Studying survivors of nearly lethal suicide attempts: an important strategy in suicide research

The series of articles in this special issue of SLTB from the Centers for Disease Control and Prevention (CDC) study of nearly lethal suicide attempts represents an important contribution to research on suicidal behavior. The investigative approach used is attractive, yet also challenging in terms of research methodology. In this commentary I take the opportunity to highlight certain aspects of this line of research as well as to comment on the specific findings of the CDC study and their relationship to existing knowledge. I also discuss the future potential for this research approach and further questions that might be addressed by it.

Deliberate self-harm patients with alcohol disorders: characteristics, treatment, and outcome

Deliberate self-harm (DSH) patients with alcohol problems present a considerable challenge for clinical services. In a study of a sample of 150 DSH patients who were representative of all such patients seen at a general hospital during the study period, 40 patients with an ICD-10 diagnosis of alcohol dependence or harmful use of alcohol were compared with the remainder of the sample. The treatment of the patients with alcohol disorders before and after the episode of DSH and the outcome 12-20 months later were also investigated. Compared with other DSH patients, those with an alcohol diagnosis were older and more often male, living alone, unemployed, sick, disabled, or with a past history of DSH. They also had higher scores on measures of anger, aggression, and impulsivity. Comorbid psychiatric disorder was present in 37 (92.5%) patients, this being depression in three-quarters of those cases. Fourteen (35.0%) patients were receiving treatment from the psychiatric services prior to DSH, and 33 (82.5%) were subsequently offered treatment. Of the patients who were followed up, 37.9% remained in contact with psychiatric services, 55.2% showed poor compliance with treatment and 44.8% reported a further episode of DSH. All patients presenting after DSH need to be carefully screened for alcohol disorders and for comorbid psychiatric diagnoses. Treatment of DSH patients with alcohol disorders should include the treatment of any comorbid depressive illness.

Suicide in female nurses in England and Wales

BACKGROUND

Female nurses appear to have an increased risk of suicide but the reasons are unknown.

METHOD

We have concluded a study of nurse suicides (N = 106) in England and Wales, including a psychological autopsy study (N = 42) and case-control comparison with living nurses (N = 84).

RESULTS

Nearly three-quarters of the nurse suicides had previous contact with psychiatric services and almost half had been psychiatric in-patients in the past. There were particularly marked differences between the cases and controls for current psychiatric disorder (90.5% v. 7.1%, OR = 68.5), personality disorder (38.1% v. 12%, OR = 32), and history of deliberate self-harm (71.4% v. 2.4%, OR = 58.5). Family background and social factors (especially concerning interpersonal relationships) also distinguished the two groups. Smoking and serious alcohol abuse were much more frequent in the suicides. There was some indication that while many of the suicides were in contact with psychiatric services, care may not have been optimal in some cases.

CONCLUSIONS

The most important strategies for suicide prevention in nurses are in prevention, detection and management of psychiatric disorders. In assessing suicide risk a history of DSH and the presence of comorbid psychiatric and personality disorders are particularly important.

Psychosocial and pharmacological treatment of patients following deliberate self-harm: the methodological issues involved in evaluating effectiveness

Development of effective treatments for patients following deliberate self-harm (self-poisoning or self-injury) is a very important element in suicide prevention. The randomized controlled trial (RCT) is the mainstay of evaluation of treatments. In a systematic review of the literature, the effectiveness of treatments based on RCTs was examined and the quality of the RCTs was assessed. Twenty trials were identified, and where possible, these were grouped on the basis of similarities among the types of treatment. In this paper, we examine the methodological aspects of the trials and consider what may be learned that will assist in the design of future studies in this field. The methodological quality of the trials was reasonable, but most trials included too few participants to detect clinically important differences in rates of repeated self-harm. In planning future trials, the following major issues should be addressed: investigators should perform power calculations to determine the number of subjects necessary to detect clinically important effects, provide information on method of randomization and interventions, use standard measures of outcome, and focus on homogeneous subgroups of patients. Improving the methodology of future studies in this field will be essential if sound evidence is to be obtained which can inform effective service provision for deliberate self-harm patients.

Abuse and deliberate self-poisoning in women: a matched case-control study

OBJECTIVE

Controlled studies have shown deliberate self-harm to be more common in abused populations, but no controlled studies have shown abuse to be more common in self-harming populations. This is the first controlled study to determine whether abuse experiences (sexual, physical, and psychological) occurred more commonly in women who take overdoses than in controls.

METHOD

The design was a matched (1:1) case-control study set in a district general hospital in England. The subjects were 36 women admitted following deliberate self-poisoning. They were matched with the next non-overdose admission to the same hospital on six variables (sex, age, ethnicity, social class, marital status, and geographical locality). The main outcome measures used were modified versions of standardized self-report questionnaires of sexual, physical, and psychological abuse, together with measures of parenting style and general psychopathology.

RESULTS

Women who had taken an overdose were more likely (odds ratio 15.0, 95% confidence interval 2.0 to 113.6) to have been sexually abused, and somewhat more likely to have been psychologically (1.02, 1.00 to 1.05) but not physically abused. They also had higher measures of psychopathology (GHQ-30: 1.19, 1.07 to 1.31), were more likely to have been abused at a younger age, exposed to the "affectionless control" style of parenting by their mothers, and to have harmed themselves in other ways.

CONCLUSIONS

The management of women presenting to hospital after self-poisoning should include assessment of abuse experiences, and instigation of appropriate treatment in those with significant sequelae of abuse.

Repetition of attempted suicide among teenagers in Europe: frequency, timing and risk factors

BACKGROUND

Adolescents in many countries show high rates of suicide attempts and repetitions of attempts as a common feature. Attempted suicide is the best predictor of future suicide. Repetition of attempts further increases the risk of suicide. The present study sought to identify patterns and risk factors for repetition of attempts in older teenagers.

METHODS

Data were collected by uniform procedures in a longitudinal follow-up study in seven European centres participating in the WHO/EURO Multicentre Study on Suicidal Behaviour. Information on attempted suicide in the 15-19-year age group during the period 1989-1995 was analysed.

RESULTS

A total of 1,720 attempts by 1,264 individuals over a mean follow-up period of 204 weeks (SD 108.9) were recorded. When life-table analysis was performed, 24% of the individuals who had previously attempted suicide made another attempt within one year after the index attempt, compared with 6.8% of the "first-evers", with no major gender difference. Cox regression analysis revealed that previous attempted suicide (OR 3.3, 95% CI 2.4-4.4) and use of "hard" methods (OR 1.5, 95% CI 1.1-2.1) were both significantly associated with repetition of attempted suicide. Stepwise Cox regression analysis showed that a history of previous attempted suicide was the most important independent predictor of repetition (OR 3.2, 95% CI 2.4-4.4).

