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Alwan I, Awadh A, Tangiisuran B, Khan HM, Yahaya N, Majid M. Pharmaceuticals poisoning: Reported by the National Poison Centre in Malaysia between 2010 and 2015. J Pharm Bioallied Sci 2020; 12:475-481. [PMID: 33679096 PMCID: PMC7909058 DOI: 10.4103/jpbs.jpbs_340_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 06/03/2020] [Accepted: 06/11/2020] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose: The wide availability of medications has led to an increased exposure of humans to the possibility of poisoning. An unavoidable effect due to the availability of these medications has also led to a rising increment in the number of poisoning cases. All drugs, especially when administered in large doses or overextended periods, can initiate a toxic condition. Therefore, the objective of this study was to examine nationwide, the patterns attributed to poisoning, and to describe the sociodemographic, and geographic distribution of poisoning, by identifying the category of substances implicated in these cases. Data Sources and Methods: A retrospective study based on telephone calls reported on poisoning caused by pharmaceutical products undertaken by the National Poisoning Centre (NPC) in Penang (Malaysia) was used as the basis of this study covering the period between 2010 and 2015. The study included the mode and type of poisoning, exposure routes as well as the incidence locations. Results: A total of 10,998 cases were examined, finding that females represented 5,899 cases (53.6%) being intoxicated more frequently compared to the number of males, 3,839 (34.9%). The age group of poisoning cases ranged between 20 and 29 years representing 2,579 (23.4%) of reported cases. The common mode of poisoning was attributed to suicide 5,203 (47.3%) from among the 10,998 cases and the highest poisoning agents reported were from the psychiatric group of pharmaceutical products of 2,287 (21%). Conclusion and Implications: These findings indicate a rising trend of suicidal poisoning attempts between 2013 and 2015, which emphasizes the need for more stringent and effective enforcement protocols to limit the rising incidence of poisoning. As such, analyzing the trends in poisoning in a particular zone periodically could help health policy-makers to develop management policies and prevention strategies.
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Abstract
Aims and MethodA repetition after 5 years of a prospective case note audit, looking at the impact of a recently established deliberate self-harm (DSH) assessment team on the quality of DSH assessments at Kettering general hospital.ResultsAspecialist DSH team achieved improvement in the quality of psychiatric assessments for the majority of patients who harmed themselves. Assessments of mental state by accident and emergency (A & E) and medical staff before referral to the psychiatric team remain problematic.Clinical ImplicationsSetting up aspecialist team to assess patients who harm themselves can improve the quality of the psychiatric care they receive, but emphasis must still be placed on an adequate assessment of mental state by medical and nursing staff in A&E and on medical wards.
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Scorer RC, Beck P, Bisson J, White S, Routledge PA. A dedicated district poisons treatment unit: response to the College guidance on the management of deliberate self-harm. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.23.6.352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and methodAn examination of the activities of a district-wide dedicated admission unit for poisoned patients in Cardiff, Wales, between 1987 and 1997. Number of admission episodes, gender, drugs taken. intent, psychiatric diagnosis and disposal were recorded.ResultsAlthough the number of admission episodes almost doubled over the 10–year period, the median length of stay fell by almost half.Clinical implicationsThe results suggest that a dedicated unit is a cost-effective model for the management of poisoned patients.
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Wang X, Wu Q, Liu A, Anadón A, Rodríguez JL, Martínez-Larrañaga MR, Yuan Z, Martínez MA. Paracetamol: overdose-induced oxidative stress toxicity, metabolism, and protective effects of various compounds in vivo and in vitro. Drug Metab Rev 2017; 49:395-437. [PMID: 28766385 DOI: 10.1080/03602532.2017.1354014] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Paracetamol (APAP) is one of the most widely used and popular over-the-counter analgesic and antipyretic drugs in the world when used at therapeutic doses. APAP overdose can cause severe liver injury, liver necrosis and kidney damage in human beings and animals. Many studies indicate that oxidative stress is involved in the various toxicities associated with APAP, and various antioxidants were evaluated to investigate their protective roles against APAP-induced liver and kidney toxicities. To date, almost no review has addressed the APAP toxicity in relation to oxidative stress. This review updates the research conducted over the past decades into the production of reactive oxygen species (ROS), reactive nitrogen species (RNS), and oxidative stress as a result of APAP treatments, and ultimately their correlation with the toxicity and metabolism of APAP. The metabolism of APAP involves various CYP450 enzymes, through which oxidative stress might occur, and such metabolic factors are reviewed within. The therapeutics of a variety of compounds against APAP-induced organ damage based on their anti-oxidative effects is also discussed, in order to further understand the role of oxidative stress in APAP-induced toxicity. This review will throw new light on the critical roles of oxidative stress in APAP-induced toxicity, as well as on the contradictions and blind spots that still exist in the understanding of APAP toxicity, the cellular effects in terms of organ injury and cell signaling pathways, and finally strategies to help remedy such against oxidative damage.
