Trends in the severity of self-poisoning

Changing Ethnic and Social Characteristics of Patients Admitted for Self-Poisoning in West London during 1971/2 and 1983/4

The characteristics of adult patients admitted for self-poisoning to an inner London district general hospital were examined during 1971/72 and 1983/84. The incidence of self-poisoning halved over the 12 years, from 326 to 178 per 100 000. Although no West Indians were admitted in the first period, they comprised 7% of such admissions 12 years later. The West Indian population in the catchment area remained constant at around 6%. Amongst all patients admitted for self-poisoning, there was a fall in the number of patients diagnosed as depressed, having a personality disorder or admitting to prior psychiatric care, but an increase in alcoholism. Paracetamol became more common as a drug used in self-poisoning and barbiturates were taken less often. Only one patient died in the series. These results should stimulate more soundly based epidemiological studies on ethnic variation in self-poisoning, and on self-injury in inner-city areas.

Hospital mortality among poisoned patients presenting unconscious

OBJECTIVES

The hospital mortality from acute poisoning in the western world is approximately 0.6%. However, this figure is based on series of consecutive cases, including mild intoxications. The aim of this paper was to investigate the mortality among poisoned patients with CNS depression on admission.

DESIGN

This report is based on two case series. One observational study of 352 prospectively included cases of poisoning with a Glasgow coma scale (GCS) score ≤10 at presentation during the 2-year-period 2003-2005, and one retrospective review of all poisonings admitted to a hospital in Stockholm 2009-2011.

RESULTS

The observational study showed a hospital mortality rate of 2.8%. Nine of the 10 fatalities had a GCS score below 7 on admission. The more recent retrospective review consisted of 1314 cases of poisoning of whom 419 (32%) had a GCS score ≤10 on admission. The hospital mortality among these 419 cases was 2.4%. All 10 deaths in this cohort had a GCS score below 7 at presentation. The subgroup of patients pooled from both case series with a GCS score of 3-6 (n =444) had a mortality rate of 4.3%.

CONCLUSIONS

Based on the findings in this report, and on a literature search, about 30% of hospitalized poisonings have a significant CNS depression on admission. Based on our experience, cases of poisoning with a GCS score of 7-10 on admission do not seem to have a worse prognosis than poisonings in general. However, cases of poisoning presenting with deeper coma (GCS score 3-6) have a mortality rate approximately seven times higher than the overall hospital mortality from acute poisoning.

Prognosis in patients presenting with non-traumatic coma

BACKGROUND

Studies of patients presenting with coma are limited, and little is known about the prognosis of these cases.

OBJECTIVE

The aim of this study was to investigate the acute and long-term prognosis after an episode of non-traumatic coma.

METHODS

Adults admitted consecutively to an emergency department in Stockholm, Sweden between February 2003 and May 2005 with a Glasgow Coma Scale (GCS) score of 10 or below were enrolled prospectively. All available data were used to explore the cause of the impaired consciousness on admission. Patients surviving hospitalization were followed-up for 2 years regarding survival.

RESULTS

The final study population of 865 patients had the following eight different coma etiologies: poisoning (n = 329), stroke (n = 213), epilepsy (n = 113), circulatory failure (n = 60), infection (n = 56), metabolic disorder (n = 44), respiratory insufficiency (n = 33), and intracranial malignancy (n = 17). The hospital mortality rate among the 865 patients was 26.5%, varying from 0.9% for epilepsy to 71.7% for circulatory failure. The accumulated total 2-year mortality rate was 43.0%, varying from 13.7% for poisoning to 88.2% for malignancy. The level of consciousness on admission also influenced the prognosis: a GCS score of 3-6 was associated with a significantly higher hospital mortality rate than a GCS score of 7-10.

CONCLUSION

The prognosis in patients presenting with non-traumatic coma is serious and depends largely on both the level of consciousness on admission and the etiology of the coma. Adding the suspected coma etiology to the routine coma grading of these emergencies may more accurately predict their prognosis.

