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Bandara P, Page A, Hammond TE, Sperandei S, Stevens GJ, Gunja N, Anand M, Jones A, Carter G. Surveillance of Hospital-Presenting Intentional Self-Harm in Western Sydney, Australia, During the Implementation of a New Self-Harm Reporting Field. CRISIS 2023; 44:135-145. [PMID: 35138153 DOI: 10.1027/0227-5910/a000845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background: Hospital-presenting self-harm is a strong predictor of suicide and has substantial human and health service costs. Aims: We aimed to identify changes in case ascertainment after implementation of a new self-harm reporting field at a tertiary hospital in New South Wales, and to report event rates, demographic, and clinical characteristics. Method: Self-harm events presenting to the emergency department (October 2017 to August 2020) were identified using clinical documentation and a new reporting field. Changes in the frequency of self-harm in the period after implementation of the self-harm field were assessed through Poisson regression models. Results: A twofold increase in the frequency of self-harm was detected following the implementation of the new reporting field. The annual average age-standardized event rate of self-harm was 110.4 per 100,000 (120.8 per 100,000 for females; 100.1 per 100,000 for males). The highest rates by age and sex were for females aged 15-19 years (375 per 100,000) and males aged 20-24 years (175 per 100,000). Limitations: Self-harm identification relies on clinician coding practice, which is subject to variability and potential under-enumeration. Conclusion: These findings highlight the value of a self-harm reporting field in hospital record systems for accurate recording and long-term monitoring of self-harm event rates.
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Affiliation(s)
- Piumee Bandara
- Translational Health Research Institute, Western Sydney University, Penrith, NSW, Australia
| | - Andrew Page
- Translational Health Research Institute, Western Sydney University, Penrith, NSW, Australia
| | - Trent Ernest Hammond
- Nepean Clinical School, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Sandro Sperandei
- Translational Health Research Institute, Western Sydney University, Penrith, NSW, Australia
| | - Garry John Stevens
- School of Social Sciences, Western Sydney University, Penrith, NSW, Australia
| | - Naren Gunja
- Department of Clinical Pharmacology and Toxicology, Western Sydney Health, Wentworthville, NSW, Australia
- Digital Health Solutions, Cumberland Hospital, Western Sydney Health, Wentworthville, NSW, Australia
- Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia
| | - Manish Anand
- Consultation Liaison Psychiatry, Westmead Hospital, Westmead, NSW, Australia
| | - Alison Jones
- Department of Clinical Pharmacology and Toxicology, Western Sydney Health, Wentworthville, NSW, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, NSW, Australia
| | - Greg Carter
- School of Medicine and Public Health, University of Newcastle, NSW, Australia
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2
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Dani A, Balachandran S, McGill K, Whyte I, Carter G. Prevalence of Depression and Predictors of Discharge to a Psychiatric Hospital in Young People with Hospital-Treated Deliberate Self-Poisoning at an Australian Sentinel Unit. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15753. [PMID: 36497828 PMCID: PMC9737120 DOI: 10.3390/ijerph192315753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/18/2022] [Accepted: 11/24/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Hospital treated deliberate self-poisoning is common in young people. Internationally, estimates of rates of depression in this population are very wide (14.6% to 88%). The aims of this study were to determine the prevalence of depression and the independent predictors of referral for psychiatric hospitalisation in young people (aged 16 to 25 years) following an index episode of hospital treated deliberate self-poisoning. METHOD A retrospective cohort study design (n = 1410), with data drawn from a population-based clinical case register. Unadjusted and adjusted estimates of predictors of referral for psychiatric admission (after-care) used logistic regression models. RESULTS Prevalence of any depression diagnosis was 35.5% (n = 500); and 25.4% (n = 358) were referred for a psychiatric admission. The adjusted estimates for predictors of psychiatric inpatient referral were: high suicidal level (OR 118.21: CI 95% 63.23-220.99), low/moderate suicidal level (14.27: 9.38-21.72), any depression (2.88: 1.97-4.22), any psychosis (4.06; 1.15-14.36), older age (1.12: 1.04-1.21), and number of support people (0.88: 0.78-0.98). CONCLUSION Depression was diagnosed in more than a third and was an independent predictor of psychiatric inpatient referral, so service providers need to account for this level of need in the provision of assessment and after-care services. Evidence-based guidelines for psychiatric inpatient after-care for deliberate self-poisoning and/or depression in young people are limited. Our explanatory model included suicidal level, depression, psychosis, older age, and available support persons, suggesting that the treating clinicians were making these discharge decisions for admission in keeping with those limited guidelines, although the balance of benefits and harms of psychiatric hospitalisation are not established. Future research examining patient experiences, effectiveness of psychiatric hospitalisation, and alternatives to hospitalisation is warranted.
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Affiliation(s)
- Anitha Dani
- Child and Adolescent Mental Health Service, Hunter New England Mental Health Service, Newcastle, NSW 2302, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Srilaxmi Balachandran
- Child and Adolescent Mental Health Service, Hunter New England Mental Health Service, Newcastle, NSW 2302, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
| | - Katie McGill
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
- Research Evaluation and Dissemination (MH-READ), Hunter New England Mental Health Service, Newcastle, NSW 2298, Australia
| | - Ian Whyte
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
- Calvary Mater Newcastle Hospital, Waratah, NSW 2298, Australia
| | - Greg Carter
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW 2308, Australia
- Calvary Mater Newcastle Hospital, Waratah, NSW 2298, Australia
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3
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McGill K, Salem A, Hanstock TL, Heard TR, Garvey L, Leckning B, Whyte I, Page A, Carter G. Indigeneity and Likelihood of Discharge to Psychiatric Hospital in an Australian Deliberate Self-Poisoning Hospital-Treated Cohort. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12238. [PMID: 36231541 PMCID: PMC9566708 DOI: 10.3390/ijerph191912238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/19/2022] [Accepted: 09/20/2022] [Indexed: 06/16/2023]
Abstract
Hospital-treated self-harm rates for Aboriginal and Torres Strait Islander (Indigenous) people are at least double those for other Australians. Despite this, limited research has explored the relationship between Indigeneity and the clinical management of hospital-treated deliberate self-harm. A retrospective clinical cohort study (2003-2012) at a regional referral centre (NSW) for deliberate self-poisoning was used to explore the magnitude and direction of the relationship between Indigeneity and discharge destination (psychiatric hospital vs. other) using a series of logistic regressions. There were 149 (4%) Indigenous and 3697 (96%) non-Indigenous deliberate self-poisoning admissions during the study period. One-third (31%) were referred to the psychiatric hospital at discharge; Indigenous 21% (n = 32) vs. non-Indigenous 32% (n = 1175). Those who identified as Indigenous were less likely to be discharged to the psychiatric hospital, OR 0.59 (0.40-0.87) at the univariate level, with little change after sequential adjustment; and AOR 0.34 (0.21-0.73) in the fully adjusted model. The Indigenous cohort had a lower likelihood of psychiatric hospital discharge even after adjustment for variables associated with discharge to the psychiatric hospital highlighting the need for further investigation of the reasons accounting for this differential pattern of clinical management and the effectiveness of differential after-care allocation.
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Affiliation(s)
- Katie McGill
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2308, Australia
- Healthy Minds, Hunter Medical Research Institute, Newcastle, NSW 2308, Australia
- Mental Health-Research, Evaluation and Dissemination (MH-READ), Hunter New England Local Health District, Newcastle, NSW 2298, Australia
| | - Amir Salem
- School of Psychological Sciences, University of Newcastle, Newcastle, NSW 2308, Australia
| | - Tanya L. Hanstock
- School of Psychological Sciences, University of Newcastle, Newcastle, NSW 2308, Australia
| | - Todd R. Heard
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2308, Australia
- Healthy Minds, Hunter Medical Research Institute, Newcastle, NSW 2308, Australia
- Wiyillin Ta Child and Adolescent Mental Health Service, Hunter New England Local Health District, Newcastle, NSW 2300, Australia
| | - Leonie Garvey
- Aboriginal Health, Hunter New England Local Health District, Wallsend, NSW 2287, Australia
| | - Bernard Leckning
- Black Dog Institute, University of New South Wales, Sydney, NSW 1466, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, NT 0811, Australia
| | - Ian Whyte
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2308, Australia
- Calvary Mater Newcastle, Newcastle, NSW 2298, Australia
| | - Andrew Page
- Translational Health Research Institute, Western Sydney University, Penrith, NSW 2751, Australia
| | - Greg Carter
- Healthy Minds, Hunter Medical Research Institute, Newcastle, NSW 2308, Australia
- Calvary Mater Newcastle, Newcastle, NSW 2298, Australia
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4
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McGill K, Whyte IM, Sawyer L, Adams D, Delamothe K, Lewin TJ, Robinson J, Kay-Lambkin FJ, Carter GL. Effectiveness of the Hunter Way Back Support Service: An historical controlled trial of a brief non-clinical after-care program for hospital-treated deliberate self-poisoning. Suicide Life Threat Behav 2022; 52:500-514. [PMID: 35122297 DOI: 10.1111/sltb.12840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/27/2021] [Accepted: 11/12/2021] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Active contact and follow-up interventions have been shown to be effective in reducing repetition of hospital-treated self-harm. The Way Back Support Service (WBSS) is a new service funded by the Australian government to provide three months of non-clinical after-care following a hospital-treated suicide attempt. The aim of this study was to investigate the effectiveness of WBSS in reducing deliberate self-poisoning (DSP) and psychiatric hospital admissions over a 12-month follow-up period for a population of DSP patients within the Hunter (Australia) region. METHODS A non-randomized, historical controlled (two periods) trial design with intention-to-treat analyses. Outcome data were drawn from hospital records. RESULTS There were a total of 2770 participants across study periods. There were no significant differences between cohorts for proportion with any, or number of, re-admissions for DSP in the follow-up period. For psychiatric admissions, the intervention cohort had a non-significantly greater proportion with any psychiatric admission and significantly more admissions compared to one of the control cohorts. CONCLUSION The WBSS model of care should be modified to strengthen treatment engagement and retention and to include established, clinical, evidence-based treatments shown to reduce DSP repetition. Any modified WBSS model should be subject to further evaluation.
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Affiliation(s)
- Katie McGill
- MH-READ, Hunter New England Local Health District, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Ian M Whyte
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Lisa Sawyer
- Hunter Primary Care, Newcastle, New South Wales, Australia
| | - Danielle Adams
- Hunter Primary Care, Newcastle, New South Wales, Australia
| | | | - Terry J Lewin
- MH-READ, Hunter New England Local Health District, Newcastle, New South Wales, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Jo Robinson
- Orygen, Parkvillle, Victoria, Australia.,Centre for Youth Mental Health, University of Melbourne, Parkvillle, Victoria, Australia
| | - Frances J Kay-Lambkin
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Gregory L Carter
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia.,Calvary Mater Newcastle, Newcastle, New South Wales, Australia
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5
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Fortune S, Hetrick S, Sharma V, McDonald G, Scott KM, Mulder RT, Hobbs L. Multisite sentinel surveillance of self-harm in New Zealand: protocol for an observational study. BMJ Open 2022; 12:e054604. [PMID: 35613789 PMCID: PMC9134176 DOI: 10.1136/bmjopen-2021-054604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION New Zealand (NZ) has a persistently high rate of suicide, particularly among young people. Hospital presentation for self-harm (SH) is one of the strongest predictors of death by suicide. Improving the monitoring of SH and suicide is a key recommendation for suicide prevention by WHO. This study will establish the first ever sentinel surveillance for SH at several large hospitals and a monthly survey of all practicing paediatricians in NZ. The study will provide robust information about the epidemiology of SH, factors associated with SH and the types of interventions required for those presenting to hospital with SH. METHOD AND ANALYSIS This observational study will establish SH surveillance in the emergency departments of three public hospitals for the first time in NZ, where study population will include individuals of all ages who present with SH or suicidal ideation. The study methodology is in line with the WHO Best Practice guidelines and international collaborators in Australia and Europe. Electronic triage records will be reviewed manually by the research team to identify potential cases that meet inclusion criteria. For all eligible cases, variables of interest will be extracted from routine clinical records by the research team and recorded on a secure web-based survey application. Additionally, SH surveillance data for the national paediatric population (<15 years) will be obtained via the New Zealand Paediatric Surveillance Unit (NZPSU); paediatricians will report on included cases using the same variables using a secure survey application. A deidentified dataset will be produced for aggregated statistical analysis. ETHICS AND DISSEMINATION The University of Otago Health Ethics Committee granted ethical approval for this study in addition to local ethics approval at participating hospital sites. The study findings will be disseminated to relevant stakeholders in NZ, in addition to international audiences through publications in peer-reviewed scientific journals and conference presentations.
