Deliberate self-harm in alcohol and drug misusers: patient characteristics and patterns of clinical care

Outcomes and Costs of Poisoned Patients Admitted to an Adult Emergency Department of a Spanish Tertiary Hospital: Evaluation through a Toxicovigilance Program

Abstract

Toxicovigilance is the active process of identifying and evaluating the toxic risks existing in a community, and evaluating the measures taken to reduce or eliminate them.

Objective

Through a validated toxicovigilance program (SAT-HULP) we examined the characteristics of acute poisoning cases (APC) attended in the Emergency Department (ED) of La Paz Hospital (Madrid, Spain) and assessed their economic impact on the health system.

Material and Methods

The active poisoning surveillance system performs a daily search for cases in the hospital´s computerized case records. Found cases are entered into a database for recording of type of poisoning episode, reasons for exposure, causative agent, signs and symptoms and treatment. We carried out a cross-sectional epidemiological study with analytical projection, based on an impact study on cost per survivor. The data for the costs attributable to cases of APC observed at HULP (outpatients and inpatients) was obtained from the based on the information provided by the diagnosis-related groups (DRG) through the corresponding hospital discharge reports (available through SAT-HULP).

Results

During the first 30 month of SAT-HULP operation we found a total of 3,195 APC, a cumulative incidence rate of 1.75% of patients attended in the ED. The mean (SD) patient age was 40.9 (17.8) years and 51.2% were men. Drug abuse accounted for 47.5% of the cases. Suicide attempt was the second most frequent category (38.1%) and other causes accounted for 14.5% of APC. The total cost of hospital care for our hospital rose to €1,825,263.24 (approximately €730,105.30/year) resulting in a permanent occupation of 4 beds/year.

Conclusions

SAT-HULP constitutes a validated toxicovigilance tool, which continuously integrates available data in real-time and helps health services manage APC data flexibly, including the consumption of resources from the health system.

Alcohol use and psychiatric comorbid disorders predict deliberate self-harm behaviour and other suicidality among depressed adolescent outpatients in 1-year follow-up

BACKGROUND

Suicidality, including deliberate self-harm behaviour (DSH), represents one of the most adverse and clinically serious consequences of depression. More detailed longitudinal research is needed in order to find clinical risk factors of DSH and other suicidal behaviour among depressed adolescent outpatients in order to identify those at greatest risk of life-threatening behaviour.

AIM

This follow-up study investigated alcohol use, Axis I comorbid disorders, depressive and anxiety symptoms, and psychosocial functioning as risk factors of suicidal behaviour, including DSH, among depressed adolescent outpatients during a 1-year follow-up.

METHODS

Consecutive depressed adolescent outpatients (n = 189) aged 13-19 years were interviewed at baseline and at follow-up by using the Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime (K-SADS-PL) for DSM-IV Axis I diagnoses and self-report questionnaires. Suicidal behaviour was assessed by K-SADS suicidality items.

RESULTS

During 1-year follow-up, one-quarter of all participants, and almost three-quarters of suicidal adolescents had DSH. Alcohol use and mood disorder with Axis I comorbidity at baseline predicted both DSH and other suicidal behaviour during follow-up. Mood disorder during follow-up predicted all forms of suicidal behaviour.

CONCLUSIONS

Detection and effective treatment of continuing mood disorder, comorbid disorders and alcohol use may significantly improve clinician's ability to identify adolescent outpatients at high risk of subsequent DSH and other suicidal behaviour. Treatment interventions should aim at full recovery of depression.

Repetition of acute poisoning in Oslo: 1-year prospective study

BACKGROUND

The repetition of acute poisoning occurs frequently. The intention may change between episodes and many poisonings are treated outside the hospital setting. Few studies have taken this into account.

AIMS

To quantify the repetition frequency regardless of the level of health care or the intention behind the poisoning, and to identify possible risk factors for repetition.

METHOD

A prospective multicentre study of all acute poisonings in Oslo treated in hospital, at an out-patient clinic or by the ambulance service. Repetition was estimated using Kaplan-Meier calculations, and predictive factors were identified using Cox regression analysis.

RESULTS

The estimated 1-year repetition rate was 30% (95% CI 24-35). Independent predictors of repetition were middle age (30-49 years), poisoning with opiates or sedatives, unemployment or living on social welfare, a previous suicide attempt, and a history of psychiatric treatment. Intention was not a significant predictor.

