Does initial management affect the rate of repetition of deliberate self harm? cohort study

Ambivalent toward life, ambivalent toward psychotherapy? An investigation of the helping alliance, motivation for treatment, and control expectancies in patients with suicidal ideation in inpatient psychotherapy

BACKGROUND

Research has found that patients with suicidal ideation (SI) are at high risk for unfavorable outcomes. The present work aimed to expand the knowledge about their characteristics and treatment success.

METHODS

Data were drawn from a routine assessment of N = 460 inpatients. We used patients' self-report data as well as therapists' reports covering baseline characteristics, depression and anxiety symptoms (at the start and end of therapy), psychosocial stress factors, helping alliance, treatment motivation, and treatment-related control expectancies. In addition to group comparisons, we conducted tests of associations with treatment outcome.

RESULTS

SI was reported by 232 patients (50.4% of the sample). It co-occurred with higher symptom burden, more psychosocial stress factors, and negation of help. Patients reporting SI were more likely to be dissatisfied with the treatment outcome (although their therapists were not). SI was related to higher levels of anxiety symptoms after treatment. In regression models of depression and anxiety symptoms, interactions of SI with the external control expectancy powerful others were observed, suggesting that in patients with frequent SI, this control expectancy hindered recovery.

DISCUSSION/CONCLUSION

Patients reporting SI are a vulnerable group. Therapists could support them by addressing (potentially conflicting) motivations and control expectancies.

Predictors of intentional intoxication using decision tree modeling analysis: a retrospective study

OBJECTIVE

The suicide rate in South Korea is very high and is expected to increase in coming years. Intoxication is the most common suicide attempt method as well as one of the common reason for presenting to an emergency medical center. We used decision tree modeling analysis to identify predictors of risk for suicide by intentional intoxication.

METHODS

A single-center, retrospective study was conducted at our hospital using a 4-year registry of the institute from January 1, 2013 to December 31, 2016. Demographic factors, such as sex, age, intentionality, therapeutic adherence, alcohol consumption, smoking status, physical disease, cancer, psychiatric disease, and toxicological factors, such as type of intoxicant and poisoning severity score were collected. Candidate risk factors based on the decision tree were used to select variables for multiple logistic regression analysis.

RESULTS

In total, 4,023 patients with intoxication were enrolled as study participants, with 2,247 (55.9%) identified as cases of intentional intoxication. Reported annual percentages of intentional intoxication among patients were 628/937 (67.0%), 608/1,082 (56.2%), 536/1,017 (52.7), 475/987 (48.1%) from 2013 to 2016. Significant predictors identified based on decision tree analysis were alcohol consumption, old age, psychiatric disease, smoking, and male sex; those identified based on multiple regression analysis were alcohol consumption, smoking, male sex, psychiatric disease, old age, poor therapeutic adherence, and physical disease.

CONCLUSION

We identified important predictors of suicide risk by intentional intoxication. A specific and realistic approach to analysis using the decision tree modeling technique is an effective method to determine those groups at risk of suicide by intentional intoxication.

Introducing a nurse-led deliberate self-harm assessment service

Aims and Method

This study considered patients admitted to hospital following deliberate self-poisoning. The characteristics of the patients and the outcomes of assessments by trainee psychiatrists and a mental health nurse were compared.

Results

There were no significant differences in the outcome of 68 assessments performed by a trainee psychiatrist and 77 by a mental health nurse. The nurse assessment service was well-received by the poisons unit, a medical ward specialising in overdose treatment, and trainee psychiatrists.

Clinical Implications

Psychosocial assessments following self-poisoning can be provided by appropriately trained and supervised mental health nurses. The introduction of a nurse-led service should enhance relationships with the local poisons unit and reduce the workload of junior doctors without compromising their training needs.

Repeated self-injury from a liaison psychiatry perspective

Self-injury (self-harm) occurs frequently and is familiar in the accident and emergency departments and surgical and medical wards of ‘acute hospitals’. Despite its common presentation, there are frequent and authoritative reports that patients' experiences of emergency hospital treatment for self-harm are often negative. There is compelling evidence for the need to improve delivery of care for patients who self-harm, and to improve the training, supervision, support and coordination of the staff groups delivering that care.

A standard liaison psychiatry service structure?

Aims and Method

We surveyed all psychiatric services in the six northeast strategic health authorities to determine how the provision of liaison psychiatry services related to College recommendations and the size of the general hospital trusts served.

Results

Thirty-six (100%) services provided usable data, 8% of general hospital trusts had no liaison psychiatry service, 41% of teams were not multidisciplinary with their only staff being nurses, only 38% of services had dedicated consultant psychiatry time and only a quarter met the recommended minimum standard of 0.5 whole-time equivalents. No teams contained clinical psychologists. Disorder-specific out-patient clinic provision was idiosyncratic.

Clinical Implications

There is a lack of rational planning of liaison psychiatry services and as a result, many services are not needs-based and do not comply with College recommendations. One indication of this is the lack of multidisciplinary teams.

Risk of recurrent overdose associated with prescribing patterns of psychotropic medications after nonfatal overdose

OBJECTIVE

We aimed to estimate risk of recurrent overdose associated with psychosocial assessment by psychiatrists during hospitalization for nonfatal overdose and prescribing patterns of psychotropic medications after discharge.

METHODS

A retrospective cohort study was conducted using a nationwide claims database in Japan. We classified patients aged 19-64 years hospitalized for nonfatal overdose between October 2012 and September 2013 into two cohorts: 1) those who had consulted a psychiatrist prior to overdose (n=6,790) and 2) those who had not (n=4,950). All patients were followed up from 90 days before overdose until 365 days after discharge.