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Affiliation(s)
- Xu Wang
- a Department of Toxicology and Pharmacology, Faculty of Veterinary Medicine , Universidad Complutense de Madrid , Madrid , Spain.,b National Reference Laboratory of Veterinary Drug Residues (HZAU) and MAO Key Laboratory for Detection of Veterinary Drug Residues , Huazhong Agricultural University , Wuhan , Hubei , China
| | - Qinghua Wu
- c College of Life Science , Yangtze University , Jingzhou , China.,d Faculty of Informatics and Management , Center for Basic and Applied Research, University of Hradec Kralove , Hradec Kralove , Czech Republic
| | - Aimei Liu
- b National Reference Laboratory of Veterinary Drug Residues (HZAU) and MAO Key Laboratory for Detection of Veterinary Drug Residues , Huazhong Agricultural University , Wuhan , Hubei , China
| | - Arturo Anadón
- a Department of Toxicology and Pharmacology, Faculty of Veterinary Medicine , Universidad Complutense de Madrid , Madrid , Spain
| | - José-Luis Rodríguez
- a Department of Toxicology and Pharmacology, Faculty of Veterinary Medicine , Universidad Complutense de Madrid , Madrid , Spain
| | - María-Rosa Martínez-Larrañaga
- a Department of Toxicology and Pharmacology, Faculty of Veterinary Medicine , Universidad Complutense de Madrid , Madrid , Spain
| | - Zonghui Yuan
- b National Reference Laboratory of Veterinary Drug Residues (HZAU) and MAO Key Laboratory for Detection of Veterinary Drug Residues , Huazhong Agricultural University , Wuhan , Hubei , China.,e MAO Laboratory for Risk Assessment of Quality and Safety of Livestock and Poultry Products , Huazhong Agricultural University , Wuhan , Hubei , China.,f Hubei Collaborative Innovation Center for Animal Nutrition and Feed Safety , Wuhan , Hubei , China
| | - María-Aránzazu Martínez
- a Department of Toxicology and Pharmacology, Faculty of Veterinary Medicine , Universidad Complutense de Madrid , Madrid , Spain
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Abstract
A retrospective review of medical records was carried out to determine the pattern of drug and chemical poisoning cases admitted to a teaching hospital in Malaysia. Medical records of patients admitted during the period January 1987 to December 1995 were reviewed. They accounted for 0.2% of total admissions during the period. While all ages were represented, there was predominance of children, which showed little change throughout the nine-year period. Of all cases of poisoning, 77.8% were unintentional, 12.6% intentional and 9.6% were undetermined. Kerosene, pesticides and medicinal substances remained the common agents associated with poisoning. A significant number of patients sought treatment elsewhere before being admitted to the hospital. Of those who came directly to the hospital, many were presented late in the course of their poisoning. Only seven patients died and none were children. This study supports the need for greater emphasis on prevention of poisoning in children and among farmers in the state.
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Affiliation(s)
- A F Ab Rahman
- Drug Information Unit, Hospital Universiti Sains Malaysia, Kelantan.
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6
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Rafnsson SB, Oliver JJ, Elton RA, Bateman DN. Poisons admissions in Edinburgh 1981-2001: agent trends and predictors of hospital readmissions. Hum Exp Toxicol 2016; 26:49-57. [PMID: 17334179 DOI: 10.1177/0960327107071855] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Self-poisoning is a major public health problem. This study describes patterns of admissions and readmissions from self-poisoning to the Royal Infirmary of Edinburgh from 1981 to 2001. A database on hospital discharges with a diagnosis (ICD-9/10) of poisoning between 1981 and 2001 was used. Annual admissions were described for seven main drug categories, and proportions of patients readmitted within 1-5 years from first admission, were computed for each category. Cox proportional hazards regression was used to evaluate prognostic factors for readmission risk over 1981-2001. For both sexes, admissions increased from the early to mid 1990s, and declined thereafter. The proportion readmitted varied with the drug taken at first admission, from 11.9% (95% CI: 10.8-13%) for non-opiate analgesics, to 17.6% (16.5-18.7%) for benzodiazepines. Deprivation was positively related to readmission risk after first admissions with paracetamol (P<0.001) and benzodiazepines (P<0.001). Timing of first admissions involving paracetamol (P<0.01), benzodiazepines (P<0.001), antidepressants (P<0.001), non-opiate analgesics (P<0.001), and opiates (P<0.05), was inversely associated with readmission risk. In patients admitted for drug overdose, readmission risk is influenced by type of drug taken at first admission. Information on drug type used in self-poisoning may assist in identifying patients at risk for future events, and in reducing hospital read-missions.
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Affiliation(s)
- S B Rafnsson
- Department of Public Health Sciences, University of Edinburgh Medical School, Teviot Place, EH8 9AG, Edinburgh, UK.
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Senarathna L, Jayamanna SF, Kelly PJ, Buckley NA, Dibley MJ, Dawson AH. Changing epidemiologic patterns of deliberate self poisoning in a rural district of Sri Lanka. BMC Public Health 2012; 12:593. [PMID: 22852867 PMCID: PMC3458971 DOI: 10.1186/1471-2458-12-593] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Accepted: 07/11/2012] [Indexed: 12/01/2022] Open
Abstract
Background Acute poisoning is a major public health issue in many parts of the world. The epidemiology and the mortality rate is higher in low and middle income countries, including Sri Lanka. The aim of this study was to provide details about the epidemiology of acute poisoning in a rural Sri Lankan district and to identify the changing patterns and epidemiology of poisoning. Methods A prospective study was conducted from September 2008 to January 2010 in all hospitals with inpatient facilities in Anuradhapura district of North Central Province of Sri Lanka. Acute poisoning data was extracted from patient charts. Selected data were compared to the data collected from a 2005 study in 28 hospitals. Results There were 3813 poisoned patients admitted to the hospitals in the Anuradhapura district over 17 months. The annual population incidence was 447 poisoning cases per 100,000 population. The total number of male and female patients was approximately similar, but the age distribution differed by gender. There was a very high incidence of poisoning in females aged 15–19, with an estimated cumulative incidence of 6% over these five years. Although, pesticides are still the most common type of poison, medicinal drug poisonings are now 21% of the total and have increased 1.6 fold since 2005. Conclusions Acute poisoning remains a major public health problem in rural Sri Lanka and pesticide poisoning remains the most important poison. However, cases of medicinal drug poisoning have recently dramatically increased. Youth in these rural communities remain very vulnerable to acute poisoning and the problem is so common that school-based primary prevention programs may be worthwhile. Lalith Senarathna, Shaluka F Jayamanna, Patrick J Kelly, Nick A Buckley,michael J Dibley, Andrew H Dawson. These authors contributed equally to this work.
