Variations in the hospital management of self harm in adults in England: observational study

Comparing times of self-harm presentations to hospital emergency departments in children, adolescents, young adults and adults: a national registry study 2007-2019

PURPOSE

The few studies that have explored self-harm presentation times at hospital emergency departments (EDs) - an important factor that can determine if a patient receives a mental health assessment - primarily focus on adult samples. This study examined the times of self-harm presentations to EDs, self-harm methods used, mental health assessments, and admission data across different age-groups.

METHODS

Using data from the National Self-Harm Registry Ireland over a 13-year timeframe (2007-2019), this study compared times, days, seasons, methods of self-harm, and admission data for children (8-12 years), adolescents (13-17 years), young adults (18-25 years) and adults (> 25 years).

RESULTS

The majority of the 152,474 self-harm presentations (78.6%) for all ages occurred out-of-hours (outside the standard working hours or in-hours times of 09:00-17:00, Monday-Friday). The four hours before midnight had the highest proportions of self-harm presentations for adolescents (27.9%) and adults (23.1%), whereas the four hours after midnight had the highest proportion of self-harm presentations for young adults (22.9%). The 16:00-midnight timeframe had highest proportion of self-harm presentations in children (52.3%). Higher proportions of patients received a mental health assessment in-hours compared to out-of-hours among young adults (78.2% vs. 73.3%) and adults (76.1% vs. 72.0%). Self-harm presentations were lowest during summer months in children and adolescents.

DISCUSSION

Hospitals should ensure that adequate resources are available for individuals presenting with self-harm, especially in the case of overcrowded EDs, and protocols need to be designed for those presenting with self-harm due to intoxication. In line with national policy, protocols for patients presenting during out-of-hours should be designed that can incorporate services from allied health multidisciplinary teams, social work, addiction services and counselling organisations. Given the lower rates of self-harm during school holidays for children and adolescents, the school environment must be considered in the context of mental health and self-harm public health prevention interventions.

Global prevalence of psychosocial assessment following hospital-treated self-harm: systematic review and meta-analysis

BACKGROUND

Hospital-treated self-harm is common, costly and associated with repeated self-harm and suicide. Providing a comprehensive psychosocial assessment following self-harm is recommended by professional bodies and may improve outcomes.

AIMS

To review the provision of psychosocial assessments after hospital-presenting self-harm and the extent to which macro-level factors indicative of service provision explain variability in these estimates.

METHOD

We searched five electronic databases to 3 January 2023 for studies reporting data on the proportion of patients and/or events that were provided a psychosocial assessment. Pooled weighted prevalence estimates were calculated with the random-effects model. Random-effects meta-regression was used to investigate between-study variability.

RESULTS

119 publications (69 unique samples) were included. Across ages, two-thirds of patients had a psychosocial assessment (0.67, 95% CI 0.58-0.76). The proportion was higher for young people and older adults (0.75, 95% CI 0.36-0.99 and 0.83, 95% CI 0.48-1.00, respectively) compared with adults (0.64, 95% CI 0.54-0.73). For events, around half of all presentations had these assessments across the age range. No macro-level factor explained between-study heterogeneity.

CONCLUSIONS

There is room for improvement in the universal provision of psychosocial assessments for self-harm. This represents a missed opportunity to review and tailor aftercare supports for those at risk. Given the marked unexplained heterogeneity between studies, the person- and system-level factors that influence provision of psychosocial assessments after self-harm should be studied further.

Global prevalence of psychiatric in- and out-patient treatment following hospital-presenting self-harm: a systematic review and meta-analysis

Background

Hospital-treated self-harm is common, costly, and strongly associated with suicide. Whilst effective psychosocial interventions exist, little is known about what key factors might modify the clinical decision to refer an individual to psychiatric in- and/or out-patient treatment following an episode of hospital-treated self-harm.

Methods

We searched five electronic databases (CENTRAL, CDSR, MEDLINE, Embase, and PsycINFO) until 3 January 2023 for studies reporting data on either the proportion of patients and/or events that receive a referral and/or discharge to psychiatric in- and/or outpatient treatment after an episode of hospital-treated self-harm. Pooled weighted prevalence estimates were calculated using the random effects model with the Freedman-Tukey double arcsine adjustment in R, version 4.0.5. We also investigated whether several study-level and macro-level factors explained variability for these outcomes using random-effects meta-regression. The protocol of this review was pre-registered with PROSPERO (CRD42021261531).

Findings

189 publications, representing 131 unique studies, which reported data on 243,953 individual participants who had engaged in a total of 174,359 episodes of self-harm were included. Samples were drawn from 44 different countries. According to World Bank classifications, most (83.7%) samples were from high income countries. Across the age range, one-quarter of persons were referred for inpatient psychiatric care and, of these, around one-fifth received treatment. Just over one-third were referred to outpatient psychiatric care, whilst around half of those referred received at least one treatment session across the age range. Event rate estimates were generally of a lower magnitude. Subgroup analyses found that older adults (mean sample age: ≥60 years) may be less likely than young people (mean sample age: ≤25 years) and adults (mean sample age: >25 years to <60 years) to be referred for outpatient psychiatric care following self-harm. More recent studies were associated with a small increase in the proportion of presentations (events) that were referred to, and received, psychiatric outpatient treatment. No macro-level factor explained between-study heterogeneity.

Interpretation

There is considerable scope for improvement in the allocation and provision of both in- and out-patient psychiatric care following hospital-presenting self-harm, particularly considering that the period after discharge from general hospitals represents the peak risk period for repeat self-harm and suicide. Given the marked between-study heterogeneity, the basis for allocation of aftercare treatment is therefore not yet known and should be further studied.

Funding

There was no specific funding for this review.

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.

The Experience and Meaning of Repeated Self-Harm Among Patients Presenting to Irish Hospital Emergency Departments

BACKGROUND

Self-harm is a global public health concern in terms of increasing morbidity in addition to causing considerable financial implications for the health sector. Patients presenting with a history of self-harm are at increased risk of self-harm repetition and suicide. Research exploring the patient's experience of engaging in multiple self-harm episodes is lacking. This study aimed to explore the experiences and meaning of self-harm repetition, among patients who presented to three urban hospital emergency departments in Ireland.

METHOD

A subset of participants with a history of five or more self-harm attempts from an ongoing study, 'Improving Prediction and Risk Assessment of Self-Harm and Suicide' was selected for this article. Interview transcripts from four participants were selected for analysis using Interpretative Phenomenological Analysis. The qualitative software package NVivo 11 was used to store and organise data into themes.

RESULTS

Data were analysed based on four participants (two males and two females) ranging in age from 25 to 56 years. Three of the four participants reported a history of early traumatic emotional, physical and sexual abuse. Four superordinate themes were generated from the data, 'Significance of self-harm to the person', 'Trajectory of self-harm progression', 'Impact of abuse in adult life' and 'The road to recovery'.

CONCLUSION

Self-harm was used as a coping mechanism for participants who experienced distressing life events such as emotional and sexual abuse. The qualitative themes identified in this study have implications for the development of adequate medical and mental health support systems for patients with histories of repeated self-harm.

The comparison of psychological scales as hospitalization predictors between adult and elderly suicide attempters

BACKGROUND

During the process of managing suicide attempters in the emergency department (ED), the importance of hospitalization has been emphasized. Lethality and intent have been suggested as hospitalization determinants of suicide attempters, but their predictive values remain limited in adult and elderly populations.

METHODS

Using prospectively collected the ED-based Suicide Registry, data from suicide attempters over 18 years old was retrospectively studied (2010-2020). The enrolled participants were divided into adult (N = 832) and elderly (>65 years, N = 378) groups. Suicide lethality and intent were assessed by the Risk-Rescue Rating Scale (RRRS) and Suicide Intent Scale (SIS), respectively. The moderating effects of age on the relationship between the psychological scales and hospitalization were examined by entering the interaction terms into a multivariable regression model. The predictive ability of each scale for hospitalization was evaluated in terms of performance and goodness-of-fit.