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Affiliation(s)
- Sarah Fortune
- Department of Social and Community Health, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
- The Department of Psychological Medicine, University of Otago, Dunedin, New Zealand
| | - Sarah Hetrick
- Department of Psychological Medicine, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Vartika Sharma
- Department of Psychological Medicine, The University of Auckland Faculty of Medical and Health Sciences, Auckland, New Zealand
| | - Gabrielle McDonald
- Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Kate M Scott
- The Department of Psychological Medicine, University of Otago, Dunedin, New Zealand
| | - Roger T Mulder
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Linda Hobbs
- The Department of Psychological Medicine, University of Otago, Dunedin, New Zealand
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6
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Quinlivan L, Gorman L, Littlewood DL, Monaghan E, Barlow SJ, Campbell S, Webb RT, Kapur N. ‘Wasn’t offered one, too poorly to ask for one’ – Reasons why
some patients do not receive a psychosocial assessment following
self-harm: Qualitative patient and carer survey. Aust N Z J Psychiatry 2022; 56:398-407. [PMID: 34015945 PMCID: PMC8941717 DOI: 10.1177/00048674211011262] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Psychosocial assessment following self-harm presentations to hospital is an important aspect of care. However, many people attending hospital following self-harm do not receive an assessment. We sought to explore reasons why some patients do not receive a psychosocial assessment following self-harm from the perspective of patients and carers. METHODS Between March and November 2019, we recruited 88 patients and 14 carers aged ⩾18 years from 16 mental health trusts and community organisations in the United Kingdom, via social media, to a co-designed qualitative survey. Thematic analyses were used to interpret the data. RESULTS Patients' reasons for refusing an assessment included long waiting times, previous problematic interactions with staff and feeling unsafe when in the emergency department. Two people refused an assessment because they wanted to harm themselves again. Participants reported organisational reasons for non-assessment, including clinicians not offering assessments and exclusion due to alcohol intoxication. Other patients felt they did not reach clinically determined thresholds because of misconceptions over perceived heightened fatality risk with certain self-harm methods (e.g. self-poisoning vs self-cutting). CONCLUSION Our results provide important insights into some of the reasons why some people may not receive a psychosocial assessment following self-harm. Parallel assessments, compassionate care and specialist alcohol services in acute hospitals may help reduce the number of people who leave before an assessment. Education may help address erroneous beliefs that self-injury and self-harm repetition are not associated with greatly raised suicide risk.
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Affiliation(s)
- Leah Quinlivan
- Division of Psychology and Mental
Health, Centre for Mental Health and Safety, The University of Manchester,
Manchester, UK,Manchester Academic Health
Science Centre, The University of Manchester, Manchester, UK,NIHR Greater Manchester Patient
Safety Translational Research Centre, The University of Manchester,
Manchester Academic Health Science Centre, Manchester, UK,Leah Quinlivan, Centre for Mental
Health and Safety, The University of Manchester, Jean McFarlane
Building, Oxford Road, Manchester M13 9PL, UK.
| | - Louise Gorman
- Division of Psychology and Mental
Health, Centre for Mental Health and Safety, The University of Manchester,
Manchester, UK,Manchester Academic Health
Science Centre, The University of Manchester, Manchester, UK,NIHR Greater Manchester Patient
Safety Translational Research Centre, The University of Manchester,
Manchester Academic Health Science Centre, Manchester, UK
| | - Donna L Littlewood
- Division of Psychology and Mental
Health, Centre for Mental Health and Safety, The University of Manchester,
Manchester, UK,Manchester Academic Health
Science Centre, The University of Manchester, Manchester, UK,NIHR Greater Manchester Patient
Safety Translational Research Centre, The University of Manchester,
Manchester Academic Health Science Centre, Manchester, UK
| | - Elizabeth Monaghan
- NIHR Greater Manchester Patient
Safety Translational Research Centre, The University of Manchester,
Manchester Academic Health Science Centre, Manchester, UK
| | - Stephen J Barlow
- NIHR Greater Manchester Patient
Safety Translational Research Centre, The University of Manchester,
Manchester Academic Health Science Centre, Manchester, UK
| | - Stephen Campbell
- NIHR Greater Manchester Patient
Safety Translational Research Centre, The University of Manchester,
Manchester Academic Health Science Centre, Manchester, UK
| | - Roger T Webb
- Division of Psychology and Mental
Health, Centre for Mental Health and Safety, The University of Manchester,
Manchester, UK,Manchester Academic Health
Science Centre, The University of Manchester, Manchester, UK,NIHR Greater Manchester Patient
Safety Translational Research Centre, The University of Manchester,
Manchester Academic Health Science Centre, Manchester, UK
| | - Nav Kapur
- Division of Psychology and Mental
Health, Centre for Mental Health and Safety, The University of Manchester,
Manchester, UK,Manchester Academic Health
Science Centre, The University of Manchester, Manchester, UK,NIHR Greater Manchester Patient
Safety Translational Research Centre, The University of Manchester,
Manchester Academic Health Science Centre, Manchester, UK,Greater Manchester Mental Health
NHS Foundation Trust, Manchester, UK
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7
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McGill K, Spittal MJ, Bryant J, Lewin TJ, Whyte IM, Madden C, Carter G. Comparison of accredited person and medical officer discharge decisions under the Mental Health Act of NSW: A cohort study of deliberate self-poisoning patients. Aust N Z J Psychiatry 2022; 56:178-185. [PMID: 33951922 DOI: 10.1177/00048674211009613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Accredited Persons Programme was introduced in 2003. The relevant Mental Health Acts (NSW) authorised reviews by appropriately credentialed non-medical health professionals as part of the process of detaining and treating a person without consent: an authority previously held by medical officers. Evaluations of the Programme are needed. OBJECTIVE To compare discharge decisions for hospital-treated deliberate self-poisoning patients made by an Accredited Person and Medical Officers. METHODS For a 10-year cohort (2003-2012) of index hospital-treated deliberate self-poisoning admissions at the Calvary Mater Newcastle, we compared Accredited Person and Medical Officer discharge decisions from the general hospital. We specifically examined discharges to the psychiatric hospital under a Mental Health Act certificate (used as an index of the Accredited Person's use of the authority under the Accredited Persons Programme) compared to any other discharge destination. Unadjusted and adjusted logistic regression models and a propensity score analysis were used to explore the relationship between clinician type and discharge destination. RESULTS There were 2237 index assessments (Accredited Person = 884; Medical Officer = 1443). One-quarter (27%) were referred for assessment under the Act at the psychiatric hospital, with the Accredited Person significantly more likely (32%) to require this compared to the Medical Officers (24%); Risk Difference: 8.3% (4.5 to 12.1). However, after adjusting for patient characteristics; Risk Difference: -3.0% (-5.9 to -0.1) and for propensity score, Risk Difference: -3.3% (-6.7 to 0.1), the Accredited Person and Medical Officer likelihood of discharging for an assessment under the Act was similar. CONCLUSIONS The Accredited Person assessed more clinically complex patients than the Medical Officers. After adjusting for clinical complexity and propensity score, the likelihood of referral for involuntary psychiatric hospital care was similar for Accredited Person and Medical Officers. Our evaluation of the Accredited Person programme in the general hospital was favourable, and wider implementation and evaluation is warranted.
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Affiliation(s)
- Katie McGill
- Centre for Brain and Mental Health Research, The University of Newcastle, Newcastle, NSW, Australia.,MH-READ, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Matthew J Spittal
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Jennifer Bryant
- Department of Consultation-Liaison Psychiatry, Calvary Mater Newcastle, Waratah, NSW, Australia
| | - Terry J Lewin
- Centre for Brain and Mental Health Research, The University of Newcastle, Newcastle, NSW, Australia.,MH-READ, Hunter New England Local Health District, Newcastle, NSW, Australia
| | - Ian M Whyte
- Faculty of Medicine and Health Sciences, The University of Newcastle, Newcastle, NSW, Australia
| | - Clare Madden
- Department of Consultation-Liaison Psychiatry, Calvary Mater Newcastle, Waratah, NSW, Australia
| | - Greg Carter
- Centre for Brain and Mental Health Research, The University of Newcastle, Newcastle, NSW, Australia.,Department of Consultation-Liaison Psychiatry, Calvary Mater Newcastle, Waratah, NSW, Australia.,Faculty of Medicine and Health Sciences, The University of Newcastle, Newcastle, NSW, Australia
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8
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Gale L, McGill K, Twaddell S, Whyte IM, Lewin TJ, Carter GL. Hospital-treated deliberate self-poisoning patients: Drug-induced delirium and clinical outcomes. Aust N Z J Psychiatry 2022; 56:154-163. [PMID: 33938265 DOI: 10.1177/00048674211009608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Drug-induced delirium has been attributed to opioid, benzodiazepine, antipsychotic, antihistaminic and anticholinergic drug groups at therapeutic doses. Delirium also occurs in hospital-treated self-poisoning (at supra-therapeutic doses), although the causative drug classes are not well established and co-ingestion is common. We tested the magnitude and direction of association of five major drug groups with incident cases of delirium. METHODS A retrospective longitudinal cohort (n = 5131) study was undertaken of deliberate and recreational/chronic misuse poisoning cases from a regional sentinel toxicology unit. We described ingestion and co-ingestion patterns and estimated the unadjusted and adjusted odds for developing a drug-induced delirium. We also estimated the odds of drug-induced delirium being associated with three outcomes: intensive care unit admission, general hospital length of stay and discharge to home. RESULTS Drug-induced delirium occurred in 3.9% of cases (n = 200). The unadjusted odds ratios for development of delirium were increased for anticholinergics 10.79 (5.43-21.48), antihistamines 6.10 (4.20-8.84) and antipsychotics 2.99 (2.20-4.06); non-significant for opioids 1.31 (95% confidence interval = [0.81, 2.13]); and reduced for benzodiazepines 0.37 (0.24-0.58); with little change after adjustment for age, gender and co-ingestion. Delirium was associated with intensive care unit admission, longer length of stay and discharge destination. CONCLUSION Drug-induced delirium was uncommon in this population. Co-ingestion was common but did not alter the risk. In contrast to drug-induced delirium at therapeutic doses in older populations, opioids were not associated with delirium and benzodiazepines were protective. Drug-induced delirium required increased clinical services. Clinical services should be funded and prepared to provide additional supportive care for these deliriogenic drug group ingestions.
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Affiliation(s)
- Lindsay Gale
- Department of Consultation-Liaison Psychiatry, Calvary Mater Newcastle Hospital, Waratah, NSW, Australia
| | - Katie McGill
- MH-READ, Hunter New England Mental Health Services, Newcastle, NSW, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
| | - Scott Twaddell
- Department of Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Ian M Whyte
- School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
| | - Terry J Lewin
- MH-READ, Hunter New England Mental Health Services, Newcastle, NSW, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
| | - Gregory L Carter
- Department of Consultation-Liaison Psychiatry, Calvary Mater Newcastle Hospital, Waratah, NSW, Australia.,School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
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9
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Scarth B, Pavlova A, Hetrick SE, Witt KG, Hawton K, Fortune S. Service users’ experiences of emergency care following an episode of self-harm: a mixed evidence synthesis. Hippokratia 2021. [DOI: 10.1002/14651858.cd014940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Bonnie Scarth
- WellSouth, Primary Care Organisation; Dunedin New Zealand
| | - Alina Pavlova
- Psychological Medicine; University of Otago; Dunedin New Zealand
| | - Sarah E Hetrick
- Department of Psychological Medicine, Faculty of Medical and Health Sciences; The University of Auckland; Auckland New Zealand
- Children and Young People Satellite, Cochrane Common Mental Disorders; The University of Auckland; Auckland New Zealand
| | - Katrina G Witt
- Orygen; Parkville, Melbourne Australia
- Centre for Youth Mental Health; The University of Melbourne; Melbourne Australia
| | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry; University of Oxford; Oxford UK
| | - Sarah Fortune
- Department of Social and Community Health, Faculty of Medical and Health Sciences; The University of Auckland; Auckland New Zealand
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10
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First responder, clinician, and non‐clinical support staff knowledge, attitudes, and behaviours towards people presenting for emergency care following self‐harm: a mixed evidence synthesis. Cochrane Database Syst Rev 2021; 2021:CD014939. [PMCID: PMC8668017 DOI: 10.1002/14651858.cd014939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
This is a protocol for a Cochrane Review (qualitative). The objectives are as follows: The objectives of this review are threefold, as follows. Firstly, to assess the content of knowledge, attitudes, and behaviours of first responders, clinicians, and non‐clinical support staff towards service users with SH presentations. Secondly, to understand how service user and staff characteristics (e.g. age, gender, sociodemographic background), type of SH presentation (e.g. method, repetition), and contextual factors (e.g. hospital environment, presence of bystanders) affect the knowledge, attitudes, and behaviours of first responders, clinicians, and non‐clinical support staff in providing acute care. Thirdly, to assess whether clinicians' knowledge, attitudes, and behaviours have evolved over time.