RESULTS

Overall, 15.3% of patients with recent psychiatric treatment had a recurrent overdose within 365 days, compared with 6.0% of those without psychiatric treatment. Psychosocial assessment during hospital admission had no significant effect on subsequent overdose, irrespective of treatment by psychiatrists before overdose. There was a dose-response relationship for the association of benzodiazepine prescription after overdose with subsequent overdose in either cohort, even after accounting for average daily dosage of benzodiazepines before overdose and other confounders. In patients with recent psychiatric treatment, the cumulative proportion of recurrent overdose at 365 days was 27.7% for patients receiving excessive dosages of benzodiazepines, 22.0% for those receiving high dosages, 15.3% for those receiving normal dosages, and 7.6% for those receiving no benzodiazepines. In patients without psychiatric treatment, the cumulative proportion of recurrent overdose at 365 days was 24.3% for patients receiving excessive dosages of benzodiazepines, 18.0% for those receiving high dosages, 9.0% for those receiving normal dosages, and 4.1% for those receiving no benzodiazepines.

CONCLUSION

Lower dose of benzodiazepines after overdose is associated with lower risk of subsequent overdose.

Psychiatric intervention and repeated admission to emergency centres due to drug overdose

BACKGROUND

Repeated drug overdose is a major risk factor for suicide. Data are lacking on the effect of psychiatric intervention on preventing repeated drug overdose.

AIMS

To investigate whether psychiatric intervention was associated with reduced readmission to emergency centres due to drug overdose.

METHOD

Using a Japanese national in-patient database, we identified patients who were first admitted to emergency centres for drug overdose in 2010-2012. We used propensity score matching for patient and hospital factors to compare readmission rates between intervention (patients undergoing psychosocial assessment) and unexposed groups.

RESULTS

Of 29 564 eligible patients, 13 035 underwent psychiatric intervention. In the propensity-matched 7938 pairs, 1304 patients were readmitted because of drug overdose. Readmission rate was lower in the intervention than in the unexposed group (7.3% v. 9.1% respectively, P<0.001).

CONCLUSIONS

Psychiatric intervention was associated with reduced readmission in patients who had taken a drug overdose.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England

Objectives

To carry out a programme of linked research studies aimed at improving the management of self-harm, reducing the incidence of suicide and providing reliable data to evaluate the impact of theNational Suicide Prevention Strategy for England(2002).

Methods

There were four research streams: (1) we studied inquest records from 12 coroners and Ministry of Justice data to assess the accuracy of official suicide statistics; (2) we used Office for National Statistics mortality statistics, data from the Multicentre Study of Self-harm in England, national liver unit data, prescription data and patient interviews to assess (a) the impact of paracetamol (acetaminophen) pack size restrictions (1998), (b) the impact of withdrawal of co-proxamol in 2007 and (c) the relative toxicity in overdose of commonly used antidepressants; (3) we carried out 3-month audits of self-harm management in 32 hospitals to investigate variations between hospitals and the impact of management on repeat self-harm; and (4) we developed and piloted letter-based contact interventions aimed at reducing self-harm.

Key findings

(1) Between 1990 and 2005, the proportion of researcher-defined suicides given a verdict of suicide by the 12 coroners studied decreased by almost 7%, largely because of the increased use of misadventure/accident verdicts for deaths thought, on clinical review, to be suicides. Use of narrative verdicts increased markedly. Coroners who gave more narrative verdicts also gave fewer suicide verdicts, and geographical variations in the use of narrative verdicts appeared to distort reliable assessment of small-area differences in suicide rates. 2(a) UK legislation to reduce pack sizes of paracetamol was followed by a 43% reduction in number of deaths and a 61% reduction in registrations for liver transplantation over the next 11 years. Paracetamol overdoses were often impulsive and some were influenced by media (including the internet); sales outlets appeared mostly to be adhering to sales guidance. Smaller pack sizes of paracetamol for sale in Ireland compared with England did not result in a smaller number of tablets being taken in overdose. There was no clear evidence of an effect of the legislation on prescribing of non-steroidal anti-inflammatory drugs, nor on resulting gastrointestinal bleeds. 2(b) Withdrawal of co-proxamol from use in the UK resulted in approximately 600 fewer deaths than predicted between 2005 and 2010 based on previous trends, with no evidence of substitution by poisoning with other analgesics. 2(c) Of the tricyclic antidepressants, dosulepin and doxepin had the greatest toxicity. Citalopram was more toxic than other selective serotonin reuptake inhibitors. (3) There was marked variation between hospitals in the management of self-harm; effects of this variation on patient outcomes were unclear, although psychosocial assessment may have been associated with reduced repetition. Levels of specialist assessment remained static between 2001–2 and 2010–11, but service quality appeared to improve. (4) Findings of two pilot randomised controlled trials suggested that, although it would be feasible to scale up these interventions to full trials, these interventions might have low generalisability and be of limited benefit to patients.

Conclusion

Within the context of the strengths and limitations of the individual studies, this research programme has made significant additions to the evidence base related to suicide and self-harm prevention in the UK.

Study registration

A pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Service user perspectives on psychosocial assessment following self-harm and its impact on further help-seeking: a qualitative study

BACKGROUND

Psychosocial assessment is a central aspect of managing self-harm in hospitals, designed to encompass needs and risk, and to lead to further care. However, little is known about service user experiences of assessment, or what aspects of assessment service users value. The aim of this study was to explore service user experiences of assessment, and examine the short-term and longer-term meanings of assessment for service users.

METHOD

Interpretative phenomenological analysis was applied to 13 interviews with service users following hospital attendance, and seven follow-up interviews conducted 3 months later.

RESULTS

Few participants had a clear understanding of assessment's purpose. Assessment had the potential to promote or challenge hope, dependent on whether it was experienced as accepting or critical. If follow-up care did not materialise, this reinforced hopelessness and promoted disengagement from services.

LIMITATIONS

The study sample was small and the participants heterogeneous in terms of self-harm history, method and intent, which may limit the transferability of the findings to other settings. Only self-report data on clinical diagnosis were collected.

CONCLUSIONS

This was the first study to utilise an in-depth qualitative approach to investigate service user experiences of assessment and follow-up. The findings suggest that re-conceptualising psychosocial assessment as primarily an opportunity to engage service users therapeutically may consequently affect how health services are perceived. In order to maintain benefits established during the hospital experience, follow-up needs to be timely and integrated with assessment.

