of medication levels and self-harm

This paper uses a case study to illustrate an application of the scientist-practitioner model to clinical practice. Through consultation with a clinical psychologist, a simple method of obtaining an objective overview of the therapeutic use of medication was developed. Focusing on a woman in a Regional Secure Unit, data were gathered from incident forms of self-harm and the corresponding drug charts. Using basic statistical techniques (such as frequencies and measures of central tendency) to summarize these data, useful clinical information was obtained. Actual data from the case study are presented, as an example of a research process that can be applied to understanding the role of extraneous variables when pursuing a course of chemical treatment. Analyses of drug effects suggest that additional variables such as environmental, interpersonal and engagement factors needed to be considered. The paper advocates the ease of applicability of research methods to clinical investigation.

Recurrent overdose: patient characteristics, habits, and outcomes

OBJECTIVES

Patients who overdose repeatedly on drugs and poisons (repeaters) are of major concern. This study aimed to examine the demographics, types of drugs ingested, associated self inflicted trauma, and medium term outcome of repeaters and to compare these patients with those who overdosed on one occasion only (single presenters) during the study period.

METHODS

The study was undertaken in the emergency department of a large, provincial Australian hospital. A retrospective case note examination was made for all patients who presented, after drug overdose, during the two year study period. These patients were also followed up for a further 12 months after the study period.

RESULTS

The study identified 335 single presenters and 46 repeaters. Females formed about two thirds of each group but repeaters tended to be older (p > 0.05) and to present more frequently before midnight (p > 0.05). Significantly more repeat presentations were triaged to the low priority categories 4 or 5 (odds ratio (OR) 0.48; 95% confidence interval (CI) 0.26 to 0.90, p = 0.023) and this group required fewer admissions to the hospital (OR 1.85; 95% CI 1.16 to 2.93, p = 0.009). Repeaters tended to take single drug overdoses. There were significantly more paracetamol only overdoses (OR 0.54; 95% CI 0.32 to 0.92, p = 0.024) and neuroleptic only overdoses (OR 0.27; 95% CI 0.11 to 0.67, p = 0.005) in the repeater group. More repeaters caused self inflicted trauma during the study period (OR 0.20; 95% CI 0.06 to 0.64, p = 0.007). No repeater completed suicide during the study or the 12 month follow up periods but repeaters presented more frequently, after overdose, during follow up (OR 0.38; 95% CI 0.13 to 1.11, p = 0.078).

CONCLUSIONS

The study concludes that there are some significant differences between patients who overdose repeatedly and those who overdose on one occasion only. The study findings suggest that the medium term suicidal risk for repeaters is relatively low. However, this risk will vary and individual patients must be assessed thoroughly and managed accordingly.

Suicide attempts in a cohort of drug abusers: a 5-year follow-up study

A group of 125 drug abusers admitted consecutively for detoxification and short-term rehabilitation were followed up 5 years after discharge. They were asked about possible suicide attempts in a semi-structured face-to-face interview. Nearly half of the group (45%) reported having attempted suicide at some point in their life. The most common reasons given were the loss of a person whom they loved, and feelings of loneliness. Only three respondents reported using their drug of choice in the attempt(s). The suicide attempters were more often found to have been in child psychiatric treatment earlier, and to have experienced loss of significant others in childhood, than those who did not report attempting suicide. At follow-up the suicide attempters indicated that they experienced more depressive moods and more severe psychological problems than those who had never made a suicide attempt. The importance of assessing the risk of suicide attempts among drug addicts in order to be able to take measures to prevent future suicidal behaviour is emphasized.

A 5-year follow-up study of suicide attempts

Seventy-five patients were admitted to the ward of the Lund Suicide Research Center following a suicide attempt. After 5 years, the patients were followed up by a personal semistructured interview covering sociodemographic, psychosocial and psychiatric areas. Ten patients (13%) had committed suicide during the follow-up period, the majority within 2 years. They tended to be older at the index attempt admission, and most of them had a mood disorder in comparison with the others. Two patients had died from somatic diseases. Forty-two patients were interviewed, of whom 17 (40%) had reattempted during the follow-up period, most of them within 3 years. Predictors for reattempt were young age, personality disorder, parents having received treatment for psychiatric disorder, and a poor social network. At the index attempt, none of the reattempters had diagnoses of adjustment disorders or anxiety disorders. At follow-up, reattempters had more psychiatric symptoms (SCL-90), and their overall functioning (GAF) was poor compared to those who did not reattempt. All of the reattempters had long-lasting treatment ( > 3 years) as compared to 56% of the others. It is of great clinical importance to focus on treatment strategies for the vulnerable subgroup of self-destructive reattempters.

Deliberate self-poisoning: treatment follow-up of repeaters and nonrepeaters

Since 1986 psychiatrists and social workers of the Lund Suicide Research Center have investigated subjects admitted to the medical intensive care unit after a suicide attempt. Fifty-nine of 79 deliberate self-poisoners were interviewed 12 months after a suicide attempt. Twenty-one had previously been interviewed 6 months after the index suicide attempt. We obtained minor information on 8 subjects. Two patients had committed suicide. Sixteen subjects (27%) of those who were interviewed showed repeated suicidal behavior (repeaters) during the 1-year follow-up, and their psychiatric diagnoses at the index attempt were most commonly alcohol abuse and dysthymia (DSM-III, Axis I). Compared with nonrepeaters, repeaters had more often made previous suicide attempts, their index attempt was less serious and they were more often in psychiatric treatment at index. At follow-up, repeaters more often than nonrepeaters expressed the need for professional mental health support. Two-thirds of the patients were in treatment at follow-up. About half had remained in continuous treatment and most in psychiatric care for more than 1 year. Repeated self-poisoning occurred despite ongoing treatment. In view of the fact that numerous suicide attempters obviously remain in treatment for several years, we suggest further development and evaluation of long-term treatment strategies.

Deliberate self-poisoning: repeaters and nonrepeaters admitted to an intensive care unit

Seventy-nine patients admitted to the Lund Intensive Care Unit after deliberate self-poisoning were investigated by a psychiatrist and a social worker by means of a semistructured interview. Suicide risk evaluation included statistical risk factors according to the SAD PERSONS Scale, severity of suicidal intent according to the Suicidal Intent Scale, and interviewer reaction according to Motto. Two-thirds of the patients were in treatment or had had counselling with a social worker. More than half of the sample were repeaters. Compared with nonrepeaters, repeaters were less often employed, lacked social support and more often had relational problems. The majority of the repeaters had ongoing treatment, mostly psychiatric treatment. Repeaters more often acted impulsively, and their suicidal intent tended to be less severe than those of nonrepeaters. Interviewers more often reacted with negative or neutral feelings towards repeaters. Our results indicate that those who repeat suicidal behaviour differ from nonrepeaters. Self-poisoners, and especially repeaters, often had ongoing or previous psychiatric treatment. For the repeater group it is important to consider their impulse dyscontrol and their hostile attitude when alternative treatment strategies are devised and evaluated.