RESULTS

Both scales' scores in both age groups were significantly higher in hospitalized patients than non-hospitalized patients. Interaction result indicated that only the odds of RRRS for hospitalization significantly differed by age group. Moreover, the predictive performance for hospitalization significantly differed by age group in RRRS but not SIS. In predicting hospitalization, the AUC of the RRRS was significantly higher than that of the SIS in the elderly group but not in the adult group. Comparing the two groups, the RRRS of the elderly group tended to have higher AUC than the adult group, whereas the AUC of the SIS was similar. The RRRS in both groups had a better overall fit compared to the SIS for hospitalization, but its best overall fit and strength with greater power were observed in the elderly group.

CONCLUSIONS

The age-by-RRRS interaction is significantly associated with hospitalization, and the RRRS implementation as a hospitalization determinant is more useful and suitable for elderly suicide attempters than for adult suicide attempters in an emergency setting.

Long-term impact of the expansion of a hospital liaison psychiatry service on patient care and costs following emergency department attendances for self-harm

BACKGROUND

In September 2014, as part of a national initiative to increase access to liaison psychiatry services, the liaison psychiatry services at Bristol Royal Infirmary received new investment of £250 000 per annum, expanding its availability from 40 to 98 h per week. The long-term impact on patient outcomes and costs, of patients presenting to the emergency department with self-harm, is unknown.

AIMS

To assess the long-term impact of the investment on patient care outcomes and costs, of patients presenting to the emergency department with self-harm.

METHOD

Monthly data for all self-harm emergency department attendances between 1 September 2011 and 30 September 2017 was modelled using Bayesian structural time series to estimate expected outcomes in the absence of expanded operating hours (the counterfactual). The difference between the observed and expected trends for each outcome were interpreted as the effects of the investment.

RESULTS

Over the 3 years after service expansion, the mean number of self-harm attendances increased 13%. Median waiting time from arrival to psychosocial assessment was 2 h shorter (18.6% decrease, 95% Bayesian credible interval (BCI) -30.2% to -2.8%), there were 45 more referrals to other agencies (86.1% increase, 95% BCI 60.6% to 110.9%) and a small increase in the number of psychosocial assessments (11.7% increase, 95% BCI -3.4% to 28.5%) per month. Monthly mean net hospital costs were £34 more per episode (5.3% increase, 95% BCI -11.6% to 25.5%).

CONCLUSIONS

Despite annual increases in emergency department attendances, investment was associated with reduced waiting times for psychosocial assessment and more referrals to other agencies, with only a small increase in cost per episode.

Suicide risk assessment in the emergency department: An investigation of current practice in Scotland

BACKGROUND

Suicide is a global public health issue. Approximately one third of individuals who complete suicide have attended an emergency department in the year preceding their death. The aim of this study was to investigate current suicide risk assessment practices across emergency department clinicians in Scotland.

METHODS

A mixed-methods design was employed. A total of 112 surveys for emergency department clinicians were posted to 23 emergency departments in Scotland between March and September 2016. Follow-up semi-structured interviews were also conducted exploring clinician's experiences of suicide risk assessment. Interviews were analysed using thematic analysis.

RESULTS

Fifty-one emergency department clinicians across 17 emergency departments completed the survey. Thirty-five (68.6%) participants were currently using a suicide risk assessment tool; with most using locally developed tools and proformas (n = 20, 62.5%) or the SAD PERSONS scale (n = 13, 40.6%). Remaining participants (n = 16, 31.4%) did not use suicide risk assessment tools during assessment. Variation in practice was found both across and within emergency departments. Six clinicians participated in follow-up interviews, which identified four major themes: Clinician Experiences of Suicide Risk Assessment; Components of Suicide Risk Assessment; Clinical Decision-Making; and Supporting Clinicians.

CONCLUSIONS

There is substantial variation in current practice, with around two-thirds of clinicians using a variety of empirically and locally developed tools, and a third using their judgement alone. Clinicians find suicide risk assessment a challenging part of their role and discuss the need for increased training, and appropriate and helpful guidelines to improve practice.

Self-harm attempters' perception of community services and its implication on service provision

Objective

This study aimed at exploring the attempters’ perception of community social services included any barriers to seeking help and services.

Method

The participants were patients with self-harming behavior aged 15 years or above. A set of guiding questions were designed to explore the general barriers and accessibility to community social services. A voice recording was made, which was later converted into a text transcript and then preceded for content analysis with co-occurrence and similarity matrix interpretation. Two males and nine females with a history of self-harm aged between 24 and 58 years were recruited for the interviews.

Result

The participants had diverse experiences and backgrounds, and attitudes toward community social services. However, there was a shared perception of the need to enhance community social services. There were four main themes and 12 sub themes identified. The main theme included the service availability, service accessibility, affordability and acceptability. For details, participants were unaware of the available types of care/social services in the community, and were unaware about the nearby social services. They also suggested extending service hours and focused services should be offered to help people with different backgrounds and needs. Actually, those with experience of service utilization had both positive and negative perspectives and they gave suggestions for service delivery, mainly extending service hours and offering focused services such as for gambling control and financial planning. In view of interaction with service providers, counseling skills and trust were highly appreciated by the participants.

Conclusion

The results identified common circumstances of falling into financial hardship (gambling) and social fragmentation (divorce, poor family relationships, and poor marital relationships), which also suggested to enhance services on center location, service arrangement, and skill of caregivers.

Factors associated with hospitalization after self-poisoning in France: special focus on the impact of alcohol use disorder

BACKGROUND

Previous studies have identified factors associated with admission to hospital after suicide spectrum behaviors. In this study, we aim to identify specific factors associated with psychiatric hospitalization after self-poisoning. Given earlier findings suggesting that alcohol use disorder is not associated with hospital admission, we also aim to consider its impact, as well as blood alcohol concentrations, on hospitalization decisions after a suicide attempt.

METHODS

We studied the association between demographic features, suicide intent, psychiatric characteristics and admission to hospital in self-poisoning patients in an emergency department in France.

RESULTS

Suicide intent, a past history of suicide attempts, bipolar disorder and depression were associated with psychiatric hospital admissions. Despite alcohol use disorder being known to be associated with a suicide risk, it was not linked with psychiatric hospitalization. A positive blood alcohol concentration in the emergency department likewise had no association with admission to a psychiatric ward for inpatient care.

CONCLUSIONS

Our findings were similar to those reported for other suicide spectrum behaviors. Alcohol use disorder was not associated with admission for inpatient psychiatric care, whereas depression clearly was. The cause of this discrepancy must be determined in future research.

Acute hospital reconfiguration and self-harm presentations: a before-and-after study

BACKGROUND

The evidence for improved patient outcomes following acute hospital reconfiguration is limited.

AIMS

We assessed the impact of the reconfiguration of acute services within a hospital group in terms of the number and clinical management of self-harm presentations.

METHODS

The study was conducted across the three Mid-Western regional hospitals in Ireland during 2004-2014. Reconfiguration in April 2009 involved two hospitals reducing the operation of their emergency departments (EDs) from 24 to 12 h. We used Poisson regression analysis of data from the National Self-Harm Registry Ireland to assess change in the hospital burden and clinical management of self-harm associated with the reconfiguration.

RESULTS

We observed that the cumulative decrease in self-harm presentations at the two reconfigured hospitals was of a similar magnitude to the increase observed at the larger hospital. Despite this large increase in presentations, there was only a small increase in admissions. Reconfiguration of hospital services was also associated with changes in the provision of assessments for self-harm patients.

CONCLUSIONS

There is evidence to suggest that acute hospital reconfiguration of hospital services impacts on patterns of patient flow. Findings have implications for those implementing reconfiguration of acute services.

