Variation between hospitals in inpatient admission practices for self-harm patients and its impact on repeat presentation

Variation in the clinical management of self-harm by area-level socio-economic deprivation: findings from the multicenter study of self-harm in England

BACKGROUND

We investigated disparities in the clinical management of self-harm following hospital presentation with self-harm according to level of socio-economic deprivation (SED) in England.

METHODS

108 092 presentations to hospitals (by 57 306 individuals) after self-harm in the Multicenter Study of Self-harm spanning 17 years. Area-level SED was based on the English Index of Multiple Deprivation. Information about indicators of clinical care was obtained from each hospital's self-harm monitoring systems. We assessed the associations of SED with indicators of care using mixed effect models.

RESULTS

Controlling for confounders, psychosocial assessment and admission to a general medical ward were less likely for presentations by patients living in more deprived areas relative to presentations by patients from the least deprived areas. Referral for outpatient mental health care was less likely for presentations by patients from the two most deprived localities (most deprived: adjusted odd ratio [aOR] 0.77, 95% CI 0.71-0.83, p < 0.0001; 2nd most deprived: aOR 0.80, 95% CI 0.74-0.87, p < 0.0001). Referral to substance use services and 'other' services increased with increased SED. Overall, referral for aftercare was less likely following presentations by patients living in the two most deprived areas (most deprived: aOR 0.85, 95% CI 0.78-0.92, p < 0.0001; 2nd most deprived: aOR 0.86, 95% CI 0.79-0.94, p = 0.001).

CONCLUSIONS

SED is associated with differential care for patients who self-harm in England. Inequalities in care may exacerbate the risk of adverse outcomes in this disadvantaged population. Further work is needed to understand the reasons for these differences and ways of providing more equitable care.

Estimated Average Treatment Effect of Psychiatric Hospitalization in Patients With Suicidal Behaviors: A Precision Treatment Analysis

Importance

Psychiatric hospitalization is the standard of care for patients presenting to an emergency department (ED) or urgent care (UC) with high suicide risk. However, the effect of hospitalization in reducing subsequent suicidal behaviors is poorly understood and likely heterogeneous.

Objectives

To estimate the association of psychiatric hospitalization with subsequent suicidal behaviors using observational data and develop a preliminary predictive analytics individualized treatment rule accounting for heterogeneity in this association across patients.

Design, Setting, and Participants

A machine learning analysis of retrospective data was conducted. All veterans presenting with suicidal ideation (SI) or suicide attempt (SA) from January 1, 2010, to December 31, 2015, were included. Data were analyzed from September 1, 2022, to March 10, 2023. Subgroups were defined by primary psychiatric diagnosis (nonaffective psychosis, bipolar disorder, major depressive disorder, and other) and suicidality (SI only, SA in past 2-7 days, and SA in past day). Models were trained in 70.0% of the training samples and tested in the remaining 30.0%.

Exposures

Psychiatric hospitalization vs nonhospitalization.

Main Outcomes and Measures

Fatal and nonfatal SAs within 12 months of ED/UC visits were identified in administrative records and the National Death Index. Baseline covariates were drawn from electronic health records and geospatial databases.

Results

Of 196 610 visits (90.3% men; median [IQR] age, 53 [41-59] years), 71.5% resulted in hospitalization. The 12-month SA risk was 11.9% with hospitalization and 12.0% with nonhospitalization (difference, -0.1%; 95% CI, -0.4% to 0.2%). In patients with SI only or SA in the past 2 to 7 days, most hospitalization was not associated with subsequent SAs. For patients with SA in the past day, hospitalization was associated with risk reductions ranging from -6.9% to -9.6% across diagnoses. Accounting for heterogeneity, hospitalization was associated with reduced risk of subsequent SAs in 28.1% of the patients and increased risk in 24.0%. An individualized treatment rule based on these associations may reduce SAs by 16.0% and hospitalizations by 13.0% compared with current rates.

Conclusions and Relevance

The findings of this study suggest that psychiatric hospitalization is associated with reduced average SA risk in the immediate aftermath of an SA but not after other recent SAs or SI only. Substantial heterogeneity exists in these associations across patients. An individualized treatment rule accounting for this heterogeneity could both reduce SAs and avert hospitalizations.

A comparison of daytime and out of hour mental health presentations to Beaumont Hospital Emergency Department between 2018 and 2020

BACKGROUND

In 2018, there were more than 12,000 self-harm presentations to emergency departments (EDs) in Ireland with 50% occurring between 7p.m. and 3a.m. There is evidence that the assessment quality and follow-up is variable across clinicians. To address this, The National Clinical Programme for the Management of Self-Harm in the ED (NCPSH 2016) was developed to set clear standards.