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11
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Robinson J, Witt K, Lamblin M, Spittal MJ, Carter G, Verspoor K, Page A, Rajaram G, Rozova V, Hill NTM, Pirkis J, Bleeker C, Pleban A, Knott JC. Development of a Self-Harm Monitoring System for Victoria. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17249385. [PMID: 33333970 PMCID: PMC7765445 DOI: 10.3390/ijerph17249385] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/28/2020] [Accepted: 12/10/2020] [Indexed: 12/18/2022]
Abstract
The prevention of suicide and suicide-related behaviour are key policy priorities in Australia and internationally. The World Health Organization has recommended that member states develop self-harm surveillance systems as part of their suicide prevention efforts. This is also a priority under Australia’s Fifth National Mental Health and Suicide Prevention Plan. The aim of this paper is to describe the development of a state-based self-harm monitoring system in Victoria, Australia. In this system, data on all self-harm presentations are collected from eight hospital emergency departments in Victoria. A natural language processing classifier that uses machine learning to identify episodes of self-harm is currently being developed. This uses the free-text triage case notes, together with certain structured data fields, contained within the metadata of the incoming records. Post-processing is undertaken to identify primary mechanism of injury, substances consumed (including alcohol, illicit drugs and pharmaceutical preparations) and presence of psychiatric disorders. This system will ultimately leverage routinely collected data in combination with advanced artificial intelligence methods to support robust community-wide monitoring of self-harm. Once fully operational, this system will provide accurate and timely information on all presentations to participating emergency departments for self-harm, thereby providing a useful indicator for Australia’s suicide prevention efforts.
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Affiliation(s)
- Jo Robinson
- Orygen, Parkville, VIC 3052, Australia; (K.W.); (M.L.); (G.R.); (N.T.M.H.); (C.B.)
- Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC 3052, Australia
- Correspondence: ; Tel.: +61-393-420-2866
| | - Katrina Witt
- Orygen, Parkville, VIC 3052, Australia; (K.W.); (M.L.); (G.R.); (N.T.M.H.); (C.B.)
- Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Michelle Lamblin
- Orygen, Parkville, VIC 3052, Australia; (K.W.); (M.L.); (G.R.); (N.T.M.H.); (C.B.)
- Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Matthew J. Spittal
- Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC 3010 Australia; (M.J.S.); (J.P.)
| | - Greg Carter
- Centre for Brain and Mental Health Research, Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW 2308, Australia;
- Calvary Mater Newcastle, Callaghan, NSW 2308, Australia
| | - Karin Verspoor
- School of Computing and Information Systems, The University of Melbourne, Parkville, VIC 3052, Australia; (K.V.); (V.R.)
- Centre for Digital Transformation of Health, The University of Melbourne, Melbourne, VIC 3000, Australia
| | - Andrew Page
- Translational Health Research Institute, Western Sydney University, Campbelltown, NSW 2560, Australia;
| | - Gowri Rajaram
- Orygen, Parkville, VIC 3052, Australia; (K.W.); (M.L.); (G.R.); (N.T.M.H.); (C.B.)
- Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Vlada Rozova
- School of Computing and Information Systems, The University of Melbourne, Parkville, VIC 3052, Australia; (K.V.); (V.R.)
| | - Nicole T. M. Hill
- Orygen, Parkville, VIC 3052, Australia; (K.W.); (M.L.); (G.R.); (N.T.M.H.); (C.B.)
- Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC 3052, Australia
- Telethon Kids Institute, Nedlands, WA 6009, Australia
| | - Jane Pirkis
- Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, VIC 3010 Australia; (M.J.S.); (J.P.)
| | - Caitlin Bleeker
- Orygen, Parkville, VIC 3052, Australia; (K.W.); (M.L.); (G.R.); (N.T.M.H.); (C.B.)
- Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Alex Pleban
- Mid-West Area Mental Health Service, Emergency Department, Sunshine Hospital, Sunshine, VIC 3021, Australia;
| | - Jonathan C. Knott
- Centre for Integrated Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, VIC 3010, Australia;
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Lubman DI, Heilbronn C, Ogeil RP, Killian JJ, Matthews S, Smith K, Bosley E, Carney R, McLaughlin K, Wilson A, Eastham M, Shipp C, Witt K, Lloyd B, Scott D. National Ambulance Surveillance System: A novel method using coded Australian ambulance clinical records to monitor self-harm and mental health-related morbidity. PLoS One 2020; 15:e0236344. [PMID: 32735559 PMCID: PMC7394421 DOI: 10.1371/journal.pone.0236344] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 07/04/2020] [Indexed: 01/01/2023] Open
Abstract
Self-harm and mental health are inter-related issues that substantially contribute to the global burden of disease. However, measurement of these issues at the population level is problematic. Statistics on suicide can be captured in national cause of death data collected as part of the coroner's review process, however, there is a significant time-lag in the availability of such data, and by definition, these sources do not include non-fatal incidents. Although survey, emergency department, and hospitalisation data present alternative information sources to measure self-harm, such data do not include the richness of information available at the point of incident. This paper describes the mental health and self-harm modules within the National Ambulance Surveillance System (NASS), a unique Australian system for monitoring and mapping mental health and self-harm. Data are sourced from paramedic electronic patient care records provided by Australian state and territory-based ambulance services. A team of specialised research assistants use a purpose-built system to manually scrutinise and code these records. Specific details of each incident are coded, including mental health symptoms and relevant risk indicators, as well as the type, intent, and method of self-harm. NASS provides almost 90 output variables related to self-harm (i.e., type of behaviour, self-injurious intent, and method) and mental health (e.g., mental health symptoms) in the 24 hours preceding each attendance, as well as demographics, temporal and geospatial characteristics, clinical outcomes, co-occurring substance use, and self-reported medical and psychiatric history. NASS provides internationally unique data on self-harm and mental health, with direct implications for translational research, public policy, and clinical practice. This methodology could be replicated in other countries with universal ambulance service provision to inform health policy and service planning.
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Affiliation(s)
- Dan I. Lubman
- Turning Point, Eastern Health, Richmond, Victoria, Australia
- Monash Addiction Research Centre and Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
- * E-mail:
| | - Cherie Heilbronn
- Turning Point, Eastern Health, Richmond, Victoria, Australia
- Monash Addiction Research Centre and Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Rowan P. Ogeil
- Turning Point, Eastern Health, Richmond, Victoria, Australia
- Monash Addiction Research Centre and Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Jessica J. Killian
- Turning Point, Eastern Health, Richmond, Victoria, Australia
- Monash Addiction Research Centre and Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Sharon Matthews
- Turning Point, Eastern Health, Richmond, Victoria, Australia
- Monash Addiction Research Centre and Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Karen Smith
- Ambulance Victoria, Doncaster, Victoria, Australia
- Department of Paramedicine, Monash University, Frankston, Victoria, Australia
- Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Emma Bosley
- Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Rosemary Carney
- New South Wales Ambulance, Rozelle, New South Wales, Australia
| | | | - Alex Wilson
- Ambulance Tasmania, Hobart, Tasmania, Australia
| | - Matthew Eastham
- St John Ambulance Australia (NT) Inc., Casuarina, Northern Territory, Australia
| | - Carol Shipp
- Australian Capital Territory Ambulance Service, Fairbairn, Australian Capital Territory, Australia
| | - Katrina Witt
- Turning Point, Eastern Health, Richmond, Victoria, Australia
- Monash Addiction Research Centre and Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Belinda Lloyd
- Turning Point, Eastern Health, Richmond, Victoria, Australia
- Monash Addiction Research Centre and Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Debbie Scott
- Turning Point, Eastern Health, Richmond, Victoria, Australia
- Monash Addiction Research Centre and Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
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13
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Jackson M, McGill K, Lewin TJ, Bryant J, Whyte I, Carter G. Hospital-treated deliberate self-poisoning in the older adult: Identifying specific clinical assessment needs. Aust N Z J Psychiatry 2020; 54:591-601. [PMID: 31957465 DOI: 10.1177/0004867419897818] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hospital-treated deliberate self-poisoning is common, with a median patient age of around 33 years. Clinicians are less familiar with assessing older adults with self-poisoning and little is known about their specific clinical requirements. OBJECTIVE To identify clinically important factors in the older-age population by comparing older adults (65+ years) with middle-aged adults (45-64 years) during an index episode of hospital-treated deliberate self-poisoning. METHODS A prospective, longitudinal, cohort study of people presenting to a regional referral centre for deliberate self-poisoning (Calvary Mater Newcastle, Australia) over a 10-year period (2003-2013). We compared older-aged adults with middle-aged adults on demographic, toxicological and psychiatric variables and modelled independent predictors of referral for psychiatric hospitalisation on discharge with logistic regression. RESULTS There were (n = 157) older-aged and (n = 925) middle-aged adults. The older-aged group was similar to the middle-aged group in several ways: proportion living alone, reporting suicidal ideation/planning, prescribed antidepressant and antipsychotic drugs, and with a psychiatric diagnosis. However, the older-aged group were also different in several ways: greater proportion with cognitive impairment, higher medical morbidity, longer length of stay, and greater prescription and ingestion of benzodiazepines in the deliberate self-poisoning event. Older age was not a predictor of referral for psychiatric hospitalisation in the multivariate model. CONCLUSION Older-aged patients treated for deliberate self-poisoning have a range of clinical needs including ones that are both similar to and different from middle-aged patients. Individual clinical assessment to identify these needs should be followed by targeted interventions, including reduced exposure to benzodiazepines.
