Are hospital services for self-harm getting better? An observational study examining management, service provision and temporal trends in England

Suicide risk following ED presentation with self-harm varies by hospital

BACKGROUND

Patients presenting to Emergency Department (ED) with self-harm are recognized to be at high risk of suicide and other causes of death in the immediate period following ED presentation. It is also recognized that there is a large variation in the management and care pathways that these patients experience at EDs.

AIMS

This study asks if there is a significant variation in mortality risk according to hospital attended and if this is explained by differences in care management.

METHODS

Population-wide data from the Northern Ireland Registry of Self-Harm from April 2012 were linked with centrally held mortality records to December 2019, providing data on self-harm type and ED care. Cox proportional hazards models analyzed mortality risk, coded as suicide, all-external causes and all-cause mortality.

RESULTS

Analysis of the 64,350 ED presentations for self-harm by 30,011 individuals confirmed a marked variation across EDs in proportion of patients receiving mental health assessment and likelihood of admission to general and psychiatric wards. There was a significant variation in suicide risk following attendance according to ED attended with the three-fold range between the lowest (HRadj 0.32 95% CIs 0.16, 0.67) and highest. These differences persisted even after adjustment for patient characteristics, variation in types of self-harm, and care management at the ED.

CONCLUSIONS

This study suggests that while the management of self-harm cases in the ED is important, it is the availability and access to, and level of engagement with, the subsequent management and care in the community rather than the immediate care at EDs that is most critical for patients presenting to ED with self-harm. However, the initial care in ED is an important gateway in initiating referrals to these services.

Characteristics and outcomes of people in suicidal crisis at two emergency departments: a service evaluation

Emergency departments (EDs) provide critical opportunities for nurses to support suicide prevention. This article details a service evaluation that was undertaken to explore the characteristics and outcomes of people in suicidal crisis at two EDs in the East of England during June 2023. Data routinely collected by the ED mental health liaison team were combined with a retrospective case note review of the local NHS mental health trust's electronic patient records. Attendees had a mean age of 35 years and seven months, and were often diagnosed with depression or emotionally unstable personality disorder. Most had a history of self-harm and were currently known to mental health services. Suicide-specific interventions were rarely recorded by nurses and relapse behaviours were prevalent after presentation. Local and national suicide prevention strategies should encourage nurses to address gaps in support, thereby improving patients' experiences in and beyond the ED.

Attitudes toward and experiences of clinical and non-clinical services among individuals who self-harm or attempt suicide: a systematic review

The prevalence of self-harm has increased substantially in recent decades. Despite the development of guidelines for better management and prevention of self-harm, service users report that quality of care remains variable. A previous systematic review of research published to June 2006 documented largely negative experiences of clinical services among patients who self-harm. This systematic review summarized the literature published since then to July 2022 to examine contemporary attitudes toward and experience of clinical and non-clinical services among individuals who self-harm and their relatives. We systematically searched for literature using seven databases. Quality of studies was assessed using the Mixed-Methods Appraisal Tool and findings were summarized using a narrative synthesis. We identified 29 studies that met our inclusion criteria, all of which were from high- or middle-income countries and were generally of high methodological quality. Our narrative synthesis identified negative attitudes toward clinical management and organizational barriers across services. Generally, more positive attitudes were found toward non-clinical services providing therapeutic contact, such as voluntary sector organizations and social services, than clinical services, such as emergency departments and inpatient units. Views suggested that negative experiences of service provision may perpetuate a cycle of self-harm. Our review suggests that in recent years there has been little improvement in attitudes toward and experiences of services for patients who self-harm. These findings should be used to reform clinical guidelines and staff training across clinical services to promote patient-centered and compassionate care and deliver more effective, acceptable and accessible services.

Social services utilisation and referrals after seeking help from health services for self-harm: a systematic review and narrative synthesis

Objectives

Suicide prevention is a major public health challenge. Appropriate aftercare for self-harm is vital due to increased risks of suicide following self-harm. Many antecedents to self-harm involve social factors and there is strong rationale for social services-based self-harm aftercare. We aimed to review evidence for social service utilisation and referrals among people seeking help following self-harm.

Design

Systematic review with narrative synthesis.

Data sources

PubMed, PsycINFO, AMED, Social Policy and Practice, EMBASE, Medline, Web of Science, Social Care Online, citation lists of included articles and grey literature.

Eligibility criteria

Studies of people of any age in contact with health services following self-harm, with study outcomes including referrals to or utilisation of social workers and social services.

Data extraction and synthesis

Information was extracted from each included study using a proforma and quality was critically assessed by two reviewers. Narrative synthesis was used to review the evidence.

Results

From a total of 3414 studies retrieved, 10 reports of 7 studies were included. Study quality was generally high to moderate. All studies were based in emergency departments (EDs) and most were UK based. In studies based solely on ED data, low proportions were referred to social services (in most studies, 1%-4%, though it was up to 44% when social workers were involved in ED assessments). In one study using linked data, 15% (62/427) were referred to social services and 21% (466/2,205) attended social services over the subsequent 3-year period.

Conclusions

Overall, few patients were referred to social services after self-harm. Higher reported referral rates may reflect greater service availability, involvement of social workers in psychosocial assessments or better capture of referral activity. Social services-based and integrated approaches for self-harm aftercare are important future directions for suicide prevention. Improved links between social services and health services for people seeking support after self-harm are recommended.

Global prevalence of psychiatric in- and out-patient treatment following hospital-presenting self-harm: a systematic review and meta-analysis

Background

Hospital-treated self-harm is common, costly, and strongly associated with suicide. Whilst effective psychosocial interventions exist, little is known about what key factors might modify the clinical decision to refer an individual to psychiatric in- and/or out-patient treatment following an episode of hospital-treated self-harm.

Methods

We searched five electronic databases (CENTRAL, CDSR, MEDLINE, Embase, and PsycINFO) until 3 January 2023 for studies reporting data on either the proportion of patients and/or events that receive a referral and/or discharge to psychiatric in- and/or outpatient treatment after an episode of hospital-treated self-harm. Pooled weighted prevalence estimates were calculated using the random effects model with the Freedman-Tukey double arcsine adjustment in R, version 4.0.5. We also investigated whether several study-level and macro-level factors explained variability for these outcomes using random-effects meta-regression. The protocol of this review was pre-registered with PROSPERO (CRD42021261531).

Findings

189 publications, representing 131 unique studies, which reported data on 243,953 individual participants who had engaged in a total of 174,359 episodes of self-harm were included. Samples were drawn from 44 different countries. According to World Bank classifications, most (83.7%) samples were from high income countries. Across the age range, one-quarter of persons were referred for inpatient psychiatric care and, of these, around one-fifth received treatment. Just over one-third were referred to outpatient psychiatric care, whilst around half of those referred received at least one treatment session across the age range. Event rate estimates were generally of a lower magnitude. Subgroup analyses found that older adults (mean sample age: ≥60 years) may be less likely than young people (mean sample age: ≤25 years) and adults (mean sample age: >25 years to <60 years) to be referred for outpatient psychiatric care following self-harm. More recent studies were associated with a small increase in the proportion of presentations (events) that were referred to, and received, psychiatric outpatient treatment. No macro-level factor explained between-study heterogeneity.