AIM

Our aim was to compare diagnosis and management of patients presenting to Beaumont Hospital (BH) ED, across a 3-year period, by the on-site Liaison Psychiatry Service, during normal working hours, to the off-site on call service outside of normal working hours (OOH).

METHODS

This is a retrospective audit of BH ED patients referred for psychiatric assessment between 2018 and 2020, using patient electronic records for data collection, and Pearson's chi square testing for group differences. Post hoc analysis was performed using adjusted residuals and Bonferroni correction.

RESULTS

Of 3659 psychiatric referrals to Beaumont ED from 2018 to 2020, alcohol-related disorders were the most common diagnosis and were diagnosed more frequently during normal working hours (n = 592, 16.2%; 22.9% normal hours vs 8.5% OOH, p < 0.001), while personality disorder was diagnosed more frequently out of hours. (n = 432, 11.8%; 9.6% normal hours vs 14.4% out of hours, p < 0.001). There was a statistically significant difference in referral to voluntary services out of hours (7.2% normal hours vs 0.3% OOH).

CONCLUSION

In contrast to previous findings, our study found higher rates of alcohol-related disorders diagnosed during normal hours vs OOH. Furthermore, voluntary and addiction services were under-utilised OOH and this presents an important teaching opportunity.

Adverse clinical outcomes among youths with nonsuicidal self-injury and suicide attempts: a longitudinal cohort study

BACKGROUND

More knowledge about risks of clinical outcomes associated with nonsuicidal self-injury (NSSI) and suicide attempts (SAs) is needed to inform risk assessment and intervention.

METHODS

Longitudinal cohort study based on 1,855 youths was clinically assessed for NSSI and SA, and followed up (from December, 2011 to December 2013) for the outcomes; diagnosed self-injury, alcohol/substance use disorder, and psychiatric inpatient care data derived from Swedish registers. Hazard ratios (HRs) and 95% confidence intervals (CIs) of the outcomes were estimated with Cox regressions, and additionally adjusted for the potential effect of sex and the number of clinical assessments. NSSI and SA were treated as time-varying covariates.

RESULTS

Youths with NSSI had elevated risks of all outcomes, compared with youths without NSSI or SA; the HR was 2.3, 95% confidence interval [1.6, 3.4] for self-injury, 1.4 [0.9, 2.1] for alcohol/substance use disorder, and 1.3 [1.0, 1.7] for psychiatric inpatient care. Youths with SA displayed higher risks for the outcomes than the NSSI group; the HR was 5.5 [2.4, 12.6] for self-injury, 2.0 [0.9, 4.4] for alcohol/substance use disorder, and 2.6 [1.5, 4.5] for psychiatric inpatient care. Youths with both NSSI and SA showed similar risks as youths with SA; HR 4.1 [2.0, 8.3] for self-injury, 2.0 [1.1, 4.1] for alcohol/substance use disorder, but a higher risk of psychiatric inpatient care; HR 5.0 [3.1, 7.9]. All results remained virtually unchanged in the adjusted analyses.

CONCLUSIONS

Youths with NSSI and/or SA had higher risks for subsequent adverse clinical outcomes. These excess risks were more pronounced among youths with SA and youths with both NSSI and SA, and the risk for psychiatric inpatient care was particularly high in youths with both NSSI and SA. Our findings suggest that early interventions for youths with NSSI or SA should not exclusively focus on suicide prevention, but also consider the risk of subsequent alcohol/substance use disorder.

Psychiatric admissions after hospital presented deliberate self-harm in the young: A national study

Follow-up psychiatric care is crucial for young adults presenting to hospitals because of deliberate self-harm (DSH). However, who receives such care is not sufficiently understood. We therefore investigated the clinical and sociodemographic correlates of admissions to psychiatric inpatient treatment immediately following general hospital treatment of DSH in this age band. All episodes of hospital presented DSH among patients aged 18-35 years during the period 2008-2018 were identified from the Norwegian Patient Register. The outcome was admissions to psychiatric inpatient treatment immediately after discharge from the general hospital. The correlates of such admissions were calculated using binomial generalized estimating equation. Of 26.166 identified DSH episodes, 21.4% were admitted to psychiatric inpatient treatment. Admissions were most common for patients with a history of psychiatric treatment and a recorded diagnosis of psychosis-, mood- or personality disorders. Adjusted for other psychiatric factors, alcohol- or substance misuse diagnoses and repeated presentations of DSH were inversely associated with admissions to psychiatric inpatient treatment. Young adults admitted to psychiatric inpatient treatment following DSH have a high burden of psychiatric morbidity and risk factors for suicide. However, the inverse association seen for two important risk factors for suicide, alcohol- or substance misuse and repeated DSH, warrants further attention.