Recommended next care following hospital-treated self-harm: Patterns and trends over time

Objective

The specific objectives of this study were to examine variation in the care of self-harm patients in hospital settings and to identify the factors that predict recommended next care following self-harm.

Methods

Data on consecutive presentations to Irish emergency departments (EDs) involving self-harm from the National Self-Harm Registry Ireland from 2004 to 2012 were utilised. Univariate and multivariate regression analyses were performed to assess the associations between patients’ clinical and demographic characteristics, and recommended next care received.

Results

Across the study period a total 101,904 self-harm presentations were made to hospital EDs, involving 63,457 individuals. Over the course of the study there was a declining number of presentations resulting in patient admission following attendance with self-harm. Recommended next care varied according to hospital location, with general admission rates ranging from 11% to 61% across administrative health regions. Multinomial logistic regression identified that the factor which most strongly affected next care was the presenting hospital. Being male, older age, method, repeat self-harm, time of attendance and residence of the patient were all identified as influencing care received. Psychiatric admission was most common when highly lethal methods of self-harm were used (OR = 4.00, 95% CI, 3.63–4.41). A relatively large proportion of patients left the ED without being seen (15%) and the risk of doing so was highest for self-harm repeaters (1.64, 1.55–1.74 for those with 5+ presentations).

Conclusions

The extensive hospital variation in recommended next care indicates that management of self-harm patients may be determined more by where they present than by the needs of the patient. The study outcomes underline the need to standardise the clinical management of self-harm patients in general hospital settings.

Repeated self-injury from a liaison psychiatry perspective

Self-injury (self-harm) occurs frequently and is familiar in the accident and emergency departments and surgical and medical wards of ‘acute hospitals’. Despite its common presentation, there are frequent and authoritative reports that patients' experiences of emergency hospital treatment for self-harm are often negative. There is compelling evidence for the need to improve delivery of care for patients who self-harm, and to improve the training, supervision, support and coordination of the staff groups delivering that care.

Increasing psychosocial assessment by introducing a self-harm pathway

Aims and Method

To audit whether the introduction of a self-harm pathway and protocol increases the number of psychosocial assessments. All episodes of self-harm in a defined period during 2002 (n=335) and 2004 (n=390) were reviewed before and after the introduction of a self-harm pathway and protocol. Adherence to the protocol was also investigated.

Results

After the introduction of the self-harm pathway and protocol, the proportion of psychosocial assessments requested had risen from 57% (2002) to 85% (2004). The proportion of psychosocial assessments completed had risen from 47% to 70%. Over the 2 years, the overall number of self-harm presentations was reduced by 27%.

Clinical Implications

The introduction of a self-harm pathway and protocol through a self-harm steering group is feasible, was well accepted and increased the number of psychosocial assessments after self-harm. It may also contribute to a reduction in the number of overall presentations with self-harm to the accident and emergency department.

Extending the liaison psychiatry service in a large hospital in the UK: a before and after evaluation of the economic impact and patient care following ED attendances for self-harm

OBJECTIVES

To evaluate the impact of an expansion of liaison psychiatry services (LPS) on patient management, outcomes and treatment costs for emergency department (ED) attendances for self-harm.

DESIGN

Retrospective before and after cohort study using routinely collected Self-Harm Surveillance Register data.

SETTING

A large hospital in South West England.

SUBJECTS

Patients attending the ED for self-harm.

INTERVENTIONS

Extension of the LPS' working hours from 9:00 to 17:00, Monday to Friday to 8:00 to 22:00, 7 days a week, following a £250 000 annual investment MAIN OUTCOME MEASURES: Number and characteristics of ED attendances for self-harm. The before and after cohorts were compared in terms of key process measures, including proportion of patients receiving a psychosocial assessment, average length of hospital stay, waiting times for assessment, proportion of patients who self-discharged without an assessment, levels of repeat self-harm attendances and mean cost per patient attendance.

RESULTS

298 patients attended ED for self-harm on 373 occasions between January and March 2014, and 318 patients attended on 381 occasions between January and March 2015. The proportion of ED attendances where patients received a psychosocial assessment increased from 57% to 68% (p=0.003), median waiting time decreased by 3 hours and 14 min (p=0.017), and the proportion of episodes where patients self-discharged without a psychosocial assessment decreased from 20% to 13% (p=0.022). The mean cost per patient attendance was marginally lower after the intervention (-£84; 95% CI -£254 to £77).

CONCLUSIONS

The extended LPS seems to have had a favourable effect on the management and outcomes of self-harm patients. The cost of extending the LPS' working hours might be partially offset by more efficient assessment and discharge. The impact of the extended LPS on the care of hospitalised patients with mental health problems other than self-harm requires further evaluation.

Psychological scales as predictors of emergency department hospitalizations in suicide attempters

BACKGROUND

The purpose of this study was to evaluate the psychological scales reflecting lethality and intent as predictors of suicide attempter's hospitalization.

METHODS

Data of suicide attempters aged over 15years, who visited the ED from January 2013 to June 2016, were retrospectively collected and they were divided into the hospitalization and discharge groups. We evaluated the Risk-Rescue Rating Scale (RRRS) and Self-Inflicted Injury Severity Form (SIISF) for lethality and Suicide Intent Scale (SIS) for intent, respectively. The predictive abilities of these scales for hospitalization were compared in terms of performance (AUCs) and goodness-of-fit (the Bayesian information criterion [BIC]).

RESULTS

A total of 382 suicide attempters were enrolled, of which 233 (61%) were hospitalized. The scores of all psychological scales were significantly higher in the hospitalization group and all scales were identified as independent predictors of hospitalization. The AUC of the RRRS tended to be higher than those of the SIS and SIISF; similarly, the RRRS demonstrated the best overall fit (the lowest BIC). The AUC of combined the RRRS and SIS was superior to that of any of the individual scales alone. While the AUC of combined the SIISF and SIS was superior to that of either individual scale, it was comparable to that of the RRRS.

CONCLUSIONS

The psychological scales can be helpful for predicting suicide attempter's hospitalization in emergency settings. Especially, the RRRS seemed to have a superior predictive ability. Moreover, combining the scales had significantly better predictive performance than use of the individual scale alone did.

Community mental health care after self-harm: A retrospective cohort study

OBJECTIVE

Presentation to hospital after self-harm is an opportunity to treat underlying mental health problems. We aimed to describe the pattern of mental health contacts following hospital admission focusing on those with and without recent contact with community mental health services (connected and unconnected patients).

METHODS

We undertook a data linkage study of all individuals admitted as a general or psychiatric inpatient to hospital after self-harm in New South Wales, Australia, between 2005 and 2011. We identified the proportion of admissions where the patient received subsequent in-person community mental health care within 30 days of discharge and the factors associated with receipt of that care.

RESULTS

A total of 42,353 individuals were admitted to hospital for self-harm. In 41% of admissions, the patient had contact with a community mental health service after discharge. Patients connected with community mental health services had 5.33 (95% confidence interval = [5.09, 5.59]) times higher odds of follow-up care than unconnected patients. Other factors, such as increasing age and treatment as a psychiatric inpatient, were associated with lower odds of follow-up community care.

CONCLUSION

Our study suggests that full advantage is not being taken of the opportunity to provide comprehensive mental health care for people who self-harm once they have been discharged from the inpatient setting. This is particularly the case for those who have not previously received community mental health care. There appears to be scope for system-level improvement in the way in which those who are treated for self-harm are followed up in the community.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Epidemiology and trends in non-fatal self-harm in three centres in England, 2000-2012: findings from the Multicentre Study of Self-harm in England

OBJECTIVES

Self-harm is a major health problem in many countries, with potential adverse outcomes including suicide and other causes of premature death. It is important to monitor national trends in this behaviour. We examined trends in non-fatal self-harm and its management in England during the 13-year period, 2000-2012.