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Affiliation(s)
- Mariann Jackson
- MH-READ, Hunter New England Mental Health Services, Newcastle, NSW, Australia
| | - Katie McGill
- MH-READ, Hunter New England Mental Health Services, Newcastle, NSW, Australia.,Centre for Brain and Mental Health Research, School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Terry J Lewin
- MH-READ, Hunter New England Mental Health Services, Newcastle, NSW, Australia.,Centre for Brain and Mental Health Research, School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | | | - Ian Whyte
- Calvary Mater Newcastle, Waratah, NSW, Australia.,Discipline of Clinical Pharmacology, The University of Newcastle, Newcastle, NSW, Australia.,School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Gregory Carter
- Centre for Brain and Mental Health Research, School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia.,Calvary Mater Newcastle, Waratah, NSW, Australia
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Affiliation(s)
- Katrina Witt
- 1 Orygen, the National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, University of Melbourne, VIC, Australia.,2 Turning Point, Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Jo Robinson
- 1 Orygen, the National Centre of Excellence in Youth Mental Health, Centre for Youth Mental Health, University of Melbourne, VIC, Australia
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Parish S, Carter A, Liu YH, Humble I, Trott N, Jacups S, Little M. The impact of the introduction of a toxicology service on the intensive care unit. Clin Toxicol (Phila) 2019; 57:778-783. [PMID: 30729819 DOI: 10.1080/15563650.2019.1566553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To examine the impact of a clinical toxicology service on toxicology patients admitted to an intensive care department Methods: The authors performed a retrospective chart audit of all patients presenting to Cairns Emergency Department (ED) over a five-year period from 2011 to 2016 with a toxicology diagnosis requiring Intensive Care Unit (ICU) admission. They were divided into two groups: pre-toxicology (1 April 2011 to 30 September 2012), and post-toxicology service (1 October 2012 to 31 of March 2016) introduction. Patients were identified using ED and ICU databases. Patient charts were manually searched, and data entered on a preformatted data extraction tool. The data were statistically compared pre- versus post-toxicology service introduction using univariate (t-tests and Pearson's Chi Square) and multivariate modelling. Where appropriate, continuous variables were log transformed to enable parametric analyses. Results: There were 37 patients in the pre-toxicology and 102 in the post-toxicology group, with an increased median APACHE III J score in the post toxicology group (39 vs. 49). The introduction of a toxicology service was associated with statistically significant reductions in median ICU length of stay (LOS) (32.9 vs. 20.6 h), median duration of mechanical ventilation (29.1 vs. 20.6 h) and median time to psychiatry review (19.4 vs. 6.7 h). The reduction in ICU LOS remained statistically significant (p = 0.036) when adjusted by sex, age and duration of mechanical ventilation. There was neither increase in mortality, nor readmissions from EDSSU to ICU. Conclusions: This study has demonstrated that the introduction of a toxicology service was associated with a reduction in median ICU LOS, duration of mechanical ventilation and time to psychiatric review in patients with a toxicology diagnosis admitted to our ICU.
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Affiliation(s)
- Shaun Parish
- a Royal North Shore Hospital, formerly Cairns Hospital , Saint Leonards , Sydney , Australia
| | - Angus Carter
- b Department of Intensive Care, Cairns Hospital , Cairns North , Australia.,c DonateLife QLD.,d School of Medicine and Dentistry, James Cook University , Cairns , Australia
| | - Yu-Hsuan Liu
- b Department of Intensive Care, Cairns Hospital , Cairns North , Australia
| | - Ian Humble
- b Department of Intensive Care, Cairns Hospital , Cairns North , Australia
| | - Nicholas Trott
- b Department of Intensive Care, Cairns Hospital , Cairns North , Australia
| | - Susan Jacups
- e The Cairns Institute, James Cook University (JCU) , Cairns , Australia
| | - Mark Little
- f Department of Emergency Medicine, Cairns Hospital , Cairns , Australia.,g NSW Poisons Information Centre , Sydney , Australia
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16
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Stevens GJ, Hammond TE, Brownhill S, Anand M, de la Riva A, Hawkins J, Chapman T, Baldacchino R, Micallef JA, Andepalli J, Kotak A, Gunja N, Page A, Gould G, Ryan CJ, Whyte IM, Carter GL, Jones A. SMS SOS: a randomized controlled trial to reduce self-harm and suicide attempts using SMS text messaging. BMC Psychiatry 2019; 19:117. [PMID: 30999952 PMCID: PMC6471753 DOI: 10.1186/s12888-019-2104-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 04/05/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hospital-treated deliberate self-harm (DSH) is common, costly and has high repetition rates. Since brief contact interventions (BCIs) may reduce the risk of DSH repetition, we aim to evaluate whether a SMS (Short Message Service) text message Intervention plus Treatment As Usual (TAU) compared to TAU alone will reduce hospital DSH re-presentation rates in Western Sydney public hospitals in Australia. METHODS/DESIGN Our study is a 24-month randomized controlled trial (RCT). Adult patients who present with DSH to hospital emergency, psychiatric, and mental health triage and assessment departments will be randomly assigned to an Intervention condition plus TAU receiving nine SMS text messages at 1, 2, 3, 4, 5, 6, 8, 10 and 12-months post-discharge. Each message will contain telephone numbers for two mental health crises support tele-services. Primary outcomes will be the difference in the number of DSH re-presentations, and the time to first re-presentation, within 12-months of discharge. DISCUSSION This study protocol describes the design and implementation of an RCT using SMS text messages, which aim to reduce hospital re-presentation rates for DSH. Positive study findings would support the translation of an SMS-aftercare protocol into mental health services at minimal expense. TRIAL REGISTRATION AND ETHICS APPROVAL This trial has been registered with the Australian and New Zealand Clinical Trials Registry (Trial registration: ACTRN12617000607370 . Registered 28 April 2017) and has been approved by two Local Health Districts (LHDs). Western Sydney LHD Human Research Ethics Committee approved the study for Westmead Hospital and Blacktown Hospital (Protocol: HREC/16/WMEAD/336). Nepean Blue Mountains LHD Research Governance Office approved the study for Nepean Hospital (SSA/16/Nepean/170).
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Affiliation(s)
- Garry J. Stevens
- 0000 0000 9939 5719grid.1029.aSchool of Social Sciences and Psychology, Western Sydney University (WSU), Kingswood, NSW Australia
| | - Trent E. Hammond
- 0000 0004 0453 1183grid.413243.3Triage and Assessment Centre, Mental Health Centre, Nepean Hospital, Nepean Blue Mountains LHD, Kingswood, NSW Australia
| | - Suzanne Brownhill
- 0000 0001 0180 6477grid.413252.3Consultation Liaison Psychiatry, Westmead Hospital, Western Sydney Local Health District (WSLHD), Westmead, NSW Australia
| | - Manish Anand
- 0000 0001 0180 6477grid.413252.3Consultation Liaison Psychiatry, Westmead Hospital, Western Sydney Local Health District (WSLHD), Westmead, NSW Australia
| | - Anabel de la Riva
- 0000 0001 0180 6477grid.413252.3Consultation Liaison Psychiatry, Westmead Hospital, Western Sydney Local Health District (WSLHD), Westmead, NSW Australia
| | - Jean Hawkins
- 0000 0004 0572 7882grid.460687.bConsultation Liaison Psychiatry, Blacktown Hospital, WSLHD, Blacktown, NSW Australia
| | - Tristan Chapman
- 0000 0004 0453 1183grid.413243.3Triage and Assessment Centre, Mental Health Centre, Nepean Hospital, Nepean Blue Mountains LHD, Kingswood, NSW Australia
| | - Richard Baldacchino
- 0000 0004 0453 1183grid.413243.3Specialist Mental Health Older People Service, Mental Health Centre, Nepean Hospital, NBMLHD, Kingswood, NSW Australia
| | - Jo-Anne Micallef
- 0000 0004 0453 1183grid.413243.3Child and Youth Consultation Liaison, Nepean Hospital, NBMLHD, Kingswood, NSW Australia
| | | | - Anita Kotak
- 0000 0004 0453 1183grid.413243.3Triage and Assessment Centre, Mental Health Centre, Nepean Hospital, Nepean Blue Mountains LHD, Kingswood, NSW Australia
| | - Naren Gunja
- Department of Clinical Pharmacology and Toxicology, Western Sydney Health, Westmead, NSW Australia ,0000 0004 1936 834Xgrid.1013.3Sydney Medical School, University of Sydney, Sydney, NSW Australia
| | - Andrew Page
- Translational Health Research Institute, School of Medicine, WSU, Campbelltown, NSW Australia
| | - Grahame Gould
- 0000 0004 0486 528Xgrid.1007.6Illawarra Institute for Mental Health, University of Wollongong, Wollongong, NSW Australia
| | - Christopher J. Ryan
- 0000 0004 1936 834Xgrid.1013.3Sydney Medical School, University of Sydney, Sydney, NSW Australia
| | - Ian M. Whyte
- Department of Clinical Toxicology and Pharmacology, Calvary Mater Hospital Newcastle, Waratah, NSW Australia ,0000 0000 8831 109Xgrid.266842.cSchool of Medicine and Public Health, Faculty of Health and Medicine, Newcastle University, Callaghan, NSW Australia
| | - Gregory L. Carter
- 0000 0000 8831 109Xgrid.266842.cSchool of Medicine and Public Health, Faculty of Health and Medicine, Newcastle University, Callaghan, NSW Australia
| | - Alison Jones
- 0000 0004 0486 528Xgrid.1007.6Vice Chancellor’s Unit, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW Australia
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17
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King AM, Danagoulian S, Lynch M, Menke N, Mu Y, Saul M, Abesamis M, Pizon AF. The Effect of a Medical Toxicology Inpatient Service in an Academic Tertiary Care Referral Center. J Med Toxicol 2018; 15:12-21. [PMID: 30353414 DOI: 10.1007/s13181-018-0684-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/13/2018] [Accepted: 09/18/2018] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Morbidity and mortality from poison- and drug-related illness continue to rise in the USA. Medical toxicologists are specifically trained to diagnose and manage these patients. Inpatient medical toxicology services exist but their value-based economic benefits are not well established. METHODS This was a retrospective study where length of stay (LOS) and payments received between a hospital with an inpatient medical toxicology service (TOX) and a similar hospital in close geographic proximity that does not have an inpatient toxicology service (NONTOX) were compared. Controlling for zip code, demographics and distance patients lived from each hospital, we used a fitted multivariate linear regression model to identify factors associated with changes in LOS and payment. RESULTS Patients admitted to the TOX center had 0.87 days shorter LOS per encounter and the hospital received an average of $1800 more per patient encounter. CONCLUSION In this study, the presence of an inpatient medical toxicology service was associated with decreased patient LOS and increased reimbursement for admitted patients. Differences may be attributable to improved direct patient care provided by medical toxicologists, but future prospective studies are needed.
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Affiliation(s)
- Andrew M King
- Wayne State University School of Medicine, Detroit, MI, USA.
| | | | - Michael Lynch
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | | | - Yijia Mu
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Melissa Saul
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael Abesamis
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anthony F Pizon
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
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Legg RG, Little M. Inpatient toxicology services improve resource utilization for intoxicated patients: a systematic review. Br J Clin Pharmacol 2018; 85:11-19. [PMID: 30238503 DOI: 10.1111/bcp.13768] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 08/14/2018] [Accepted: 09/10/2018] [Indexed: 11/29/2022] Open
Abstract
AIMS Presentations of intoxicated patients to hospital are frequent and increasing. We aimed to review the existing evidence that the presence of inpatient clinical toxicology services reduces use of resources without impacting on the care of these patients. METHODS We conducted a literature search using the Cochrane Library, PubMed, and Embase for articles that measured length of stay (and other outcomes) for the target population, with toxicology services as an intervention. The articles were reviewed with respect to the ROBINS-I tool. RESULTS Seven relevant articles were identified. Six of these studies demonstrated reduced hospital length of stay for intoxicated patients in hospitals with inpatient toxicology services. None of the articles demonstrated a detriment in morbidity or mortality. There were also improvements in other resource-related outcomes. CONCLUSIONS The presence of inpatient toxicology services appears to improve resource utilization, in reduction of length of stay, as well as a number of other related outcomes. It does this without compromising on patient morbidity or mortality. Thus, it should be considered as a potential model of care for future toxicology services, especially with current trends of increasing demand for service efficiency.
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Affiliation(s)
- Robert G Legg
- Paediatric Medicine, Townsville Hospital, Queensland, Australia
| | - Mark Little
- Cairns Hospital, Queensland, Australia.,NSW Poisons Information Centre, NSW, Australia
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19
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Wilhelm K, Korczak V, Tietze T, Reddy P. Clinical pathways for suicidality in emergency settings: a public health priority. AUST HEALTH REV 2017; 41:182-184. [PMID: 27333074 DOI: 10.1071/ah16008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/01/2016] [Indexed: 11/23/2022]
Abstract
Rates of self-harm in Australia are increasing and constitute a concerning public health issue. Although there are standard treatment pathways for physical complaints, such as headache, abdominal pain and chest pain, in Emergency Medicine, there is no national pathway for self-harm or other psychiatric conditions that present to the emergency department. Herein we outline the difference between clinical practice guidelines and clinical pathways, discuss pathways we have identified on self-harm in Australia and overseas and discuss their applicability to the Australian context and the next steps forward in addressing this public health issue.