CONCLUSIONS

Repetition of acute poisoning is high, irrespective of the level of healthcare and the intention behind the poisoning.

Gender, suicide, and the sociocultural context of deliberate self-harm in an urban general hospital in Mumbai, India

Recognizing the complementary effects of social contexts and psychiatric disorders, this study clarifies the role of gender in suicidal behavior in urban Mumbai by considering psychiatric diagnoses and patient-identified sociocultural features. The cultural epidemiological approach suggests the critical impact of situational sociocultural factors that complement the customary psychopathological accounts for those who harm or kill themselves. The cultural epidemiology of deliberate self-harm (DSH), it is argued, is critical to planning for suicide prevention, community mental health and psychiatric practice. This study, based on a cultural epidemiological framework, compares male and female admissions for DSH, evaluating conditions with SCID-I and EMIC interviews. We assessed features and narratives of suicidal behavior, patient-identified underlying problems, their perceived causes and triggers. The study included 92 women and 104 men. A diagnosis of depressive disorder was made for 48.9 percent of women and 39.4 percent of men. Many patients (50.0 percent of women and 41.3 percent of men) did not fulfill the criteria for any diagnosis, or did so only for an adjustment disorder or a V-code. Men typically explained DSH with reference to work problems, financial problems and problem drinking. Women typically discussed domestic problems, in-law relations and victimization. Problem drinking affected women living with men who drank. Social and situational factors appear to play a relatively greater role than psychiatric illness in self-harm and suicide in Mumbai, as in other Asian studies, compared with Europe and North America.

A 20-year prospective study of mortality and causes of death among hospitalized opioid addicts in Oslo

BACKGROUND

To study mortality rate and causes of death among all hospitalized opioid addicts treated for self-poisoning or admitted for voluntary detoxification in Oslo between 1980 and 1981, and to compare their mortality to that of the general population.

METHODS

A prospective cohort study was conducted on 185 opioid addicts from all medical departments in Oslo who were treated for either self-poisoning (n = 93, 1980), voluntary detoxification (n = 75, 1980/1981) or both (n = 17). Their median age was 24 years; with a range from 16 to 41, and 53% were males. All deaths that had occurred by the end of 2000 were identified from the Central Population Register. Causes of death were obtained from Statistics Norway. Standardized mortality ratios (SMRs) were computed for mortality, in general, and in particular, for different causes of death.

RESULTS

During a period of 20 years, 70 opioid addicts died (37.8%), with a standardized mortality ratio (SMR) equal to 23.6 (95% CI, 18.7-29.9). The SMR remained high during the whole period, ranging from 32.4 in the first five-year period, to 13.4 in the last five-year period. There were no significant differences in SMR between self-poisonings and those admitted for voluntarily detoxification. The registered causes of death were accidents (11.4%), suicide (7.1%), cancer (4.3%), cardiovascular disease (2.9%), other violent deaths (2.9%), other diseases (71.4%). Among the 50 deaths classified as other diseases, the category "drug dependence" was listed in the vast majority of cases (37 deaths, 52.9% of the total). SMRs increased significantly for all causes of death, with the other diseases group having the highest SMR; 65.8 (95% CI, 49.9-86.9). The SMR was 5.4 (95% CI, 1.3-21.5) for cardiovascular diseases, and 4.3 (95% CI, 1.4-13.5) for cancer. The SMR was 13.2 (95% CI, 6.6-26.4) for accidents, 10.7 (95% CI, 4.5-25.8) for suicides, and 28.6 (95% CI, 7.1-114.4) for other violent deaths.

CONCLUSION

The risk of death among opioid addicts was significantly higher for all causes of death compared with the general population, implying a poor prognosis over a 20-year period for this young patient group.

The relationship between suicidal behavior, ideation, and binge drinking among college students

Suicidal ideation and behavior among college students are serious and prevalent problems that warrant considerable attention. While a variety of situational and personality factors have been linked to suicidal behavior, alcohol use is one of the most commonly cited factors. As alcohol consumption is a frequent activity for many college students, the association between alcohol use and suicidal behavior may have particularly lethal consequences for students. Yet, to date, few studies have examined the relationship between drinking and suicidal ideation and behavior in this population. This study provides empirical support for this relationship. That is, significant relationships were found between past alcohol use and past suicide attempt(s) and between past binge drinking and past suicidal behavior and ideation. The results are discussed in light of their implications for intervention with and assessment of students presenting with suicidal ideation, behavior, and/or binge drinking.