Attitudes and knowledge of clinical staff regarding people who self-harm: a systematic review

BACKGROUND

The attitudes held by clinical staff towards people who harm themselves, together with their knowledge about self-harm, are likely to influence their clinical practice and hence the experiences and outcomes of patients. Our aim was to systematically review the nature of staff attitudes towards people who engage in self-harm, including the factors that influence them, and the impact of training on attitudes, knowledge and behaviour of staff.

METHODS AND FINDINGS

A comprehensive search for relevant studies was performed on six electronic databases. Two independent reviewers screened titles, abstracts and full reports of studies, extracted data and gave each paper a quality rating. Qualitative and quantitative studies published in English were included. A total of 74 studies were included. Attitudes of general hospital staff, especially doctors, were largely negative, particularly towards individuals who repeatedly self-harm. Self-harm patients were viewed more negatively than other patients, except those abusing alcohol or drugs. Psychiatric staff in community and hospital settings displayed more positive attitudes than general hospital staff. Negative attitudes were more common among doctors than nursing staff although this was only true of general hospital staff. Active training led to consistent improvements in attitude and knowledge in all groups.

CONCLUSIONS

Attitudes of general hospital staff towards self-harm patients are often negative, mirroring the experience of service users. Interventions can have a positive impact and improve the quality of patient care.

LIMITATIONS

Included only English language publications.

Deliberate Self-Harm: Have We Scratched the Surface?

This article presents the current state of knowledge in deliberate-self harm (DSH). DSH presents as a comorbidity with a number of personality disorders and psychopathologies, but is also relatively common in the psychologically healthy population. Over the past 10 years, attention has shifted from the investigation of DSH as a cardinal or comorbid symptom of psychopathology to an attempt to understand the behaviour itself, without reference to other psychopathological processes. It is argued that this development in understanding the aetiology of DSH has not been matched by developments in treatment or management of DSH, with the majority of treatment programs targeting larger syndromes of which DSH is a symptom. Treatment regimes aimed at reducing DSH appear to be either untested or demonstrably unsuccessful.

Meeting standards set for non self-harm presentations to emergency departments

OBJECTIVES

The commonest psychiatric presentation in most emergency departments (EDs) is deliberate self-harm. However, there are other significant categories of psychiatric presentation which include alcohol and substance misuse, acute psychosis and mood disorder. In addition to the NICE Guidelines for deliberate self-harm, there are good practice guidelines available for the management of other psychiatric attendances to the ED. The aim of this study was to identify the psychiatric attendances other than deliberate self-harm to Beaumont Hospital ED over a 12-month period with the objective of studying the rates and characteristics of attendances and to investigate whether good practice guidelines were met.

METHOD

From a total of 657 psychiatric attendances other than deliberate self-harm which were recorded, data was collected on demographics, provision of a psychosocial assessment and adherence to good practice guidelines.

RESULTS

Alcohol (38%) was the most common reason for presentation. Of the total number of attendees, only 44% received a psychosocial assessment compared to 59% of attendees who had presented following deliberate self-harm during the same 12-month period.

CONCLUSIONS

The attendees who did not receive a psychosocial assessment represent a vulnerable group in which the levels of psychosocial assessment need to be improved in order to meet good practice guidelines standards of care.

Epidemiology and trends in non-fatal self-harm in three centres in England: 2000-2007

BACKGROUND

Self-harm is a common reason for presentation to a general hospital, with a strong association with suicide. Trends in self-harm are an important indicator of community psychopathology, with resource implications for health services and relevance to suicide prevention policy. Previous reports in the UK have come largely from single centres.

AIMS

To investigate trends in non-fatal self-harm in six general hospitals in three centres from the Multicentre Study of Self-harm in England, and to relate these to trends in suicide.

METHOD

Data on self-harm presentations to general hospital emergency departments in Oxford (one), Manchester (three) and Derby (two) were analysed over the 8-year period 1 January 2000 to 31 December 2007.

RESULTS

Rates of self-harm declined significantly over 8 years for males in three centres (Oxford: -14%; Manchester: -25%; Derby: -18%) and females in two centres (Oxford: -2% (not significant); Manchester: -13%; Derby: -17%), in keeping with national trends in suicide. A decreasing proportion and number of episodes involved self-poisoning alone, and an increasing proportion and number involved other self-injury (e.g. hanging, jumping, traffic related). Episodes involving self-cutting alone showed a slight decrease in numbers over time. Trends in alcohol use at the time of self-harm and repetition within 1 year were stable.

CONCLUSIONS

There were decreasing rates of non-fatal self-harm over the study period that paralleled trends in suicide in England. This was reflected mainly in a decline in emergency department presentations for self-poisoning.

Psychosocial assessment and repetition of self-harm: the significance of single and multiple repeat episode analyses

BACKGROUND

Self-harm is a common reason for presentation to the Emergency Department. An important question is whether psychosocial assessment reduces risk of repeated self-harm. Repetition has been investigated with survival analysis using various models, though many are not appropriate for recurrent events.

METHODS

Survival analysis was used to investigate associations between psychosocial assessment following an episode of self-harm and subsequent repetition, including (i) one repeat, and (ii) recurrent repetition (≤5 repeats) using (a) an independent episodes model, and (b) a stratified episodes model based on a conditional risk set. Data were from the Multicentre Study on Self-harm in England, 2000 to 2007.

RESULTS

Psychosocial assessment following an index episode of self-harm was associated with a 51% (95% CI 42%-58%) decreased risk of a repeat episode in persons with no psychiatric treatment history, and 26% (95% CI 8%-34%) decreased risk in those with a treatment history. For recurrent repetition, assessment was associated with a 57% (95% CI 51%-63%) decreased risk of repetition assuming independent episodes, and 13% (95% CI 1%-24%) decreased risk accounting for ordering and correlation of episodes by the same person (stratified episodes model). All models controlled for age, gender, method, history of self-harm, and centre differences.

LIMITATIONS

Some missing data on psychiatric treatment for non-assessed patients.

CONCLUSIONS

Psychosocial assessment appeared to be beneficial in reducing the risk of repetition, especially in the short-term. Findings for recurrent repetition were highly dependent on model assumptions. Analyses should fully account for ordering and correlation of episodes by the same person.