CONCLUSION

For young suicide attempters, follow-up and adequate aftercare are very important if repetition and risk of suicide are to be reduced. This applies particularly to those who have already made more than one attempt.

Social class and suicidal behaviour: the associations between social class and the characteristics of deliberate self-harm patients and the treatment they are offered

BACKGROUND

Rates of deliberate self-harm (DSH) in the United Kingdom are much higher in lower than upper social class groups. Previous investigations have shown differences in socio-demographic and clinical characteristics of male patients according to social class. In two studies of DSH patients in Edinburgh the extent of provision of psychiatric aftercare was inversely related to social class. These findings have not been investigated in other areas.

METHOD

Data collected through the Oxford Monitoring System for Attempted Suicide were used to examine the association between social class and socio-demographic and clinical characteristics in male and female DSH patients who presented to the general hospital in Oxford between mid-1988 and 1996 and to determine whether the previously reported social class differences in provision of psychiatric aftercare were replicated.

RESULTS

Data on social class were available for 2,828 DSH patients (1,290 males, 1,538 females). In both genders, lower social class group tended to be associated with younger age. In males, the main social class differences were found in under-35-year-olds, in whom lower social class was related to criminal record, violence to others and drug misuse. In females, psychiatric disorders were diagnosed more frequently in the higher social class groups, but only in the under-35 age group. In neither gender was there a significant association between social class and the frequency of offer of psychiatric aftercare following DSH.

CONCLUSIONS

There are considerable variations in socio-demographic and clinical characteristics of both male and female DSH patients in different social classes, especially in younger patients. The reason for the absence of a marked social class gradient in psychiatric aftercare found in this study in contrast to the results from previous investigations may be related to differences in styles of service.

The efficacy of problem-solving treatments after deliberate self-harm: meta-analysis of randomized controlled trials with respect to depression, hopelessness and improvement in problems

BACKGROUND

Brief problem-solving therapy is regarded as a pragmatic treatment for deliberate self-harm (DSH) patients. A recent meta-analysis of randomized controlled trials (RCTs) evaluating this approach indicated a trend towards reduced repetition of DSH but the pooled odds ratio was not statistically significant. We have now examined other important outcomes using this procedure, namely depression, hopelessness and improvement in problems.

METHOD

Six trials in which problem-solving therapy was compared with control treatment were identified from an extensive literature review of RCTs of treatments for DSH patients. Data concerning depression, hopelessness and improvement in problems were extracted. Where relevant statistical data (e.g. standard deviations) were missing these were imputed using various statistical methods. Results were pooled using meta-analytical procedures.

RESULTS

At follow-up, patients who were offered problem-solving therapy had significantly greater improvement in scores for depression (standardized mean difference = -0.36; 95% CI -0.61 to -0.11) and hopelessness (weighted mean difference =-3.2; 95% CI -4.0 to -2.41), and significantly more reported improvement in their problems (odds ratio = 2.31; 95% CI 1.29 to 4.13), than patients who were in the control treatment groups.

CONCLUSIONS

Problem-solving therapy for DSH patients appears to produce better results than control treatment with regard to improvement in depression, hopelessness and problems. It is desirable that this finding is confirmed in a large trial, which will also allow adequate testing of the impact of this treatment on repetition of DSH.

The influence of the economic and social environment on deliberate self-harm and suicide: an ecological and person-based study

BACKGROUND

Geographic variations in the incidence of deliberate self-harm (DSH) and suicide have been shown to be associated with area-based measures of socio-economic deprivation and social fragmentation. Previous studies have been subject to methodological limitations. None has investigated whether ecological associations are reflected in characteristics of individuals involved in suicidal behaviour.

METHODS

DSH patients presenting to a general hospital between 1985 and 1995 and suicides (including open verdicts) from the same catchment area were studied. Mean annual rates of DSH and suicide by gender were calculated for electoral wards. The wards were amalgamated into 20 groups according to their ranking for socio-economic deprivation (Townsend) and social fragmentation scores. Associations of these variables with DSH and suicide rates were investigated. Characteristics of DSH patients living in ward groups with the highest and lowest socio-economic deprivation and social fragmentation scores were compared.

RESULTS

Socio-economic deprivation was associated with DSH rates among males (r = 0.89) and females (r = 0.87). After controlling for social fragmentation the associations remained relatively strong, particularly in young males. Associations with social fragmentation in both genders (males, r = 0.83; females, r = 0.86) were attenuated after controlling for socio-economic deprivation. For suicide, the only significant association was with socio-economic deprivation in males (r = 0.79), but this was attenuated after controlling for social fragmentation. The characteristics of individual DSH patients reflected those of the areas where they lived.

CONCLUSIONS

Reducing socio-economic deprivation and its associated problems may be an important strategy in the prevention of suicidal behaviour, especially in young men.

Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study

OBJECTIVE

To evaluate the effects on suicidal behaviour of legislation limiting the size of packs of paracetamol and salicylates sold over the counter.

DESIGN

Before and after study.

SETTING

UK population, with detailed monitoring of data from five liver units and seven general hospitals, between September 1996 and September 1999.

SUBJECTS

People who died by suicidal or accidental overdose with paracetamol or salicylates or who died of undetermined causes; patients admitted to liver units with hepatic paracetamol poisoning; patients presenting to general hospitals with self poisoning after taking paracetamol or salicylates.

MAIN OUTCOME MEASURES

Mortality from paracetamol or salicylate overdose; numbers of patients referred to liver units or listed for liver transplant; numbers of transplantations; numbers of overdoses and tablets taken; blood concentrations of the drugs; prothrombin times; sales to pharmacies and other outlets of paracetamol and salicylates.

RESULTS

Numbers of tablets per pack of paracetamol and salicylates decreased markedly in the year after the change in legislation on 16 September 1998. The annual number of deaths from paracetamol poisoning decreased by 21% (95% confidence interval 5% to 34%) and the number from salicylates decreased by 48% (11% to 70%). Liver transplant rates after paracetamol poisoning decreased by 66% (55% to 74%). The rate of non-fatal self poisoning with paracetamol in any form decreased by 11% (5% to 16%), mainly because of a 15% (8% to 21%) reduction in overdoses of paracetamol in non-compound form. The average number of tablets taken in paracetamol overdoses decreased by 7% (0% to 12%), and the proportion involving >32 tablets decreased by 17% (4% to 28%). The average number of tablets taken in salicylate overdoses did not decrease, but 34% fewer (2% to 56%) salicylate overdoses involved >32 tablets. After the legislation mean blood concentrations of salicylates after overdose decreased, as did prothrombin times; mean blood concentrations of paracetamol did not change.