Interpretation

There is considerable scope for improvement in the allocation and provision of both in- and out-patient psychiatric care following hospital-presenting self-harm, particularly considering that the period after discharge from general hospitals represents the peak risk period for repeat self-harm and suicide. Given the marked between-study heterogeneity, the basis for allocation of aftercare treatment is therefore not yet known and should be further studied.

Funding

There was no specific funding for this review.

Review: Systematic review and metasynthesis of qualitative literature on young people's experiences of going to A&E/emergency departments for mental health support

BACKGROUND

There has been an increase in children and young people attending emergency departments for mental health reasons, including self-harm. Patients often report having poor experiences when attending emergency departments for mental health support. However, there has yet to be a review exploring the experiences of young people. Our aim in this study was to synthesise qualitative literature on young people's experiences of going to emergency departments for mental health support.

METHODS

A systematic review and metasynthesis were conducted. Five databases and grey literature were searched for relevant studies. Five articles met study criteria and were analysed using an iterative process of thematic synthesis.

RESULTS

The synthesis yielded four overarching themes: (a) emergency departments' inability to meet the mental health needs of young people, (b) emergency departments exacerbating patient distress, (c) patients feeling like a burden or undeserving of treatment and (d) consequences of poor emergency department experiences.

CONCLUSIONS

These findings (based on a still very limited literature) highlight the role that emergency departments have in relation to being a key point of contact with young people who self-harm. To properly engage with patients, emergency departments need to have the resources to provide compassionate care and follow clinical guidelines regarding assessments.

Secondary mental health service utilisation following emergency department contact for suicidal behaviour: A systematic review

OBJECTIVE

Engagement with secondary mental health services after an emergency department presentation with suicidal behaviours may be an important strategy for reducing the risk of repeat attempts. Our aim was to examine secondary mental health service contact following a presentation to emergency department with suicidal behaviours.

METHODS

A systematic review of papers published between 2000 and 2020 was undertaken. This identified 56 papers relating to 47 primary studies. Data were extracted and summarised separately by age group: (1) young people, (2) older adults and (3) adults and studies with participants of 'all ages'.

RESULTS

Studies in young people (n = 13) showed, on average, 44.8% were referred and 33.7% had contact with secondary mental health services within 4 weeks of emergency department discharge. In comparison, in adult/all ages studies (n = 34), on average, 27.1% were referred to and 26.2% had mental health service contact within 4 weeks. Only three studies presented data on contact with mental health services for older adults, and proportions ranged from 49.0% to 86.0%.

CONCLUSION

This review highlights poor utilisation of secondary mental health service following emergency department presentation for suicidal behaviours, and further research is needed to identify the reasons for this. Crucially, this information could assist in the allocation of resources to facilitate the timely implementation of suicide prevention services.

Assessment of machine learning algorithms in national data to classify the risk of self-harm among young adults in hospital: A retrospective study

BACKGROUND

Self-harm is one of the most common presentations at accident and emergency departments in the UK and is a strong predictor of suicide risk. The UK Government has prioritised identifying risk factors and developing preventative strategies for self-harm. Machine learning offers a potential method to identify complex patterns with predictive value for the risk of self-harm.

METHODS

National data in the UK Mental Health Services Data Set were isolated for patients aged 18-30 years who started a mental health hospital admission between Aug 1, 2020 and Aug 1, 2021, and had been discharged by Jan 1, 2022. Data were obtained on age group, gender, ethnicity, employment status, marital status, accommodation status and source of admission to hospital and used to construct seven machine learning models that were used individually and as an ensemble to predict hospital stays that would be associated with a risk of self-harm.

OUTCOMES

The training dataset included 23 808 items (including 1081 episodes of self-harm) and the testing dataset 5951 items (including 270 episodes of self-harm). The best performing algorithms were the random forest model (AUC-ROC 0.70, 95%CI:0.66-0.74) and the ensemble model (AUC-ROC 0.77 95%CI:0.75-0.79).

INTERPRETATION

Machine learning algorithms could predict hospital stays with a high risk of self-harm based on readily available data that are routinely collected by health providers and recorded in the Mental Health Services Data Set. The findings should be validated externally with other real-world, prospective data.

FUNDING

This study was supported by the Midlands and Lancashire Commissioning Support Unit.

Emergency department nurses’ perceptions of caring for patients with intentional self-poisoning: a qualitative study

Nurses have an important role in caring for patients with intentional self-poisoning. This study was attempted to explore the emergency department nurses' perception of caring for patients with intentional self-poisoning. The present qualitative study was performed using phenomenological method. This study was done on 14 emergency department nurses with experience in caring for patients with intentional self-poisoning. Data were collected through semi-structured interviews and transcribed verbatim. Data were analyzed using Colaizzi's method. Following data analysis, two themes and five sub-themes were extracted, which included being reluctant to provide care for patients with intentional self-poisoning (discomfort in providing care, and lack of desire to care for these patients) and comprehensive patient support (providing complete care and emotional support). Given that emergency department nurses are the first medical staff who face with intentional self-poisoning patients and play an important role in the care and treatment of these patients, it is necessary to improve their understanding of caring for these patients. In addition, their comprehensive support for these patients should be strengthened. Psychological support for nurses and training them on how to communicate with intentional self-poisoning patients and their families are also recommended.

Liaison psychiatry practitioners' views on accessing aftercare and psychological therapies for patients who present to hospital following self-harm: multi-site interview study

BACKGROUND

Timely provision of aftercare following self-harm may reduce risks of repetition and premature death, but existing services are frequently reported as being inadequate.

AIMS

To explore barriers and facilitators to accessing aftercare and psychological therapies for patients presenting to hospital following self-harm, from the perspective of liaison psychiatry practitioners.

METHOD

Between March 2019 and December 2020, we interviewed 51 staff members across 32 liaison psychiatry services in England. We used thematic analyses to interpret the interview data.

RESULTS

Barriers to accessing services may heighten risk of further self-harm for patients and burnout for staff. Barriers included: perceived risk, exclusionary thresholds, long waiting times, siloed working and bureaucracy. Strategies to increase access to aftercare included: (a) improving assessments and care plans via input from skilled staff working in multidisciplinary teams (e.g. including social workers and clinical psychologists); (b) supporting staff to focus on assessments as therapeutic intervention; (c) probing boundaries and involving senior staff to negotiate risk and advocate for patients; and (d) building relationships and integration across services.

CONCLUSIONS

Our findings highlight practitioners' views on barriers to accessing aftercare and strategies to circumvent some of these impediments. Provision of aftercare and psychological therapies as part of the liaison psychiatry service were deemed as an essential mechanism for optimising patient safety and experience and staff well-being. To close treatment gaps and reduce inequalities, it is important to work closely with staff and patients, learn from experiences of good practice and implement change more widely across services.

The barriers and facilitators to the reporting and recording of self-harm in young people aged 18 and under: a systematic review

BACKGROUND AND AIMS

This systematic review sought to identify, explain and interpret the prominent or recurring themes relating to the barriers and facilitators of reporting and recording of self-harm in young people across different settings, such as the healthcare setting, schools and the criminal justice setting.

METHODS

A search strategy was developed to ensure all relevant literature around the reporting and recording of self-harm in young people was obtained. Literature searches were conducted in six databases and a grey literature search of policy documents and relevant material was also conducted. Due to the range of available literature, both quantitative and qualitative methodologies were considered for inclusion.