Factors associated with psychiatric admission and subsequent self-harm repetition: a cohort study of high-risk hospital-presenting self-harm

BACKGROUND

Individuals presenting to hospital with self-harm of high lethality or high suicidal intent are at high risk of subsequent suicide.

AIM

To examine factors associated with psychiatric admission and self-harm repetition following high-risk self-harm (HRSH).

METHOD

A cohort study of 324 consecutive HRSH patients was conducted across three urban hospitals (December 2014-February 2018). Information on self-harm repetition was extracted from the National Self-harm Registry Ireland. Logistic regression models examined predictors of psychiatric admission and self-harm repetition. Propensity score (PS) methods were used to address confounding.

RESULTS

Forty percent of the cohort were admitted to a psychiatric inpatient setting. Factors associated with admission were living alone, depression, previous psychiatric admission, suicide note and uncommon self-harm methods. History of emotional, physical or sexual abuse was associated with not being admitted. Twelve-month self-harm repetition occurred in 17.3% of cases. Following inverse probability weighting according to the PS, psychiatric admission following HRSH was not associated with repetition. Predictors of repetition were recent self-harm history, young age (18-24 years) and previous psychiatric admission.

CONCLUSION(S)

Findings indicate that psychiatric admission following HRSH is not associated with repeated self-harm and reaffirms the consistent finding that history of self-harm and psychiatric treatment are strong predictors of repetition.

Study designs and outcomes used in evaluation studies of hospital-presenting self-harm: protocol for a methodological systematic review

INTRODUCTION

Self-harm is the most common risk factor for suicide, and so those who present to hospital following self-harm provide an opportunity for targeted clinical care interventions. Observational studies evaluating such interventions may be useful in overcoming limitations of controlled trials, but study design, statistical analyses and outcomes used must be appropriate. This methodological systematic review will describe, categorise, synthesise and compare the methodological aspects of studies evaluating interventions and aspects of clinical management following hospital-presenting self-harm in both observational and experimental (ie, controlled trials or quasi-experimental studies) study designs.

METHODS AND ANALYSIS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Protocol guidelines were followed in drafting this protocol. Search terms were developed (related to self-harm, hospital presentation and evaluation studies) and adapted for MEDLINE, PsycINFO, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials and grey literature databases. Two reviewers will independently screen 100 titles/abstracts until consensus is reached, with the remaining screened by one reviewer. Full-text screening will be conducted independently by two reviewers. Data will be extracted by one reviewer, and a second will check all data extracted. Validated risk of bias tools will be used. Data synthesis will focus on the heterogeneity of outcomes used in individual studies. Descriptive summary statistics of the data (eg, key study characteristics, type and frequency of outcomes) will be provided in categorical format, using frequencies and percentages. Outcomes will be reported separately for trials (both randomised and non-randomised trials), observational and quasi-experimental studies. Categorisation of outcomes will be guided by Cochrane Effective Practice and Organisation of Care resources for reviews of health systems interventions.

ETHICS AND DISSEMINATION

Results will be disseminated at national and international conferences and published in a peer-reviewed journal. Findings will be used to inform future studies in the area of hospital-presenting self-harm. Ethical approval is not required for this review.

PROSPERO REGISTRATION NUMBER

CRD42020208714.

A Comparison of Presentations with Self-Harm to Hospital in Lithuania and Ireland

Suicide is a serious problem globally, especially in Europe, with suicide rates varying between different countries. Self-harm is a known risk factor for dying by suicide and represents an opportunity to intervene in order to treat any associated mental illness and reduce risk. This study aimed to compare the characteristics of people presenting to hospital with self-harm at two clinical sites: Galway, Ireland and Kaunas, Lithuania. Data were obtained from the services’ database and anonymised for analysis. Over a 5-month period, 89 patients presented with self-harm at the Lithuanian site and 224 patients presented with self-harm at the Irish site. This study found significant differences in presentation, diagnosis and treatment between the two sites. All patients at the Lithuanian site were admitted to psychiatry, compared to 22% of patients at the Irish site (p < 0.001). In Lithuania, the main clinical diagnoses were adjustment disorder (37.1%) and major depression (20.2%), compared to substance misuse being the main clinical diagnosis (33.8%) in Ireland (p < 0.001). There were significant differences in the prescription of psychotropic medications (which were three times more commonly prescribed at the Lithuanian site) after controlling for age, gender and psychiatric history (p < 0.001). Further research is required to understand the cultural context behind and further association between hospitalisation and future death by suicide.