CONCLUSION

Legislation restricting pack sizes of paracetamol and salicylates in the United Kingdom has had substantial beneficial effects on mortality and morbidity associated with self poisoning using these drugs.

Substances used in deliberate self-poisoning 1985-1997: trends and associations with age, gender, repetition and suicide intent

BACKGROUND

Rates of deliberate self-poisoning have increased in recent years. While over-the-counter availability and prescribing patterns may influence trends in substances used in overdose, these may also be related to clinical characteristics of patients. We investigate trends in substances used for self-poisoning and the influence of age, gender, suicidal intent and repetition status on the substances used.

METHOD

Data collected by the Oxford Monitoring System for Attempted Suicide were used to review trends and patterns of self-poisoning between 1985 and 1997.

RESULTS

There were substantial increases in self-poisoning with paracetamol and antidepressants. While the increase in antidepressant self-poisoning closely paralleled local prescribing figures during 1995-97, SSRI antidepressant overdoses occurred somewhat more often than expected compared with tricyclic overdoses. Paracetamol overdoses were more common in first-timers and young people, whereas overdoses of antidepressants and tranquillizers were more common in repeaters and older people. Self-poisoning with gas and non-ingestible poisons was associated with high suicidal intent.

CONCLUSIONS

There have been marked changes in the substances used for self-poisoning, which seem primarily to reflect availability, as do the influences of age and repeater status on choice of substances used. Degree of suicidal intent may also influence choice of method of self-poisoning.

Suicide in doctors: a study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995

STUDY OBJECTIVE

To investigate the suicide risk of doctors in England and Wales, according to gender, seniority and specialty.

DESIGN

Retrospective cohort study. Suicide rates calculated by gender, age, specialty, seniority and time period. Standardised mortality ratios calculated for suicide (1991-1995), adjusted for age and sex.

SETTING

England and Wales.

SUBJECTS

Doctors in the National Health Service who died by suicide between 1979 and 1995, identified by death certificates. Population at risk based on Department of Health manpower data.

MAIN RESULTS

Two hundred and twenty three medical practitioners in the National Health Service who died by suicide or undetermined cause were identified. The annual suicide rates in male and female doctors were 19.2 and 18.8 per 100 000 respectively. The suicide rate in female doctors was higher than in the general population (SMR 201.8; 95% CI 99.7, 303.9), whereas the rate in male doctors was less than that of the general population (SMR 66.8; 95% CI 46.6, 87.0). The difference between the mortality ratios of the female and male doctors was statistically significant (p=0.01), although the absolute suicide risk was similar in the two genders. There were significant differences between specialties (p=0.0001), with anaesthetists, community health doctors, general practitioners and psychiatrists having significantly increased rates compared with doctors in general hospital medicine. There were no differences with regard to seniority and time period.

CONCLUSIONS

There is an increased risk of suicide in female doctors, but male doctors seem to be at less risk than men in the general population. The excess risk of suicide in female doctors highlights the need to tackle stress and mental health problems in doctors more effectively. The risk requires particular monitoring in the light of the very large increase in the numbers of women entering medicine.

Use of paracetamol (acetaminophen) for suicide and nonfatal poisoning: worldwide patterns of use and misuse

Paracetamol (acetaminophen) is one of the most frequently used drugs in intentional overdoses. We have investigated associations between its availability and its use for overdose and suicide around the world by means of a postal questionnaire and literature review. Countries that limit the quantity of paracetamol available in a single purchase generally report lower rates of paracetamol-related morbidity and mortality. National policy decisions regarding restrictions on its availability need to weigh the inconvenience caused to the many who use the drug safely against those of the few in whom overdose may be fatal. We recommend restricting the quantity of drug available as a single purchase as the most pragmatic means of reducing paracetamol-related suicide and liver failure.

Attempted and completed suicide in older subjects: results from the WHO/EURO Multicentre Study of Suicidal Behaviour

OBJECTIVE

The authors present an analysis of findings for the 65 years and over age group from the WHO/EURO Multicentre Study of Suicidal Behaviour (1989-93).

METHODS

Multinational data on non-fatal suicidal behaviour is derived from 1518 subjects in 16 European centres. Local district data on suicide were available from 10 of the collaborating centres.

RESULTS

Stockholm (Sweden), Pontoise (France) and Oxford (UK) had the highest suicide attempts rates. In most centres, the majority of elderly who attempted suicide were widow(er)s, often living alone, who used predominantly voluntary drug ingestion. Non-fatal suicidal behaviour decreased with increasing age, whereas suicide rates rose. The ratio between fatal and non-fatal behaviours was 1:2, that for males/females almost 1:1. In the years considered, substantial stability in suicide and attempted suicide rates was observed. As their age increased, suicidal subjects displayed only a limited tendency to repeat self-destructive acts. Moreover, there was little correlation between attempted suicide and suicide rates, which carries different clinical implications for non-fatal suicidal behaviour in the elderly compared with younger subjects in the same WHO/EURO study.

Suicide in young people aged 15-24: a psychological autopsy study

BACKGROUND

The suicide rate in young people in the United Kingdom has increased over the last decade. As there is a paucity of information about the characteristics of young suicides we have undertaken a detailed investigation of suicides in people aged 15-24 years by means of the psychological autopsy approach.

METHODS

The sample consisted of 27 subjects (25 males, two females) whose deaths received a verdict of suicide (N=24) or undetermined cause (N=3). Information was collected from informant interviews, coroners' inquest notes, medical records and psychiatric case notes. A sub-sample of 22 male subjects was compared with an age-matched sample of male deliberate self-harm (DSH) patients.

RESULTS

Psychiatric disorders were diagnosed in 19 (70.4%) subjects. These were most commonly depressive disorders (55.5%). Very few individuals were receiving treatment for their disorders. Substance abuse disorders were uncommon but a substantial proportion of individuals had problems with alcohol or drug misuse. Personality disorders were present in 29.6% of subjects and disorders or personality trait accentuation in 55.6%. Comorbidity of psychiatric disorders was found in a third of subjects. The suicides were often the end-point of long-term difficulties extending back to childhood or early adolescence. In addition to mental disorders, relationship and legal difficulties were identified as relatively common contributory factors to the suicides. In comparison to deliberate self-harm patients, male suicides were more likely to use dangerous methods and live alone.