RESULTS

Following the completion of the literature searches and sifting, nineteen papers were eligible for inclusion. Facilitators to reporting self-harm across the different settings were found to be recognising self-harm behaviours, using passive screening, training and experience, positive communication, and safe, private information sharing. Barriers to reporting self-harm included confidentiality concerns, negative perceptions of young people, communication difficulties, stigma, staff lacking knowledge around self-harm, and a lack of time, money and resources. Facilitators to recording self-harm across the different settings included being open to discussing what is recorded, services working together and co-ordinated help. Barriers to recording self-harm were mainly around stigma, the information being recorded and the ability of staff being able to do so, and their length of professional experience.

CONCLUSION

Following the review of the current evidence, it was apparent that there was still progress to be made to improve the reporting and recording of self-harm in young people, across the different settings. Future work should concentrate on better understanding the facilitators, whilst aiming to ameliorate the barriers.

A Systematic Review of Training Interventions for Emergency Department Providers and Psychosocial Interventions delivered by Emergency Department Providers for Patients who self-harm

OBJECTIVES

People who self-harm frequently present to the emergency department (ED) and are treated by generalist healthcare staff with no specialist mental health training. We systematically reviewed (i) training interventions for generalist ED providers and (ii) psychosocial interventions delivered predominantly by generalist ED providers for people who self-harm.

METHOD

Five databases were searched for studies reporting on training interventions for generalist ED staff (at least 50% of the sample needed to be generalist ED staff) or psychosocial interventions for people who self-harm delivered predominantly by generalist ED staff. No limitations were placed regarding study design/country. Narrative synthesis was conducted.

RESULTS

Fifteen studies from high-income countries were included. Nine studies of moderate methodological quality evaluated training for generalist ED providers (n = 1587). Six studies of good methodological quality evaluated psychosocial interventions for adults who self-harm (n = 3133). Only one randomized controlled trial was identified. Training was linked with pre-post improvements in staff knowledge, and less consistently with improvement in skills, attitudes, and confidence. Evidence on patient outcomes was lacking. Patient-level interventions involving common suicide prevention strategies-safety planning and follow-up contact-were consistently linked to pre-post reductions in suicide attempts. Effects on treatment engagement and psychiatric admissions were unclear.

CONCLUSIONS

There is a clear need for further RCTs to improve the evidence base for ED generalist providers managing patients with self-harm. Evidence supports potential benefits of training for improving staff knowledge, attitudes, and skills, and of safety planning and follow-up contact for reducing repeat suicide attempts. HIGHLIGHTSMore RCTs are needed to improve the evidence base for ED providers managing self-harmSafety planning and follow up contacts are linked to reductions in repeat suicide attemptsFuture research should investigate the impact of staff training on patient outcomes.

‘Wasn’t offered one, too poorly to ask for one’ – Reasons why some patients do not receive a psychosocial assessment following self-harm: Qualitative patient and carer survey

OBJECTIVE

Psychosocial assessment following self-harm presentations to hospital is an important aspect of care. However, many people attending hospital following self-harm do not receive an assessment. We sought to explore reasons why some patients do not receive a psychosocial assessment following self-harm from the perspective of patients and carers.

METHODS

Between March and November 2019, we recruited 88 patients and 14 carers aged ⩾18 years from 16 mental health trusts and community organisations in the United Kingdom, via social media, to a co-designed qualitative survey. Thematic analyses were used to interpret the data.

RESULTS

Patients' reasons for refusing an assessment included long waiting times, previous problematic interactions with staff and feeling unsafe when in the emergency department. Two people refused an assessment because they wanted to harm themselves again. Participants reported organisational reasons for non-assessment, including clinicians not offering assessments and exclusion due to alcohol intoxication. Other patients felt they did not reach clinically determined thresholds because of misconceptions over perceived heightened fatality risk with certain self-harm methods (e.g. self-poisoning vs self-cutting).

CONCLUSION

Our results provide important insights into some of the reasons why some people may not receive a psychosocial assessment following self-harm. Parallel assessments, compassionate care and specialist alcohol services in acute hospitals may help reduce the number of people who leave before an assessment. Education may help address erroneous beliefs that self-injury and self-harm repetition are not associated with greatly raised suicide risk.

Experiences of care for self-harm in the emergency department: the perspectives of patients, carers and practitioners

Emergency departments are often the point of entry to the healthcare system for people who self-harm, and these individuals are at high risk of further self-harm and suicide in the post-discharge period. These settings therefore provide a critical opportunity for intervention. However, many studies have identified that the experiences of patients, carers and the emergency department staff themselves is often suboptimal. In this editorial we summarise one such study, by O'Keeffe and colleagues, and consider strategies for improving the experiences of patients and their carers when presenting to the emergency department. We also reiterate the need for wider systemic change in attitudes and approaches towards people who self-harm that are pervasive across the healthcare system and beyond.

Translating promise into practice: a review of machine learning in suicide research and prevention

In ever more pressured health-care systems, technological solutions offering scalability of care and better resource targeting are appealing. Research on machine learning as a technique for identifying individuals at risk of suicidal ideation, suicide attempts, and death has grown rapidly. This research often places great emphasis on the promise of machine learning for preventing suicide, but overlooks the practical, clinical implementation issues that might preclude delivering on such a promise. In this Review, we synthesise the broad empirical and review literature on electronic health record-based machine learning in suicide research, and focus on matters of crucial importance for implementation of machine learning in clinical practice. The challenge of preventing statistically rare outcomes is well known; progress requires tackling data quality, transparency, and ethical issues. In the future, machine learning models might be explored as methods to enable targeting of interventions to specific individuals depending upon their level of need-ie, for precision medicine. Primarily, however, the promise of machine learning for suicide prevention is limited by the scarcity of high-quality scalable interventions available to individuals identified by machine learning as being at risk of suicide.

Cost-effectiveness of psychosocial assessment for individuals who present to hospital following self-harm in England: a model-based retrospective analysis

Background

Guidance in England recommends psychosocial assessment when presenting to hospital following self-harm but adherence is variable. There is some evidence suggesting that psychosocial assessment is associated with lower risk of subsequent presentation to hospital for self-harm, but the potential cost-effectiveness of psychosocial assessment for hospital-presenting self-harm is unknown.

Methods

A three-state four-cycle Markov model was used to assess cost-effectiveness of psychosocial assessment after self-harm compared with no assessment over 2 years. Data on risk of subsequent self-harm and hospital costs of treating self-harm were drawn from the Multicentre Study of Self-Harm in England, while estimates of effectiveness of psychosocial assessment on risk of self-harm, quality of life, and other costs were drawn from literature. Incremental cost-effectiveness ratios (ICERs) for cost per Quality Adjusted Life Year (QALY) gained were estimated. Parameter uncertainty was addressed in univariate and probabilistic sensitivity analyses.

Results

Cost per QALY gained from psychosocial assessment was £10,962 (95% uncertainty interval [UI] £15,538–£9,219) from the National Health Service (NHS) perspective and £9,980 (95% UI £14,538–£6,938) from the societal perspective. Results were generally robust to changes in model assumptions. The probability of the ICER being below £20,000 per QALY gained was 78%, rising to 91% with a £30,000 threshold.

Conclusions

Psychosocial assessment as implemented in the English NHS is likely to be cost-effective. This evidence could support adherence to NICE guidelines. However, further evidence is needed about the precise impacts of psychosocial assessment on self-harm repetition and costs to individuals and their families beyond immediate hospital stay.