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Affiliation(s)
- Lalith Senarathna
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka.
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Kokkevi A, Rotsika V, Arapaki A, Richardson C. Adolescents' self-reported suicide attempts, self-harm thoughts and their correlates across 17 European countries. J Child Psychol Psychiatry 2012; 53:381-9. [PMID: 21895649 DOI: 10.1111/j.1469-7610.2011.02457.x] [Citation(s) in RCA: 159] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Suicide is a leading cause of death among adolescents in Europe. Self-harm thoughts and behaviours are documented precursors of completed suicide. It is therefore of great importance to investigate the prevalence of suicide thoughts and attempts and their correlates, with the aim of preventing this major life-threatening public health problem. This study provides cross-national European data on self-reported suicidal thoughts and attempts among adolescents. METHODS Data were obtained from 45,806 high school students aged 15-16 years from 17 countries that participated in the European School Survey Project on Alcohol and Other Drugs (ESPAD) 2007 school survey. The standardised methods of the ESPAD survey ensure comparability across countries. Students completed an anonymous questionnaire in their classrooms. The prevalences of suicidal thoughts and attempts are reported as well as their sociodemographic and psychosocial correlates identified in logistic regression. RESULTS The median prevalence of any lifetime self-reported suicide attempt was 10.5% across the participating countries (range 4.1%-23.5%). The median of frequent self-harm thoughts (at least five times) was 7.4% (range 2.1%-15.3%). Suicidal behaviour and thoughts had significant associations with gender, substance use, family integrity and socioeconomic status. Countries with higher prevalence of substance use tended to have a weaker association between substance use and self-reported suicide attempts. CONCLUSION Although self-reported self-harm thoughts and suicide attempts vary in prevalence within Europe, there are common correlates across countries. These have an important impact on understanding the phenomenon of suicide among young people and in guiding prevention.
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Affiliation(s)
- A Kokkevi
- A'Department of Psychiatry, Medical School, Athens University, University Mental Health Research Institute, Soranou tou Efesiou 2, Athens, Greece.
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Ghazinour M, Emami H, Richter J, Abdollahi M, Pazhumand A. Age and gender differences in the use of various poisoning methods for deliberate parasuicide cases admitted to loghman hospital in Tehran (2000-2004). Suicide Life Threat Behav 2009; 39:231-9. [PMID: 19527164 DOI: 10.1521/suli.2009.39.2.231] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Different methods of poisoning used by individuals with the diagnosis of parasuicide admitted to the Loghman Hospital, Tehran, from 2000 to 2004 were investigated, with particular focus on gender and age differences. Drugs, pesticides, and other agricultural chemicals (women: 12.7%, men: 9%) were the most commonly used methods. In males, the percentage of use of drugs increased with age, but the frequency of pesticides use decreased with age. In females, drugs were most often used in the youngest age group, whereas the use of pesticides was lowest in the youngest age category. Females outnumbered males, especially in the youngest age group of 10 to 19 years olds. Drugs and pesticides were the substances used most often for parasuicide in each age group regardless of gender.
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Hovda K, Bjornaas M, Skog K, Opdahl A, Drottning P, Ekeberg O, Jacobsen D. Acute poisonings treated in hospitals in Oslo: A one-year prospective study (I): Pattern of poisoning. Clin Toxicol (Phila) 2009; 46:35-41. [DOI: 10.1080/15563650601185969] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Fathelrahman AI, Ab Rahman AF, Mohd Zain Z. MS 04-044: Demographic Features of Drug and Chemical Poisoning in Northern Malaysia. Clin Toxicol (Phila) 2008. [DOI: 10.1081/clt-50416] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Gavrielatos G, Komitopoulos N, Kanellos P, Varsamis E, Kogeorgos J. Suicidal attempts by prescription drug overdose in the elderly: a study of 44 cases. Neuropsychiatr Dis Treat 2006; 2:359-63. [PMID: 19412483 PMCID: PMC2671820 DOI: 10.2147/nedt.2006.2.3.359] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A series of 44 consecutive elderly, admitted to a busy general hospital following deliberate self-poisoning, is reviewed for associated medical and psychosocial factors. In all but 3 cases the act involved an overdose of drugs prescribed for the treatment of a chronic medical and/or psychiatric disorder. Women outnumbered men by 2.7 to 1. There was high proportion of chronic psychiatric (80%, mostly depressive) and medical (60%) conditions. Chronic stress from the physical illness, social isolation, or tacit family conflict were common and seemed instrumental in the self-poisoning act. Most attempts were carried out around the weekend and during winter. One man succumbed to complications of the overdose but the rest of the patients recovered. Psychosocial (especially depressive) and medical vulnerability, plus availability of prescribed drugs, were the most important determinants of suicidal behavior among these elderly attempters.