DESIGN AND SETTING

This observational study was undertaken in the three centres of the Multicentre Study of Self-harm in England. Information on all episodes of self-harm by individuals aged 15 years and over presenting to five general hospitals in three cities (Oxford, Manchester and Derby) was collected through face-to-face assessment or scrutiny of emergency department electronic databases. We used negative binomial regression models to assess trends in rates of self-harm and logistic regression models for binary outcomes (eg, assessed vs non-assessed patients).

PARTICIPANTS

During 2000-2012, there were 84,378 self-harm episodes (58.6% by females), involving 47,048 persons.

RESULTS

Rates of self-harm declined in females (incidence rate ratio (IRR) 0.98; 95% CI 0.97 to 0.99, p<0.0001). In males, rates of self-harm declined until 2008 (IRR 0.96; 95% CI 0.95 to 0.98, p<0.0001) and then increased (IRR 1.05; 95% CI 1.02 to 1.09, p=0.002). Rates of self-harm were strongly correlated with suicide rates in England in males (r=0.82, p=0.0006) and females (r=0.74, p=0.004). Over 75% of self-harm episodes were due to self-poisoning, mainly with analgesics (45.7%), antidepressants (24.7%) and benzodiazepines (13.8%). A substantial increase in self-injury occurred in the latter part of the study period. This was especially marked for self-cutting/stabbing and hanging/asphyxiation. Psychosocial assessment by specialist mental health staff occurred in 53.2% of episodes.

CONCLUSIONS

Trends in rates of self-harm and suicide may be closely related; therefore, self-harm can be a useful mental health indicator. Despite national guidance, many patients still do not receive psychosocial assessment, especially those who self-injure.

Medical students' attitude toward suicide attempters

BACKGROUND

Majority of health professionals have unfavorable attitudes toward the patients presenting with self-harm, which further compromises their therapeutic endeavors and outcomes.

OBJECTIVES

This study was aimed to assess the medical students' attitudes toward suicide attempters.

MATERIALS AND METHODS

A cross-sectional study was conducted in a tertiary care medical institute of Haryana, a Northern state of India. Two hundred and five final year medical students were recruited through total enumeration method. "Suicide Opinion Questionnaire" was administered to assess their attitudes toward suicide attempters.

RESULTS

Only minority had previous exposure of managing any suicidal patient and attended suicide prevention programs. Majority agreed for suicide attempters being lonely and depressed. Nearly half of the students reported small family, disturbed interpersonal relationship, weak personality, self-punishment approach, cultural inhibitions in emotional expression, national instability, and disbelief in afterlife, as a major push to attempt suicide. Compared to boys, girls reported the greater contribution of weak personality and self-destructive behaviors and lesser contribution of family disturbances and religious convictions as suicide triggers. They held favorable attitude for only one-third of the attitudinal statement, and they were uncertain for two-third of the attitudinal statements.

CONCLUSIONS

Such a high proportion of uncertain responses imply toward lack of awareness and clinical expertise for managing suicide attempters. It also signifies the urgent need for enhancing their educational and clinical exposure, to improve their attitudes toward patients presenting with self-harm.

Variation between hospitals in inpatient admission practices for self-harm patients and its impact on repeat presentation

PURPOSE

Self-harm patient management varies markedly between hospitals, with fourfold differences in the proportion of patients who are admitted to a medical or psychiatric inpatient bed. The current study aimed to investigate whether differences in admission practices are associated with patient outcomes (repeat self-harm) while accounting for differences in patient case mix.

METHODS

Data came from the National Self-Harm Registry Ireland. A prospective cohort of 43,595 self-harm patients presenting to hospital between 2007 and 2012 were included. As well as conventional regression analysis, instrumental variable (IV) methods utilising between hospital differences in rates of hospital admission were used in an attempt to gain unbiased estimates of the association of admission with risk of repeat self-harm.

RESULTS

The proportion of self-harm patients admitted to a medical bed varied from 10 to 74 % between hospitals. Conventional regression and IV analysis suggested medical admission was not associated with risk of repeat self-harm. Psychiatric inpatient admission was associated with an increased risk of repeat self-harm in both conventional and IV analyses. This increased risk persisted in analyses stratified by gender and when restricted to self-poisoning patients only.

CONCLUSIONS

No strong evidence was found to suggest medical admission reduces the risk of repeat self-harm. Models of health service provision that encourage prompt mental health assessment in the emergency department and avoid unnecessary medical admission of self-harm patients appear warranted. Psychiatric inpatient admission may be associated with a heightened risk of repeat self-harm in some patients, but these findings could be biased by residual confounding and require replication.

Non-fatal repetition of self-harm in Taipei City, Taiwan: cohort study

BACKGROUND

Repeat self-harm is an important risk factor for suicide. Few studies have explored risk factors for non-fatal repeat self-harm in Asia.

AIMS

To investigate the risk of non-fatal repeat self-harm in a large cohort of patients presenting to hospital in Taipei City, Taiwan.

METHOD

Prospective cohort study of 7601 patients with self-harm presenting to emergency departments (January 2004-December 2006). Survival analysis was used to examine the rates, timing and factors associated with repeat self-harm.

RESULTS

In total 778 (10.2%) patients presented to hospital with one or more further episodes of self-harm. The cumulative risk of non-fatal repetition within 1 year of a self-harm episode was 9.3% (95% CI 8.7-10.1). The median time to repetition within 1 year was 105 days. Females had a higher incidence of repeat self-harm than males (adjusted hazard ratio 1.25, 95% CI 1.05-1.48) but males had shorter median time to repetition (107 v. 80 days). Other independent risk factors for repeat self-harm within 1 year of an index episode were: young age, self-harm by medicine overdose and increasing number of repeat episodes of self-harm.

CONCLUSIONS

The risk of non-fatal repeat self-harm in Taipei City is lower than that seen in the West. Risk factors for repeat non-fatal self-harm differ from those for fatal self-harm. The first 3 months after self-harm is a crucial period for intervention.

Interventions to prevent repeat suicidal behavior in patients admitted to an emergency department for a suicide attempt: a meta-analysis

BACKGROUND

A huge number of patients with self-harm and suicide attempt visit emergency departments (EDs). We systematically reviewed studies and examined the effect of interventions to prevent repeat suicidal behavior in patients admitted to EDs for a suicidal attempt.

METHOD

We searched the databases of MEDLINE, PsychoINFO, CINAHL, and EMBASE through August 2013. Eligible studies were randomized controlled trials assessing the effects on repeat suicidal behavior of interventions initiated in suicidal patients admitted to EDs. Interventions in each trial were classified into groups by consensus. Meta-analyses were performed to determine pooled relative risks (RRs) and 95% confidence intervals (CIs) of repetition of suicide attempt for interventions in each group.

RESULTS

Out of 5390 retrieved articles, 24 trials were included and classified into four groups (11 trials in the Active contact and follow-up, nine in the Psychotherapy, one in the Pharmacotherapy, and three in the Miscellaneous). Active contact and follow-up type interventions were effective in preventing a repeat suicide within 12 months (n=5319; pooled RR=0.83; 95% CI: 0.71 to 0.97). However, the effect at 24 months was not confirmed (n=925; pooled RR=0.98; 95% CI: 0.76-1.22). The effects of the other interventions on preventing a repetition of suicidal behavior remain unclear.

LIMITATION

Caution is needed regarding the heterogeneity of the effects.

CONCLUSION

Interventions of active contact and follow-up are recommended to reduce the risk of a repeat suicide attempt at 12 months in patients admitted to EDs with a suicide attempt. However, the long-term effect was not confirmed.

Variations in the hospital management of self-harm and patient outcome: a multi-site observational study in England

INTRODUCTION

Studies have shown wide variations in delivery of self-harm services but it is unclear how these relate to important outcomes such as self-harm repetition.