Collaboration between general hospitals and community health services in the care of suicide attempters in Norway: a longitudinal study

BACKGROUND

The aim of this paper was to study the collaboration between emergency departments (EDs) in general hospitals and community health services (CHS) in Norway when providing psychosocial care and aftercare to patients treated in EDs following a suicide attempt. We wanted to explore the extent to which quality indicators at the hospital level measured in 1999 and 2006 could predict the presence or absence of a chain of care structure in the CHS in 2006.

METHODS

Data were collected through structured interviews with informants from 95% of all general hospitals in Norway in 1999 and 2006, and informants from CHS, in a stratified sample of Norwegian municipalities in 2006 (n = 47).

RESULTS

In 15 of the 47 municipalities (32%), the CHS reported having a chain of care structure in 2006. A discriminant function analysis revealed that the hospitals that in 1999 had: (a) a collaboration agreement with aftercare providers, and (b) written guidelines, including a quality assurance system, were significantly more likely to have municipalities with a chain of care structure in their catchment area in 2006.

CONCLUSIONS

Hospitals' and municipalities' self-reported provision of aftercare services for patients treated after a suicide attempt was markedly below the recommendations given in national standards. Systems at the hospital level for the management and care of patients admitted after a suicide attempt and systematic collaboration between hospitals and aftercare providers seem to be important elements in the long-term maintenance of continuity of care for suicide attempters.

Assessment rates and compliance with assertive follow-up after self-harm: cohort study

The objectives of this study were to identify 1) the proportion of self-harm episodes that resulted in assessment by a specialist self-harm team and offers, attendance, and completion of brief therapy and 2) the factors associated with these treatment options. A prospective cohort study of 717 hospital presentations of self-harm was conducted. Rates of assessment, offers and completion of therapy ranged from 50% to 60%. Of those offered therapy, 73% attended one or more sessions. Attendance was associated with depressive psychopathology and existing treatment in primary care. These results may reflect some of the challenges of engaging this patient group. We found that receipt of treatment was determined by patient factors. Future studies might also examine the role of service-related or clinician factors.

Continuity of care in the treatment of suicide attempters--current challenges

Suicide attempters presenting for hospital treatment is a major public health challenge in most countries. Their tendency of dropping out of treatments and their high risk of repeat suicidal behavior call for systematic assessments, in-hospital management, treatment engagement and follow-up treatments after discharge from hospital. However, hospital services provided for suicide attempters and follow-up care may have highly variable quality and favorable care programs may deteriorate over time for various reasons. Effective and sustainable treatments and interventions to create cohesive chains of care are needed to release the substantial suicide prevention potential that exist in this population.

Implementing clinical guidelines for self harm - highlighting key issues arising from the NICE guideline for self-harm

The NICE clinical guideline on self-harm has been criticized for its reliance on expert consensus view in the absence of evidence on psychological aspects of care. The relative dearth of published experiences in implementing these guidelines is a likely consequence of these doubts. This article highlights the methodological problems inherent to the development of guidelines covering the first 48 hours after a presentation of self-harm, and reviews four areas where implementation has advanced: change in staff attitudes; triage scales; psychosocial assessments; and specific interventions for borderline personality disorder (BPD). Suggestions are made for how future versions of the guidelines might be adapted to improve the process of referral for appropriate psychological care and to provide more equitable access to care for patients in distress.

Caring for patients with suicidal behaviour: an exploratory study

Patients presenting to the emergency department (ED) with suicidal behaviour is relatively common. While many of these patients may be referred on to specialist mental health services, many are either discharged with no psychiatric follow-up or leave before being seen. There is therefore an increasing onus on the staff of EDs to become involved in the assessment and initial management of this patient group. The aim of this study was to describe the experiences and challenges that nurses encounter when caring for patients who present to the ED with suicidal behaviour. Forty-two ED nurses completed a 15-item semi-structured questionnaire. Participants in this study identified risk assessment as part of their role but did not focus on psychosocial assessment or psychological management of this patient group. Feelings of sympathy and compassion were reported towards these patients; however, there was often a prior judgement of the perceived 'genuineness' of the presentation. Finally, challenges experienced included a lack of appropriate communication skills and insufficient resources within the ED to adequately care for this vulnerable patient group.

Repetition of deliberate self-harm: a study of the characteristics and subsequent deaths in patients presenting to a general hospital according to extent of repetition

Repetition of deliberate self-harm (DSH) is common. Some patients repeat multiple times. We have investigated the characteristics of repeaters, and mortality in three groups of DSH patients by repetition status. Data collected by the Oxford Monitoring System for Attempted Suicide were used to examine the pattern of repetition of DSH patients presenting to a general hospital between 1990 and 1997. Each patient was tracked through the monitoring system with regard to repetition. Patients traceable through National Death Registers were followed up until 2000 with respect to mortality. A total of 4,167 patients were studied of which 1,022 (24.5%) repeated at least once during follow-up. Using multinomial regression, past history of DSH was the variable most strongly associated with frequent (4+) and less frequent (1-3) repetitions. Risk of suicide was significantly increased in females with frequent repetition (7.7% dying by suicide), compared with both those with 1-3 repetitions (2.3%) and those not repeating (1.0%). The analyses were repeated for the 2,167 patients with no past history of DSH at their first presentation. Using multinomial regression, personality disorder was the only variable that was associated with 4+ repetitions compared with no repetitions, although a number of variables distinguished between patients with 1-3 repetitions and no repeat episodes. For clinicians assessing DSH patients, past history of DSH is the best predictor of infrequent and frequent repetition. In patients with no past history of DSH the presence of personality disorder increases the risk of frequent repetition of DSH.

Characteristics and trends of self-harming behaviour in young people

Deliberate self-harm is recognized as a serious public health issue in young people. There is evidence that young people who self-harm are more likely to repeat self-harm, and this in turn increases their risk of completed suicide. Prevalence studies have identified that the rate of self-harm among young people is on the increase, information largely based on data arising from review and analysis of hospital attendances. However, community-based studies indicate that the prevalence is much higher, with those seen in emergency departments representing the 'tip of the iceberg' (Hawton and Rodham, 2006). Young people's motives for self-harm are discussed, as are research findings which indicate that nurses can have negative attitudes towards patients who self-harm. The article considers the implications of this for young people and identifies areas for future research.