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Belgamwar DRB, Hodgson RE, Waters K. Trends and characteristics of deliberate self-harm hospital presentations in an English County. Int J Psychiatry Clin Pract 2006; 10:59-63. [PMID: 24926770 DOI: 10.1080/13651500500410679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background. This study investigates deliberate self-harm (DSH) presentations to Southern Derbyshire hospitals from 1990 to 1997. Methods. Retrospective evaluation of deliberate self-harm rates and socio-demographic variables associated with DSH in 9961 consecutive attendances at Derby's two district general hospitals. Results. A significant rise in the rates of DSH in Derbyshire was noted (82%). The gender ratio has changed, with rising numbers of DSH episodes in males. The ratio of DSH episodes to the total Accident & Emergency (A&E) attendances changed from 1.54 to 2.42, with a 36% (95% CI 32-40%) rise in DSH presentations. Overdose remains the most common method of DSH (F = 85%, M = 78%). Two-thirds of the DSH presentations were first DSH attempts. Conclusions. Overall DSH rates are increasing especially in men. In contrast, official suicide rates have reduced during the same period. The increase in DSH rates has implications for already overworked A&E Departments, as well as other emergency and psychiatric services. Service provision and organisation should be reviewed in light of this increasing demand.
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O'Loughlin S, Sherwood J. A 20-year review of trends in deliberate self-harm in a British town, 1981-2000. Soc Psychiatry Psychiatr Epidemiol 2005; 40:446-53. [PMID: 16003594 DOI: 10.1007/s00127-005-0912-3] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/17/2005] [Indexed: 01/23/2023]
Abstract
BACKGROUND It is important to identify trends in deliberate self-harm because of potential links both with complex mental health problems and with suicide itself, and because of its significant impact on resources in both mental health and acute health services. METHOD Patients presenting at the A&E department at Kidderminster General Hospital following an act of deliberate self-harm between the years 1981 and 2000 were assessed by the Parasuicide Counselling Group. These data were used to examine trends in deliberate self-harm and patient characteristics. RESULTS The 20-year study examined 4,474 episodes of deliberate self-harm in the Kidderminster district. Rates of deliberate self-harm were higher in females throughout, although the difference between the genders narrowed in the second half of the 1990s. In both males and females, the rate of deliberate self-harm was highest in those aged 15-24. Since the mid-1990s, there have been increases in the rate of deliberate self-harm in males aged 45-54 and in females aged 25-44. Rates were highest in males and females who were separated. Although the most common method of deliberate self-harm in both males and females was overdose, males used cutting and other methods of deliberate self-harm proportionally more than females. There was a relentless rise in paracetamol use until a decline at the end of the study period following the introduction of a restriction on sales. Alcohol use at the time of deliberate self-harm rose markedly in both genders. There was a significant increase in deliberate self-harm repetition in both males and females over the study period. In males and females, psychiatric involvement or admission increased in the 1990s compared to the 1980s. CONCLUSIONS Higher levels of deliberate self-harm repetition and psychiatric involvement suggest increasing pressures on health services and a continuing need to develop understanding of deliberate self-harm.
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Affiliation(s)
- Simon O'Loughlin
- Dept. of Clinical Psychology, Kidderminster General Hospital, Bewdley Road, Kidderminster (WOR) DY11 6RJ, UK. simon.o'
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Møller LR, Nielsen GL, Olsen ML, Thulstrup AM, Mortensen JT, Sørensen HT. Hospital discharges and 30-day case fatality for drug poisoning: a Danish population-based study from 1979 to 2002 with special emphasis on paracetamol. Eur J Clin Pharmacol 2004; 59:911-5. [PMID: 14991208 DOI: 10.1007/s00228-003-0713-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2003] [Accepted: 12/01/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To examine the number of hospital discharges and 30-day case fatalities due to drug poisoning based on data from a Danish County Hospital Discharge Registry from 1979 to 2002. METHODS All patients with a hospital discharge diagnosis of drug poisoning were identified and separated into groups taking: (1) opioid analgesics; (2) non-opioid analgesics; (3) anxiolytics; (4) antidepressants; (5) antipsychotics; or (6) non-specified. Paracetamol and salicylate were analysed separately. From 1994 to 2001, the total amount of drugs sold in the county was identified from a national drug database. RESULTS A total of 13,432 patients with a median age 41.5 years at discharge of whom 59% were females accounted for 20,249 discharges for drug poisoning. The overall number of discharges remained essentially stable around 170 discharges per 100,000 inhabitants per year. From the mid-1990's, paracetamol became the most frequently used drug in poisoning with the largest increase in female teenagers. Thirty-day case fatality in poisoning with opioids was 3.6% compared with around 1% in other drug categories. For most drug categories, a sale of around 80,000 defined daily doses was associated with one hospital discharge due to drug poisoning. CONCLUSION The overall number of hospital discharges remained stable and seems primarily related to amount of drugs available. With almost 10 years delay, the easier access to paracetamol was followed by an increase in hospitalisation due to poisoning with paracetamol. However, although the majority of hospitalisations were found in the younger age group, the highest mortality was seen among the elderly.
