How to establish case registers: II. Non-fatal deliberate self-harm

Establishing a clinical database for hospital attendances because of self-harm

Self-harm is a major risk factor for suicide (Gunnell & Frankel, 1994) with around a quarter of suicides preceded by non-fatal self-harm in the previous year (Owens & House, 1994). Strategies for suicide prevention should include accurate monitoring of health service contacts due to self-harm. Unfortunately, the published literature points to few practical steps for ensuring this accuracy. We offer an account of running a database, to assist others who might be setting out on this monitoring process.

Sleep problems and hospitalization for self-harm: a 15-year follow-up of 9,000 Norwegian adolescents. The Young-HUNT Study

OBJECTIVES

To investigate the association between sleeping problems in adolescence and subsequent hospital admission for self-harm (SH).

DESIGN

Prospective cohort study, linking health survey information on sleep problems to hospital-based patient records.

SETTING

Residents of Nord-Trøndelag County, Norway, aged 13-19 years in 1995-97.

PATIENTS OR PARTICIPANTS

10,202 adolescents were invited to participate in the Young-HUNT study; 8,983 (88%) completed the health survey.

MEASUREMENTS AND RESULTS

10% of participants reported difficulties initiating sleep, 4% reported early morning wakening. Ninety-eight participants (27% male) were hospitalized following SH over a mean 12 years follow-up. Difficulties initiating sleep/early morning wakening were associated with increased risk of SH (HR 2.11, 95% CI 1.29-3.46, sex- and age-adjusted) compared with no problems, yet coexistent symptoms of combined anxiety/depression explained most of the association with sleep problems (fully adjusted HR 1.19, 95% CI 0.66-2.16). The HR of combined difficulties initiating sleep/early morning wakening differed in those with and without anxiety/depression at baseline (P interaction = 0.03); among those without caseness symptoms of anxiety/depression it was 5.58 (95% CI 2.02-15.40), while in those with caseness symptoms of anxiety/ depression it was 0.82 (95% CI 0.19-3.44).

CONCLUSIONS

Sleep problems are common among Norwegian adolescents. The strong association between sleep problems and subsequent hospitalization for self-harm could mainly be related to coexistent symptoms of anxiety and depression. Prevention of adolescent sleep problems, anxiety and depression should be targeted when seeking to reduce and prevent self-harm.

Crisis card following self-harm: 12-month follow-up of a randomised controlled trial

No intervention has been shown to be effective in preventing repetition of self-harm. In the 6-month follow-up of a large randomised controlled trial, we previously reported no effectiveness of the provision of a card offering 24-h crisis telephone consultation on repetition of self-harm. However, there was a possible benefit among those presenting following a first episode (OR=0.64, 95% CI 0.34-1.22). Here we report the 12-month follow-up of the trial. The results confirm no overall benefit of the intervention (OR=1.19, 95% CI 0.85-1.67). Among those with a first episode of self-harm, the possible benefit of the intervention had diminished (OR=0.89, 95% CI 0.52-1.52), although a modest effect cannot be excluded.

An examination of the accident and emergency management of deliberate self harm

OBJECTIVE

To examine the adequacy of assessment and management of deliberate self harm (DSH) undertaken by accident and emergency (A&E) medical staff.

METHODS

The records for attendances to the Leicester Royal Infirmary A&E department with a diagnosis of "self inflicted" injury for the 12 month period April 1994 to March 1995 were scrutinised. If the episode was identified as DSH, then assessment and management were examined, using an instrument based on the Royal College of Psychiatrists' standards of service for the general hospital management of adult DSH.

RESULTS

There were 934 episodes of DSH involving 854 patients. The mean age was 32 (SD 14.2), with an even sex distribution. Overdose was by far the most common method of DSH (91.5%). Information concerning suicide intent was documented in 70% of cases, and psychiatric history in 67%. Less information was recorded for medical history (50%), mental state (51%), recent stress (55%), or previous DSH (47%), and only 23% had an assessment of risk of further DSH. Very little was recorded concerning alcohol or substance misuse. In 291 cases (31%), the patient was discharged directly home by A&E medical staff, and 50 of these were referred for psychiatric outpatient follow up; 210 (23%) were referred for specialist assessment in the department and 423 (45.5%) were admitted to medical/surgical wards. The frequency with which information was recorded varied significantly between outcome groups. At night A&E staff were far more likely to discharge a patient home themselves than refer for specialist assessment (P << 0.001).

CONCLUSIONS

With over half the sample not admitted, the responsibility for the initial risk assessment lies with A&E medical staff. The study reveals a need for improved planning and delivery of services.