Variations in time of hospital presentation for deliberate self-harm and their implications for clinical services

BACKGROUND

Variation in number, characteristics and management of deliberate self-harm (DSH) patients presenting to hospital during the 24-h cycle and day of the week may have implications for patient services. We have investigated how patient characteristics and clinical management of DSH episodes vary according to hour and day of presentation.

METHODS

Time of presentation was studied in 5348 DSH patients who presented to a general hospital following 9101 episodes during a 6-year period. Patient characteristics were identified through routine clinical monitoring.

RESULTS

Presentations varied markedly during the 24-h cycle, ranging from a peak between 8 pm and 3 am (average hourly rate of 6.6% of all episodes) to a low between 4 am and 10 am (1.4%). The majority (72.0%) occurred outside office hours. DSH associated with alcohol use and interpersonal problems was more frequent during the late evening or night, and at the weekend. A greater proportion of daytime presentations involved high suicide intent (although a larger number of high intent acts presented at other times), and more were admitted and assessed.

LIMITATIONS

This study was based on DSH presentations to one hospital. Time and date of presentation and of psychosocial assessment, not time of DSH, were available for analysis.

CONCLUSIONS

Peak times for DSH presentations are at night and the weekend, suggesting that specialist DSH services in general hospitals should be available 24 h a day, 7 days a week. Time of presentation should not be used as a proxy measure of suicide intent.

A Clinical Tool for Assessing Risk After Self-Harm

STUDY OBJECTIVE

Our aim is to develop a risk-stratification model for use by emergency department (ED) clinical staff in the assessment of patients attending with self-harm.

METHODS

Participants were patients who attended 5 EDs in Manchester and Salford, England, after self-harm between September 1, 1997, and February 28, 2001. Social, demographic, and clinical information was collected for each patient at each attendance. With data from the Manchester and Salford Self-Harm Project, a clinical decision rule was derived by using recursive partitioning to discriminate between patients at higher and lower risk of repetition or subsequent suicide occurring within 6 months. Data from 3 EDs were used for the derivation set. The model was validated with data from the remaining 2 EDs.

RESULTS

Data for 9,086 patients who presented with self-harm were collected during this study period, including 17% that reattended within 6 months and 22 patients who died by suicide within 6 months. A 4-question rule, with a sensitivity of 94% (92.1-95.0% [95% confidence interval]) and specificity of 25% (24.2-26.5% [95% confidence interval]), was derived to identify patients at higher risk of repetition or suicide.

CONCLUSION

Application of this simple, highly sensitive rule may facilitate assessment in the ED and help to focus psychiatric resources on patients at higher risk.

Patients with deliberate self-harm seen by a consultation-liaison service

OBJECTIVE

To examine Australian trends in deliberate self-harm in order to explore aetiological factors and improve clinical practice.

METHOD

A database recording 5 years of activity of a consultation-liaison service from a large tertiary referral hospital in Sydney was analysed to discover trends in types of self-harm, sex, age, marital status, repetition rates, diagnoses and follow up.

RESULTS

1295 patients with deliberate self-harm were referred to the Service over the 5 years. Of these patients, women exceeded men (ratio of 1.48:1). Self-poisoning constituted 79.5% of the referrals. Rates of self-harm referrals increased from 1999 to 2001, but appeared to plateau in 2002 and 2003. Eighty-eight per cent of referrals were first presentations of self-harm. Most referrals received the diagnosis of adjustment disorder with depressed mood, but a significant proportion was diagnosed with major depressive disorder and schizophrenia, particularly in those that violently self-harmed. There was a significant decline in the rate of admission to hospital over the study period.

CONCLUSIONS

While patient characteristics did not change significantly, there was a decline in admission rates to hospital. Many patients had serious mental illnesses, highlighting the importance of a thorough psychiatric assessment of people who self-harm.

Diminution des répétitions suicidaires grâce à une réorganisation des soins psychiatriques dans un service d’accueil-urgences

OBJECTIVES

To investigate the impact of the reorganization of psychiatric care in the Accident and Emergency (A&E) unit on repeated suicide attempts.

METHOD

The study includes suicide attempters admitted to the Rennes University Hospital (Brittany, France) A&E unit in 1994 (n=1003) and 2000 (n=1018). We compared the clinical data (age, gender, marital status, suicide history, methods, and outcome at discharge from A&E) and psychiatric management of the two cohorts. The rate of repeated suicide attempts was measured according to the same criterion in 1994 and 2000 (re-admission to the A&E unit).

RESULTS

Both populations of suicide attempters were very similar from both a clinical and demographic point of view. The repetition rate at 1 month was significantly higher (OR=4.16, p=0.0001) in 1994 than in 2000. The difference between the cohorts continued at three and six months, but became statistically insignificant at one year.

CONCLUSION

By 2000, organization of psychiatric care in the A&E unit had been substantially strengthened. The presence of a complete psychiatric team (nurses, junior psychiatrist, and senior psychiatrist) in the A&E unit, 24 hours a day, seven days a week, was associated with a lower rate of repeated suicide attempts.

Trends and characteristics of deliberate self-harm hospital presentations in an English County

Background. This study investigates deliberate self-harm (DSH) presentations to Southern Derbyshire hospitals from 1990 to 1997. Methods. Retrospective evaluation of deliberate self-harm rates and socio-demographic variables associated with DSH in 9961 consecutive attendances at Derby's two district general hospitals. Results. A significant rise in the rates of DSH in Derbyshire was noted (82%). The gender ratio has changed, with rising numbers of DSH episodes in males. The ratio of DSH episodes to the total Accident & Emergency (A&E) attendances changed from 1.54 to 2.42, with a 36% (95% CI 32-40%) rise in DSH presentations. Overdose remains the most common method of DSH (F = 85%, M = 78%). Two-thirds of the DSH presentations were first DSH attempts. Conclusions. Overall DSH rates are increasing especially in men. In contrast, official suicide rates have reduced during the same period. The increase in DSH rates has implications for already overworked A&E Departments, as well as other emergency and psychiatric services. Service provision and organisation should be reviewed in light of this increasing demand.