Parasuicide in the county of Sør-Trøndelag, Norway. General epidemiology and psychological factors

During the period 1 October 1988 to 31 December 1993, 2068 episodes of parasuicide involving 1543 persons were registered in the county of Sør-Trøndelag, Norway. Parasuicide rates decreased in the area compared with 1987, more for females than for males. Rates were higher for divorced females and separated males than for those of other marital statuses, but these rates were lower than previously found in the same area. The proportion of unemployed patients remained fairly stable, while the rate of unemployment increased in the general population. Compared to males, female parasuicide patients more often reported family problems and economic inactivity, and more often had been victims of violence or sexual abuse. Male parasuicide patients more often than females were living alone, were unemployed, abused alcohol, had financial problems, and had been engaged in criminal activity. Compared with older parasuicide patients, the young of both sexes were more often unemployed and abused drugs, but had less often been in contact with the health or social services. In addition, young female parasuicide patients more often had experienced family problems and suicidal behaviour among family or friends. The results were generally considered to be consistent with theories of sex role stereotypes, which emphasize expressive traits in an affiliative context for females and instrumental traits in a public or economic context for men.

Etiology of intoxication: a study of 557 cases

Our results were obtained from the emergency service at Elche General Hospital, which covers an adult population of 275,076 inhabitants. We studied intoxicated patients aged 15 years and above, during 1988. Our aim was to investigate the etiological and epidemiological circumstances of intoxications. We obtained a prevalence of voluntary cases (61.6%) over accidental cases (38.3%), with self-poisoning being more frequent than drug addiction, in the first group and animal stings being more frequent than domestic or occupational intoxication in the second. Mortality resulted in 1.6% of cases; the etiology of the highest mortality was self-poisoning and the most common toxic substances were caustic substances.

Self-poisonings with psychopharmacological agents in Zagreb

1. A 5-year retrospective study of 1743 episodes of self-poisoning in 1608 adult patients, was undertaken to determine the frequency of self-poisoning with psychopharmacological agents, the frequency of each toxic agent usage and the epidemiological characteristics of the poisoned population. 2. The annual incidence of self-poisoning in Zagreb was 38.7 per 100,000 adult inhabitants. The anxiolytic-antipsychotic-antidepressant usage ratio was 8.8:1.5:1.0 in total self-poisoning, whereas it was 4.9:1.5:1.0 in patients with a previous history of self-poisoning. The use of anxiolytics decreased and the use of antidepressants increased during the 5 years. 3. The female-male ratio was 3.8:1 and 77% of self-poisoned persons were aged 15-44 years. The incidence of self-poisoning was 74% higher in the urban than in the rural population. The proportion of self-poisoned persons was 204% higher among the unemployed than in the population as a whole. There were 76% more repetitors among highly educated and 43% fewer repetitors among students than in the general population. The use of antipsychotics was 120% higher in males than in females. The use of antidepressants was 107% higher in the highly educated. 4. The increased use of antidepressants in self-poisoning is an alarming signal and caution in their prescription seems to be indicated.

Self-harm patients not admitted to hospital

In recent years a large proportion of self-harm patients attending hospital have not been admitted to medical or short-stay wards but have returned home directly from accident and emergency departments. A continued trend towards such a policy seems likely despite limited and conflicting evidence on its desirability. The clinical, training and epidemiological implications of changes in self-harm admission policy are outlined, together with recommendations concerning clinical audit.

Why parasuicides repeat despite problem resolution

To discover why parasuicides who resolved their difficulties repeated self-harm within three-month follow-up at the same rate as those who had not resolved problems, a group of 30 repeaters was compared with 156 non-repeaters. The repeaters had a history of more frequent episodes, beginning younger. Their problems were more severe, the acts of self-harm potentially less lethal. They experienced greater feelings of externally directed hostility, powerlessness, and 'normlessness'. A constellation of nine variables correctly predicted 81.5% of the repeaters and 77.5% of the non-repeaters. At follow-up the non-repeaters had improved on several parameters but the repeaters were essentially unchanged. The resolvers among the subgroup of repeaters were more like repeaters in the overall sample than the resolvers, which may explain why some parasuicides repeat in spite of resolving their problems.