A Brief Breathing Space: Experiences of Brief Admission by Self-Referral for Self-Harming and Suicidal Individuals with a History of Extensive Psychiatric Inpatient Care

Individuals with severe self-harm and experiences of lengthy psychiatric admissions often have complex mental health conditions and are at risk of suicide. In this qualitative study, self-harming individuals with >180 days of psychiatric admission over 12 months shared their experiences of Brief Admission (BA), a standardized crisis-management intervention encouraging self-admission and autonomy. Phenomenological hermeneutic analysis formulated BA as a worthy respite, replacing an old system of having to prove need 'in blood' or wait and get worse. Successes and struggles in early help-seeking, interpreted in the light of human rights and person-centered care, suggested that individual development of autonomy depended on perceived focus on recovery and compassion. Future research may consider ethical and health-economic aspects of BA in a broader perspective.

Prevalence and clinical correlates of self-harm and suicidality during admission of children in a mental health inpatient unit

Background

Self-harm and suicidality are common presentations in children and adolescents requiring a mental health inpatient admission. Although there are several studies on adolescents, there is relatively limited research into childhood self-harm and suicidality during such admissions.

Methods

A retrospective electronic file review was conducted on all children discharged from a national mental health inpatient children’s unit over a 6-year period. Several independent variables were compared between self-harm/suicidal and non-self-harm/non-suicidal children. Separate analyses investigated changes in self-harm/suicidality, functional outcomes, and risk assessment ratings between admission and discharge.

Results

A total of 105 children were included in this study. During admission, 65.7% of them reported self-harm thoughts, 61% engaged in self-harm, 50.5% expressed suicidal thoughts, and 14.3% engaged in suicidal behavior. Thoughts and acts of self-harm were associated with previous self-harm, longer admissions, and Attention Deficit Hyperactivity Disorder. Suicidality overlapped with self-harm and was strongly predicted by previous self-harm. The prevalence of self-harm and suicidal thoughts and acts significantly decreased during admission. Children in the non-self-harm group had marginally better functional outcomes upon discharge compared to those in the self-harm group. Children and parents/caregivers were similarly satisfied with treatment, irrespective of children’s self-harm/suicidality.

Conclusions

Self-harm and suicidality were widespread among children admitted to hospital. Better understanding of the mechanisms and factors related to self-harm and suicidality in this age group could help mitigate associated risks and improve existing safety strategies.

How the emergency department four-hour target affects clinical outcomes for patients diagnosed with a personality disorder

Emergency departments (EDs) may already be invalidating environments for patients diagnosed with a personality disorder, with negative attitudes from staff perpetuating patients' feelings of dismissal and rejection. Despite a higher prevalence of patients with personality disorder in health services, including EDs, than the general population, there is a lack of literature on how achieving ED targets may affect this patient group. This article expands on Harden's concept of destructive goal pursuit in relation to the four-hour target and uses the literature to illustrate how pressures to meet the target may distort clinical priorities and result in adverse clinical outcomes for patients. It makes recommendations for practice including using short-stay units in which patients can be treated outside of the target wait time and introducing mental health triage in EDs to improve delivery of psychosocial assessments.

Recommended next care following hospital-treated self-harm: Patterns and trends over time

Objective

The specific objectives of this study were to examine variation in the care of self-harm patients in hospital settings and to identify the factors that predict recommended next care following self-harm.

Methods

Data on consecutive presentations to Irish emergency departments (EDs) involving self-harm from the National Self-Harm Registry Ireland from 2004 to 2012 were utilised. Univariate and multivariate regression analyses were performed to assess the associations between patients’ clinical and demographic characteristics, and recommended next care received.

Results

Across the study period a total 101,904 self-harm presentations were made to hospital EDs, involving 63,457 individuals. Over the course of the study there was a declining number of presentations resulting in patient admission following attendance with self-harm. Recommended next care varied according to hospital location, with general admission rates ranging from 11% to 61% across administrative health regions. Multinomial logistic regression identified that the factor which most strongly affected next care was the presenting hospital. Being male, older age, method, repeat self-harm, time of attendance and residence of the patient were all identified as influencing care received. Psychiatric admission was most common when highly lethal methods of self-harm were used (OR = 4.00, 95% CI, 3.63–4.41). A relatively large proportion of patients left the ED without being seen (15%) and the risk of doing so was highest for self-harm repeaters (1.64, 1.55–1.74 for those with 5+ presentations).

Conclusions

The extensive hospital variation in recommended next care indicates that management of self-harm patients may be determined more by where they present than by the needs of the patient. The study outcomes underline the need to standardise the clinical management of self-harm patients in general hospital settings.