Alcohol dependence, excessive drinking and deliberate self-harm: trends and patterns in Oxford, 1989-2002

BACKGROUND

Problems relating to alcohol use are very common among deliberate self-harm (DSH) patients, and alcohol abuse increases the risk of both DSH and suicide. In the UK, per capita consumption of alcohol has risen by 50% since 1970. The proportion of women (but not men) drinking in excess of government-recommended limits has also increased. We investigate trends, by gender and age group, in alcohol problems and usage among DSH patients.

METHOD

Data collected by the Oxford Monitoring System for Attempted Suicide were used to examine trends in alcohol disorders and alcohol consumption shortly before, or at, the time of self-harm by patients aged 15 years or over between 1989 and 2002.

RESULTS

Data were available on 10,414 patients who were involved in 17,511 episodes of DSH. The annual numbers of both male and female DSH patients rose progressively over the study period. Although rates of alcohol disorders and consumption remained higher in males than females, substantial increases were seen in females of all ages in rates of alcohol problems, excessive drinking and consumption of alcohol within 6 h of DSH and as part of the act of DSH. Rates for males largely remained unchanged.

CONCLUSIONS

There has been a significant increase in excessive drinking and consumption of alcohol around the time of DSH by females but not males. These changes may relate to increases in the affordability and availability of alcohol and to social changes in drinking patterns. They have implications for services for DSH patients and may have an impact on future patterns of suicidal behaviour.

Australian and New Zealand clinical practice guidelines for the management of adult deliberate self-harm

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.

Alcohol-dependent patients attempting and not attempting suicide: a comparison

BACKGROUND

Alcohol dependence is a psychiatric disorder associated with an increased risk of suicidal behaviour. This is also associated with an increased number of suicide risk factors.

OBJECTIVE

The current study examined the sociodemographic and clinical characteristics of a number of alcohol-dependent patients who attempted suicide.

METHODS

We studied a consecutive series of 377 alcohol-dependent patients in our in-patient clinics. Their alcohol-use histories were assessed through semistructured interviews. The Suicidal Behaviors Questionnaire, the Childhood Trauma Questionnaire, the Michigan Alcoholism Screening Test and the Hamilton Depression Rating Scale were administered to all patients. Serum total cholesterol levels, mean corpuscular volume, the liver enzymes gamma glutamyl transferase, aspartate aminotransferase and alanine aminotransferase were routinely measured. In the statistical analyses, Student's t-test and chi-squared tests were applied.

RESULTS

Of the 377 alcohol-dependent patients, 89 (23.6%) had histories of attempted suicide. Thirty-four (42.5%) of the 80 female alcohol-dependent patients and 55 (18.5%) of the 297 male alcohol-dependent patients had attempted suicide; this gender difference was statistically significant (χ2 = 27.7, P < 0.001). A greater proportion of the suicide attempters than of the non-attempters met the Diagnostic Statistical Manual IV criteria for another psychiatric disorder (60.6%, n = 54, vs. 40.6%, n = 117; χ2 = 14.8; df = 6; P < 0.05). The difference of total cholesterol levels between female (mean = 144.0, SD = 58.3; mean = 158.0, SD = 83.9; t = 4.5; P < 0.05) and male (mean = 133.7, SD = 50.5; mean = 163.6, SD = 69.7; t = 11.7; P < 0.01) attempters and non-attempters was statistically significant.

CONCLUSION

These results suggest that suicide attempts in alcohol-dependent patients are associated with more profound biopsychosocial pathology and decreased serum cholesterol levels.

Transitions of employment status among suicide attempters during a severe economic recession

Previous studies have shown a positive association between unemployment and attempted suicide. This study investigated transitions of employment status among suicide attempters during the severe economic recession. The main research question was whether inequality in the labour market also prevails among as selected a population as suicide attempters. The material consisted of 2495 persons who attempted suicide during 1989-1994 in Helsinki, Finland. Logistic regression analysis and survival analysis were used. Unemployment rates among suicide attempters were higher than in the general population, male rates being higher than female rates throughout the recession. There were significant changes in the employment status of the entire attempted suicide population from 1989 to 1994, especially in terms of the transition from employment to unemployment. Gender, age and education level predicted exit from the labour market. Among suicide attempters young middle-aged men with low education had the highest risk of unemployment.

Deliberate Self-Harm Patients with Alcohol Disorders: Characteristics, Treatment, and Outcome

Summary: 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.