METHODS

Data were collected on self-harm presentations and hospital management from 31 hospitals in England. Key staff were interviewed about service provision for self-harm patients and responses were mapped to a 21-item service quality scale. Our main outcome was repeat hospital-presenting self-harm within six months.

RESULTS

6347 individuals presented with 7599 episodes of self-harm during a three month period in 2010-2011. Re-attendance with self-harm within six months of index episode occurred in 21% (1308/6347) of individuals (range between hospitals 9-27%). We found little association between clinical management at hospital level (i.e. proportion of episodes receiving psychosocial assessment, medical or psychiatric admission, and referral to statutory or non-statutory services) and repetition rate. The median score on service quality scale was 14.5 (range between hospitals 10.5-19). There was no evidence of correlation between total service quality score and repetition of self-harm (Spearman׳s r=-0.06, p=0.73) or between individual service items and repetition.

LIMITATIONS

We did not explore certain aspects of service provision e.g. quality of psychosocial assessments and length of admission. Hospital presentation for repeat self-harm may not be the most reliable measure of service quality.

CONCLUSION

At aggregate level aspects of management and service structures did not appear to be associated with self-harm repetition rates. Future research should focus on better understanding the processes underlying the delivery of services at hospital level and their relationship to outcome.

Factors associated with hospitalization after suicide spectrum behaviors: results from a multicenter study in Spain

The objective of this study was to identify factors associated with hospital admission after suicide spectrum behaviors. Patients' characteristics, the nature of the suicidal behavior, admission rates between centers, and factors associated with admission have been examined in suicide spectrum presentations to emergency departments in 3 Spanish cities. The intent of the suicidal behavior had the greatest impact on hospitalization. Older age, living alone, self-harm method not involving drug overdose, previous history of suicide spectrum behaviors, and psychiatric diagnosis of schizophrenia, mood, or personality disorder were independently associated with being admitted. There was a 3-fold between-center difference in the rate of hospitalization. Widespread differences in the rate of hospitalization were primarily accounted for by characteristics of the individual patients and their suicidal behavior.

Hospital management of self-harm patients and risk of repetition: systematic review and meta-analysis

BACKGROUND

Self-harm is a common reason for hospital presentation; however, evidence to guide clinical management of these patients to reduce their risk of repeat self-harm and suicide is lacking.

METHODS

We undertook a systematic review to investigate whether between study differences in reported clinical management of self-harm patients were associated with the risk of repeat self-harm and suicide.

RESULTS

Altogether 64 prospective studies were identified that described the clinical care of self-harm patients and the incidence of repeat self-harm and suicide. The proportion of a cohort psychosocially assessed was not associated with the recorded incidence of repeat self-harm or suicide; the incidence of repeat self-harm was 16.7% (95% CI 13.8-20.1) in studies in the lowest tertile of assessment levels and 19.0% (95% CI 15.7-23.0) in the highest tertile. There was no association of repeat self-harm with differing levels of hospital admission (n=47 studies) or receiving specialist follow-up (n=12 studies). In studies reporting on levels of hospital admission and suicide (n=5), cohorts where a higher proportion of patients were admitted to a hospital bed reported a lower incidence of subsequent suicide (0.6%, 95% CI 0.5-0.8) compared to cohorts with lower levels of admission (1.9%, 95% CI 1.1-3.2).

LIMITATIONS

In some analyses power was limited due to the small number of studies reporting the exposures of interest. Case mix and aspects of care are likely to vary between studies.

DISCUSSION

There is little clear evidence to suggest routine aspects of self-harm patient care, including psychosocial assessment, reduce the risk of subsequent suicide and repeat self-harm.

Scales for predicting risk following self-harm: an observational study in 32 hospitals in England

OBJECTIVE

To investigate the extent to which risk scales were used for the assessment of self-harm by emergency department clinicians and mental health staff, and to examine the association between the use of a risk scale and measures of service quality and repeat self-harm within 6 months.

DESIGN

Observational study.

SETTING

A stratified random sample of 32 hospitals in England.

PARTICIPANTS

6442 individuals presenting with self-harm to 32 hospital services during a 3-month period between 2010 and 2011.

OUTCOMES

21-item measure of service quality, repeat self-harm within 6 months.

RESULTS

A variety of different risk assessment tools were in use. Unvalidated locally developed proformas were the most commonly used instruments (reported in n=22 (68.8%) mental health services). Risk assessment scales were used in one-third of services, with the SAD PERSONS being the single most commonly used scale. There were no differences in service quality score between hospitals which did and did not use scales as a component of risk assessment (median service quality score (IQR): 14.5 (12.8, 16.4) vs 14.5 (11.4, 16.0), U=121.0, p=0.90), but hospitals which used scales had a lower median rate of repeat self-harm within 6 months (median repeat rate (IQR): 18.5% vs 22.7%, p=0.008, IRR (95% CI) 1.18 (1.00 to 1.37). When adjusted for differences in casemix, this association was attenuated (IRR=1.13, 95% CI (0.98 to 1.3)).

CONCLUSIONS

There is little consensus over the best instruments for risk assessment following self-harm. Further research to evaluate the impact of scales following an episode of self-harm is warranted using prospective designs. Until then, it is likely that the indiscriminant use of risk scales in clinical services will continue.

Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis

Background

Non-fatal self-harm is one of the most frequent reasons for emergency hospital admission and the strongest risk factor for subsequent suicide. Repeat self-harm and suicide are key clinical outcomes of the hospital management of self-harm. We have undertaken a comprehensive review of the international literature on the incidence of fatal and non-fatal repeat self-harm and investigated factors influencing variation in these estimates as well as changes in the incidence of repeat self-harm and suicide over the last 30 years.

Methods and Findings

Medline, EMBASE, PsycINFO, Google Scholar, article reference lists and personal paper collections of the authors were searched for studies describing rates of fatal and non-fatal self-harm amongst people who presented to health care services for deliberate self-harm. Heterogeneity in pooled estimates of repeat self-harm incidence was investigated using stratified meta-analysis and meta-regression. The search identified 177 relevant papers. The risk of suicide in the 12 months after an index attempt was 1.6% (CI 1.2–2.4) and 3.9% (CI 3.2–4.8) after 5 years. The estimated 1 year rate of non-fatal repeat self-harm was 16.3% (CI 15.1–17.7). This proportion was considerably lower in Asian countries (10.0%, CI 7.3–13.6%) and varies between studies identifying repeat episodes using hospital admission data (13.7%, CI 12.3–15.3) and studies using patient report (21.9%, CI 14.3–32.2). There was no evidence that the incidence of repeat self-harm was lower in more recent (post 2000) studies compared to those from the 1980s and 1990s.

Conclusions

One in 25 patients presenting to hospital for self-harm will kill themselves in the next 5 years. The incidence of repeat self-harm and suicide in this population has not changed in over 10 years. Different methods of identifying repeat episodes of self-harm produce varying estimates of incidence and this heterogeneity should be considered when evaluating interventions aimed at reducing non-fatal repeat self-harm.

Validation of suicide and self-harm records in the Clinical Practice Research Datalink

AIMS

The UK Clinical Practice Research Datalink (CPRD) is increasingly being used to investigate suicide-related adverse drug reactions. No studies have comprehensively validated the recording of suicide and nonfatal self-harm in the CPRD. We validated general practitioners' recording of these outcomes using linked Office for National Statistics (ONS) mortality and Hospital Episode Statistics (HES) admission data.

METHODS

We identified cases of suicide and self-harm recorded using appropriate Read codes in the CPRD between 1998 and 2010 in patients aged ≥15 years. Suicides were defined as patients with Read codes for suicide recorded within 95 days of their death. International Classification of Diseases codes were used to identify suicides/hospital admissions for self-harm in the linked ONS and HES data sets. We compared CPRD-derived cases/incidence of suicide and self-harm with those identified from linked ONS mortality and HES data, national suicide incidence rates and published self-harm incidence data.