A comparative prospective study of self-poisoned patients in Trondheim, Norway between 1978 and 1987: epidemiology and clinical data

1. In a prospective study of patients hospitalized for deliberate self-poisoning between 1978 and 1987 the number of admissions increased from 303 to 425. The annual incidence increased significantly for both women (P less than 0.05) and men (P less than 0.01). The mean age decreased significantly in the male group (P less than 0.05), but increased in the female group (P less than 0.05). 2. The median latency time for patients presenting at the hospital was short; 3.7 h in 1978 and 2.9 h in 1987. 3. There was a significant reduction in the percentage using barbiturates (9% in 1978 and 1% in 1987; P less than 0.001) and the use of benzodiazepines increased (18% in 1978 and 32% in 1987; P less than 0.05). The percentage of unconscious patients did not change significantly. 4. In 1987 N-acetyl-cysteine was the most frequently used antidote. Physostigmine has almost been abandoned since 1978. 5. Significantly more patients were hypotensive in 1978: 24% vs 11% in 1987; (P less than 0.001) and significantly less patients needed treatment in the central intensive care unit (2% in 1987 and 5% in 1978; P less than 0.05). Complications were few (8-10%) and the mortality low (approximately 1%) in both years studied. 6. The mean duration of hospitalization in 1978 was 65 h vs 30 h in 1987, (P less than 0.001).

Clinical toxicology--past, present and future

1. The alarming increase in the incidence of self-poisoning in Western countries in the 1950s prompted the establishment of the National Poisons Information Service in the UK and the designation of certain Regional Poisoning Treatment Centres. 2. The substances taken in acute poisoning episodes largely reflect the poisons available in the community and, in the UK at least, have changed with fashions in prescribing although psychotropic drugs and analgesics always predominate. 3. Intensive supportive care with repeat-dose oral activated charcoal and even haemoperfusion has been proved effective in acute poisoning with central nervous depressant drugs such as barbiturates even though these latter drugs are now rarely encountered in overdose. 4. Other advances in clinical toxicology include the introduction of the opiate antagonist naloxone, Fab antibody fragments for life-threatening digoxin overdosage and proven treatment for paracetamol poisoning. Analytical toxicology has also made a major contribution. 5. On the debit side, formal psychiatric assessment of patients after acute poisoning remains contentious, tricyclic antidepressants are still a major problem and there is no effective treatment for poisoning with paraquat or for paracetamol when presentation is delayed. 6. As to the future, although the 'epidemic' of serious acute poisoning of the 1960s and 70s appears to be past its peak, there will always be unusual and serious problems and the UK poisons information services must develop to make the best use of computer-based technology.

Recent clinical and epidemiological trends in parasuicide in Edinburgh and Oxford: a tale of two cities

This is a report of clinical and epidemiological trends in parasuicide in Edinburgh and Oxford over the period of 1976 to 1984. Rates of parasuicide declined in both cities, but more markedly among women than men. Male rates tended to be higher in Edinburgh and female rates higher in Oxford. Age-specific rates were similar for the two cities in 1983-84, with peak rates for females among 15-19 year olds and those for males among 20-24 year olds in Edinburgh and 25-34 year olds in Oxford. Parasuicide incidence was higher in lower social class groups and among the unemployed in both cities. During the study period there was a massive decline in barbiturate overdoses, a more modest decline in minor tranquillizer overdoses but, in Oxford, a marked increase in self-poisoning with paracetamol. By the end of the study period the proportion of patients receiving a diagnosis of drug addiction had doubled in Edinburgh, although it had remained fairly constant in Oxford. There were differences in patterns of aftercare offered to patients in the two cities; these almost certainly reflect differing clinical policies.

Suicide, and other causes of death, following attempted suicide

The number of deaths in a large series of suicide attempters followed up after their attempts was 3.3 times greater than expected. Suicide or probable suicide occurred in 2.8% by the end of the eighth year of follow-up, the rate of suicidal deaths being 26.9 times the expected rate. The highest risk of suicide was during the first 3 years, especially in the first 6 months, following an attempt. Factors identified at the time of the attempts which were associated with suicide risk included: being male, advancing age (females only), psychiatric disorder (especially schizophrenia), long-term use of hypnotics, poor physical health, and repeat attempts. Recent disruption of a relationship with a partner and major rows rarely preceded the attempts of those who later killed themselves. Factors predicting long-term risk of suicide also predicted short-term risk. There were more than double the expected number of deaths from natural causes, the excess being greatest in females. Markedly high death rates were found for endocrine, circulatory and respiratory diseases, and accidents.