LIMITATIONS

Several potential informants could not be interviewed and there was no general population control sample.

CONCLUSIONS

The process leading to suicide in young people is often long term, with untreated depression in the context of personality and/or relationship difficulties being a common picture at the time of death. The prevention of suicide in the young clearly requires multiple strategies.

Deliberate self-harm patients who leave the accident and emergency department without a psychiatric assessment: a neglected population at risk of suicide

OBJECTIVES

Deliberate self-harm (DSH) patients, despite their risk of suicide, are often discharged directly from accident and emergency (A&E) departments without undergoing a psychiatric assessment. The aims of this study were to determine the characteristics and outcome of these patients.

METHODS

The characteristics of DSH patients who were discharged directly from an A&E department over a 2-year period were investigated, comparing those who had a psychiatric assessment with those who did not. In a matched control design, the outcome of a group of patients who did not receive a psychiatric assessment was compared with that of a group of patients who were assessed.

RESULTS

Of DSH patients who were discharged directly from the A&E department 58.9% (145/246) did not have a psychiatric assessment. Nonassessed patients were more likely to have a past history of DSH, to be in the 20-34 year age group, and to have exhibited difficult behaviour in the A&E department. Patients presenting between 5 p.m. and 9 a.m. were less likely to be assessed than those attending between 9 a.m. and 5 p.m. Further DSH during the subsequent year occurred in 37.5% of the nonassessed patients compared with 18.2% of matched assessed patients. They were also more likely to have psychiatric treatment.

CONCLUSION

A substantial proportion of DSH patients discharged directly from A&E departments do not receive a psychiatric assessment. Nonassessed patients may be at greater risk of further DSH and completed suicide than those who are assessed. Hospital services need to be organised such that DSH patients managed in A&E departments can receive an assessment of psychosocial problems and risk.

Psychiatric disorder and personality factors associated with suicide in older people: a descriptive and case-control study

OBJECTIVE

To determine the rates of psychiatric disorder and personality variables in a sample of older people who had committed suicide and to compare the rates in a subgroup of this sample with those in a control group of people who died from natural causes.

DESIGN

Descriptive psychological autopsy study, including interviews with informants, of psychiatric and personality factors in 100 suicides in older people. Case-control study using subgroup of 54 cases and matched control group.

SETTING

Four counties and one large urban area in central England, UK.

SUBJECTS

Individuals 60 years old and over at the time of death who had died between 1 January 1995 and 1 May 1998, and whose deaths had received a coroner's verdict of suicide (or an open or accidental verdict, where the circumstances of death indicated probable suicide). The control group was an age-and sex-matched sample of people dying through natural causes in the same time period.

MAIN OUTCOME MEASURES

ICD-10 psychiatric disorder, personality disorder and trait accentuation.

MAIN RESULTS

Seventy-seven per cent of the suicide sample had a psychiatric disorder at the time of death, most often depression (63%). Personality disorder or personality trait accentuation was present in 44%, with anankastic or anxious traits the most frequent. Depression, personality disorder, and personality trait accentuation emerged as predictors of suicide in the case-control analysis.

CONCLUSION

Personality factors, as well as depression, are important risk factors for suicide in older people.

Psychiatric and personality disorders in deliberate self-harm patients

BACKGROUND

Previous UK studies have reported much lower rates of psychiatric and personality disorder in those who attempt suicide than in those who die by suicide.

AIMS

To determine the nature and prevalence of psychiatric and personality disorders in deliberate self-harm (DSH) patients.

METHOD

A representative sample of 150 DSH patients who presented to a general hospital were assessed using a structured clinical interview and a standardised instrument. Follow-up interviews were completed for 118 patients approximately 12-16 months later.

RESULTS

ICD-10 psychiatric disorders were diagnosed in 138 patients (92.0%), with comorbidity of psychiatric disorders in 46.7%. The most common diagnosis was affective disorder (72.0%). Personality disorder was identified in 45.9% of patients interviewed at follow-up. Comorbidity of psychiatric and personality disorder was present in 44.1%.

CONCLUSIONS

Psychiatric and personality disorders, and their comorbidity, are common in DSH patients. This has important implications for assessment and management.

Outcome of women admitted to hospital for depressive illness: factors in the prognosis of severe depression

BACKGROUND

A previous study of women 9 months after discharge from in-patient treatment for depression found that low self-esteem as measured by a self-report questionnaire at admission was associated with a worse prognosis. This study investigates the womens' outcome more than 4 years after discharge and the continued prognostic relevance of self-esteem and other variables.

METHOD

Fifty-six women who had been admitted to hospital with major depression and studied in detail during their admission and 9 months following discharge were traced 4-5 years later. Possible prognostic factors were investigated in relation to time to recovery and recurrence, and to a global outcome measure.

RESULTS

In keeping with other published work only 16 out of 52 (31%) women had recovered and remained well. Fifteen out of 52 (29%) subjects had experienced depressive symptoms for more than 70% of the follow-up time or died from unnatural causes. Low self-esteem scores recorded at the initial admission correlated with slow recovery but not subsequent recurrence of depression. The occurrence of one or more life events in the year preceding admission was associated with a better prognosis.

CONCLUSIONS

The poor long-term prognosis of many women with severe depression was confirmed. Social factors, such as social support and marital relationships were less important for prognosis than in previous studies of less severely ill subjects. The prognostic value of self-esteem warrants further investigation and appears to have therapeutic implications.

Effect of death of Diana, princess of Wales on suicide and deliberate self-harm

BACKGROUND

The death of the Princess of Wales in 1997 was followed by widespread public mourning. Such major events may influence suicidal behaviour.

AIMS

To assess the impact of the Princess's death on suicide and deliberate self-harm (DSH).

METHOD

Analysis, using Poisson regression, of the number of suicides and open verdicts ('suicides') in England and Wales following the Princess's death compared to the 3 months beforehand, and the equivalent periods in 1992-1996. Similar analysis on DSH presentations to a general hospital.

RESULTS

Suicides increased during the month following the Princess's funeral (+17.4%). This was particularly marked in females (+33.7%), especially those aged 25-44 years (+45.1%). Suicides did not fall in the week between the death and the funeral. Presentations for DSH increased significantly during the week following the death (+44.3%), especially in females (+65.1%). Examination of case notes suggested that the influence of the death was largely through amplification of personal losses or exacerbation of existing distress.