A 20-year review of trends in deliberate self-harm in a British town, 1981-2000

BACKGROUND

It is important to identify trends in deliberate self-harm because of potential links both with complex mental health problems and with suicide itself, and because of its significant impact on resources in both mental health and acute health services.

METHOD

Patients presenting at the A&E department at Kidderminster General Hospital following an act of deliberate self-harm between the years 1981 and 2000 were assessed by the Parasuicide Counselling Group. These data were used to examine trends in deliberate self-harm and patient characteristics.

RESULTS

The 20-year study examined 4,474 episodes of deliberate self-harm in the Kidderminster district. Rates of deliberate self-harm were higher in females throughout, although the difference between the genders narrowed in the second half of the 1990s. In both males and females, the rate of deliberate self-harm was highest in those aged 15-24. Since the mid-1990s, there have been increases in the rate of deliberate self-harm in males aged 45-54 and in females aged 25-44. Rates were highest in males and females who were separated. Although the most common method of deliberate self-harm in both males and females was overdose, males used cutting and other methods of deliberate self-harm proportionally more than females. There was a relentless rise in paracetamol use until a decline at the end of the study period following the introduction of a restriction on sales. Alcohol use at the time of deliberate self-harm rose markedly in both genders. There was a significant increase in deliberate self-harm repetition in both males and females over the study period. In males and females, psychiatric involvement or admission increased in the 1990s compared to the 1980s.

CONCLUSIONS

Higher levels of deliberate self-harm repetition and psychiatric involvement suggest increasing pressures on health services and a continuing need to develop understanding of deliberate self-harm.

Psychosocial assessment of patients who attend an accident and emergency department with self-harm

It has been recommended that all patients attending hospital accident and emergency departments in the United Kingdom (UK) with self-harm should be offered adequate psychosocial assessment to identify those at risk of completed suicide or repeated self-harm. This paper focuses on the extent to which this recommendation has been implemented in a large district general hospital in Wales, and compares the characteristics and hospital management of patients who received no specialist assessment with those who were assessed by a psychiatric liaison nurse or a psychiatrist. Data were routinely collected as part of the hospital annual audit procedure and confirm previous findings that guidelines for the general hospital management of self-harm patients have not been well implemented. Whilst we found some evidence that certain high risk patient groups were more likely to receive specialist assessment, this was far from universal. We conclude that if there is to be a reduction in the rate of suicide in Wales and the UK as a whole, it is crucial that services for people who self-harm are more appropriately targeted on patients who are at greatest risk.

Substance use and male gender as risk factors for deaths and suicide--a 5-year follow-up study after deliberate self-harm

OBJECTIVE

The aim of this study was to determine the mortality by suicide and other causes of death in a cohort of suicide attempters and identify predictive factors, including contact to healthcare after the attempt.

METHOD

All consecutive 1198 deliberate self-harm patients treated in hospital emergency rooms in Helsinki during a 12-month period were identified. Data were gathered on healthcare contacts preceding and following the index attempt, and cause-specific mortality over a 5-year period.

RESULTS

By the end of the 5-year follow-up period, 171 (14%) of the patients had died. A total of 57 (5%) had committed suicide. The age- and sex-adjusted risk for suicide among deliberate self-harm patients was 40-fold, and for death overall tenfold, compared to general population during the 5-year follow-up period. Risk factors for subsequent suicide were a diagnosis of substance use disorder, male gender and previous suicide attempts. A diagnosis of substance use disorder and male gender predicted death. Furthermore, male gender and substance use disorders had a strong interaction for both classes of death.

CONCLUSIONS

The findings of this study suggest that deliberate self-harm patients have a high risk for both suicide and other causes of death. Male gender and substance use disorders are significant risk factors for both later suicide and other causes of death. Male suicide attempters with substance use disorders have remarkably high total and suicide mortality.

Deliberate Self-Harm Patients Who Discharge Themselves from the General Hospital Without Adequate Psychosocial Assessment

Abstract: Deliberate self-harm patients who leave the acute hospital environment before the completion of psychiatric assessment have an increased risk of subsequent self-harm. We considered the available data on 50 premature self-discharges identified prospectively in a general hospital with a well-developed integrated-care pathway for self-harm patients, and compared them to a control group. The self-discharge group was found to be more likely to have attempted self-poisoning without alcohol intoxication or other forms or combinations of self-harm, and an absence of identifiable previous self-harm or prior contact with local specialist psychiatric services. The two groups showed no difference in age, sex, or area of residence based on community mental health team sectors. It is proposed that these findings indicate hypotheses for further studies of why people leave the hospital without adequate assessment, and how service design could be improved in order to help them.

Level of suicidal intent predicts overall mortality and suicide after attempted suicide: a 12-year follow-up study

BACKGROUND

The aim of this study was to comprehensively examine clinical risk factors, including suicide intent and hopelessness, for suicide and risk of death from all causes after attempted suicide over a 12-year follow-up period.

METHODS

A systematic sample of 224 patients from consecutive cases of attempted suicide referred to health care in four Finnish cities between 1 January and 31 July 1990 was interviewed.

RESULTS

After 12 years of follow-up 22% of these patients had died, 8% by committing suicide. The only statistically significant risk factor for eventual suicide was high scores on Beck's Suicidal Intention Scale. Male gender, older age, physical illness or disability and high scores on Beck's Suicidal Intention Scale predicted death overall.

CONCLUSIONS

Following attempted suicide, high intention to kill oneself is a significant risk factor for both death from all causes and suicide.

Self-harm patients who take early discharge from the accident and emergency department: How do they differ from those who stay?