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Affiliation(s)
- Lene Ruge Møller
- Department of Clinical Epidemiology, Aalborg and Aarhus University Hospitals, Stengade 10, 9000, Aalborg, Denmark
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Camidge DR, Wood RJ, Bateman DN. The epidemiology of self-poisoning in the UK. Br J Clin Pharmacol 2003; 56:613-9. [PMID: 14616420 PMCID: PMC1884308 DOI: 10.1046/j.1365-2125.2003.01910.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2002] [Accepted: 05/19/2003] [Indexed: 11/20/2022] Open
Abstract
Self-poisoning by ingestion or inhalation is common, and it is important to study its various epidemiological manifestations with clear definitions. Data on fatal self-poisonings are recorded nationally within the UK and are codified according to the International Classification of Diseases (ICD) revision relevant at the time. Most fatal self-poisonings are codified as suicides, accidental deaths or undetermined deaths ('open verdicts'). Non-fatal self-poisoning data, whether accidental or as a manifestation of deliberate self-harm, are recorded through hospital discharge information nationally but are not routinely published in the same way as mortality data. The bulk of the UK's published epidemiological information on nonfatal self-poisoning episodes is largely based on individual hospitals' admission or discharge records ('special studies'). After establishing definitions for different self-poisoning categories we discuss the published data on self-poisoning as they relate to suicide, accidental self-poisoning and deliberate self-harm in the UK.
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Affiliation(s)
- D R Camidge
- Scottish Poisons Information Bureau, Royal Infirmary of Edinburgh, Edinburgh EH3 9YW, UK.
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Lo A, Shalansky S, Leung M, Hollander Y, Raboud J. Patient characteristics associated with nonprescription drug use in intentional overdose. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2003; 48:232-6. [PMID: 12776389 DOI: 10.1177/070674370304800406] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Over-the-counter (OTC) medications remain freely available to suicidal patients, despite their potential lethality and common use in suicide. The study's main objective was to identify patient characteristics, particularly psychiatric diagnosis associated with the use of OTC medications in intentional overdose. METHODS We retrospectively reviewed 95 charts from patients who presented to St Paul's Hospital from August 1, 1997, to July 31, 1998, with a discharge diagnosis of intentional drug overdose. Univariate analysis was carried out to identify potential risk markers for OTC medication use, and logistic regression was performed using these variables. RESULTS When the variables age, sex, and concurrent psychiatric diagnoses were controlled, use of OTC medications in overdose was significantly lower in patients with a DSM-IV diagnosis of substance abuse (OR 0.11, P = 0.005) and in those who possessed prescription medications at the time of overdose (OR 0.18, P = 0.007). Most patients in this cohort (82%) had at least 1 of these 2 traits. Although not statistically significant, younger patients appeared more likely to choose OTC medications for overdose. CONCLUSION Suicide-prone patients with a diagnosis of substance abuse and who possess prescription medications are unlikely to use OTC medications in overdose. For this cohort, this represents a relatively small proportion of patients whom clinicians should consider to be at greater risk for attempting suicide when using OTC medication, especially acetaminophen.
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Affiliation(s)
- Andre Lo
- Department of Pharmacy, St Paul's Hospital, Providence Health Care, 1081 Burrard Street, Vancouver, BC V6Z 1Y6.
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18
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Raine R, Goldfrad C, Rowan K, Black N. Influence of patient gender on admission to intensive care. J Epidemiol Community Health 2002; 56:418-23. [PMID: 12011195 PMCID: PMC1732172 DOI: 10.1136/jech.56.6.418] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
STUDY OBJECTIVES To compare the case mix and outcomes of male and female patients admitted to intensive care units for a wide range of conditions. DESIGN Cross sectional study of prospectively collected data. SETTING The Intensive Care National Audit and Research Centre, (ICNARC) Case Mix Programme. PARTICIPANTS 46 587 admissions to 91 units across England, Wales, and Northern Ireland. MAIN RESULTS No gender differences were found in case mix on admission or in mortality for five conditions (cardiac arrhythmia, chronic obstructive airways disease, asthma, self poisoning, and seizures). There was some evidence of horizontal and vertical inequity for female patients with myocardial infarction and with neurological bleeding. Vertical equity was not achieved for male pneumonia and ventricular failure patients and for women with primary brain injury. CONCLUSIONS This study demonstrated, for the first time, possible inequitable use of intensive care for patients with certain conditions. This may be secondary to gender bias and can result in either over-treatment in the favoured group, or under-treatment in the neglected group. It would therefore be pertinent to re-examine these findings using other databases, and to further investigate the causative factors, including gender bias.
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Affiliation(s)
- Rosalind Raine
- Health Services Research Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
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Abstract
Most instances of hepatotoxicity due to paracetamol in the United Kingdom and Australia are the result of large overdoses of the drug taken with suicidal or parasuicidal intent. In contrast, serious hepatotoxicity at recommended or near-recommended doses for therapeutic purposes has been reported, mainly from the United States and in association with chronic alcohol use, leading to the widely held belief that chronic alcoholics are predisposed to paracetamol-related toxicity at relatively low doses. Yet the effects of alcohol on paracetamol metabolism are complex. Studies performed in both experimental animals and humans indicate that chronic alcohol use leads to a short-term, two- to threefold increase in hepatic content of cytochrome P4502E1, the major isoform responsible for the generation of the toxic metabolite from paracetamol, although increased oxidative metabolism of paracetamol at recommended doses has not been demonstrated clinically. A reduced hepatic content of glutathione, required to detoxify the reactive metabolite, has been documented in chronic alcoholics, due probably to associated fasting and malnutrition, providing a metabolic basis for any possible predisposition of this group to hepatotoxicity at relatively low paracetamol doses. Simultaneous alcohol and paracetamol ingestion reduces oxidative metabolism of paracetamol in both rodents and humans, predominantly as a consequence of depletion in cytosol of free NADPH. The possibilities that chronic alcohol use may predispose to paracetamol-related hepatotoxicity and that alcohol taken with paracetamol may protect against it, based on these metabolic observations, are examined in this review.