Patients' Experiences of Engagement with Healthcare Services Following a High-Risk Self-Harm Presentation to a Hospital Emergency Department: A Mixed Methods Study

Experiences of engaging with healthcare services following a self-harm presentation to hospital of high lethality or high suicidal intent have not been examined previously, despite this subgroup of self-harm patients being at high risk of suicide. Therefore, this study addressed this issue by documenting patients' experiences of engaging with healthcare services after a high-risk self-harm (HRSH) presentation to hospital. Demographic, psychiatric and psychosocial factors associated with variations in perceptions of care received were also examined. Quantitative information was obtained by interview administered questionnaires 0-3 months following a HRSH presentation to hospital. Semi-structured follow-up interviews, conducted, 6-9 months later, provided qualitative data (n = 32). Satisfaction with aftercare varied. Positive experiences of care included "supportive and compassionate relationships" and "timely and comprehensive follow-up care." The establishment of trust in the services encouraged help-seeking and psychotropic treatment adherence. Conversely, "superficial and unsupportive relationships" and "care lacking continuity and comprehensiveness" left some participants feeling isolated, contributing to inhibited help-seeking and resistance to psychotropic treatment. Participants with a history of self-harm and mental health service engagement were more likely to report dissatisfaction with care provided. Those who described unsupportive relationships more frequently reported repeated self-harm, alcohol misuse, and hopelessness at follow-up. Our findings show that satisfaction with services, help-seeking and treatment adherence may be improved by ensuring the consistent provision of timely, comprehensive and supportive aftercare following a HRSH presentation. Absence of these aspects of care may contribute to ongoing distress and further suicidal behavior.

Understanding suicide clusters through exploring self-harm: Semi-structured interviews with individuals presenting with near-fatal self-harm during a suicide cluster

There was a highly publicised cluster of at least ten suicides in South Wales, United Kingdom, in 2007-2008. We carried out a qualitative descriptive study using cross-case thematic analysis to investigate the experiences and narratives of eight individuals who lived in the area where the cluster occurred and who survived an episode of near-fatal self-harm at the time of the cluster. Interviews were conducted from 01.01.2015 to 31.12.2015. All interviewees denied that the other deaths in the area had affected their own suicidal behaviour. However, in other sections of the interviews they spoke about the cluster contributing to difficulties they were experiencing at the time, including damage to social relationships, feelings of loss and being out of control. When asked about support, the interviewees emphasized the importance of counselling, which they would have found helpful but in most cases did not receive, even in the case of close contacts of individuals who had died. The findings suggest that effective prevention messaging must be subtle, since those affected may not be explicitly aware of or acknowledge the imitative aspects of their behaviour. This could be related to stigma attached to suicidal behaviour in a cluster context. Lessons for prevention include changing the message from asking if people 'have been affected by' the suicide deaths to emphasising the preventability of suicide, and directly reaching out to individuals rather than relying on people to come forward.

National audit to assess standards of care for deliberate self-harm patients presenting to trauma centres with penetrating wounds and recommendations for action

BACKGROUND

The authors assessed the standard of care for patients presenting with deliberate self-harm (DSH) injuries to major trauma centres (MTCs) in England as well as hospitals within the major trauma network in Scotland. This was to generate an understanding of current practice, identify any shortfall and develop recommendations to improve safety and patient care.

METHODS

We contacted all MTCs in England and hospitals in the major trauma network in Scotland, asking their permission to be included in this study. Emergency department (ED) consultants at each unit were then invited to complete a telephone questionnaire clarifying their current management policies of DSH patients against NICE guidance. The telephone questionnaire was carried out by the same author to ensure interpretation was consistent.

RESULTS

Twenty-seven MTCs within England as well as the four hospitals in the major trauma network within Scotland were contacted. There was a total of 15 responses - 14 responses from MTCs within England and 1 response from a hospital in the trauma network in Scotland. The clear deficit in practice was identified and recommendations were generated.

CONCLUSION

Our study has shown that patients are transferred following DSH without a clear review of their physical, psychological and social needs. We hope to share our recommendations for the implementation of a local protocol to improve standards and safety.

Experiences of care for self-harm in the emergency department: comparison of the perspectives of patients, carers and practitioners

Background

Each year, 220 000 episodes of self-harm are managed by emergency departments in England, providing support to people at risk of suicide.

Aims

To explore treatment of self-harm in emergency departments, comparing perspectives of patients, carers and practitioners.

Method

Focus groups and semi-structured interviews with 79 people explored experiences of receiving/delivering care. Participants were patients (7 young people, 12 adults), 8 carers, 15 generalist emergency department practitioners and 37 liaison psychiatry practitioners. Data were analysed using framework analysis.

Results

We identified four themes. One was common across stakeholder groups: (a) the wider system is failing people who self-harm: they often only access crisis support as they are frequently excluded from services, leading to unhelpful cycles of attending the emergency department. Carers felt over-relied upon and ill-equipped to keep the person safe. Three themes reflected different perspectives across stakeholders: (b) practitioners feel powerless and become hardened towards patients, with patients feeling judged for seeking help which exacerbates their distress; (c) patients need a human connection to offer hope when life feels hopeless, yet practitioners underestimate the therapeutic potential of interactions; and (d) practitioners are fearful of blame if someone takes their life: formulaic question-and-answer risk assessments help make staff feel safer but patients feel this is not a valid way of assessing risk or addressing their needs.

Conclusions

Emergency department practitioners should seek to build a human connection and validate patients’ distress, which offers hope when life feels hopeless. Patients consider this a therapeutic intervention in its own right. Investment in self-harm treatment is indicated.

Negative stance towards treatment in psychosocial assessments: The role of personalised recommendations in promoting acceptance

People presenting to the emergency department with self-harm or thoughts of suicide undergo a psychosocial assessment involving recommendations for e.g. contact with other practitioners, charity helplines or coping strategies. In these assessments, patients frequently adopt a negative stance towards potential recommendations. Analysing 35 video-recorded liaison psychiatry psychosocial assessments from an emergency department in England (2018-2019), we ask how these practitioners transform this negative stance into acceptance. We show that practitioners use three steps to anticipate and address negative stance (1) asking questions about the patient's experience/understanding that help the patient to articulate a negative stance (e.g., "what do you think about that"); (2) accepting or validating the reasons underlying the negative stance (e.g., "that's a very real fear and thought to have"); and (3) showing the patient that their reasons were incorporated in the recommendation (e.g., "it's telephone support if you're a bit more uncomfortable with face to face"). These steps personalise the recommendation based on the patient's specific experiences and understanding. When practitioners followed all three of these steps, the patient moved from a negative stance to acceptance in 84% of cases. When practitioners made a recommendation but did not follow all three steps, the patient moved from a negative stance to acceptance in only 14% of cases. It is not the case that each communication practice works on its own to promote patient acceptance, rather Steps 1 and 2 build on each other sequentially to develop and demonstrate shared understanding of the patient's negative stance. In this way, acceptance and validation play an indispensable role in addressing a patient's concerns about treatment.

Self-harm and the COVID-19 pandemic: A study of factors contributing to self-harm during lockdown restrictions

INTRODUCTION

The COVID-19 pandemic and resulting public health measures may have major impacts on mental health, including on self-harm. We have investigated what factors related to the pandemic influenced hospital presentations following self-harm during lockdown in England.