There is evidence that patients presenting at a hospital Accident and Emergency (A&E) department with self-harm are considerably more likely than many others to discharge themselves before their assessment or treatment are complete. This paper reports a study that is part of a broader analysis of all self-harm presentations to a hospital A&E department over a five-year period. Self-harm patients who chose to remain for assessment and treatment were compared with those who chose to discharge themselves prematurely. We found a mean proportion of 18% of self-harm patients per annum took early discharge between 1996 and 2000 and noted that these patients were more likely than other self-harm patients to have consumed alcohol in the hours immediately prior to their self-harm and attendance at the hospital. Self-harm patients who took early discharge were less likely than other self-harm patients to be admitted to an in-patient bed and less likely to receive a psychosocial assessment from a mental health specialist. We also found that aftercare arrangements were significantly less likely to be made for those patients who took early discharge. Some suggestions are made about approaches that clinical staff could adopt in order to reduce early discharge in self-harm patients.

Therapist sensitivity towards emotional life-career issues and the working alliance with suicide attempters

This study investigated the usefulness of an action theoretical model of suicide in interviewing suicide attempters. Eighteen interviews were video-recorded and transcribed. The patients' narratives were reconstructed and life-career issues relevant for the patient's suicidality formulated. Skin conductance response was used to determine narrative content associated with actualized emotions. Scores of the patients' ratings of helping alliance experienced in the interview were positively associated with the therapists' sensitivity towards emotionally relevant life-career issues. Furthermore, relationship satisfaction was related to a narrative interviewing style. We conclude that working alliance in clinical interviews with suicide attempters can be improved when the interviewer uses a patient-oriented approach aimed at understanding the patient's suicidality in the context of personal life-career, or identity issues.

Self-injury attendances in the accident and emergency department: Clinical database study

BACKGROUND

Self-injury is a neglected area of self-harm research and we know little about its epidemiology, hospital care and outcome. Aims To provide epidemiological data on self-injury and compare hospital management of self-injury with that for self-poisoning.

METHOD

Data were collected on all self-harm attendances to the general hospitals in Leeds over an 18-month period.

RESULTS

People attending hospital for self-injury or self-poisoning do not form mutually exclusive groups. There were higher proportions of self-injury episodes compared with self-poisoning, where a history of self-harm or contact with mental health services had been recorded. Fewer psychosocial assessments were carried out after episodes of self-injury compared with self-poisoning but, when they were, follow-up was recommended more often.

CONCLUSIONS

The clinical importance of self-injury is not mirrored by the level of psychosocial assessment and after-care provided.

Assessment and management of self-harm in older adults attending accident and emergency: a comparative cross-sectional study

OBJECTIVE

Older people who undertake self-harm are at higher suicide risk than are younger patients. This study examines whether this greater risk is reflected in the assessment and after-care that older patients receive when they attend accident and emergency.

METHOD

This cross-sectional study, set in the two accident and emergency departments in a large industrial city in Northern England, compared 141 consecutive attendances due to self-harm among older patients (aged 55 years and over) with a random sample of 125 attendances of younger people (aged 15-54) attending because of self-harm. Data were drawn from accident and emergency records and from psychiatric and general hospital casenotes.

RESULTS

Compared with the younger group, older patients were significantly more likely to be admitted from accident and emergency to the general hospital, to receive a specialist assessment whilst at the hospital, and to be offered psychiatric after-care-either as a psychiatric in-patient or an out-patient.

CONCLUSIONS

Fortunately, older people attending accident and emergency following self-harm seemed likely to receive psychosocial assessment from a mental health specialist, and they were much more likely than younger patients to be offered after-care. Hospitals will need to monitor accident and emergency and other records if they are to check that their services are responding to the high risks seen in older patients.

Assessment and Aftercare for Deliberate Self-Harm Patients Provided by a General Hospital Psychiatric Service

Summary: We report on a sample of 135 deliberate self-harm (DSH) patients who were assessed by a general hospital DSH service, and on those who were offered aftercare by, or telephone open access to, the service. Patients' satisfaction with assessment and treatment, and their outcome were investigated at follow-up 12-20 months later. Four-fifths of patients reported the assessment following DSH to have been helpful and the assessor sympathetic. Thirty-three (24%) of the 135 patients assessed were offered treatment by the DSH service but 13 declined or failed to attend. Of the 20 who engaged in treatment, 17 (94%) were satisfied with their care. Open access to the DSH service by telephone was offered to 53 (39%) patients, nine (22%) of whom reported at follow-up that they had used this facility. A specialist DSH service can effectively assess and treat patients following DSH. It is important that the service is accessible and acceptable to patients.

Service variation in baseline variables and prediction of risk in a randomised controlled trial of psychological treatment in repeated parasuicide: the POPMACT Study

The treatment protocol and baseline characteristics of 480 subjects with a history of repeated parasuicide recruited in five centres to a randomised therapeutic trial of manual assisted cognitive-behaviour therapy (MACT) and treatment as usual (TAU) are described. Most patients had significant anxiety and depressive disturbance with 42% having a personality disorder. Variation in service policies influenced recruitment, with earlier assessment centres seeing people with more frequent episodes of self-harm and greater parasuicide risk than later ones. Parasuicide risk was also significantly greater in those with their first parasuicide episode at an earlier age and in those with a more recent latest episode.

Do we manage deliberate self-harm appropriately? Characteristics of general hospital patients who are offered psychiatric aftercare

BACKGROUND The appropriateness of psychiatric management decisions following an episode of deliberate self-harm is under-researched. AIM To determine whether the offer of follow-up or psychiatric admission by psychiatric doctors is related to known predictors of repetition of self-harm or completed suicide, and recognition of a depressive disorder. METHODS Prospective survey of 158 adult self-harm referrals from the general hospital. RESULTS Offer of aftercare was significantly associated with a definite wish to die at the time of the attempt (P&lt;0.001), Beck's Suicide Intent score (P=0.001), Beck's Hopelessness score (P=0.001), age (P&lt;0.01) and an ICD-10 diagnosis of depression (P&lt;0.001). Psychiatric admission was more likely for men (P=0.01) and accommodation problems (P=0.04) and less likely for relationship problems (P=0.01). CONCLUSIONS Psychiatrists are selectively admitting or following up patients from established high-risk groups. Given the limitations of suicide prevention and mental health resources, their management is appropriate.

Nurses' attitudes towards clients who self-harm

BACKGROUND

Deliberate self-harm is frequently encountered by emergency department (ED) nurses. However, clients are often dissatisfied with the care provided and clinicians feel ambivalent, helpless or frustrated when working with clients who self-harm.