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Affiliation(s)
- Kay Wilhelm
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Randwick, NSW 2031, Australia
| | - Viola Korczak
- St Vincent's Urban Mental Health and Wellbeing Research Institute, St Vincent's Hospital, Victoria Street, Darlinghurst, NSW 2010, Australia.
| | - Tad Tietze
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Randwick, NSW 2031, Australia
| | - Prasuna Reddy
- St Vincent's Urban Mental Health and Wellbeing Research Institute, St Vincent's Hospital, Victoria Street, Darlinghurst, NSW 2010, Australia.
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20
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Impact of an emergency short stay unit on emergency department performance of poisoned patients. Am J Emerg Med 2017; 35:764-768. [DOI: 10.1016/j.ajem.2017.01.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 01/13/2017] [Accepted: 01/14/2017] [Indexed: 11/18/2022] Open
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Isoardi KZ, Armitage MC, Harris K, Page CB. Establishing a dedicated toxicology unit reduces length of stay of poisoned patients and saves hospital bed days. Emerg Med Australas 2017; 29:310-314. [PMID: 28266169 DOI: 10.1111/1742-6723.12755] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/21/2016] [Accepted: 01/10/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study evaluates the effect on the average length of stay (LOS), relative stay index (RSI), bed days and costs saved following the establishment of a dedicated clinical toxicology unit in an Australian tertiary referral hospital. METHODS This retrospective descriptive study uses Health Roundtable and other state and federal data to compare the average LOS, RSI, estimated bed days and costs saved by patients admitted with a diagnosis-related group (DRG) of X62 (Poisoning/Toxic Effects of Drugs and Other Substances), over the 4 year period 2012-2015. This period corresponds to before and after the introduction of the clinical toxicology unit in February 2014 at the Princess Alexandra Hospital, a tertiary referral teaching hospital in Brisbane, Queensland, Australia. RESULTS There was a reduction in the average LOS and RSI from 2.1 days and 122% in 2012 to 0.9 days and 52% in 2015, respectively. This reduction correlates with a reduction in 1350 bed days and a saving of $2.25 million over the 2 year period 2014-2015 since the clinical toxicology unit was established. CONCLUSION The reduction in average LOS is similar to results previously published by two Australian toxicology units over 15 years ago. Despite changes in healthcare delivery since this time, these results continue to support the efficiency and associated cost saving of a dedicated toxicology unit in managing poisoned patients.
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Affiliation(s)
- Katherine Z Isoardi
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Melanie C Armitage
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Keith Harris
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Colin B Page
- Clinical Toxicology Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Clinical Toxicology Research Group, The University of Newcastle, Newcastle, New South Wales, Australia
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Pillans PI, Page CB, Ilango S, Kashchuk A, Isbister GK. Self‐poisoning by older Australians: a cohort study. Med J Aust 2017; 206:164-169. [DOI: 10.5694/mja16.00484] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 07/19/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Peter I Pillans
- Princess Alexandra Hospital, Brisbane, QLD
- University of Queensland, Brisbane, QLD
| | - Colin B Page
- Princess Alexandra Hospital, Brisbane, QLD
- University of Queensland, Brisbane, QLD
| | | | | | - Geoffrey K Isbister
- University of Newcastle, Newcastle, NSW
- Calvary Mater Newcastle, Newcastle, NSW
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Hassanian-Moghaddam H, Sarjami S, Kolahi AA, Lewin T, Carter G. Postcards in Persia: A Twelve to Twenty-four Month Follow-up of a Randomized Controlled Trial for Hospital-Treated Deliberate Self-Poisoning. Arch Suicide Res 2017; 21:138-154. [PMID: 25774646 DOI: 10.1080/13811118.2015.1004473] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This study reports the outcomes, during follow-up, of a low-cost postcard intervention in a Randomized Control Trial of hospital-treated self-poisoning (n = 2300). The intervention was 9 postcards over 12 months (plus usual treatment) versus usual treatment. Three binary endpoints at 12-24 months (n = 2001) were: any suicidal ideation, suicide attempt, or self-cutting. There was a significant reduction in any suicidal ideation (RRR 0.20 CI 95% 0.13-0.27), (NNT 8, 6-13), and any suicide attempt (RRR 0.31, 0.06-0.50), (NNT 35, 19-195), in this non-western population. However, there was no effect on self-cutting (RRR -0.01, -1.05-0.51). Sustained, brief contact by mail may reduce some forms of suicidal behavior in self-poisoning patients during the post intervention phase.
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Carter G, Page A, Large M, Hetrick S, Milner AJ, Bendit N, Walton C, Draper B, Hazell P, Fortune S, Burns J, Patton G, Lawrence M, Dadd L, Dudley M, Robinson J, Christensen H. Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm. Aust N Z J Psychiatry 2016; 50:939-1000. [PMID: 27650687 DOI: 10.1177/0004867416661039] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations. METHOD Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm. RESULTS The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guidelines for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care. CONCLUSION The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus.
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Affiliation(s)
- Gregory Carter
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Centre for Translational Neuroscience and Mental Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia Department of Consultation Liaison Psychiatry, Calvary Mater Newcastle Hospital, Waratah, NSW, Australia
| | - Andrew Page
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Centre for Health Research, Western Sydney University, Richmond, NSW, Australia
| | - Matthew Large
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia School of Psychiatry, The University of New South Wales, Sydney, NSW, Australia
| | - Sarah Hetrick
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia
| | - Allison Joy Milner
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Centre for Population Health Research, School of Health and Social Development, Deakin University, Burwood VIC, Australia Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Nick Bendit
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia School of Psychology, Faculty of Science and Information Technology, The University of Newcastle, Callaghan, NSW, Australia
| | - Carla Walton
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Centre for Psychotherapy, Hunter New England Mental Health Service and Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Callaghan, NSW, Australia
| | - Brian Draper
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia School of Psychiatry, The University of New South Wales, Sydney, NSW, Australia Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Philip Hazell
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Sarah Fortune
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia The University of Auckland, Auckland, New Zealand University of Leeds, Leeds, UK Kidz First, Middlemore Hospital, Auckland, New Zealand
| | - Jane Burns
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Young and Well Cooperative Research Centre, The University of Melbourne, Melbourne, VIC, Australia Brain & Mind Research Institute, The University of Sydney, Sydney, NSW, Australia Orygen Youth Health Research Centre, Melbourne, VIC, Australia
| | - George Patton
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia National Health and Medical Research Council, Canberra, ACT, Australia Centre for Adolescent Health, The Royal Children's Hospital, Melbourne, VIC, Australia Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Mark Lawrence
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Tauranga Hospital, Bay of Plenty, New Zealand
| | - Lawrence Dadd
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Mental Health & Substance Use Service, Hunter New England, NSW Health, Waratah, NSW, Australia Awabakal Aboriginal Medical Service, Hamilton, NSW, Australia Pital Tarkin, Aboriginal Medical Student Mentoring Program, The Wollotuka Institute, The University of Newcastle, Callaghan, NSW, Australia Specialist Outreach NT, Darwin, Northern Territory, Australia
| | | | - Jo Robinson
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia
| | - Helen Christensen
- Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia Black Dog Institute, The University of New South Wales, Sydney, NSW, Australia
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Hetrick SE, Robinson J, Spittal MJ, Carter G. Effective psychological and psychosocial approaches to reduce repetition of self-harm: a systematic review, meta-analysis and meta-regression. BMJ Open 2016; 6:e011024. [PMID: 27660314 PMCID: PMC5051331 DOI: 10.1136/bmjopen-2016-011024] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 08/11/2016] [Accepted: 08/23/2016] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To examine the efficacy of psychological and psychosocial interventions for reductions in repeated self-harm. DESIGN We conducted a systematic review, meta-analysis and meta-regression to examine the efficacy of psychological and psychosocial interventions to reduce repeat self-harm in adults. We included a sensitivity analysis of studies with a low risk of bias for the meta-analysis. For the meta-regression, we examined whether the type, intensity (primary analyses) and other components of intervention or methodology (secondary analyses) modified the overall intervention effect. DATA SOURCES A comprehensive search of MEDLINE, PsycInfo and EMBASE (from 1999 to June 2016) was performed. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials of psychological and psychosocial interventions for adult self-harm patients. RESULTS Forty-five trials were included with data available from 36 (7354 participants) for the primary analysis. Meta-analysis showed a significant benefit of all psychological and psychosocial interventions combined (risk ratio 0.84; 95% CI 0.74 to 0.96; number needed to treat=33); however, sensitivity analyses showed that this benefit was non-significant when restricted to a limited number of high-quality studies. Meta-regression showed that the type of intervention did not modify the treatment effects. CONCLUSIONS Consideration of a psychological or psychosocial intervention over and above treatment as usual is worthwhile; with the public health benefits of ensuring that this practice is widely adopted potentially worth the investment. However, the specific type and nature of the intervention that should be delivered is not yet clear. Cognitive-behavioural therapy or interventions with an interpersonal focus and targeted on the precipitants to self-harm may be the best candidates on the current evidence. Further research is required.
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Affiliation(s)
- Sarah E Hetrick
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jo Robinson
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew J Spittal
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Greg Carter
- Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Newcastle, New South Wales, Australia
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Neurocognitive Recovery After Hospital-Treated Deliberate Self-Poisoning With Central Nervous System Depressant Drugs: A Longitudinal Cohort Study. J Clin Psychopharmacol 2015; 35:672-80. [PMID: 26485340 DOI: 10.1097/jcp.0000000000000417] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hospital-treated deliberate self-poisoning (DSP) by central nervous system depressant drugs (CNS-D) has been associated with impairments in cognitive and psychomotor functions at the time of discharge. We aimed to replicate this finding and to compare recovery in the first month after discharge for CNS-D and CNS nondepressant drug ingestions. We also examined a series of multivariate explanatory models of recovery of neurocognitive outcomes over time. The CNS-D group was impaired at discharge compared with the CNS-nondepressant group in cognitive flexibility, cognitive efficiency, and working memory. There were no significant differences at discharge in visual attention, processing speed, visuomotor speed, or inhibition speed. Both groups improved in the latter measures over 1 month of follow-up. However, the CNS-D group's recovery was significantly slower for key neurocognitive domains underlying driving in complex traffic situations, namely, cognitive flexibility, cognitive efficiency, and working memory. Patients discharged after DSP with CNS-D drugs have impairments of some critical cognitive functions that may require up to 1 month to recover. Although more pre- than post-DSP variables were retained as explanatory models of neurocognitive performance overall, recovery over time could not be explained by any one of the measured covariates. Tests of cognitive flexibility could be used in clinical settings as a proxy measure for recovery of driving ability. Regulatory authorities should also consider the implications of these results for the period of nondriving advised after ingestion of CNS-D in overdose. Future research, with adequate sample size, should examine contributions of other variables to the pattern of recovery over time.
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Buckley NA, Whyte IM, Dawson AH, Isbister GK. A prospective cohort study of trends in self-poisoning, Newcastle, Australia, 1987-2012: plus ça change, plus c'est la même chose. Med J Aust 2015; 202:438-42. [PMID: 25929508 DOI: 10.5694/mja14.01116] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 01/09/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine inhospital mortality and morbidity associated with self-poisoning with different drug classes over an extended period. DESIGN, SETTING AND PARTICIPANTS A prospective cohort study over 26 years (1987-2012) with limited follow-up of patients presenting consecutively to a primary and tertiary referral toxicology centre covering Newcastle, Lake Macquarie and Port Stephens, Australia. MAIN OUTCOME MEASURES Hospital length of stay, types of drugs ingested, intensive care unit (ICU) admission, requirement for ventilation, inhospital deaths and rates of antidepressant drug use in Australia. RESULTS Over the study period, there were 17 266 admissions of patients poisoned by 34 342 substances (16 723 drugs available only on prescription). The median length of stay was 16 hours, 12.2% of patients (2101/17 266) were admitted to an ICU, 7.4% (1281/17 266) were ventilated and 78 (0.45%) died in hospital. Patient demographics, social and psychiatric factors remained stable over the 26-year period, but case fatality decreased (from 0.77% [15/1955] to 0.17% [7/4060]) as did ICU admissions (19.2% [376/1955] to 6.9% [280/4060]), ventilation (13.7% [268/1955] to 4.8% [193/4060]) and LOS. The most frequently ingested substances were alcohol, benzodiazepines, paracetamol, antidepressants and antipsychotics. There was a substantial fall in some highly toxic drugs (tricyclic antidepressants, barbiturates, conventional antipsychotics and theophylline), but increases in less toxic selective serotonin reuptake inhibitors, serotonin-noradrenaline reuptake inhibitors and paracetamol. A greater than sixfold increase in community antidepressant use was accompanied by only minor changes in overall and antidepressant self-poisoning rates. CONCLUSION Over two decades, there were decreases in poisonings by many highly toxic drugs which were associated with substantial reductions in morbidity and inhospital deaths. Despite massive increases in the number of antidepressant prescriptions, neither rates of self-harm nor the proportion of antidepressant poisonings increased markedly.