METHOD

Mental health clinicians assessing individuals aged 18 years and over presenting to hospitals in Oxford and Derby following self-harm during the period March 23rd to May 17, 2020 recorded whether the self-harm was related to the impact of COVID-19 and, if so, what specific factors were relevant. These factors were organized into a classification scheme. Information was also collected on patients' demographic characteristics, method of self-harm and suicide intent.

RESULTS

Of 228 patients assessed, in 46.9% (N = 107) COVID-19 and lockdown restrictions were identified as influencing self-harm. This applied more to females than males (53.5%, N = 68/127 v 38.6%, N = 39/101, χ² = 5.03, p = 0.025), but there were no differences in age, methods of self-harm or suicide intent between the two groups. The most frequent COVID-related factors were mental health issues, including new and worsening disorders, and cessation or reduction of services (including absence of face-to-face support), isolation and loneliness, reduced contact with key individuals, disruption to normal routine, and entrapment. Multiple, often inter-connected COVID-related factors were identified in many patients.

CONCLUSIONS

COVID-related factors were identified as influences in nearly half of individuals presenting to hospitals following self-harm in the period following introduction of lockdown restrictions. Females were particularly affected. The fact that mental health problems, including issues with delivery of care, predominated has implications for organisation of services during such periods. The contribution of isolation, loneliness and sense of entrapment highlight the need for relatives, friends and neighbours to be encouraged to reach out to others, especially those living alone. The classification of COVID-related factors can be used as an aide-memoire for clinicians.

Self-harm during the early period of the COVID-19 pandemic in England: Comparative trend analysis of hospital presentations

BACKGROUND

The COVID-19 pandemic and public health measures necessary to address it may have major effects on mental health, including on self-harm. We have used well-established monitoring systems in two hospitals in England to investigate trends in self-harm presentations to hospitals during the early period of the pandemic.

METHOD

Data collected in Oxford and Derby on patients aged 18 years and over who received a psychosocial assessment after presenting to the emergency departments following self-harm were used to compare trends during the three-month period following lockdown in the UK (23^rd March 2020) to the period preceding lockdown and the equivalent period in 2019.

RESULTS

During the 12 weeks following introduction of lockdown restrictions there was a large reduction in the number of self-harm presentations to hospitals by individuals aged 18 years and over compared to the pre-lockdown weeks in 2020 (mean weekly reduction of 13.5 (95% CI 5.6 - 21.4) and the equivalent period in 2019 (mean weekly reduction of 18.0 (95% CI 13.9 - 22.1). The reduction was greater in females than males, occurred in all age groups, with a larger reduction in presentations following self-poisoning than self-injury.

CONCLUSIONS

A substantial decline in hospital presentations for self-harm occurred during the three months following the introduction of lockdown restrictions. Reasons could include a reduction in self-harm at the community level and individuals avoiding presenting to hospital following self-harm. Longer-term monitoring of self-harm behaviour during the pandemic is essential, together with efforts to encourage help-seeking and the modification of care provision.

Self-harm on roads: Register-based study of methods and characteristics of individuals involved

BACKGROUND

Suicide on roads is receiving increased attention. However, there has been little research on non-fatal road-related self-harm. This study was conducted in order to investigate the characteristics of such acts.

METHOD

Information on non-fatal road self-harm was extracted from a self-harm monitoring system database of self-harm presentations to a major general hospital in England during 2005-2017. Patients were identified through being referred for psychosocial assessment by a clinical service and through scrutiny of medical records.

RESULTS

During the 13-year study period 110 individuals (67 males, 43 females) presented to the hospital with road-related self-harm: 38 (34.5%) jumped from bridges, 34 (30.9%) jumped or lay in front of vehicles, 27 (24.5%) crashed vehicles and 11 (10.0%) jumped from moving vehicles. Crashing vehicles was more common in males and jumping from vehicles more common in females. In patients who received a psychosocial assessment, their most frequent problems were with a partner, employment and family members. Over half had been in psychiatric care and nearly two-thirds had a history of previous self-harm. Suicide intent was often high, especially in those who crashed a vehicle or jumped from a bridge.

LIMITATION

The study was based on presentations to a single hospital. Some data were not available for non-assessed patients.

CONCLUSIONS

Road-related self-harm, while not common, more frequently involves males and the acts are often of high suicidal intent. The range of problems preceding this method of self-harm indicates that there needs to be a variety of aftercare interventions, adapted to each individual's situation.

Associations of sleep phenotypes with severe intentional self-harm: a prospective analysis of the UK Biobank cohort

STUDY OBJECTIVES

We aimed to investigate the prospective associations of sleep phenotypes with severe intentional self-harm (ISH) in middle-aged and older adults.

METHODS

A total of 499,159 participants (mean age: 56.55 ± 8.09 years; female: 54.4%) were recruited from the UK Biobank between 2006 and 2010 with follow-up until February 2016 in this population-based prospective study. Severe ISH was based on hospital inpatient records or a death cause of ICD-10 codes X60-X84. Patients with hospitalized diagnosis of severe ISH before the initial assessment were excluded. Sleep phenotypes, including sleep duration, chronotype, insomnia, sleepiness, and napping, were assessed at the initial assessments. Cox regression analysis was used to estimate temporal associations between sleep phenotypes and future risk of severe ISH.

RESULTS

During a follow-up period of 7.04 years (SD: 0.88), 1,219 participants experienced the first hospitalization or death related to severe ISH. After adjusting for demographics, substance use, medical diseases, mental disorders, and other sleep phenotypes, short sleep duration (HR: 1.50, 95% CI: 1.23-1.83, P < .001), long sleep duration (HR: 1.56, 95% CI: 1.15-2.12, P = .004), and insomnia (usually: HR: 1.57, 95% CI: 1.31-1.89, P < .001) were significantly associated with severe ISH. Sensitivity analyses excluding participants with mental disorders preceding severe ISH yielded similar results.

CONCLUSION

The current study provides the empirical evidence of the independent prediction of sleep phenotypes, mainly insomnia, short and long sleep duration, for the future risk of severe ISH among middle-aged and older adults.

Theorising health professionals' prevention and management practices with children and young people experiencing self-harm: a qualitative hospital-based case study

Self-harm in young people remains a significant concern. Studies of emergency departments have centred on negative professional attitudes. There has been limited interrogation and theorisation of what drives such attitudes, and the contexts that sustain them. Adopting a complex systems lens, this study aimed to explore how systems shape professional and patient interactions. It draws upon interviews with healthcare and affiliated professionals (n = 14) in a UK case study hospital, with primary focus on the emergency department. Data were analysed using a thematic approach and the principles of grounded theory. Four themes emerged, with the first three centralising how professionals' practices operate within: (1) a framework of risk management; (2) expectations of progressing patients through the care pathway; and (3) a culture of specialist expertise, with resulting uncertainty about who is responsible for self-harm. The fourth theme considers barriers to system change. A small number of participants described efforts to enact positive modifications to practices, but these were frustrated by entrenched system structures. The potential detrimental impacts for patient care and professional wellbeing are considered. Future practice needs systemic action to support professionals in treating patients experiencing self-harm, while future research requires more ethnographic explorations of the complex system in situ.

Predicting self-harm within six months after initial presentation to youth mental health services: A machine learning study

BACKGROUND

A priority for health services is to reduce self-harm in young people. Predicting self-harm is challenging due to their rarity and complexity, however this does not preclude the utility of prediction models to improve decision-making regarding a service response in terms of more detailed assessments and/or intervention. The aim of this study was to predict self-harm within six-months after initial presentation.