RESULTS

Only 26.1% (n = 590) of the 'true' (ONS-confirmed) suicides were identified using Read codes. Furthermore, only 55.5% of Read code-identified suicides were confirmed as suicide by the ONS data. Of the HES-identified cases of self-harm, 68.4% were identified in the CPRD using Read codes. The CPRD self-harm rates based on Read codes had similar age and sex distributions to rates observed in self-harm hospital registers, although rates were underestimated in all age groups.

CONCLUSIONS

The CPRD recording of suicide using Read codes is unreliable, with significant inaccuracy (over- and under-reporting). Future CPRD suicide studies should use linked ONS mortality data. The under-reporting of self-harm appears to be less marked.

Methods of suicide predict the risks and method-switching of subsequent suicide attempts: a community cohort study in Taiwan

OBJECTIVE

Suicide is a major public health concern. This study aimed to determine the predictors of repeated suicide attempts, focusing on whether lethality level of the suicidal method predicts the risk of subsequent suicide attempts.

METHODS

All consecutive individuals (N=2,070) with an episode of nonfatal self-harm registered in a surveillance database provided by the Department of Health of Keelung City Government in Taiwan from January 1, 2006 to December 31, 2010 were enrolled and followed up until the end of 2011. The earliest attempt recorded in the database was defined as the index attempt. Subjects were classified according to suicide method into low-lethal and high-lethal groups. Data on time of and methods chosen for subsequent suicide attempts during the follow-up period were analyzed.

RESULTS

Of the total people screened for the study, 18.1% made a repeated suicide attempt. Subjects in the high-lethal group were more likely to be male; aged 35-64 years; and single, divorced, or widowed. Compared to other time intervals, most subsequent suicide attempts occurred within 6 months from the index attempt. The independent predictors for repeated suicide attempts were the use of low-lethal methods in the index attempt and being 35-49 years old. Using high-lethal methods and being older than 50 years were associated with changing suicide method for the second attempt.

CONCLUSION

Lethality level of former suicidal method could predict repeated suicide attempts and changing of suicide methods. Further clarification is needed on whether a higher risk of repeat attempts is associated with higher rates of suicide mortality.

Can postdischarge follow-up contacts prevent suicide and suicidal behavior? A review of the evidence

BACKGROUND

The time period following discharge from inpatient psychiatry and emergency department (ED) treatment is one of heightened risk for repeat suicide attempts for patients. Evidence reported in the literature shows that follow-up contacts might reduce suicide risk, although there has not been a comprehensive and critical review of the evidence to date.

AIMS

To evaluate evidence for the effectiveness of suicide prevention interventions that involve follow-up contacts with patients.

METHODS

Published empirical studies of follow-up interventions with suicidal behaviors (suicide, attempts, and ideation) as outcomes were searched. Study populations were inpatient psychiatric or ED patients being discharged to home. Contact modalities included phone, postal letter, postcards, in-person, and technology-based methods (e-mail and texting).

RESULTS

Eight original studies, two follow-up studies, and one secondary analysis study met inclusion criteria. Five studies showed a statistically significant reduction in suicidal behavior. Four studies showed mixed results with trends toward a preventative effect and two studies did not show a preventative effect.

CONCLUSIONS

Repeated follow-up contacts appear to reduce suicidal behavior. More research is needed, however, especially randomized controlled trials, to determine what specific factors might make follow-up contact modalities or methods more effective than others.

Are hospital services for self-harm getting better? An observational study examining management, service provision and temporal trends in England

OBJECTIVES

To describe the characteristics and management of individuals attending hospital with self-harm and assess changes in management and service quality since an earlier study in 2001, a period in which national guidance has been available.

DESIGN

Observational study.

SETTING

A stratified random sample of 32 hospitals in England, UK.

PARTICIPANTS

6442 individuals presenting with 7689 episodes of self-harm during a 3-month audit period between 2010 and 2011.

OUTCOME

Self-harm episodes, key aspects of individual management relating to psychosocial assessment and follow-up, and a 21-item measure of service quality.

RESULTS

Overall, 56% (3583/6442) of individuals were women and 51% (3274/6442) were aged under 35 years. Hospitals varied markedly in their management. The proportion of episodes that received a psychosocial assessment by a mental health professional ranged from 22% to 88% (median 58%, IQR 48-70%); the proportion of episodes resulting in admission to general hospitals varied from 22% to 85% (median 54%, IQR 41-63%); a referral for specialist mental health follow-up was made in 11-64% of episodes (median 28%, IQR 22-38%); a referral to non-statutory services was made in 4-62% of episodes (median 15%, IQR 8-23%); 0-21% of episodes resulted in psychiatric admission (median 7%, QR 4-12%). The specialist assessment rate varied by method of harm; the median rate for self-cutting was 45% (IQR 28-63%) vs 58% (IQR 48-73%) for self-poisoning. Compared with the 2001 study, there was little difference in the proportion of episodes receiving specialist assessment; there was a significant increase in general hospital admission but a decrease in referrals for specialist mental health follow-up. However, scores on the service quality scale had increased from a median of 11.5-14.5 (a 26% increase).

CONCLUSIONS

Services for the hospital management of self-harm remain variable despite national guidelines and policy initiatives. We found no evidence for increasing levels of assessment over time but markers of service quality may have improved. This paper forms part of the study 'Variations in self-harm service delivery: an observational study examining outcomes and temporal trends'. The National Institute for Health Research Clinical Research Network (NIHR CRN) Portfolio database registration number: HOMASH 2 (7333). The NIHR Coordinated System for gaining NHS Permission (CSP) registration number: 23226.

A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England

Objectives

To carry out a programme of linked research studies aimed at improving the management of self-harm, reducing the incidence of suicide and providing reliable data to evaluate the impact of theNational Suicide Prevention Strategy for England(2002).

Methods

There were four research streams: (1) we studied inquest records from 12 coroners and Ministry of Justice data to assess the accuracy of official suicide statistics; (2) we used Office for National Statistics mortality statistics, data from the Multicentre Study of Self-harm in England, national liver unit data, prescription data and patient interviews to assess (a) the impact of paracetamol (acetaminophen) pack size restrictions (1998), (b) the impact of withdrawal of co-proxamol in 2007 and (c) the relative toxicity in overdose of commonly used antidepressants; (3) we carried out 3-month audits of self-harm management in 32 hospitals to investigate variations between hospitals and the impact of management on repeat self-harm; and (4) we developed and piloted letter-based contact interventions aimed at reducing self-harm.

Key findings

(1) Between 1990 and 2005, the proportion of researcher-defined suicides given a verdict of suicide by the 12 coroners studied decreased by almost 7%, largely because of the increased use of misadventure/accident verdicts for deaths thought, on clinical review, to be suicides. Use of narrative verdicts increased markedly. Coroners who gave more narrative verdicts also gave fewer suicide verdicts, and geographical variations in the use of narrative verdicts appeared to distort reliable assessment of small-area differences in suicide rates. 2(a) UK legislation to reduce pack sizes of paracetamol was followed by a 43% reduction in number of deaths and a 61% reduction in registrations for liver transplantation over the next 11 years. Paracetamol overdoses were often impulsive and some were influenced by media (including the internet); sales outlets appeared mostly to be adhering to sales guidance. Smaller pack sizes of paracetamol for sale in Ireland compared with England did not result in a smaller number of tablets being taken in overdose. There was no clear evidence of an effect of the legislation on prescribing of non-steroidal anti-inflammatory drugs, nor on resulting gastrointestinal bleeds. 2(b) Withdrawal of co-proxamol from use in the UK resulted in approximately 600 fewer deaths than predicted between 2005 and 2010 based on previous trends, with no evidence of substitution by poisoning with other analgesics. 2(c) Of the tricyclic antidepressants, dosulepin and doxepin had the greatest toxicity. Citalopram was more toxic than other selective serotonin reuptake inhibitors. (3) There was marked variation between hospitals in the management of self-harm; effects of this variation on patient outcomes were unclear, although psychosocial assessment may have been associated with reduced repetition. Levels of specialist assessment remained static between 2001–2 and 2010–11, but service quality appeared to improve. (4) Findings of two pilot randomised controlled trials suggested that, although it would be feasible to scale up these interventions to full trials, these interventions might have low generalisability and be of limited benefit to patients.

