What happens to patients who frequently harm themselves? A retrospective one-year outcome study

Self-reported Usual Care for Self-directed Violence During the 6 Months Before Emergency Department Admission

BACKGROUND

The literature describing the health services individuals receive before and following self-directed violence (SDV) is limited.

OBJECTIVES

This study examines services received for the 6 months preceding admission to an urban county medical center emergency department (ED) for SDV. We predicted that individuals with at least 1 prior act of SDV in the past 6 months would have received more services than those for whom the index admission was their only recent act.

METHODS

Participants were recruited from ED admissions during shifts selected to maximize representativeness. Participants (n=202) were interviewed using the Suicide Attempt Self-Injury Interview, Suicide Attempt Self-Injury Count, Treatment History Interview, Mini International Neuropsychiatric Interview, Brief Symptom Index, and SF-12.

RESULTS

The majority of index acts of SDV (79%) were suicide attempts. The participants were characterized by low socioeconomic status, substantial symptomatology, low physical and mental health functioning, and multiple psychiatric diagnoses. In the preceding 6 months, 34% were admitted to a hospital and 56% received crisis services (including 44% in the ED). Although three quarters (76%) had seen an outpatient medical provider and most (70%) received psychotropic medications, less than half of the sample received psychiatric services (40%) or outpatient psychosocial treatment (48%). As predicted, utilization for most types of usual care was higher for those engaging in SDV in the 6 months preceding the index admission.

CONCLUSION

Individuals admitted to this ED for SDV received inadequate outpatient psychosocial and psychiatric services despite severe illness and disability.

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

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

Deliberate self-harm and suicide attempt in custody: distinguishing features in male inmates' self-injurious behavior

Self-injurious behavior involving deliberate self-harm and suicide attempts by inmates while under custodial authority is a major problem for prisons and jails (prevalence, legal obligation for suicide prevention, and stress for officers). The differentiation of "serious" vs. "non-serious" and often manipulative suicide attempts as distinct phenomena, each with its own clinical features, is controversially discussed in current literature and a challenge for every diagnostician. If distinct clinical presentations and histories can be observed, an estimation of the seriousness of each act of self-injurious behavior can be simplified, whereby appropriate treatment of the individual case becomes possible. The aim of the study was to find differences between self-injurious behavior of "low seriousness" (i.e. low lethality and low suicidal intent) and of "high seriousness". Therefore, inmates showing self-injurious behavior were divided into subgroups of deliberate self-harm and suicide attempters on the basis of the act's intent and lethality. This was followed by a comparison of the clinical presentations of the individual inmates constituting the subgroups. Hence, 49 inmates showing self-injurious behavior were interviewed and tested with a variety of instruments (SCID-I and II, PCL-R, BDI-II, BHS, BSS, SIS, etc.), and their prison and health files were examined. The results indicate significant correlations between seriousness and some demographic, prison-related variables as well as different measures of depression. Negative, but nonsignificant correlations could be observed with regard to cluster B personality disorders. The PCL-R total score as well as PCL-R factor 1 showed a statistical trend for negative correlations with measures of seriousness. Inmates showing deliberate self-harm and suicide attempters seem to differ in a number of ways. Implications on how the individual prisoner should be treated are discussed.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

DESIGN

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

SETTING

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

SUBJECTS

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

OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Recurrent overdose: patient characteristics, habits, and outcomes

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Suicide attempts among Turkish psychiatric patients

OBJECTIVES

The aim of this study was to investigate the sociodemographic characteristics of those who attempt suicide in an Islamic country, the effect of religion on suicide attempts, and the frequency of DSM-III-R diagnoses in suicide attempters referred to the Gazi Medical School Psychiatry Department.

METHOD

Medical records of 185 cases of suicide attempts were reviewed.

RESULTS

There was a predominance of single, female subjects. Students, housewives, and employees represented the 3 largest groups. Drug overdose was the most common method of suicide attempt, and the most common DSM-III-R diagnosis was depression. The rate of repetition of suicide attempt was 43.3%.

CONCLUSION

Suicide is one of the major problems among Turkish psychiatric patients, although the Islamic religion strongly disapproves of it.

Recurrent self-injurious behavior in forensic patients

A high prevalence of self-injurious behavior has been reported in the forensic psychiatric population and the correctional psychiatric population. Severely and recurrently self-destructive patients pose great therapeutic challenges. The present study examined forensic patients who engaged in multiple acts of self-injury while hospitalized and compared them to forensic patients who engaged in a single act of self-injury. The groups did not differ on demographic or diagnostic measures, but the recurringly self-injurious patients were more frequently and more severely aggressive against others (verbally as well as physically), and required longer hospitalization. The results are interpreted to suggest that the high cost of recurring self-injury in human and financial terms may be reduced by a strategy of early and vigorous intervention.

Repetition of overdose: a retrospective 5-year study

This study investigated the number, timing and disposal (admission or discharge) of patients repeating an overdose who attended the accident and emergency department of a district general hospital during a 5-year period. There was a total of 1958 overdoses by 1597 individuals over the 5-year period. Overdoses were repeated by 12% (n = 191) of patients and accounted for 552 of the total overdoses (representing 361 repeats). First repeats were found to occur more frequently in the 3 months following the original overdose for 43% of patients, 70% of repetitions occurring within a year. The distribution of first repeats showed a similar pattern for males and females. During the 5-year period 49% of all repetitions occurred within 3 months. Almost one-fifth of repeaters were discharged, irrespective of whether it was the patient's 'index' (first overdose within the study period) or a repeat overdose. Within the repeater population, 31% of overdoses occurred on a Friday, Saturday and on, or immediately prior to, a Bank Holiday. Since there was no on-site psychiatric service available at such times, those patients had to wait until the next working day for assessment. The study recommends that all overdose patients should receive psychiatric assessment, and therefore on-site psychiatric services should be available for accident and emergency patients.

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

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