METHOD

The study included 1962 young people (12-30 years) presenting to youth mental health services in Australia. Six machine learning algorithms were trained and tested with ten repeats of ten-fold cross-validation. The net benefit of these models were evaluated using decision curve analysis.

RESULTS

Out of 1962 young people, 320 (16%) engaged in self-harm in the six months after first assessment and 1642 (84%) did not. The top 25% of young people as ranked by mean predicted probability accounted for 51.6% - 56.2% of all who engaged in self-harm. By the top 50%, this increased to 82.1%-84.4%. Models demonstrated fair overall prediction (AUROCs; 0.744-0.755) and calibration which indicates that predicted probabilities were close to the true probabilities (brier scores; 0.185-0.196). The net benefit of these models were positive and superior to the 'treat everyone' strategy. The strongest predictors were (in ranked order); a history of self-harm, age, social and occupational functioning, sex, bipolar disorder, psychosis-like experiences, treatment with antipsychotics, and a history of suicide ideation.

CONCLUSION

Prediction models for self-harm may have utility to identify a large sub population who would benefit from further assessment and targeted (low intensity) interventions. Such models could enhance health service approaches to identify and reduce self-harm, a considerable source of distress, morbidity, ongoing health care utilisation and mortality.

Services for self-harm: progress and promise?

This editorial considers whether the quality of care for people who present to clinical services in the UK following self-harm has improved or stagnated. Some real progress has been made in the areas of service provision and research, and self-harm has never had a higher priority in policy terms. However, major gaps remain. We need to enhance people's experience of services and improve access to high-quality assessment and aftercare.

Health Care Management Models for the Evolution of Hospitalization in Acute Inpatient Psychiatry Units: Comparative Quantitative Study

BACKGROUND

Mental health disorders are a problem that affects patients, their families, and the professionals who treat them. Hospital admissions play an important role in caring for people with these diseases due to their effect on quality of life and the high associated costs. In Spain, at the Healthcare Complex of Zamora, a new disease management model is being implemented, consisting of not admitting patients with mental diseases to the hospital. Instead, they are supervised in sheltered apartments or centers for patients with these types of disorders.

OBJECTIVE

The main goal of this research is to evaluate the evolution of hospital days of stay of patients with mental disorders in different hospitals in a region of Spain, to analyze the impact of the new hospital management model.

METHODS

For the development of this study, a database of patients with mental disorders was used, taking into account the acute inpatient psychiatry unit of 11 hospitals in a region of Spain. SPSS Statistics for Windows, version 23.0 (IBM Corp), was used to calculate statistical values related to hospital days of stay of patients. The data included are from the periods of 2005-2011 and 2012-2015.

RESULTS

After analyzing the results, regarding the days of stay in the different health care complexes for the period between 2005 and 2015, we observed that since 2012 at the Healthcare Complex of Zamora, the total number of days of stay were reduced by 64.69%. This trend is due to the implementation of a new hospital management model in this health complex.

CONCLUSIONS

With the application of a new hospital management model at the Healthcare Complex of Zamora, the number of days of stay of patients with mental diseases as well as the associated hospital costs were considerably reduced.

Factors explaining variation in recommended care pathways following hospital-presenting self-harm: a multilevel national registry study

BACKGROUND

People who present to hospital following self-harm are at high risk of suicide. Despite this, there are considerable variations in the management of this group across hospitals and the factors influencing such variations are not well understood.

AIMS

The aim of this study was to identify the specific hospital and individual factors associated with care pathways following hospital-presenting self-harm.

METHOD

Data on presentations to hospitals by those aged 18 years and over were obtained from the National Self-Harm Registry Ireland for 2017 and 2018. Factors associated with four common outcomes following self-harm (self-discharge, medical and psychiatric admission and psychosocial assessment before discharge) were examined using multilevel Poisson regression models.

RESULTS

Care pathways following self-harm varied across hospitals and were influenced by both hospital and individual factors. Individual factors were primarily associated with self-discharge (including male gender, younger age and alcohol involvement), medical admission (older age, drug overdose as a sole method and ambulance presentations) and psychiatric admission (male gender, methods associated with greater lethality and older age). The hospital admission rate for self-harm was the only factor associated with all outcomes examined. The availability of psychiatric in-patient facilities and specialist mental health staff contributed to variation in psychiatric admissions and psychosocial assessments prior to discharge. Hospital factors explained the majority of observed variation in the provision of psychosocial assessments.

CONCLUSIONS

Characteristics of the presenting hospital and hospital admission rates influence the recommended care pathways following self-harm. Provision of onsite mental health facilities and specialist mental health staff has a strong impact on psychiatric care of these patients.

Thinking about suicidal thinking

Suicide has emerged as a major cause of death from non-communicable disease worldwide, leading to a burgeoning interest in its prevention. Naturally, in this context one of the focuses of research and clinical interest is the presence of suicidal thinking-a potentially identifiable and reversible precursor of suicide-with much interest lately being in the relation between suicidal thinking and suicidal behaviour. In this Personal View we argue that, notwithstanding important and nuanced research into the nature of these phenomena, the field currently suffers from approaches to the terminology and reporting of suicidal thinking that pay insufficient regard to key features of its definition, and that these have clinical and research implications.

Healthcare professionals' implementation of national guidelines with patients who self-harm

BACKGROUND

National guidelines for the short-term management of self-harm are aimed at healthcare professionals who may be involved in the care of people who have self-harmed. However, evidence from small-scale studies globally suggest there is a lack of awareness of such guidelines among some groups of healthcare professionals. For the first time in a large representative sample of patient-facing healthcare professionals, we aimed to identify: (a) which healthcare professionals are aware of guidelines for the management of self-harm; (b) the perceived availability of training; (c) the use of risk screening tools; and (d) the extent to which healthcare professionals implement guidelines for the management of self-harm.

METHODS

1020 UK healthcare professionals completed a cross-sectional survey online.

RESULTS

85.6% (873/1020) of the sample had heard of the national guidelines, but only 24.3% (248/1020) knew "a fair amount" or more about them. Of the respondents who had previously encountered a patient who had self-harmed or was at risk of repeat self-harm, the guidelines were implemented in fewer than 50% (M = 43.89%, SD = 38.79) of encounters. 31% (312/1020) of the sample had received training in managing self-harm and, contrary to guidelines, 2.25% (23/1020) of the sample had used self-harm risk screening tools.

CONCLUSIONS

Our findings highlight a need to improve knowledge of self-harm management guidelines, and identifies professional groups where awareness and knowledge is currently low. Further work is required to develop interventions to change healthcare professional practice with respect to the implementation of self-harm management guidelines.

Factors Affecting Collaborations between a Tertiary-level Emergency Department and Community-based Mental Healthcare Centers for Managing Suicide Attempts

BACKGROUND

Community-based active contact and follow-up are known to be effective in reducing the risk of repeat suicide attempts among patients admitted to emergency departments after attempting suicide. However, the characteristics that define successful collaborations between emergency departments and community-based mental healthcare centers in this context are not well known.

METHODS

This study investigated patients visiting the emergency department after suicide attempts from May 2017 to April 2019. Patients were classified in either the successful collaboration group or the failed collaboration group depending on whether or not they were linked to a community-based follow-up intervention. Clinical features and socioeconomic status were considered as independent variables. Logistic regression analysis was performed to identify factors influencing the collaboration.