AIM

The aim of the study was to develop and test a scale to identify relevant dimensions of ED nurses' attitudes to clients who present with self-injury.

METHODS

Items on Attitudes Towards Deliberate Self-Harm Questionnaire (ADSHQ) were drawn from a literature review and focus group discussions with ED nurses. The tool was piloted with 20 ED nurses not working in the target agencies. A survey of nurses working within 23 major public and 14 major private EDs in Queensland, Australia (n = 1008) was then undertaken.

RESULTS

A total of 352 questionnaires were returned (35% response). Analysis revealed four factors that reflected nurses' attitudes toward these clients. The factors related to nurses' perceived confidence in their assessment and referral skills; ability to deal effectively with clients, empathic approach; and ability to cope effectively with legal and hospital regulations that guide practice. There was a generally negative attitude towards clients who self-harm. Correlations were found between years of ED experience and total score on the ADSHQ, and years of ED experience and an empathic approach towards clients who deliberately self-harm.

CONCLUSION

There is a need for continuing professional development activities to address negative attitudes and provide practical strategies to inform practice and clinical protocols.

Staff perceptions of care for deliberate self-harm patients in rural Western Australia: a qualitative study

Suicide has been a major community concern in Esperance, a geographically isolated port on the south coast of Western Australia. This study explores the views of regional health staff on barriers to the effective management of deliberate self-harm (DSH) and ways in which those barriers could be addressed. Semi-structured interviews were tape-recorded, transcribed and subjected to qualitative content analysis. Interviewees included 77% of general practitioners (n = 7), 18% of nurses (n = 13) and 55% of mental health professionals (n = 5). The most important barrier was a lack of structure to treating DSH, resulting in deficiencies and inconsistencies in its management. Suggestions to improve the management of DSH included better communication between services, support for nurses in raising the issue of suicide, use of a simple risk assessment tool, the development of a nurse liaison position, and a multidisciplinary planning group. The higher rates of DSH and completed suicide in rural and remote regions compared with metropolitan areas make secondary prevention particularly important.

Presentations by youth to Auckland emergency departments following a suicide attempt

The objective of this study was to describe the population of European youth (15-24 years) presenting to emergency departments (EDs) at one of the three Auckland public hospitals following attempted suicide; and to identify factors associated with presentations to EDs by these youth. A 1-year medical record review was undertaken. A total of 212 presentations (196 individuals) occurred during the surveillance; alcohol was present for 29%. Attempts involving alcohol were more likely to occur at weekends (P < 0.01); involve cutting and piercing (P < 0.05); be undertaken by employed people (P < 0.05), and be undertaken by those not residing with family (P < 0.01). Two groups of particular concern were identified: those who involved alcohol in their attempt; and those who represented during the study period following multiple suicide attempts. These findings have implications for immediate care within an ED setting, and long-term follow-up healthcare options for distressed young people.

Fatal and non-fatal repetition of self-harm. Systematic review

BACKGROUND

Non-fatal self-harm frequently leads to non-fatal repetition and sometimes to suicide. We need to quantify these two outcomes of self-harm to help us to develop and test effective interventions.

AIMS

To estimate rates of fatal and non-fatal repetition of self-harm.

METHOD

A systematic review of published follow-up data, from observational and experimental studies. Four electronic databases were searched and 90 studies met the inclusion criteria.

RESULTS

Eighty per cent of studies found were undertaken in Europe, over one-third in the UK. Median proportions for repetition 1 year later were: 16% non-fatal and 2% fatal; after more than 9 years, around 7% of patients had died by suicide. The UK studies found particularly low rates of subsequent suicide.

CONCLUSIONS

After 1 year, non-fatal repetition rates are around 15%. The strong connection between self-harm and later suicide lies somewhere between 0.5% and 2% after 1 year and above 5% after 9 years. Suicide risk among self-harm patients is hundreds of times higher than in the general population.

Study of Queensland emergency department nurses' actions and formal and informal procedures for clients who self-harm

Emergency department nurses are often required to assess and manage the needs of people who self-harm. A survey of 352 nurses working within 23 major public and 14 major private emergency departments in Queensland, Australia, investigated the extent to which formal and informal procedures are available and the extent to which these procedures guide how nurses respond to clients who present with deliberate self-harm. The Risk Assessment Questionnaire was developed and found that nurses are frequently called to respond to clients presenting because of deliberate self-harm, but most have no formal training in this area. In some services there is a lack of formal and comprehensive procedures for assessment and treatment. Where procedures do exist, significant therapeutic areas related to assessment are not explored with clients. These findings have implications for continuing professional development activities, nursing education programs and clinical practice procedures.

The psychosocial assessment of deliberate self harm: using clinical audit to improve the quality of the service

OBJECTIVES

To determine whether simple service initiatives resulted in an improvement in the quality of the psychosocial assessment of adults presenting with deliberate self harm (DSH) by accident and emergency (A&E) medical staff.

METHOD

The quality of psychosocial assessment of adults presenting to an A&E department after DSH for a 12 month period was examined using an audit instrument developed from the Royal College of Psychiatrists' standards of service provision for the general hospital management of adult DSH. The results were then compared with a similar audit that had been conducted three years previously. A number of service improvements had been implemented after this first audit.

RESULTS

A total of 1359 episodes of adult DSH were identified. When compared with the previous audit, the frequency of information recorded in the case notes was significantly improved in all areas of the psychosocial assessment (p < 0.001) apart from mental state. There were significant changes in treatment between the two audits, with a higher proportion in 1997/8 (362, 26.5%) assessed by a mental health specialist in the department than in 1994/5 (154, 16.5%; chi(2) = 33, p < 0.001). The frequency of recorded information for those who were not admitted directly to medical or surgical wards was significantly higher for all factors (p<0.01) apart from conscious level and medical history.

CONCLUSIONS

A substantial improvement in the quality of the psychosocial assessment of adults presenting with DSH by A&E medical staff was achieved with the introduction of simple service developments. Encouraging staff to use a comprehensive checklist, proved particularly beneficial.