CONCLUSIONS

The death of a major public figure can influence rates of suicidal behaviour. For DSH, the impact may be immediate, but for suicide it may be delayed.

Deliberate self poisoning with antidepressant drugs: a comparison of the relative hospital costs of cases of overdose of tricyclics with those of selective-serotonin re-uptake inhibitors

BACKGROUND

Debate continues over the relative merits of tricyclics and selective serotonin re-uptake inhibitors (SSRIs) as first line antidepressant treatment for depression. SSRIs are safer in overdose but more expensive than tricyclics. This report compared the hospital costs of cases of overdose with both groups of drug.

METHODS

Records of all persons aged over thirteen years presenting to a general hospital in one year were analysed for demographic information and details of their attendance.

RESULTS

There were 1165 episodes of self-poisoning, 151 involving tricyclics as the sole antidepressant and 69 SSRIs as the sole antidepressant. Those taking SSRIs had a shorter (1.96 vs. 2.59 days) and less expensive ( pound330 vs. pound567) stay. A large proportion of this difference in cost was due to a small number of admissions to the Intensive Care Unit.

LIMITATIONS

This study used only hospital costs, so excluding costs associated with primary care.

CONCLUSIONS AND CLINICAL RELEVANCE

If there were similar cost differences countrywide, the difference in hospital costs of self poisoning with SSRIs and tricyclics would represent an additional pound3.87 million per year due to self poisoning with tricyclics across the whole of England and Wales. This is a small proportion of the estimated pound100 million cost of switching to first-line prescribing of SSRIs for depression.

Suicide in older people: mode of death, demographic factors, and medical contact before death

OBJECTIVE

To determine the demographic characteristics, mode of death, and nature and timing of medical contacts in the year before death in a sample of suicides in older people.

DESIGN

Descriptive study of a case series of 195 suicides in older people.

SETTING

Four counties and one large urban area in central England, UK.

SUBJECTS

Individuals 60 years old and over at time of death, who had died between 1 January 1995 and 1 May 1998, and whose deaths has received a coroner's verdict of suicide, or an open or accidental verdict where the circumstances of death indicated probable suicide.

MAIN OUTCOME MEASUREMENTS

Demographic details and information on mode of death and medical contact prior to death derived from coroners' inquest notes, General Practitioners' (GP) case-notes and psychiatric records.

MAIN RESULTS

67.7% were male. A higher proportion of men than women were single or divorced. The commonest methods of suicide were hanging in men and drug overdose in women, 49.8% had seen their GP in the month before death, although over half these last consultations were for physical complaints. Only 15.4% were under psychiatric care at the time of death.

CONCLUSIONS

Older men are at higher risk of suicide than women. Given the high proportion of drug overdoses in the sample, effective strategies to prevent suicide in older people might include improving the prescribing of analgesics and antidepressants. Although older people at risk of suicide often consult their GP shortly before death, GPs may have difficulty identifying those at risk because of the high proportion of physical complaints.

Recommended care for young people (15-19 years) after suicide attempts in certain European countries

Data on recommended care for young people aged 15-19 years after attempted suicide from nine European research centres during the period 1989-1992 were analysed in terms of gender, history of previous suicide attempt and methods used. Altogether 438 suicide attempts made by 353 boys and 1,102 suicide attempts made by 941 girls were included. Analyses of the total data from all centres showed that young people with a history of previous suicide attempt and those using violent methods had significantly higher chance of being recommended aftercare than first-time attempters or those choosing self-poisoning. There were no significant differences of being recommended care between genders. Logistic regression analyses of the material were performed and the results were similar. Both having previous attempted suicide (odds ratio 2.0, 95% CI 1.53-2.61) and using "hard" methods (odds ratio 1.71, 95% CI 1.49-1.96) were significantly associated with increased possibility of being recommended aftercare. When individual centres were analysed, large disparities of recommended care after suicide attempts were found and there were no uniform criteria of recommending care for young suicide attempters in Europe.

Doctors who kill themselves: a study of the methods used for suicide

Medical practitioners have a relatively high rate of suicide. Death entry data for doctors who died by suicide or undetermined cause between 1979 and 1995 in England and Wales were used to compare methods used for suicide by doctors with those used by the general population. Methods used were analysed according to gender, occupational status and speciality, to assess the extent to which access to dangerous means influences the pattern of suicide. Self-poisoning with drugs was more common in the doctors than in general population suicides (57% vs. 26.6%; OR=3.65, 95% CI 2.85-4. 68), including in retired doctors. Barbiturates were the most frequent drugs used. Half of the anaesthetists who died used anaesthetic agents. Self-cutting was also more frequently used as a method of suicide. The finding that the greater proportion of suicide deaths in doctors were by self-poisoning may reflect the fact that doctors have ready access to drugs, and have knowledge of which drugs and doses are likely to cause death. The specific finding that a large proportion of suicides in anaesthetists involved anaesthetic agents supports this explanation. Availability of method may be a factor contributing to the relatively high suicide rate of doctors. This fact might influence clinical management of doctors who are known to be depressed or suicidal.

Methods used for parasuicide: results of the WHO/EURO Multicentre Study on Parasuicide

BACKGROUND

National suicide statistics show remarkable differences in the frequencies of various methods used for completed suicide. The WHO/EURO Multicentre Study on Parasuicide makes possible for the first time an international comparison of the frequencies of methods used in attempted suicide, because the data are based on geographical catchment areas of medical institutions.

METHOD

Ongoing standardized monitoring of attempted suicide in all medical institutions serving the catchment areas was performed in 14 centres in 12 European countries. The data analysis is based on 20,649 events involving 15,530 persons, recorded between 1989 and 1993.

RESULTS

The comparison of rates per 100,000 shows striking differences between the centres. The highest rates for drug overdoses were found for female attempters in Oxford (347/100,000), Helsinki (238/100,000) and Stockholm (221/100,000). Guipuzcoa had the lowest rates (61/100,000). The differences were most prominent in the age group 15-24, with outstanding rates for women in Oxford (653/100,000), which was mainly due to the frequent use of analgesics. Szeged had outstandingly high rates for pesticides and solvents. In some centres the use of multiple methods was frequent.

CONCLUSIONS

There is a need, especially for areas with high frequencies for certain methods, to understand the factors involved and to develop new and specific prevention projects and to monitor their effects. The WHO/EURO Multicentre Study on Parasuicide has proved to be a useful and reliable instrument for continuous monitoring of trends in parasuicide.