RESULTS

Of 674 patients, 153 (22.7%) were managed successfully via the targeted collaboration. Completion of hospital-based psychological counseling (adjusted odds ratio [aOR], 233.55; 95% confidence interval [CI], 14.99-3,637.67), supported out-of-pocket expenses (aOR, 11.17; 95% CI, 3.03-41.03), Korean Triage and Acuity Scale 1-3 (aOR, 4.31; 95% CI, 1.18-15.73), suicide attempt associated with mental disorder (aOR, 0.15; 95% CI, 0.04-0.52), and self-discharge against medical advice (aOR, 0.12; 95% CI, 0.02-0.70) were independent factors influencing the collaboration.

CONCLUSION

Completion of hospital-based psychological counseling was the most highly influential factor determining the outcome of the collaboration between the emergency department and community-based mental healthcare center in the management of individuals who had attempted suicide. Completion of hospital-based psychological counseling is expected to help reduce the risk of repeat suicide attempts.

Characteristics and risk of repeat suicidal ideation and self-harm in patients who present to emergency departments with suicidal ideation or self-harm: A prospective cohort study

BACKGROUND

Characteristics and outcomes of patients presenting to Emergency Departments (EDs) have been under-examined. This paper describes the characteristics and risk of repeat suicidality amongst patients presenting to EDs with (1) suicidal ideation and (2) self-harm, compared to (3) controls in mental health crisis.

METHODS

The Clinical Record Interactive Search tool identified 2211 patients who presented to three London EDs with suicidal ideation or self-harm, and 1108 control patients. All patients received a full psychosocial assessment. Chi-squared tests examined group characteristics. Cox regression models assessed the risk of re-presentation with suicidal ideation or self-harm within one year.

RESULTS

There were a higher proportion of females and individuals under the age of 25 in the self-harm group. Patients presenting with suicidal ideation or self-harm were more likely to be white, live in more deprived areas, and less likely to receive a psychiatric diagnosis within one year compared to controls. Risk of repeat suicidality within one year was 3-4 times higher in those with baseline suicidal ideation (adjusted HR = 3.66, 95% CI 2.44-5.48) or self-harm (HR = 3.53 95% CI 2.47-5.04) compared to controls.

LIMITATIONS

To be included patients needed to have a full psychosocial assessment. Incomplete records meant 21.4% of the sample was excluded. This will have introduced bias which might confound observed associations.

CONCLUSION

Individuals presenting with either suicidal ideation or self-harm have similar risk for re-presentation within one year. Both groups would benefit from personalised risk management plans and active follow-up to reduce the risk of repeat suicidal behaviour.

Comparing short-term risk of repeat self-harm after psychosocial assessment of patients who self-harm by psychiatrists or psychiatric nurses in a general hospital: Cohort study

BACKGROUND

There is mixed evidence for whether psychosocial assessment following hospital presentation for self-harm reduces self-harm repetition. A possible reason is the differences in professional background of assessors (primarily psychiatrists and psychiatric nurses) due to variability in training and therapist style.

METHODS

Using data from the Oxford Monitoring System for Self-harm, we analysed data on patients making their first emergency department (ED) presentation for self-harm between 2000 and 2014, followed-up until 2015. Using logistic regression, we estimated the probability of repeat self-harm within 12 months, comparing: (i) patients receiving psychosocial assessment versus none, adjusting for age, gender, self-harm method, past self-harm presentation, and general hospital admission; and (ii) patients assessed by a psychiatric nurse versus those assessed by a psychiatrist, adjusting for age, self-harm method, time and year of presentation.

RESULTS

The 12,652 patients who had an index ED presentation for self-harm during the study period accounted for 24,450 presentations, in 17,303 (71%) of which a psychosocial assessment was conducted; in 9318 (54%) by a psychiatric nurse and in 7692 (45%) by a psychiatrist. We found a reduced probability of repeat self-harm presentation among patients receiving psychosocial assessment versus none (adjusted odds ratio [AOR] = 0.70; 95% CI = 0.65-0.75; p < 0.001), but no differences between patients assessed by a psychiatric nurse or a psychiatrist (AOR = 1.05; 95% CI = 0.98-1.13; p = 0.129).

LIMITATIONS

Findings from a single hospital may not be generalizable to other settings.

CONCLUSIONS

Short-term risk of repeat self-harm after psychosocial assessment for self-harm may not differ by the assessor's professional background.

Long-term impact of the expansion of a hospital liaison psychiatry service on patient care and costs following emergency department attendances for self-harm

BACKGROUND

In September 2014, as part of a national initiative to increase access to liaison psychiatry services, the liaison psychiatry services at Bristol Royal Infirmary received new investment of £250 000 per annum, expanding its availability from 40 to 98 h per week. The long-term impact on patient outcomes and costs, of patients presenting to the emergency department with self-harm, is unknown.

AIMS

To assess the long-term impact of the investment on patient care outcomes and costs, of patients presenting to the emergency department with self-harm.

METHOD

Monthly data for all self-harm emergency department attendances between 1 September 2011 and 30 September 2017 was modelled using Bayesian structural time series to estimate expected outcomes in the absence of expanded operating hours (the counterfactual). The difference between the observed and expected trends for each outcome were interpreted as the effects of the investment.

RESULTS

Over the 3 years after service expansion, the mean number of self-harm attendances increased 13%. Median waiting time from arrival to psychosocial assessment was 2 h shorter (18.6% decrease, 95% Bayesian credible interval (BCI) -30.2% to -2.8%), there were 45 more referrals to other agencies (86.1% increase, 95% BCI 60.6% to 110.9%) and a small increase in the number of psychosocial assessments (11.7% increase, 95% BCI -3.4% to 28.5%) per month. Monthly mean net hospital costs were £34 more per episode (5.3% increase, 95% BCI -11.6% to 25.5%).

CONCLUSIONS

Despite annual increases in emergency department attendances, investment was associated with reduced waiting times for psychosocial assessment and more referrals to other agencies, with only a small increase in cost per episode.

Incidence and general hospital costs of self-harm across England: estimates based on the multicentre study of self-harm

AIMS

The aim of this study was to estimate incidence of self-harm presentations to hospitals and their associated hospital costs across England.

METHODS

We used individual patient data from the Multicentre Study of Self-harm in England of all self-harm presentations to the emergency departments of five general hospitals in Oxford, Manchester and Derby in 2013. We also obtained cost data for each self-harm presentation from the hospitals in Oxford and Derby, as well as population and geographical estimates from the Office for National Statistics. First, we estimated the rate of self-harm presentations by age and gender in the Multicentre Study and multiplied this with the respective populations to estimate the number of self-harm presentations by age and gender for each local Clinical Commissioning Group (CCG) area in England. Second, we performed a regression analysis on the cost data from Oxford and Derby to predict the hospital costs of self-harm in Manchester by age, gender, receipt of psychosocial assessment, hospital admission and type of self-harm. Third, the mean hospital cost per age year and gender were combined with the respective number of self-harm presentations to estimate the total hospital costs for each CCG in England. Sensitivity analysis was performed to address uncertainty in the results due to the extrapolation of self-harm incidence and cost from the Multicentre Study to England.