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Affiliation(s)
| | - Ian M Whyte
- Calvary Mater Newcastle, Newcastle, NSW, Australia
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Hiles S, Bergen H, Hawton K, Lewin T, Whyte I, Carter G. General hospital-treated self-poisoning in England and Australia: comparison of presentation rates, clinical characteristics and aftercare based on sentinel unit data. J Psychosom Res 2015; 78:356-62. [PMID: 25623486 DOI: 10.1016/j.jpsychores.2015.01.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 12/30/2014] [Accepted: 01/14/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Hospital-treated deliberate self-poisoning (DSP) is common and the existing national monitoring systems are often deficient. Clinical Practice Guidelines (UK and Australia) recommend universal psychosocial assessment within the general hospital as standard care. We compared presentation rates, patient characteristics, psychosocial assessment and aftercare in UK and Australia. METHODS We used a cross sectional design, for a ten year study of all DSP presentations identified through sentinel units in Oxford, UK (n=3042) and Newcastle, Australia (n=3492). RESULTS Oxford had higher presentation rates for females (standardised rate ratio 2.4: CI 99% 1.9, 3.2) and males (SRR 2.5: CI 99% 1.7, 3.5). Female to male ratio was 1.6:1, 70% presented after-hours, 95% were admitted to a general hospital and co-ingestion of alcohol occurred in a substantial minority (Oxford 24%, Newcastle 32%). Paracetamol, minor tranquilisers and antidepressants were the commonest drug groups ingested, although the overall pattern differed. Psychosocial assessment rates were high (Oxford 80%, Newcastle 93%). Discharge referral for psychiatric inpatient admission (Oxford 8%, Newcastle 28%), discharge to home (Oxford 80%, Newcastle 70%) and absconding (Oxford 11%, Newcastle 2%) differed between the two units. CONCLUSIONS Oxford has higher age-standardised rates of DSP than Newcastle, although many other characteristics of patients are similar. Services can provide a high level of assessment as recommended in clinical guidelines. There is some variation in after-care. Sentinel service monitoring routine care of DSP patients can provide valuable comparisons between countries.
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Affiliation(s)
- Sarah Hiles
- Centre for Translational Neuroscience and Mental Health, University of Newcastle, Australia
| | - Helen Bergen
- Centre for Suicide Research, University Department of Psychiatry, University of Oxford, Warneford Hospital, Headington, Oxford, UK
| | - Keith Hawton
- Centre for Suicide Research, University Department of Psychiatry, University of Oxford, Warneford Hospital, Headington, Oxford, UK
| | - Terry Lewin
- Centre for Translational Neuroscience and Mental Health, University of Newcastle, Australia
| | - Ian Whyte
- Department of Clinical Toxicology and Pharmacology (Hunter Area Toxicology Service - HATS), Calvary Mater Newcastle, Australia; Discipline of Clinical Pharmacology, School of Medicine and Public Health, Faculty of Health, University of Newcastle, Australia
| | - Gregory Carter
- Centre for Translational Neuroscience and Mental Health, University of Newcastle, Australia.
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Carter GL, Clover K, Whyte IM, Dawson AH, D'Este C. Postcards from the EDge: 5-year outcomes of a randomised controlled trial for hospital-treated self-poisoning. Br J Psychiatry 2013; 202:372-80. [PMID: 23520223 DOI: 10.1192/bjp.bp.112.112664] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Repetition of hospital-treated self-poisoning and admission to psychiatric hospital are both common in individuals who self-poison. AIMS To evaluate efficacy of postcard intervention after 5 years. METHOD A randomised controlled trial of individuals who have self-poisoned: postcard intervention (eight in 12 months) plus treatment as usual v. treatment as usual. Our primary outcomes were self-poisoning admissions and psychiatric admissions (proportions and event rates). RESULTS There was no difference between groups for any repeat-episode self-poisoning admission (intervention group: 24.9%, 95% CI 20.6-29.5; control group: 27.2%, 95% CI 22.8-31.8) but there was a significant reduction in event rates (incidence risk ratio (IRR) = 0.54, 95% CI 0.37-0.81), saving 306 bed days. There was no difference for any psychiatric admission (intervention group: 38.1%, 95% CI 33.1-43.2; control group: 35.5%, 95% CI 30.8-40.5) but there was a significant reduction in event rates (IRR = 0.66, 95% CI 0.47-0.91), saving 2565 bed days. CONCLUSIONS A postcard intervention halved self-poisoning events and reduced psychiatric admissions by a third after 5 years. Substantial savings occurred in general hospital and psychiatric hospital bed days.
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Affiliation(s)
- Gregory L Carter
- Centre for Translational Neuroscience and Mental Health, Faculty of Health, University of Newcastle, Newcastle, Australia.
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Dassanayake TL, Michie PT, Jones AL, Mallard T, Whyte IM, Carter GL. Cognitive skills underlying driving in patients discharged following self-poisoning with central nervous system depressant drugs. TRAFFIC INJURY PREVENTION 2012; 13:450-457. [PMID: 22931174 DOI: 10.1080/15389588.2012.671983] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Central nervous system-depressant (CNS-Ds) drugs can impair cognitive functions and driving. They are also the most common drugs taken in overdose in hospital-treated episodes of self-poisoning. In Australia most of these patients are discharged within 48 h, while they still have possible subclinical drug effects. We aimed to determine whether patients treated for self-poisoning with CNS-Ds are impaired in the Trail-Making Test (TMT, parts A and B), a neuropsychological test that is known to correlate with driving performance. METHODS This study was a conducted from November 2008 to April 2011 in a referral center for poisonings in New South Wales, Australia. One hundred seven patients discharged from the clinical toxicology unit following treatment for self-poisoning of CNS-Ds (benzodiazepines, atypical antipsychotics, or opioids) and a control group of 68 discharged following self-poisoning of non-CNS-depressant drugs (acetaminophen or nonsedating antidepressants) were tested with the TMT (parts A and B). Due to the known association of impaired TMT with driving impairment and increased risk of traffic accidents, performance less than the 10th percentile for age was defined as significant impairment in each part of the TMT. The odds ratio (OR) for impairment in each part was calculated in multivariate logistic regression (MLR) models adjusted for gender, education, IQ, and the presence of a major psychiatric illness. A secondary MLR analysis was conducted only for those patients (78 CNS-D and 54 control group participants) who were directly discharged home, after excluding those who were transferred for further psychiatric care. RESULTS The odds of impairment in the CNS-D group was 2.8 times that of the control group on the TMT-A (38 [35.5%] vs. 11 [16.2%]: adjusted OR = 2.76, 95% confidence interval [CI]: 1.28-5.97), and 4.6 times on the TMT-B (67 [62.6%] vs. 22 [32.4%]: adjusted OR = 4.63, 95% CI: 2.06-10.42). The results were similar in the subgroup of patients discharged home, and the odds of impairment in the CNS-D group was 3.3 times that of the control group on the TMT-A (25 [32.1%] vs. 7 [13.0%]: adjusted OR = 3.30, 95% CI: 1.28-8.52), and 3.6 times on the TMT-B (46 [59.0%] vs. 17 [31.5%]: adjusted OR = 3.64, 95% CI: 1.44-9.20). TMT-B impairment in the CNS-D group remained significant even after adjusting for TMT-A performance. CONCLUSIONS Patients with CNS-D overdose may have significant impairment in cognitive skills underlying driving at the time of discharge from hospitals. Clinicians should warn these patients that their driving skills might still be impaired, even if they are considered clinically recovered and advise them not to drive during the first 1 to 2 days following discharge.
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Affiliation(s)
- Tharaka L Dassanayake
- School of Psychology, The University of Newcastle, Newcastle, New South Wales, Australia.
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Dawson AH, Buckley NA. Toxicologists in public health--Following the path of Louis Roche (based on the Louis Roche lecture "An accidental toxicologist in public health", Bordeaux, 2010). Clin Toxicol (Phila) 2011; 49:94-101. [PMID: 21370945 DOI: 10.3109/15563650.2011.554420] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The global burden of clinical toxicology suggests a natural partnership with public health. This article reflects the content of a Louis Roche lecture given in 2010. HISTORICAL CONTEXT: Our practice and research in clinical toxicology has evolved from clinical cases to toxico-epidemiology to public health. This evolution in practice was initially unplanned but gained momentum and impact as we placed it more formally in a public health framework. This perspective is implicit in Louis Roche's call to "examine all aspects of the poisoning problem" and still provides a valuable starting point for any clinical toxicologist. DISCUSSION Clinical toxicology has always had a patient centered focus but its greatest successes have been related to public health interventions. Our early failures and later success in pubic health toxicology correlated with our understanding of the importance of partnerships outside our field. The most rapid dissemination and implementation of information derived from research occur through apriori partnerships with other agencies and international partners. CONCLUSION Addressing both local and global need has a number of bilateral synergies. Repositioning clinical toxicology into a public health framework increases access to strategic partnerships, research funds, and policy implementation while still addressing questions that are important to clinical practice.
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Affiliation(s)
- Andrew H Dawson
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Sri Lanka.
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Jayasekera H, Carter G, Clover K. Comparison of the Composite International Diagnostic interview (CIDI-Auto) with clinical diagnosis in a suicidal population. Arch Suicide Res 2011; 15:43-55. [PMID: 21293999 DOI: 10.1080/13811118.2011.540208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The objective was to examine agreement between routine clinician diagnoses of DSM-IV Anxiety, Depressive, Substance-Use disorders with diagnoses generated by CIDI-Auto Version 2.1, administered by trained interviewers. Subjects were 329 deliberate self poisoning patients at a tertiary referral center in Australia. Tests of agreement were: percentage agreement, sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios, and Cohen's kappa coefficients, for 1 month and 12 month CIDI diagnoses. Agreement was poor (kappa <0.40) for Anxiety, Depressive and Substance-Use disorders. Since diagnosis largely determines subsequent treatment, these findings did not support the use of the less expensive CIDI-Auto procedure to replace clinical diagnosis by experienced clinicians for this group of patients exhibiting suicidal behavior.
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Affiliation(s)
- Himali Jayasekera
- Hunter New England Mental Health Services, Newcastle, NSW, Australia
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Carter GL, Willcox CH, Lewin TJ, Conrad AM, Bendit N. Hunter DBT project: randomized controlled trial of dialectical behaviour therapy in women with borderline personality disorder. Aust N Z J Psychiatry 2010; 44:162-73. [PMID: 20113305 DOI: 10.3109/00048670903393621] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Deliberate self-harm (DSH), general hospital admission and psychiatric hospital admission are common in women meeting criteria for borderline personality disorder (BPD). Dialectical behaviour therapy (DBT) has been reported to be effective in reducing DSH and hospitalization. METHOD A randomized controlled trial of 73 female subjects meeting criteria for BPD was carried out with intention-to-treat analyses and per-protocol analyses. The intervention was DBT and the control condition was treatment as usual plus waiting list for DBT (TAU+WL), with outcomes measured after 6 months. Primary outcomes were differences in proportions and event rates of: any DSH; general hospital admission for DSH and any psychiatric admission; and mean difference in length of stay for any hospitalization. Secondary outcomes were disability and quality of life measures. RESULTS Both groups showed a reduction in DSH and hospitalizations, but there were no significant differences in DSH, hospital admissions or length of stay in hospital between groups. Disability (days spent in bed) and quality of life (Physical, Psychological and Environmental domains) were significantly improved for the DBT group. CONCLUSION DBT produced non-significant reductions in DSH and hospitalization when compared to the TAU+WL control, due in part to the lower than expected rates of hospitalization in the control condition. Nevertheless, DBT showed significant benefits for the secondary outcomes of improved disability and quality of life scores, a clinically useful result that is also in keeping with the theoretical constructs of the benefits of DBT.