Suicide in psychiatric hospital in-patients. Risk factors and their predictive power

BACKGROUND

Psychiatric hospital in-patients are known to be at high risk of suicide, yet there is little reliable knowledge of risk factors or their predictive power.

AIMS

To identify risk factors for suicide in psychiatric hospital in-patients and to evaluate their predictive power in detecting people at risk of suicide.

METHOD

Using a case-control design, 112 people who committed suicide while in-patients in psychiatric hospitals were compared with 112 randomly selected controls. Univariate analysis and multivariate analyses were used to estimate odds ratios and adjusted likelihood ratios.

RESULTS

The rate of suicide in psychiatric in-patients was 13.7 (95% CI 11.7-16.1) per 10,000 admissions. There were five predictive factors with likelihood ratios > 2, following adjustment: planned suicide attempt, 4.1; actual suicide attempt, 4.9; recent bereavement, 4.0; presence of delusions, 2.3; chronic mental illness, 2.2; and family history of suicide, 4.6. On this basis, only two of the patients who committed suicide had a predicted risk of suicide above 5%.

CONCLUSIONS

Although several factors were identified that were strongly associated with suicide, their clinical utility is limited by low sensitivity and specificity, combined with the rarity of suicide, even in this high-risk group.

Deliberate self-harm in adolescents in Oxford, 1985-1995

Deliberate self-harm (DSH) has been one of the major health problems of adolescents in the U.K. for many years. Any changes in rates of DSH or the demographic characteristics of the patient population are likely to have important implications for clinical services and for future suicidal behaviour. Following a decline in rates in the late 1970s and mid 1980s, there were signs in the late 1980s that rates were beginning to increase again. We have used data collected by the Oxford Monitoring System for Attempted Suicide on the basis of patients presenting to the general hospital in Oxford to review trends in DSH in under 20-year-olds between 1985 and 1995. There was a substantial increase in the numbers of teenage DSH patients during the 11-year study period, with an increase between 1985-1986 and 1994-1995 of 27.7% in males, 28.3% in females, and 28.1% overall. There were no demographic changes within the catchment area to explain a change of this size. As rates of repetition of DSH also increased in both sexes during the study period the overall number of episodes of DSH rose even more between 1985-1986 and 1994-1995 (+56.9% in males, +46.3% in females, and +49.4% overall). As in previous studies the majority of adolescents had interpersonal problems and/or difficulties with studying or employment. Self-poisoning with paracetamol and paracetamol compounds became increasingly common such that by 1995 these were used in almost two-thirds of overdoses. The recent increase in DSH in adolescents has important implications for general hospital and adolescent psychiatric services. The greater frequency of repetition of DSH may herald increased future suicide rates. The case for restricting the amount of paracetamol available is overwhelming. Evaluative trials of specific interventions following adolescent DSH are urgently required.

Psychosocial versus pharmacological treatments for deliberate self harm

OBJECTIVES

To identify and synthesise the findings from all randomised controlled trials that have examined the effectiveness of treatments of patients who have deliberately harmed themselves.

SEARCH STRATEGY

Electronic databases screened: MEDLINE (from 1966-February 1999); PsycLit (from 1974-March 1999); Embase (from 1980-January 1999); The Cochrane Controlled Trials Register (CCTR) No.1 1999. Ten journals in the field of psychiatry and psychology were hand searched for the first version of this review. We have updated the hand search of three specialist journals in the field of suicidal research until the end of 1998. Reference lists of papers were checked and trialists contacted.

SELECTION CRITERIA

All RCTs of psychosocial and/or psychopharmacological treatment versus standard or less intensive types of aftercare for patients who shortly before entering a study engaged in any type of deliberately initiated self-poisoning or self-injury, both of which are generally subsumed under the term deliberate self-harm.

DATA COLLECTION AND ANALYSIS

Data were extracted from the original reports independently by two reviewers. Studies were categorized according to type of treatment. The outcome measure used to assess the efficacy of treatment interventions for deliberate self-harm was the rate of repeated suicidal behaviour. We have been unable to examine other outcome measures as originally planned (e.g. compliance with treatment, depression, hopelessness, suicidal ideation/thoughts, change in problems/problem resolution).

MAIN RESULTS

A total of 23 trials were identified in which repetition of deliberate self-harm was reported as an outcome variable. The trials were classified into 11 categories. The summary odds ratio indicated a trend towards reduced repetition of deliberate self-harm for problem-solving therapy compared with standard aftercare (0.70; 0.45 to 1.11) and for provision of an emergency contact card in addition to standard care compared with standard aftercare alone (0.45; 0.19 to 1.07). The summary odds ratio for trials of intensive aftercare plus outreach compared with standard aftercare was 0.83 (0.61 to 1.14), and for antidepressant treatment compared with placebo was 0.83 (0. 47 to 1.48). The remainder of the comparisons were in single small trials. Significantly reduced rates of further self-harm were observed for depot flupenthixol vs. placebo in multiple repeaters (0. 09; 0.02 to 0.50), and for dialectical behaviour therapy vs. standard aftercare (0.24; 0.06 to 0.93).

REVIEWER'S CONCLUSIONS

There still remains considerable uncertainty about which forms of psychosocial and physical treatments of self-harm patients are most effective, inclusion of insufficient numbers of patients in trials being the main limiting factor. There is a need for larger trials of treatments associated with trends towards reduced rates of repetition of deliberate self-harm. The results of small single trials which have been associated with statistically significant reductions in repetition must be interpreted with caution and it is desirable that such trials are also replicated.

Do adolescents who take overdoses have specific psychological characteristics? A comparative study with psychiatric and community controls

OBJECTIVE

To determine whether specific psychological factors characterize adolescents who take overdoses.

METHOD

Measures of problem-solving, depression, anger, impulsivity, and self-esteem were investigated in 33 adolescents after an overdose, 30 psychiatric controls, and 30 community controls, the groups being matched for age and sex. All subjects were interviewed twice, 6 weeks apart. The first interview in the overdose group followed an overdose.

RESULTS

Significant differences were found between the 3 groups on all of the variables at both interviews. However, when depressive affect (Beck Depression Inventory) was controlled for, all of these differences disappeared, except for impulsivity at the second interview. Here the overdose group remained more impulsive than the other groups even when depression was considered.