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Affiliation(s)
- Stephen M Riordan
- Gastrointestinal and Liver Unit, The Prince of Wales Hospital and University of New South Wales, Sydney, Australia
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Abstract
Paracetamol (acetaminophen) is one of the most frequently used analgesics, and is the most commonly used substance in self-poisoning in the US and UK. Paracetamol toxicity is manifested primarily in the liver. Treatment with N-acetyl-cysteine (NAC), if started within 10 hours from ingestion, can prevent hepatic damage in most cases. Pharmacokinetic data relating plasma paracetamol concentration to time after ingestion have been used to generate a 'probable hepatoxicity line' to predict which cases of paracetamol overdose will result in hepatotoxicity and should be treated with NAC. However, later studies use a 25% lower line as their 'possible hepatotoxicity line'. Although adopting the original line may save considerable resources, further studies are needed to determine whether such an approach is safe. On the basis of the metabolism of paracetamol, several risk factors for paracetamol toxicity have been proposed. These risk factors include long term alcohol (ethanol) ingestion, fasting and treatment with drugs that induce the cytochrome P450 2E1 enzyme system. Although some studies have suggested that these risk factors may be associated with worse prognosis, the data are inconclusive. However, until further evidence is available, we suggest that the lower line should be used when risk factors are present. In Canada and the UK, the intravenous regimen for NAC is used almost exclusively; in the US, an oral regimen is used. Both regimens have been shown to be effective. There is no large scale study with direct comparison between these 2 therapeutic protocols and controversy still exists as to which regimen is superior. During the last few years there has been an increase in the number of reports of liver failure associated with prolonged paracetamol administration for therapeutic reasons. The true incidence of this phenomenon is not known. We suggest testing liver enzyme levels if a child has received more than 75 mg/kg/day of paracetamol for more than 24 hours during febrile illness, and to treat with NAC when transaminase levels are elevated. Paracetamol overdose during pregnancy should be treated with either oral or intravenous NAC according to the regular protocols in order to prevent maternal, and potentially fetal, toxicity. Unless severe maternal toxicity develops, paracetamol overdose does not appear to increase the risk for adverse pregnancy outcome.
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Affiliation(s)
- E Kozer
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Chan TY. Fulminant hepatic failure due to acetaminophen poisoning may be less common in Hong Kong. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 2001; 39:175-7. [PMID: 11407506 DOI: 10.1081/clt-100103837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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McMahon GT, McGarry K. Deliberate self-poisoning in an Irish county hospital. Ir J Med Sci 2001; 170:94-7; discussion 90. [PMID: 11491059 DOI: 10.1007/bf03168817] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND In 1997, 433 people committed suicide in Ireland, one-quarter of whom were less than 24 years of age. AIM To determine demographics, agent choice and source, suicidality and follow-up care of deliberate self-poisoning patients. METHOD Details of 111 patients admitted to one hospital in 1997 following drug overdose were studied retrospectively. Eleven had been accidental ingestions, the remaining 100 were deliberate self-poisoning. RESULTS Men accounted for 38% of the presentations and were more likely to have suicidal intent than women. An average of 2.3 different agents were used. Paracetamol was taken by 37%, hypnotics/anxiolytics by 33% and nonsteroidal anti-inflammatories by 17%. Alcohol was consumed synchronously by 51% and 17% fulfilled criteria for alcohol dependency. One-third of patients were clinically depressed. All six patients requiring ventilation had consumed a combination of tricyclic antidepressants and alcohol. There were no deaths. CONCLUSION Deliberate self-poisoning remains a significant problem. Paracetamol and alcohol use are particularly marked in this population. The combination of tricyclic antidepressant drugs and alcohol were the most dangerous.
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Affiliation(s)
- G T McMahon
- Department of Medicine, Our Lady's Hospital, Navan, Co Meath, Ireland
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Abstract
AbstractObjectives: To review the most recent information on completed suicide for the general adult psychiatrist.Methods: Literature review.Results: Suicide is the result of a complex interaction of multiple variables. Prediction is highly dependent on clinical evaluation. Predictive factors identify groups better than individuals. Prevention has both clinical and political implications.Conclusions: Reduced access to lethal methods (historically, from barbiturates to modified vehicle exhaust systems and paracetamol), attention to social factors (such as alcohol availability and employment levels) and clinical vigilance, coupled with adequate treatment of psychiatric disorders and close follow-up, should help to reduce suicide rates. Wider cultural issues (eg. religion) are poorly understood and require further research.
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Affiliation(s)
- C Poulin
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Kinmond KS, Bent M. Attendance for self-harm in a West Midlands hospital A&E department. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2000; 9:215-20. [PMID: 11033638 DOI: 10.12968/bjon.2000.9.4.6379] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article focuses on the issue of self-harm. It reviews the literature and details specifically a comparison of data collected in the accident and emergency (A&E) department of a hospital in the West Midlands in 1990 and in 1997. Both the research literature and the data collected at the hospital suggest that there is a rise in the numbers of people self-harming and presenting to A&E departments. Any changes in rates of self-harm or the demographic characteristics of the patient population are likely to have important implications for clinical services. Additionally, the links between self-harm and suicide are well documented (Hawton and Fagg, 1988; Morgan and Williams, 1994) and there is an urgent need to ensure quality service for this high-risk group. An effective assessment of the area is difficult. The limited number of comprehensive studies prohibits definitive epidemiological data. Furthermore, confusion over terminology hinders clear analysis and comparison of that which is collected.