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Affiliation(s)
- Gregory L Carter
- Centre for Brain and Mental Health Research, University of Newcastle, New South Wales, Australia.
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HUTTON JENNIE, DENT ANDREW, BUYKX PENNY, BURGESS STEPHEN, FLANDER LOUISA, DIETZE PAUL. The characteristics of acute non-fatal medication-related events attended by ambulance services in the Melbourne Metropolitan Area 1998-2002. Drug Alcohol Rev 2009; 29:53-8. [DOI: 10.1111/j.1465-3362.2009.00086.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Senarathna L, Adams J, De Silva D, Buckley NA, Dawson AH. Personal and professional challenges in the management of deliberate self-poisoning patients in rural Sri Lanka: a qualitative study of rural hospital doctors' experiences and perceptions. BMC Public Health 2008; 8:373. [PMID: 18954469 PMCID: PMC2583998 DOI: 10.1186/1471-2458-8-373] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2008] [Accepted: 10/28/2008] [Indexed: 11/15/2022] Open
Abstract
Background Deliberate self-poisoning is a major public heath issue in developing countries. In rural Sri Lanka deliberate self-poisoning is one of the leading causes of hospital death. The majority of patients with poisoning present to rural hospitals for initial treatment that are staffed by non-specialist and often relatively junior doctors. The treatment of self-poisoning patients poses numerous clinical challenges and further difficulties are experienced if patients are uncooperative and aggressive, intoxicated with alcohol or suffering mental illness. Previous research in developed countries has examined self-poisoning patients and their treatment but little is know about self-poisoning patient care in the context of rural health provision in developing countries. This study provides the first focused exploration of the experiences and perceptions of primary care rural hospital doctors in Sri Lanka toward the treatment of self-poisoning patients. Methods Semi-structured in-depth interviews were conducted with fifteen doctors from rural hospitals in the North Central Province, Sri Lanka. All interviews were recorded and transcribed and subject to thematic analysis. Results Participating doctors did perceive that treating self-poisoning patients in a primary care rural hospital as potentially confidence-building. However, resource issues such as the lack of medication, equipment and staffing were seen as important challenges to treating self-poisoning patients. Other challenges identified included disparity with community and other staff members regarding expectations of care, a sense of professional isolation and a lack of continuing education programs. Conclusion Addressing professional isolation through educational and trainee programs for doctors and reducing the variance in expectations between professional groups and the community has the potential to improve delivery of care for self-poisoning patients.
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Affiliation(s)
- Lalith Senarathna
- Faculty of Medicine, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka.
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36
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Adverse drug reactions and deliberate self-poisoning as cause of admission to the intensive care unit: a 1-year prospective observational cohort study. Intensive Care Med 2008; 35:266-74. [DOI: 10.1007/s00134-008-1250-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2007] [Accepted: 07/17/2008] [Indexed: 12/29/2022]
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Carter GL, Clover K, Whyte IM, Dawson AH, D'Este C. Postcards from the EDge: 24-month outcomes of a randomised controlled trial for hospital-treated self-poisoning. Br J Psychiatry 2007; 191:548-53. [PMID: 18055960 DOI: 10.1192/bjp.bp.107.038406] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Repetition of self-poisoning is common. AIMS To report the 24-month outcomes of a non-obligatory postcard intervention (plus treatment as usual) compared with treatment as usual. METHOD In a randomised-controlled trial (Zelen design) conducted in Newcastle, Australia, eight postcards were sent to participants over a 12-month period. The principal outcomes were the proportion of participants with one or more repeat episodes of self-poisoning and the number of repeat episodes per person. RESULTS No significant reduction was observed in the proportion of people repeating self-poisoning in the intervention group (21.2%, 95% CI 17.0-25.3) compared with the control group (22.8%, 95% CI 18.7-27.0; chi(2)=0.32, d.f.=1, P=0.57); the difference between groups was -1.7% (95% CI -7.5 to 4.2). There was a significant reduction in the rate of repetition, with an incidence risk ratio of 0.49 (95% CI 0.33-0.73). CONCLUSIONS A postcard intervention maintained the halving of the rate of repetition of hospital-treated self-poisoning events over a 2-year period, although it did not significantly reduce the proportion of individuals who repeated self-poisoning.
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Affiliation(s)
- Gregory L Carter
- Department of Consultation-Liaison Psychiatry, Locked Bag 7, Hunter Region Mail Centre, NSW 2310, Australia.
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Carter GL, Child C, Page A, Clover K, Taylor R. Modifiable risk factors for attempted suicide in Australian clinical and community samples. Suicide Life Threat Behav 2007; 37:671-80. [PMID: 18275373 DOI: 10.1521/suli.2007.37.6.671] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Modifiable risk factors for suicide attempt require identification in clinical and community samples. The aim of this study was to determine if similar social and psychiatric factors are associated with suicide attempts in community and clinical settings and whether the magnitude of effect is greater in clinical populations. Two case-control studies were used: nationwide community-based lifetime attempted suicide (ComAS) cases compared to nationwide community controls; and clinical deliberate self-poisoning (ClinDSP) cases that had hospital treatment compared to normative controls of similar demographic composition. The pattern of risk factors in ComAS and ClinDSP cases was similar, the magnitude of risk usually greater in clinical cases. Greatest attributable fractions were: ComAS current unemployment (39.8% male, 15.5% female) and anxiety disorders (14.0% males, 22.6% females); and ClinDSP current unemployment (69.6% male, 55.5% female) and affective disorders (45.4% male, 39.1% female). Practical intervention targets were unemployment, anxiety and substance use disorders, affective disorders (clinical only), and personality disorder (females only).
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Affiliation(s)
- Gregory L Carter
- Suicide Prevention Research Unit, Centre for mental Health Studies, Newcastle Mater Miseriocordae Hospital, Warath, NSW 2298, Australia.
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Daly FFS, Little M, Murray L. A risk assessment based approach to the management of acute poisoning. Emerg Med J 2006; 23:396-9. [PMID: 16627846 PMCID: PMC2564094 DOI: 10.1136/emj.2005.030312] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Early assessment and management of poisoning constitutes a core emergency medicine competency. Medical and psychiatric emergencies coexist; the acute poisoning is a dynamic medical illness that represents an acute exacerbation of a chronic underlying psychosocial disorder. The emergency physician must use an approach that ensures early decisions address potentially time critical interventions, while allowing management to be tailored to the individual patient's needs in that particular medical setting. This article outlines a rationale approach to the management of the poisoned patient that emphasises the importance of early risk assessment. Ideally, this approach should be used in the setting of a health system designed to optimise the medical and psychosocial care of the poisoned patient.
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Affiliation(s)
- F F S Daly
- Royal Perth Hospital, Perth, Western Australia, Australia
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Kapur N, Turnbull P, Hawton K, Simkin S, Mackway-Jones K, Gunnell D. The hospital management of fatal self-poisoning in industrialized countries: an opportunity for suicide prevention? Suicide Life Threat Behav 2006; 36:302-12. [PMID: 16805658 DOI: 10.1521/suli.2006.36.3.302] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Suicide by self-poisoning is a prevalent cause of death worldwide. A substantial proportion of individuals who poison themselves come into contact with medical services before they die. Our focus in the current study was the medical management of drug self-poisoning in industrialized countries and its possible contribution to suicide prevention. We reviewed the literature to determine the proportion of self-poisoning suicides who reach hospital alive, the sociodemographic and clinical characteristics of in-hospital overdose deaths, the in-hospital management this group of patients receives, and whether there are specific aspects of pre-hospital care and in-hospital management that have the potential to improve survival. Between 11% and 28% of individuals who died following deliberate ingestion of drugs reached hospital alive. The substances which were most frequently implicated in death were paracetamol (acetaminophen) and paracetamol compounds, tricyclic antidepressants, and benzodiazepines. Most patients received fairly intensive treatment, yet death may have been preventable in a small proportion of cases. Only one intervention (the administration of acetylcysteine) was shown to reduce mortality and this was in a highly selected group of patients (those who had ingested paracetamol and developed fulminant hepatic failure). It is possible that other interventions such as better airway management, the prompt administration of activated charcoal, and improved pre-hospital care may improve outcomes but their potential contribution to suicide prevention needs to be investigated in future studies.
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Affiliation(s)
- Navneet Kapur
- Centre for Suicide Prevention, University of Manchester, England.
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Carter GL, Safranko I, Lewin TJ, Whyte IM, Bryant JL. Psychiatric hospitalization after deliberate self-poisoning. Suicide Life Threat Behav 2006; 36:213-22. [PMID: 16704325 DOI: 10.1521/suli.2006.36.2.213] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The decision for psychiatric hospitalization after deliberate self-poisoning (DSP) is not well understood. This study, a longitudinal cohort study of 3,148 consecutive DSP patients found 920 (29.2%) subjects were referred for psychiatric hospitalization, 576 (18.3%) on involuntary basis. A logistic regression analysis showed increased risk for: age 25 or older, homelessness, unemployment, previous self-harm, psychiatric inpatient treatment within 12 months, earlier psychiatric inpatient treatment, suicidal ideation or plan, mood or psychotic disorders, and lower clinician experience; and lower risk for being married/defacto, and after hours presentation. Recommendation for psychiatric hospitalization was based on complex decision making. These findings have implications for clinical practice guidelines, service costs, and service organization.
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Affiliation(s)
- Gregory L Carter
- Suicide Prevention Research Unit, Centre for Mental Health Studies at the University of Newcastle and Hunter and New England Area Health Service, Australia.
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Carter GL, Clover K, Whyte IM, Dawson AH, D'Este C. Postcards from the EDge project: randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self poisoning. BMJ 2005; 331:805. [PMID: 16183654 PMCID: PMC1246077 DOI: 10.1136/bmj.38579.455266.e0] [Citation(s) in RCA: 174] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2005] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine whether an intervention using postcards (postcards from the EDge project) reduces repetitions of hospital treated deliberate self poisoning. DESIGN Randomised controlled trial. SETTING Regional referral service for general hospital treated deliberate self poisoning in Newcastle, Australia. PARTICIPANTS 772 patients aged over 16 years with deliberate self poisoning. INTERVENTION Non-obligatory intervention using eight postcards over 12 months along with standard treatment compared with standard treatment alone. MAIN OUTCOME MEASURES Proportion of patients with one or more repeat episodes of deliberate self poisoning and the number of repeat episodes for deliberate self poisoning per person in 12 months. RESULTS The proportion of repeaters with deliberate self poisoning in the intervention group did not differ significantly from that in the control group (57/378, 15.1%, 95% confidence interval 11.5% to 18.7% v 68/394, 17.3%, 13.5% to 21.0%: difference between groups -2%, -7% to 3%). In unadjusted analysis the number of repetitions were significantly reduced (incidence risk ratio 0.55, 0.35 to 0.87). CONCLUSION A postcard intervention reduced repetitions of deliberate self poisoning, although it did not significantly reduce the proportion of individual repeaters.
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Affiliation(s)
- Gregory L Carter
- Suicide Prevention Research Unit, Centre for Mental Health Studies, Faculty of Health, University of Newcastle, Newcastle, Australia.
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Carter GL, Lewin TJ, Stoney C, Whyte IM, Bryant JL. Clinical management for hospital-treated deliberate self-poisoning: comparisons between patients with major depression and borderline personality disorder. Aust N Z J Psychiatry 2005; 39:266-73. [PMID: 15777364 DOI: 10.1080/j.1440-1614.2005.01564.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To compare the initial clinical management of hospital-treated deliberate self-poisoning patients with major depressive disorder (MDD) or borderline personality disorder (BPD) after controlling for demographic factors and level of suicide ideation. METHOD This study compared sequential hospital treated deliberate self-poisoning patients (n = 570) with either MDD or BPD (but no major comorbid psychopathology) on four outcomes modelled using logistic regression: (i) length of stay in the general hospital; (ii) discharge to a psychiatric hospital; (iii) psychiatric follow-up; and (iv) general practitioner (GP) follow-up. RESULTS BPD and MDD patients were discharged to psychiatric inpatient care at very similar rates (33%-35%) and almost all subjects with high levels of suicidal ideation were discharged to psychiatric hospital. However, for mild to moderate levels of suicidal ideation BPD patients were more likely to be discharged to psychiatric hospital than MDD patients. After controlling for demographics and suicidal ideation, BPD patients were more likely to be referred for psychiatric hospitalization on discharge (adjusted OR = 1.79, 95% CI = 1.01-3.18) and less likely to be referred to GPs if discharged to home (adjusted OR = 0.44, 95% CI = 0.24-0.81). There were no differences in general hospital length of stay or arrangements made for psychiatric follow-up for those discharged to home. CONCLUSIONS This suggests that for mild to moderate suicidal ideation levels clinicians are more likely to choose to send BPD patients, after deliberate self-poisoning, to inpatient psychiatric care than MDD patients. Clinicians are also apparently more likely to choose to manage MDD patients in primary care settings, for those patients discharged to home. This has implications for service planning and clinical guidelines.