CONCLUSIONS

Depression is the most important factor in the presentation of a range of psychological characteristics of adolescents who take overdoses, and this remains true at 6-week follow-up. Impulsivity is apparently an important factor, independent of depression, in adolescent self-poisoning. Further research is required to determine the mediating role of impulsivity in this behavior and to identify treatment strategies for it.

Suicide in young people. Study of 174 cases, aged under 25 years, based on coroners' and medical records

BACKGROUND

Suicide rates in young males in the UK have risen markedly in recent years.

AIMS

To investigate the characteristics of a series of consecutive suicides in under-25-year-olds.

METHOD

We studied coroners' inquest notes, general practitioners' records and psychiatric case notes of 174 individuals (148 males and 26 females) whose deaths received a verdict of suicide or an open or accidental verdict (excluding traffic accidents) where the circumstances strongly suggested suicide.

RESULTS

More individuals were of lower social class and unemployed than in the local population. Hanging and carbon monoxide poisoning were the most frequent methods of suicide, and coproxamol was the drug most often used in overdoses. Previous self-harm had occurred in 44.8%, nearly half of these having carried out multiple episodes and 80% having self-harmed within the previous year. Little support was found for an earlier finding of increasing frequency of general practitioner visits shortly before death. Only 22.4% of individuals were in the care of psychiatric services.

CONCLUSIONS

Diverse strategies are required to prevent suicide in the very young.

Repetition of deliberate self-harm by adolescents: the role of psychological factors

The aim of this study was to examine the relationship between psychological variables and repetition of deliberate self-harm by adolescents (n=45) aged 13-18 years who had been admitted to a general hospital having taken overdoses. Standardized measures of depression, hopelessness, suicidal intent, impulsivity, trait and state anger, self-esteem and problem-solving (both self-report and observer-rated) were administered to the adolescents while still in the general hospital. Repetition was assessed on the basis of previous overdoses (n=14) and repetition of self-harm (self-poisoning and self-injury) during the subsequent year (n=9). Adolescents with a history of a previous overdose and/or who repeated self-harm during the following year (n=18) differed from non-repeaters in having higher scores for depression, hopelessness and trait anger, and lower scores for self-esteem, self-rated problem-solving and effectiveness of problem-solving rated on the basis of the Means End Problem Solving test, all measured at the initial assessment. These differences largely disappeared when level of depression was controlled for. Similarly, differences found between repeaters and non-repeaters in the year following the index overdoses for problem-solving were much reduced when account was taken of differences in depression scores. Depression is a key factor associated with risk of repetition of adolescent self-harm (and hence of suicide risk). In the management of adolescents who have harmed themselves, careful assessment of depression and appropriate management of those who are depressed is essential.

Attempted suicide and major public holidays in Europe: findings from the WHO/EURO Multicentre Study on Parasuicide

OBJECTIVE

The aim of the study was to examine the relationship between suicide attempts and major public holidays in Europe.

METHOD

The analysis was based on data on 24 388 suicide attempts by persons aged 15 years or older in the period 1989-1996. Data from 13 centres (representing 11 countries) participating in the WHO/EURO Multicentre Study on Parasuicide were analysed. The analysis of the fluctuation of suicide attempts around public holidays was based on the daily number of suicide attempts for each centre. For each day in the period under examination a mean number of suicide attempts (mu) was calculated. The analysis was based on the assumption that the data followed a Poisson distribution. The observed number of daily suicide attempts was compared with the expected number of attempts. A multiplicative model for the expected number in each centre was developed.

RESULTS

Before Christmas there were fewer suicide attempts than expected, and after Christmas there were approximately 40% more attempts than expected. In addition, more attempts than expected were registered on New Year's Day. In countries where people have the day off work on Whit Monday there were significantly fewer attempts during the 3 days before, but where Whit Monday is a normal working day significantly fewer attempts occurred on the Monday to Wednesday after Whit Sunday.

CONCLUSION

There appears to be a transposition of a significant number of suicide attempts from before (and during) a major public holiday until after it. The division of holidays into non-working and working days showed that a 'holiday effect' could only be found around major public holidays, particularly Christmas, Easter and Whitsun. These findings support the theory of the 'broken-promise effect' for major public holidays.

Suicide in nurses

The worldwide English language literature on suicide in nurses is reviewed in this article. There is evidence from several countries that female nurses are at increased risk of suicide. Very little information is available about the specific causes. Increased risk in nurses has been statistically associated with smoking and negatively related to extent of caffeine consumption. Unlike some other high-risk occupational groups, it is unclear to what extent access to means for suicide contributes to nurses' risk. The methodological issues and specific needs of research concerning suicide in nurses are discussed.

Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study

OBJECTIVES

To determine whether a serious paracetamol overdose in the medical television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning.

DESIGN

Interrupted time series analysis of presentations for self poisoning at accident and emergency departments during three week periods before and after the broadcast. Questionnaire responses collected from self poisoning patients during the same periods.

SETTING

49 accident and emergency departments and psychiatric services in United Kingdom collected incidence data; 25 services collected questionnaire data.

SUBJECTS

4403 self poisoning patients; questionnaires completed for 1047.

MAIN OUTCOME MEASURES

Change in presentation rates for self poisoning in the three weeks after the broadcast compared with the three weeks before, use of paracetamol and other drugs for self poisoning, and the nature of overdoses in viewers of the broadcast compared with non-viewers.

RESULTS

Presentations for self poisoning increased by 17% (95% confidence interval 7% to 28%) in the week after the broadcast and by 9% (0 to 19%) in the second week. Increases in paracetamol overdoses were more marked than increases in non-paracetamol overdoses. Thirty two patients who presented in the week after the broadcast and were interviewed had seen the episode-20% said that it had influenced their decision to take an overdose, and 17% said it had influenced their choice of drug. The use of paracetamol for overdose doubled among viewers of Casualty after the episode (rise of 106%; 28% to 232%).

CONCLUSIONS

Broadcast of popular television dramas depicting self poisoning may have a short term influence in terms of increases in hospital presentation for overdose and changes in the choice of drug taken. This raises serious questions about the advisability of the media portraying suicidal behaviour.