Conclusion

Within the context of the strengths and limitations of the individual studies, this research programme has made significant additions to the evidence base related to suicide and self-harm prevention in the UK.

Study registration

A pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Service user perspectives on psychosocial assessment following self-harm and its impact on further help-seeking: a qualitative study

BACKGROUND

Psychosocial assessment is a central aspect of managing self-harm in hospitals, designed to encompass needs and risk, and to lead to further care. However, little is known about service user experiences of assessment, or what aspects of assessment service users value. The aim of this study was to explore service user experiences of assessment, and examine the short-term and longer-term meanings of assessment for service users.

METHOD

Interpretative phenomenological analysis was applied to 13 interviews with service users following hospital attendance, and seven follow-up interviews conducted 3 months later.

RESULTS

Few participants had a clear understanding of assessment's purpose. Assessment had the potential to promote or challenge hope, dependent on whether it was experienced as accepting or critical. If follow-up care did not materialise, this reinforced hopelessness and promoted disengagement from services.

LIMITATIONS

The study sample was small and the participants heterogeneous in terms of self-harm history, method and intent, which may limit the transferability of the findings to other settings. Only self-report data on clinical diagnosis were collected.

CONCLUSIONS

This was the first study to utilise an in-depth qualitative approach to investigate service user experiences of assessment and follow-up. The findings suggest that re-conceptualising psychosocial assessment as primarily an opportunity to engage service users therapeutically may consequently affect how health services are perceived. In order to maintain benefits established during the hospital experience, follow-up needs to be timely and integrated with assessment.

Developing measures of quality for the emergency department management of pediatric suicide-related behaviors

OBJECTIVE

Given the public health importance of suicide-related behaviors and the corresponding gap in the performance measurement literature, we sought to identify key candidate process indicators (quality of care measures) and structural measures (organizational resources and attributes) important for emergency department (ED) management of pediatric suicide-related behaviors.

METHODS

We reviewed nationally endorsed guidelines and published research to establish an inventory of measures. Next, we surveyed expert pediatric ED clinicians to assess the level of agreement on the relevance (to patient care) and variability (across hospitals) of 42 candidate process indicators and whether 10 hospital and regional structural measures might impact these processes.

RESULTS

Twenty-three clinicians from 14 pediatric tertiary-care hospitals responded (93% of hospitals contacted). Candidate process indicators identified as both most relevant to patient care (≥87% agreed or strongly agreed) and most variable across hospitals (≥78% agreed or strongly agreed) were wait time for medical assessment; referral to crisis intervention worker/program; mental health, psychosocial, or risk assessment requested; any inpatient admission; psychiatric inpatient admission; postdischarge treatment plan; wait time for first follow-up appointment; follow-up obtained; and type of follow-up obtained. Key hospital and regional structural measures (≥87% agreed or strongly agreed) were specialist staffing and type of specialist staffing in or available to the ED; regional policies, protocols, or procedures; and inpatient psychiatric services.

CONCLUSIONS

This study highlighted candidate performance measures for the ED management of pediatric suicide-related behaviors. The 9 candidate process indicators (covering triage, assessment, admission, discharge, and follow-up) and 4 hospital and regional structural measures merit further development.

Deliberate Self-Harm: Have We Scratched the Surface?

This article presents the current state of knowledge in deliberate-self harm (DSH). DSH presents as a comorbidity with a number of personality disorders and psychopathologies, but is also relatively common in the psychologically healthy population. Over the past 10 years, attention has shifted from the investigation of DSH as a cardinal or comorbid symptom of psychopathology to an attempt to understand the behaviour itself, without reference to other psychopathological processes. It is argued that this development in understanding the aetiology of DSH has not been matched by developments in treatment or management of DSH, with the majority of treatment programs targeting larger syndromes of which DSH is a symptom. Treatment regimes aimed at reducing DSH appear to be either untested or demonstrably unsuccessful.

Meeting standards set for non self-harm presentations to emergency departments

OBJECTIVES

The commonest psychiatric presentation in most emergency departments (EDs) is deliberate self-harm. However, there are other significant categories of psychiatric presentation which include alcohol and substance misuse, acute psychosis and mood disorder. In addition to the NICE Guidelines for deliberate self-harm, there are good practice guidelines available for the management of other psychiatric attendances to the ED. The aim of this study was to identify the psychiatric attendances other than deliberate self-harm to Beaumont Hospital ED over a 12-month period with the objective of studying the rates and characteristics of attendances and to investigate whether good practice guidelines were met.

METHOD

From a total of 657 psychiatric attendances other than deliberate self-harm which were recorded, data was collected on demographics, provision of a psychosocial assessment and adherence to good practice guidelines.

RESULTS

Alcohol (38%) was the most common reason for presentation. Of the total number of attendees, only 44% received a psychosocial assessment compared to 59% of attendees who had presented following deliberate self-harm during the same 12-month period.

CONCLUSIONS

The attendees who did not receive a psychosocial assessment represent a vulnerable group in which the levels of psychosocial assessment need to be improved in order to meet good practice guidelines standards of care.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

The Role of Suicide Risk in the Decision for Psychiatric Hospitalization After a Suicide Attempt

Background: Suicide prevention can be improved by knowing which variables physicians take into account when considering hospitalization or discharge of patients who have attempted suicide. Aims: To test whether suicide risk is an adequate explanatory variable for predicting admission to a psychiatric unit after a suicide attempt. Methods: Analyses of 840 clinical records of patients who had attempted suicide (66.3% women) at four public general hospitals in Madrid (Spain). Results: 180 (21.4%) patients were admitted to psychiatric units. Logistic regression analyses showed that explanatory variables predicting admission were: male gender; previous psychiatric hospitalization; psychiatric disorder; not having a substance-related disorder; use of a lethal method; delay until discovery of more than one hour; previous attempts; suicidal ideation; high suicidal planning; and lack of verbalization of adequate criticism of the attempt. Conclusions: Suicide risk appears to be an adequate explanatory variable for predicting the decision to admit a patient to a psychiatric ward after a suicide attempt, although the introduction of other variables improves the model. These results provide additional information regarding factors involved in everyday medical practice in emergency settings.

Epidemiology and trends in non-fatal self-harm in three centres in England: 2000-2007

BACKGROUND

Self-harm is a common reason for presentation to a general hospital, with a strong association with suicide. Trends in self-harm are an important indicator of community psychopathology, with resource implications for health services and relevance to suicide prevention policy. Previous reports in the UK have come largely from single centres.

AIMS

To investigate trends in non-fatal self-harm in six general hospitals in three centres from the Multicentre Study of Self-harm in England, and to relate these to trends in suicide.

METHOD

Data on self-harm presentations to general hospital emergency departments in Oxford (one), Manchester (three) and Derby (two) were analysed over the 8-year period 1 January 2000 to 31 December 2007.

RESULTS

Rates of self-harm declined significantly over 8 years for males in three centres (Oxford: -14%; Manchester: -25%; Derby: -18%) and females in two centres (Oxford: -2% (not significant); Manchester: -13%; Derby: -17%), in keeping with national trends in suicide. A decreasing proportion and number of episodes involved self-poisoning alone, and an increasing proportion and number involved other self-injury (e.g. hanging, jumping, traffic related). Episodes involving self-cutting alone showed a slight decrease in numbers over time. Trends in alcohol use at the time of self-harm and repetition within 1 year were stable.