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Hawton K, Fagg J, Simkin S, Bale E, Bond A. Deliberate self-harm in adolescents in Oxford, 1985-1995. J Adolesc 2000; 23:47-55. [PMID: 10700371 DOI: 10.1006/jado.1999.0290] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Deliberate self-harm (DSH) has been one of the major health problems of adolescents in the U.K. for many years. Any changes in rates of DSH or the demographic characteristics of the patient population are likely to have important implications for clinical services and for future suicidal behaviour. Following a decline in rates in the late 1970s and mid 1980s, there were signs in the late 1980s that rates were beginning to increase again. We have used data collected by the Oxford Monitoring System for Attempted Suicide on the basis of patients presenting to the general hospital in Oxford to review trends in DSH in under 20-year-olds between 1985 and 1995. There was a substantial increase in the numbers of teenage DSH patients during the 11-year study period, with an increase between 1985-1986 and 1994-1995 of 27.7% in males, 28.3% in females, and 28.1% overall. There were no demographic changes within the catchment area to explain a change of this size. As rates of repetition of DSH also increased in both sexes during the study period the overall number of episodes of DSH rose even more between 1985-1986 and 1994-1995 (+56.9% in males, +46.3% in females, and +49.4% overall). As in previous studies the majority of adolescents had interpersonal problems and/or difficulties with studying or employment. Self-poisoning with paracetamol and paracetamol compounds became increasingly common such that by 1995 these were used in almost two-thirds of overdoses. The recent increase in DSH in adolescents has important implications for general hospital and adolescent psychiatric services. The greater frequency of repetition of DSH may herald increased future suicide rates. The case for restricting the amount of paracetamol available is overwhelming. Evaluative trials of specific interventions following adolescent DSH are urgently required.
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Affiliation(s)
- K Hawton
- Centre for Suicide Research, University Department of Psychiatry, Oxford, UK
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Moore P. Toxic confusional state presenting as mental illness. JOURNAL OF CLINICAL FORENSIC MEDICINE 1999; 6:159-60. [PMID: 15335486 DOI: 10.1016/s1353-1131(99)90064-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
A 44-year-old man was arrested under section 136 Mental Health Act 1983 after behaving strangely outside a club. When assessed he appeared to be suffering from a toxic confusional state. On admission to hospital his salicylate levels were found to be high. The confusion proved to be caused by an aspirin overdose.
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Affiliation(s)
- P Moore
- Police Surgeon, Devon and Cornwall Constabulary, Torbay, UK
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Affiliation(s)
- A House
- Department of Psychiatry, University of Leeds, UK.
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Abstract
Several countries in the Western hemisphere have experienced a marked increase in suicide rates in young males in recent years. This article considers this phenomenon largely from the perspective of the United Kingdom, where rates of suicide in 15-24-year-old males nearly doubled in just over a decade. The possible reasons for this are considered, particularly in the context of relative stability of suicide rates in young females.
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Bradley MP, Nguyen-Van-Tam JS, Pearson JC. "Late presenters" after paracetamol self poisoning. J Epidemiol Community Health 1998; 52:762-3. [PMID: 10396512 PMCID: PMC1756643 DOI: 10.1136/jech.52.11.762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- M P Bradley
- Division of Public Health Medicine and Epidemiology, School of Community Health Sciences, University of Nottingham Medical School, Queen's Medical Centre
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Hawton K, Arensman E, Townsend E, Bremner S, Feldman E, Goldney R, Gunnell D, Hazell P, van Heeringen K, House A, Owens D, Sakinofsky I, Träskman-Bendz L. Deliberate self harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition. BMJ (CLINICAL RESEARCH ED.) 1998; 317:441-7. [PMID: 9703526 PMCID: PMC28637 DOI: 10.1136/bmj.317.7156.441] [Citation(s) in RCA: 292] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To identify and synthesise the findings from all randomised controlled trials that have examined the effectiveness of treatments of patients who have deliberately harmed themselves. DESIGN Systematic review of randomised controlled trials of psychosocial and physical treatments. Studies categorised according to type of treatment. When there was more than one investigation in a particular category a summary odds ratio was estimated with the Mantel-Haenszel method. SETTING Randomised trials available in electronic databases in 1996, in the Cochrane Controlled Trials Register in 1997, and from hand searching of journals to 1997. SUBJECTS Patients who had deliberately harmed themselves shortly before entry into the trials with information on repetition of behaviour. The included trials comprised 2452 randomised participants with outcome data. MAIN OUTCOME MEASURE Repetition of self harm. RESULTS 20 trials reported repetition of self harm as an outcome variable, classified into 10 categories. Summary odds ratio (all for comparison with standard aftercare) indicated reduced repetition for problem solving therapy (0.73; 95% confidence interval 0.45 to 1.18) and for provision of an emergency contact card in addition to standard care (0.45; 0.19 to 1.07). The summary odds ratios were 0.83 (0.61 to 1.14) for trials of intensive aftercare plus outreach and 1.19 (0.53 to 2.67) for antidepressant treatment compared with placebo. Significantly reduced rates of further self harm were observed for depot flupenthixol versus placebo in multiple repeaters (0.09; 0.02 to 0.50) and for dialectical behaviour therapy versus standard aftercare (0.24; 0.06 to 0.93). CONCLUSION There remains considerable uncertainty about which forms of psychosocial and physical treatments of patients who harm themselves are most effective. Further larger trials of treatments are needed.