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Affiliation(s)
- Gregory L Carter
- Faculty of Health, University of Newcastle, Callaghan, NSW, Australia.
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Carter G, Reith DM, Whyte IM, McPherson M. Repeated self-poisoning: increasing severity of self-harm as a predictor of subsequent suicide. Br J Psychiatry 2005; 186:253-7. [PMID: 15738507 DOI: 10.1192/bjp.186.3.253] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Prediction of suicide risk is difficult in clinical practice. AIMS To identify changes in clinical presentation predictive of suicide in patients treated for repeated episodes of self-poisoning. METHOD A nested case-control study used the Hunter Area Toxicology Service database to identify exposure variables and the National Death Index to identify suicide. Cases were patients who had hospital treatment on more than one occasion between 15 January 1987 and 31 December 2000. RESULTS There were 31 cases, for which 93 controls were selected. Study variables associated with an increased risk of subsequent suicide were an increase in the number of drugs ingested (odds ratio 2.59, 95% CI 1.48-4.51), an increase in the dose ingested (OR 1.33, 95% CI 1.01-1.76), an increase in coma score (OR 1.71, 95% CI 1.11-2.66), a decrease in Glasgow Coma Score (OR 1.21, 95% CI 1.03-1.43) and an increase in drug or alcohol misuse (OR 2.33, 95% CI 1.06-5.10). CONCLUSIONS Patients who have escalating severity of self-poisoning episodes are at high risk of completed suicide.
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Affiliation(s)
- Greg Carter
- Faculty of Medicine and Health Services, Suicide Prevention Research Unit, Centre for Mental Health Studies, University of Newcastle, Newcastle, New South Wales, Australia
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45
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Abstract
OBJECTIVE To quantify the non-suicidal mortality subsequent to hospital treated self-poisoning, and to identify risk factors for non-suicidal death. METHOD A prospective longitudinal cohort design was used, with data-linkage between the Hunter Area Toxicology Service database and the National Death Index. All patients with deliberate self-poisoning for a 10-year period (1991-2000) were studied and the first episode in the period was used as the index episode. The outcomes were: accidental, 'natural' and non-suicidal death, with follow-up for the study duration. RESULTS There were 4044 patients studied, and 170 (4.2%) of these had non-suicidal death; 64 were accidental and 106 were 'natural' cause deaths. The standardized mortality ratio (95% CI) for non-suicidal death for males, females and combined were 4.98 (4.08-6.07), 3.78 (3.0-4.75) and 4.20 (3.62-4.88), respectively. The increased mortality was apparent for both males and females, and was more marked in the younger age groups. For non-suicidal death the adjusted hazard ratio (95% CI) for increased risk were: increasing age 1.07 (1.06-1.08), male gender 1.77 (1.24-2.52), psychiatric diagnosis of substance related disorder 1.49 (1.03-2.16), prescription of a respiratory drug 2.69 (1.31-5.55), and prescription of an anti-diabetic drug 1.95 (0.93-4.07), while psychiatric diagnosis of adjustment disorder 0.64 (0.38-1.053) was associated with decreased risk. CONCLUSIONS Patients who present with self-poisoning have increased mortality from accidental and 'natural' causes. Long-term treatment goals for these patients need to address non-suicide mortality in addition to suicide mortality.
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Affiliation(s)
- Greg Carter
- Children's Pavillion, Dunedin Public Hospital, Dunedin, New Zealand
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Abstract
This study explored posttraumatic stress disorder (PTSD) among suicide attempters. Participants were 330 hospital-treated deliberate self-poisoning (DSP) patients. Twelve-month prevalence of PTSD and comorbid psychiatric disorders was determined using the Composite International Diagnostic Interview (CIDI-A). Standard disability measures and demographic information were also obtained. PTSD prevalence was 32% among women and 15% among men. The PTSD group had significantly higher levels of affective disorder, anxiety disorders other than PTSD, psychiatric disability, and service utilization than DSP patients without PTSD. Logistic regression modeling showed that PTSD was associated with the type of traumatic event, number of events, affective disorder, and anxiety disorder other than PTSD.
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Affiliation(s)
- Kerrie Clover
- Consultation-Liaison Psychiatry, Newcastle Mater Hospital, Newcastle, Australia.
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47
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Abstract
BACKGROUND The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. METHOD For these guidelines, the CPG Team for Deliberate Self-harm reviewed the treatment outcome literature (including meta-analyses) and consulted with practitioners and patients. TREATMENT RECOMMENDATIONS (i) Organization of general hospital services to provide: emergency department admission; a safe environment; integrated medical and psychiatric management; risk assessment; identification of psychiatric morbidity, and adequate follow-up. (ii) Detection and treatment of any psychiatric disorder. (iii) Dialectical behaviour therapy, psychoanalytically orientated partial hospitalization or home-based interpersonal therapy (for certain patients) to reduce repetition of deliberate self-harm (DSH). CONCLUSION Deliberate self-harm is common and is costly in terms of both individual distress and service provision. General hospitals are often the first point of clinical contact, but may not be appropriately organized to care for these patients. Evidence for the effectiveness of psychological treatments is based on single RCTs without replication. The three recommended psychological treatments are not widely available in Australia and New Zealand, and the interventions that are, such as cognitive behaviour therapy, problem solving and 'green cards' (an agreement guaranteeing access to services), do not reduce repetition of DSH. The effect of follow-up in psychiatric hospitals or in the community is poorly understood. We need to develop and evaluate interventions that will reduce repetition of both fatal and non-fatal deliberate self-harm and improve the person's functioning and quality of life.
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Reith DM, Whyte I, Carter G, McPherson M, Carter N. Risk factors for suicide and other deaths following hospital treated self-poisoning in Australia. Aust N Z J Psychiatry 2004; 38:520-5. [PMID: 15255824 DOI: 10.1080/j.1440-1614.2004.01405.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To analyze the risk factors for suicide, premature death and all-cause death in a representative population of hospital-treated deliberate self-poisoning patients. METHOD A prospective cohort study using data-linkage between the Hunter Area Toxicology Service Database and the National Death Index of the Australian Institute of Health and Welfare, from January 1991 to December 2000. RESULTS There were 4105 subjects, of whom 228 (5.6%) died, 122 (2.9%) by premature death and 58 (1.4%) by suicide. The probability of suicide after 10 years follow-up was 2%. The adjusted hazard ratios (95% CI) for suicide were: 'disorders usually diagnosed in infancy, childhood and adolescence', 5.28 (95% CI = 2.04-13.65): male gender, 4.25 (95% CI = 2.21-8.14); discharge to involuntary psychiatric hospital admission, 3.20 (95% CI = 1.78-5.76); and increasing age, 1.02 (95% CI = 1.01-1.04). Men and women showed different patterns of multivariate risks, although increased risk with increasing age and discharge to an involuntary psychiatric admission was true for both. The standardized all-cause mortality ratio (95% CI) was: for men, 6.42 (95% CI = 5.44-7.57), and for women 4.39 (95% CI = 3.56-5.41). The standardized suicide mortality ratio (95% CI) was: for men, 20.55 (95% CI = 15.24-27.73), and for women 22.95 (95% CI = 13.82-38.11). CONCLUSIONS Men and women have different risk factors for subsequent suicide after self-poisoning. Hospital-treated self-poisoning patients have increased risk of subsequent suicide, premature and all-cause death. Psychiatric assessment, leading to discharge decisions, is worthwhile in identifying patients at long-term risk of suicide, premature and all-cause death.
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Affiliation(s)
- David M Reith
- Discipline Of Paediatrics, University of Otago and Children's Pavilion, Dunedin Public Hospital, Great King St, Dunedin, New Zealand.
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Carter GL, Issakidis C, Clover K. Correlates of youth suicide attempters in Australian community and clinical samples. Aust N Z J Psychiatry 2003; 37:286-93. [PMID: 12780466 DOI: 10.1046/j.1440-1614.2003.01179.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE This study (i) explores differences between a clinical sample of deliberate self-poisoning (DSP) patients and a community sample who reported previous attempted suicide (AS); and (ii) examines correlates of suicidal behaviour in these groups compared with a community control group (CC) with no suicidal behaviour. METHOD The study design was: case-case, case-control and cross-sectional population studies. A clinical sample of DSP (n = 51), a community sample of AS (n = 31) and a community sample with no suicidal behaviour (n = 842) were used, all aged 18-24 years. The DSP and AS groups were compared on several variables and two logistic regression models were developed for risk of (i) DSP and (ii) AS compared to community controls. RESULTS The adjusted odds ratios for DSP were: female gender (OR = 5.7, CI = 1.7-19.4), anxiety (OR = 7.4, CI = 2.2-25.1), affective (OR = 23.0, CI = 6.9-76.5), or substance-use disorder (OR = 19.2, CI = 5.6-65.4) and greater mental health related disability (OR = 0.5, CI = 0.3-0.7 for 1 SD decrease). For AS the results were: anxiety (OR = 9.4, CI = 1.7-52.8) or substance-use disorder (OR = 3.0, CI = 1.1-8.7) and greater mental health disability (OR = 0.5, CI = 0.4-0.7). Affective disorder was close to significant for the AS group (OR = 4.0, CI = 0.9-17.1). CONCLUSIONS Correlates of DSP/AS were usually more powerful in the clinical group, but showed a similar pattern of psychiatric disorder and disability factors in both groups, supporting a continuum of risk factors across these groups. Interventions based on modifiable risk factors could target the same factors for public health, primary care or hospital populations: anxiety, depression and substance use disorders and mental health related disability.
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Affiliation(s)
- Gregory L Carter
- Faculty of Health, University of Newcastle, Newcastle, Australia.
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Abstract
OBJECTIVES To examine risk factors associated with re-presentation (event rates) following an initial episode of hospital treated self-poisoning. METHOD A longitudinal cohort study using the Hunter Area Toxicology Service (HATS) database of all presentations to hospital of self-poisoned patients aged 10-19 in Newcastle and Lake Macquarie Regions of New South Wales from January 1991 to December 1995. The study factors were: age, gender, employment status, 'substance abuse' and psychiatric diagnosis at index (first documented episode during the study time-period) admission. The main outcome measure was re-presentations per unit time. Time-event analysis (multivariate) was used to compare re-presentation rates per person-year exposure to the study factors. RESULTS There were 450 patients who presented on a total of 551 occasions. The median and modal age at initial presentation was 17. Three hundred and nine (69%) were female and 141 (31%) were male. The probability (95% CI) of a patient re-presenting within one year of an index admission with self poisoning was 0.09 (0.07-0.12) and within 5 years was 0.16 (0.12-0.21). The adjusted rate ratios for episodes of re-presentation were: any 'substance abuse (ever)' 3.87 (2.08-7.21), 'alcohol abuse' 2.32 (1.15-4.68),'benzodiazepine abuse' 4.89 (1.63-14.62), schizophrenia and other psychotic disorders (DSM-IV) 2.85 (1.2-6.79), and any personality disorder (DSM-IV) 2.68 (1.73-4.16). CONCLUSIONS Interventions to decrease recurrence rates for adolescent self poisoning should be directed towards substance (particularly alcohol or benzodiazepine) abuse, non-affective psychoses and personality disorder.
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Affiliation(s)
- David Martin Reith
- Discipline of Paediatrics, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
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