CONCLUSIONS

There were decreasing rates of non-fatal self-harm over the study period that paralleled trends in suicide in England. This was reflected mainly in a decline in emergency department presentations for self-poisoning.

Suicide and deliberate self harm in older Irish adults

BACKGROUND

Hospital-treated deliberate self harm and suicide among older adults have rarely been examined at a national level.

METHODS

The Irish Central Statistics Office provided suicide and undetermined death data for 1980-2006. The National Registry of Deliberate Self Harm collected data relating to deliberate self harm presentations made in 2006-2008 to all 40 Irish hospital emergency departments.

RESULTS

Rates of female suicide among older adults (over 55 years) were relatively stable in Ireland during 1980-2006 whereas male rates increased in the 1980s and decreased in more recent decades. Respectively, the annual male and female suicide and undetermined death rate was 22.1 and 7.6 per 100,000 in 1997-2006. Male and female deliberate self harm was 3.0 and 11.0 times higher at 67.4 and 83.4 per 100,000, respectively. Deliberate self harm and suicide decreased in incidence with increasing age. Deliberate self harm generally involved drug overdose (male: 72%; female 85%) or self-cutting (male: 15%; female 9%). The most common methods of suicide were hanging (41%) and drowning (29%) for men and drowning (39%) and drug overdose (24%) for women. City and urban district populations had the highest rates of hospital-treated self harm. The highest suicide rates were in urban districts.

CONCLUSIONS

Older Irish adults have high rates of hospital-treated deliberate self harm but below average rates of suicide. Drowning was relatively common as a method of suicide. Restricting availability of specific medications may reduce both forms of suicidal behavior.

Risk assessment following self-harm: comparison of mental health nurses and psychiatrists

AIM

This paper is a report of a study conducted to compare risk assessments by psychiatrists and mental health nurses following an episode of self-harm.

BACKGROUND

Self-harm assessments by nurses and psychiatrists are similar in terms of overall content, but risk assessment may vary by professional discipline. To our knowledge previous researchers have not compared the positive predictive value of risk assessments by nurses and psychiatrists, the factors that inform those assessments in clinical practice or the management of people assessed as being at high risk.

METHODS

We conducted a prospective cohort study (2002-2006) of 3491 individuals presenting with self-harm to three hospitals in the North West of England. A standard assessment form including detailed demographic and clinical data was completed by the assessing psychiatrist or nurse.

RESULTS

The positive predictive value of risk assessments for self-harm repetition was 25% (95% CI: 20-31) among nurses and 23% (95% CI: 13-37) among psychiatrists. There was strong agreement on factors associated with high risk assessment by both professions. Following assessment of high risk, psychiatrists were much more likely than nurses to admit people for inpatient treatment (RR=5.6, 95% CI: 3.2-9.7). This difference remained highly statistically significant after controlling for case-mix differences (RR=4.3, 95% CI: 2.4-7.7).

CONCLUSION

Our finding that risk assessments were comparable by profession supports the provision of nurse-led assessment services. However, inpatient admission was influenced largely by assessor type rather than patient characteristics. This has important implications for equity of care and may reflect professional differences in referral practices.

Trends in prescribing and self-poisoning in relation to UK regulatory authority warnings against use of SSRI antidepressants in under-18-year-olds

AIMS

To assess the impact of the UK Medicines and Healthcare products Regulatory Authority (MHRA) warning in December 2003 not to prescribe selective serotonin reuptake inhibitor (SSRI) antidepressants, except fluoxetine, to under-18-year-olds.

METHODS

Interrupted time series analysis of prescriptions (UK) and general hospital presentations for nonfatal self-poisoning (three centres in England) for 2000-2006.

RESULTS

Following the MHRA warning in December 2003 there were significant decreases in prescribing of SSRI antidepressants (conservative estimate 51%) to young people aged 12-19 years. Surprisingly, this decrease also affected fluoxetine (conservative estimate 20%) and tricyclics (conservative estimate 27%). Nonfatal self-poisoning in this age group following the warning also declined significantly for SSRIs (conservative estimate 44%), but not for fluoxetine, tricyclic antidepressants, or all drugs and other substances. Rates of nonfatal self-harm did not change significantly over the study period.

CONCLUSIONS

The reduction in both prescribing and self-poisoning with SSRI antidepressants (except fluoxetine) following the MHRA warning is in keeping with reduced availability of these drugs. There was some evidence of substitution from other SSRIs to fluoxetine for use in self-poisoning. Importantly, overall rates of nonfatal self-harm and self-poisoning did not change, indicating no substitution of method or increases in self-injury.

Psychosocial Assessment Following Self-Harm

Background: Patients admitted to hospital because of self-harm should receive psychosocial assessment before discharge. In practice many of these assessments in the United Kingdom and elsewhere are undertaken by trainee rather than specialist psychiatrists. Aims: To compare psychosocial assessments, aftercare, and the pattern of non-fatal repetition for patients admitted to general hospital after self-harm: comparing assessments carried out by trainee psychiatrists, allocated to the task alongside other duties on a roster, or by mental health nurses with a designated role in self-harm services. Methods: Arrangements for aftercare and rates of non-fatal repetition of self-harm in 787 consecutive psychosocial assessments in a large UK city were compared, according to whether the assessments were carried out by trainee psychiatrists or mental health nurses. Results: Compared with nurses, psychiatrists were much more likely to arrange psychiatric admission or outpatient follow-up. Nurses more often pointed people towards voluntary sector help – such as drug, alcohol or relationship counselling. Repetition of self-harm was equally common among those assessed by nurses or psychiatrists (33%; hazard ratio 0.93, 95% confidence interval 0.71 to 1.2). Conclusions: Despite making fewer aftercare arrangements that involved statutory mental health care services, psychosocial assessment by mental health nurses showed no sign of detrimental effects on repetition of self-harm.

Collaboration between general hospitals and community health services in the care of suicide attempters in Norway: a longitudinal study

BACKGROUND

The aim of this paper was to study the collaboration between emergency departments (EDs) in general hospitals and community health services (CHS) in Norway when providing psychosocial care and aftercare to patients treated in EDs following a suicide attempt. We wanted to explore the extent to which quality indicators at the hospital level measured in 1999 and 2006 could predict the presence or absence of a chain of care structure in the CHS in 2006.

METHODS

Data were collected through structured interviews with informants from 95% of all general hospitals in Norway in 1999 and 2006, and informants from CHS, in a stratified sample of Norwegian municipalities in 2006 (n = 47).

RESULTS

In 15 of the 47 municipalities (32%), the CHS reported having a chain of care structure in 2006. A discriminant function analysis revealed that the hospitals that in 1999 had: (a) a collaboration agreement with aftercare providers, and (b) written guidelines, including a quality assurance system, were significantly more likely to have municipalities with a chain of care structure in their catchment area in 2006.

CONCLUSIONS

Hospitals' and municipalities' self-reported provision of aftercare services for patients treated after a suicide attempt was markedly below the recommendations given in national standards. Systems at the hospital level for the management and care of patients admitted after a suicide attempt and systematic collaboration between hospitals and aftercare providers seem to be important elements in the long-term maintenance of continuity of care for suicide attempters.

Assessment rates and compliance with assertive follow-up after self-harm: cohort study

The objectives of this study were to identify 1) the proportion of self-harm episodes that resulted in assessment by a specialist self-harm team and offers, attendance, and completion of brief therapy and 2) the factors associated with these treatment options. A prospective cohort study of 717 hospital presentations of self-harm was conducted. Rates of assessment, offers and completion of therapy ranged from 50% to 60%. Of those offered therapy, 73% attended one or more sessions. Attendance was associated with depressive psychopathology and existing treatment in primary care. These results may reflect some of the challenges of engaging this patient group. We found that receipt of treatment was determined by patient factors. Future studies might also examine the role of service-related or clinician factors.