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Affiliation(s)
- K Hawton
- Department of Psychiatry, Oxford University, Warneford Hospital, Oxford OX3 7JX
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Hawton K, Arensman E, Wasserman D, Hultén A, Bille-Brahe U, Bjerke T, Crepet P, Deisenhammer E, Kerkhof A, De Leo D, Michel K, Ostamo A, Philippe A, Querejeta I, Salander-Renberg E, Schmidtke A, Temesváry B. Relation between attempted suicide and suicide rates among young people in Europe. J Epidemiol Community Health 1998; 52:191-4. [PMID: 9616425 PMCID: PMC1756691 DOI: 10.1136/jech.52.3.191] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
STUDY OBJECTIVE To determine if there are associations between rates of suicide and attempted suicide in 15-24 year olds in different countries in Europe. DESIGN Attempted suicide rates were based on data collected in centres in Europe between 1989 and 1992 as part of the WHO/EURO Multicentre Study of Parasuicide. Comparison was made with both national suicide rates and local suicide rates for the areas in which the attempted suicide monitoring centres are based. SETTING 15 centres in 13 European countries. PATIENTS Young people aged 15-24 years who had taken overdoses or deliberately injured themselves and been identified in health care facilities. MAIN RESULTS There were positive correlations (Spearman rank order) between rates of attempted suicide and suicide rates in both sexes. The correlations only reached statistical significance for male subjects: regional suicide rates, r = 0.65, p < 0.02; national suicide rates, r = 0.55, p < 0.02. CONCLUSIONS Rates of attempted suicide and suicide in the young covary. The recent increase in attempted suicide rates in young male subjects in several European countries could herald a further increase in suicide rates.
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Affiliation(s)
- K Hawton
- University Department of Psychiatry, Warneford Hospital, Oxford, United Kingdom
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Hawton K, Fagg J, Simkin S, Bale E, Bond A. Trends in deliberate self-harm in Oxford, 1985-1995. Implications for clinical services and the prevention of suicide. Br J Psychiatry 1997; 171:556-60. [PMID: 9519096 DOI: 10.1192/bjp.171.6.556] [Citation(s) in RCA: 201] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Deliberate self-harm (DSH) has been a major health problem in the UK for nearly three decades. Any changes in rates of DSH or the demographic characteristics of the patient population are likely to have important implications for clinical services and suicide prevention. METHOD Data collected by the Oxford Monitoring System for Attempted Suicide were used to review trends in DSH between 1985-1995. RESULTS There was a substantial increase in DSH rates during the 11-year study period, with a 62.1% increase in males and a 42.2% increase in females. The largest rise was in 15-24-year-old males (+ 194.1%). Changes in DSH rates correlated with changes in national suicide rates in both males and females in this age group. Rates of repetition of DSH increase in both genders during the study period. Paracetamol self-poisoning has continued to increase, half of all overdoses in 1995 involving paracetamol, and antidepressant overdoses have become more common. CONCLUSIONS The increase in DSH, especially in young males, has important implications for general hospital DSH and medical services. It may herald a reversal of recent progress towards achievement of national suicide targets.
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Affiliation(s)
- K Hawton
- University Department of Psychiatry, Warneford Hospital, Oxford
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Gunnell D, Hawton K, Murray V, Garnier R, Bismuth C, Fagg J, Simkin S. Use of paracetamol for suicide and non-fatal poisoning in the UK and France: are restrictions on availability justified? J Epidemiol Community Health 1997; 51:175-9. [PMID: 9196648 PMCID: PMC1060441 DOI: 10.1136/jech.51.2.175] [Citation(s) in RCA: 104] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To investigate the relationship between the availability of paracetamol and its use for overdose and suicide. DESIGN Analysis of routinely collected information on time trends for paracetamol suicides, non-fatal overdoses, and sales. SETTING England and Wales and France. RESULTS There were strong correlations between trends in paracetamol sales in the UK and trends in non-fatal paracetamol overdose in Oxford between 1976 and 1993 (Spearman's r = 0.86; 95% confidence interval (CI) 0.54, 0.96) and between paracetamol sales and non-fatal overdoses in France between 1974 and 1990 (r = 0.99; 95% CI 0.97, 1.00). Sales figures were also correlated with paracetamol related suicides in both England and Wales, 1983-91 (r = 0.72; 95% CI 0.11, 0.94) and France, 1974-90 (r = 0.79; 95% CI 0.50, 0.92). Similarly strong relationships were observed between trends in non-fatal overdoses and suicide by paracetamol poisoning in England and Wales (r = 0.85; 95% CI 0.61, 0.95) and France (r = 0.79; 95% CI 0.50, 0.92). It is estimated that approximately 32,000 overdoses involving paracetamol occur annually in England and Wales. Fatality rates from paracetamol overdose were four times as high in England and Wales (0.4%, 95% CI 0.38, 0.46) as in France (0.1%, 95% CI 0.06, 0.17). CONCLUSION Trends towards greater availability of paracetamol are paralleled by increases in its use for both non-fatal overdose and suicide. Paracetamol related morbidity and mortality seem to be less frequent in France where the quantity of paracetamol in a single purchase is limited. Although not conclusive, these data add to a body of evidence which suggests that restrictions in the quantity of paracetamol available as a single purchase in the UK may reduce suicide and liver failure related to paracetamol.
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Affiliation(s)
- D Gunnell
- Department of Social Medicine, University of Bristol
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