The geographical distribution of suicides in farmers in England and Wales

Farmers in England and Wales have an elevated risk of suicide. The aim of this study was to investigate the geographical distribution of suicides in farmers. Rates of suicide (including suicide and open verdicts) of farmers in England and Wales between 1981 and 1993 were calculated on a county basis. Trends in rates and differences in rates between counties, regions and England and Wales were then analysed. There were 719 suicides (634 suicide verdicts and 85 open verdicts). There was evidence of a decline in annual rates of suicide in farmers during the study period in England but not Wales. There was no evidence of geographical heterogeneity of farming suicides according to counties, but a relatively high rate for Devon (N = 62 suicides). County farming suicide rates did not appear to be related to local general population suicide rates, density of farmers or type of farm holding. While identification of counties with relatively large numbers of farming suicides should assist targeting of local preventive programmes, it is clear that any significant prevention strategies should be implemented on a national basis.

Why has suicide increased in young males?

Several countries in the Western hemisphere have experienced a marked increase in suicide rates in young males in recent years. This article considers this phenomenon largely from the perspective of the United Kingdom, where rates of suicide in 15-24-year-old males nearly doubled in just over a decade. The possible reasons for this are considered, particularly in the context of relative stability of suicide rates in young females.

Stress in farmers: a survey of farmers in England and Wales

OBJECTIVES

To investigate potential sources of stress for farmers in England and Wales

METHOD

A postal questionnaire was sent to a randomly selected group of 800 members of the National Farmers' Union and 200 members of the Farmers' Union of Wales.

RESULTS

500 questionnaires (51%) were returned completed between October 1995 and March 1996. Farmers had problems with record keeping and paperwork (62%), difficulty understanding forms (56%), and problems arising from the effects of new legislation and regulations (49%). Nearly a quarter (23%) reported financial problems and most worried about money (79%). Very few were socially isolated, with over 90% having at least one confidant. 70% worked > 10 hours a day, and 31% had health problems which interfered with their work, including more than a quarter of those < 50. 16% of the sheep farmers reported symptoms which they attributed to organophosphate poisoning. The farmers most vulnerable to financial and other problems were those with small farms and mixed farming operations. Farmers in Wales also seemed more vulnerable than those in England, but a lower response rate from members of the Farmers' Union of Wales means this difference should be interpreted cautiously.

CONCLUSION

The survey confirms findings from several regional studies that many farmers are experiencing considerable stress from various causes. Local and national initiatives to assist farmers, including outreach programmes, should be encouraged. Policy makers should be aware of the potential impact of legislation, particularly on the more vulnerable groups.

Methods used for suicide by farmers in England and Wales. The contribution of availability and its relevance to prevention

BACKGROUND

Farmers in the UK have an elevated risk of suicide. It has been suggested that this may be related to their ease of access to dangerous means for suicidal behaviour. The extent to which farmers use these means and changes in their use may be relevant to suicide prevention.

METHOD

Data on 719 deaths in farmers of both genders in England and Wales between 1981 and 1993 in which a verdict of suicide or undetermined cause (open verdict) was recorded were analysed.

RESULTS

Of 702 deaths in male farmers, firearms were involved in 40.0%, hanging in 29.6%, carbon monoxide in 16.4%, poisoning in 8.0% (over half of which involved agricultural or horticultural poisons) and other methods in 6.1%. There was a considerable excess of deaths due to firearms compared with the distribution of methods of suicide and open verdict deaths in males in the general population. Hanging was also somewhat more frequent. During the study period there was a reduction in firearm death rates, particularly after 1989 when there was national legislation on firearm ownership, registration and storage. There were also fewer farming suicides after this date. By the end of the study period hanging was more frequent than deaths involving firearms.

CONCLUSIONS

Farmers who commit suicide tend to use methods to which they have easy access. Restriction of the ready availability of such methods, particularly in farmers known to be depressed or otherwise at risk, might prevent some suicides.

The psychological autopsy approach to studying suicide: a review of methodological issues

The psychological autopsy approach to studying suicide is becoming an increasingly used research method. It presents considerable methodological problems. In order to assist future researchers in this field and to help readers assess reports of psychological autopsy studies the authors have reviewed these issues on the basis of their own experience and those of other workers. The areas covered include research design, identification of subjects, sources of information and the particular issues concerned with approaching relatives and other informants, choice and recruitment of controls, the difficulties of conducting psychological autopsy interviews with relatives, problems for interviewers, the selection of appropriate measures to obtain information, and achieving valid and reasonably reliable conclusions from diverse information sources.

Deliberate self harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition

OBJECTIVE

To identify and synthesise the findings from all randomised controlled trials that have examined the effectiveness of treatments of patients who have deliberately harmed themselves.

DESIGN

Systematic review of randomised controlled trials of psychosocial and physical treatments. Studies categorised according to type of treatment. When there was more than one investigation in a particular category a summary odds ratio was estimated with the Mantel-Haenszel method.

SETTING

Randomised trials available in electronic databases in 1996, in the Cochrane Controlled Trials Register in 1997, and from hand searching of journals to 1997.

SUBJECTS

Patients who had deliberately harmed themselves shortly before entry into the trials with information on repetition of behaviour. The included trials comprised 2452 randomised participants with outcome data.

MAIN OUTCOME MEASURE

Repetition of self harm.

RESULTS

20 trials reported repetition of self harm as an outcome variable, classified into 10 categories. Summary odds ratio (all for comparison with standard aftercare) indicated reduced repetition for problem solving therapy (0.73; 95% confidence interval 0.45 to 1.18) and for provision of an emergency contact card in addition to standard care (0.45; 0.19 to 1.07). The summary odds ratios were 0.83 (0.61 to 1.14) for trials of intensive aftercare plus outreach and 1.19 (0.53 to 2.67) for antidepressant treatment compared with placebo. Significantly reduced rates of further self harm were observed for depot flupenthixol versus placebo in multiple repeaters (0.09; 0.02 to 0.50) and for dialectical behaviour therapy versus standard aftercare (0.24; 0.06 to 0.93).

CONCLUSION

There remains considerable uncertainty about which forms of psychosocial and physical treatments of patients who harm themselves are most effective. Further larger trials of treatments are needed.

Adolescents who take overdoses: outcome in terms of changes in psychopathology and the adolescents' attitudes to care and to their overdose

Adolescent self-poisoners were followed up 3 months after taking an overdose. High levels of psychopathology were found, with 72% (18/25) of the adolescents having a diagnosable psychiatric disorder and 48% (12/25) major depression. All the adolescents were offered follow-up treatment from health or social services. Compliance with treatment was very high. Seventy-two per cent of the adolescents found treatment useful to them. The adolscents received a generally sympathetic response from their significant others. Fifty-four per cent of the adolescents thought that their overdose had resulted overall in improvements to their lives but 44% would consider taking an overdose again in similar circumstances.