RESULTS

There were 228 075 estimated self-harm presentations (61% were female) by 159 857 patients in 2013 in England. The largest proportions of self-harm presentations were in the age group 40-49 years (30%) for men and 19-29 years (28%) for women. Associated hospital costs were approximately £128.6 (95% CI 117.8-140.9) million in 2013. The estimated incidence of self-harm and associated hospital costs were lower in the majority of English coastal areas compared to inland regions but the highest costs were in Greater London. Costs were also higher in more socio-economically deprived areas of the country compared with areas that are more affluent. The sensitivity analyses provided similar results.

CONCLUSIONS

The results of this study highlight the extent, hospital costs and distribution of self-harm presentations to hospitals in England and identify potential sub-populations that might benefit from targeted actions to help prevent self-harm and assist those who have self-harmed. They can support national as well as local health stakeholders in allocating funds and prioritising interventions in areas with the greatest need for preventing and managing self-harm.

Suicide prediction models: a critical review of recent research with recommendations for the way forward

Suicide is a leading cause of death. A substantial proportion of the people who die by suicide come into contact with the health care system in the year before their death. This observation has resulted in the development of numerous suicide prediction tools to help target patients for preventive interventions. However, low sensitivity and low positive predictive value have led critics to argue that these tools have no clinical value. We review these tools and critiques here. We conclude that existing tools are suboptimal and that improvements, if they can be made, will require developers to work with more comprehensive predictor sets, staged screening designs, and advanced statistical analysis methods. We also conclude that although existing suicide prediction tools currently have little clinical value, and in some cases might do more harm than good, an even-handed assessment of the potential value of refined tools of this sort cannot currently be made because such an assessment would depend on evidence that currently does not exist about the effectiveness of preventive interventions. We argue that the only way to resolve this uncertainty is to link future efforts to develop or evaluate suicide prediction tools with concrete questions about specific clinical decisions aimed at reducing suicides and to evaluate the clinical value of these tools in terms of net benefit rather than sensitivity or positive predictive value. We also argue for a focus on the development of individualized treatment rules to help select the right suicide-focused treatments for the right patients at the right times. Challenges will exist in doing this because of the rarity of suicide even among patients considered high-risk, but we offer practical suggestions for how these challenges can be addressed.

Community-based aftercare following an emergency department presentation for attempted suicide or high risk for suicide: study protocol for a non-randomised controlled trial

BACKGROUND

Suicide is a major public health issue worldwide. Those who have made a recent suicide attempt are at high risk for dying by suicide in the future, particularly during the period immediately following departure from a hospital emergency department. As such the transition from hospital-based care to the community is an important area of focus in the attempt to reduce suicide rates. There is a need for evaluation studies to test the effectiveness of interventions directed to this stage (termed 'aftercare' interventions).

METHODS

A controlled non-randomised two group (intervention vs treatment-as-usual control) design, using an intention-to-treat model, will evaluate the effectiveness of a suicide prevention aftercare intervention providing follow-up after presentations to a hospital emergency department as a result of a suicide attempt or high risk for suicide. The intervention is a community-based service, utilising two meetings with a mental health clinician and follow-up contacts by peer workers via a combination of face-to-face and telephone for four weeks, with the option of extension to 12 weeks. Seventy-five participants of the intervention service will be recruited to the study and compared to 1265 treatment-as-usual controls. The primary hypotheses are that over 12 months, those who participate in the aftercare follow-up intervention are less likely than controls to present to a hospital emergency department for a repeat suicide attempt or because of high risk for suicide, will have fewer re-presentations during this period and will have lower all-cause mortality. As a secondary aim, the impact of the intervention on suicide risk factors for those who participate in the service will be evaluated using pre- and post-intervention repeated measures of depression, anxiety, stress, hopelessness, belongingness, burdensomeness, and psychological distress. Enrolments into the study commenced on 1 November 2017 and are anticipated to cease in November 2019.

DISCUSSION

The study aims to contribute to the understanding of effective interventions for individuals who have presented to a hospital emergency department as a result of a suicide attempt or at high risk for suicide and provide evidence in relation to interventions that incorporate peer-workers.

TRIAL REGISTRATION

ACTRN12618001701213 . Registered on 16 October 2018. Retrospectively registered.

The case for case-control studies in the field of suicide prevention

Much of our knowledge about the risk factors for suicide comes from case-control studies that either use a psychological autopsy approach or are nested within large register-based cohort studies. We would argue that case-control studies are appropriate in the context of a rare outcome like suicide, but there are issues with using this design. Some of these issues are common in psychological autopsy studies and relate to the selection of controls (e.g. selection bias caused by the use of controls who have died by other causes, rather than live controls) and the reliance on interviewing informants (e.g. recall bias caused by the loved ones of cases having thought about the events leading up to the suicide in considerable detail). Register-based studies can overcome some of these problems because they draw upon contain information that is routinely collected for administrative purposes and gathered in the same way for cases and controls. However, they face issues that mean that psychological autopsy studies will still sometimes be the study design of choice for investigating risk factors for suicide. Some countries, particularly low and middle income countries, don't have sophisticated population-based registers. Even where they do exist, there will be variable of interest that are not captured by them (e.g. acute stressful life events that may immediately precede a suicide death), or not captured in a comprehensive way (e.g. suicide attempts and mental illness that do not result in hospital admissions). Future studies of risk factors should be designed to progress knowledge in the field and overcome the problems with the existing studies, particularly those using a case-control design. The priority should be pinning down the risk factors that are amenable to modification or mitigation through interventions that can successfully be rolled out at scale.

Machine learning methods for developing precision treatment rules with observational data

Clinical trials have identified a variety of predictor variables for use in precision treatment protocols, ranging from clinical biomarkers and symptom profiles to self-report measures of various sorts. Although such variables are informative collectively, none has proven sufficiently powerful to guide optimal treatment selection individually. This has prompted growing interest in the development of composite precision treatment rules (PTRs) that are constructed by combining information across a range of predictors. But this work has been hampered by the generally small samples in randomized clinical trials and the use of suboptimal analysis methods to analyze the resulting data. In this paper, we propose to address the sample size problem by: working with large observational electronic medical record databases rather than controlled clinical trials to develop preliminary PTRs; validating these preliminary PTRs in subsequent pragmatic trials; and using ensemble machine learning methods rather than individual algorithms to carry out statistical analyses to develop the PTRs. The major challenges in this proposed approach are that treatment are not randomly assigned in observational databases and that these databases often lack measures of key prescriptive predictors and mental disorder treatment outcomes. We proposed a tiered case-cohort design approach that uses innovative methods for measuring and balancing baseline covariates and estimating PTRs to address these challenges.

Care of general practice patients preceding and following a suicide attempt: observational study in Flemish general practices

OBJECTIVES

First, to examine general practitioner (GP) knowledge about the care (needs) of their patients; second, to examine the quality of GP follow-up care; third, to examine the transmission of patient care information from hospitals/emergency services (ES) to GPs.

SETTING

105 general practices from the representative Belgian Network of Sentinel General Practices (SGP) in Flanders, the largest region of Belgium, during 2013-2016.

PARTICIPANTS

245 suicide attempts by regular patients.

OUTCOMES MEASURES

Ten care-related measures, including three indicators of quality of follow-up care, were based on data reported by the SGP on structured forms at baseline and at two follow-up points in time.

RESULTS

As for GP knowledge, 10.5% of SGP failed to report whether suicidal risk was noticed in patients seen in the month preceding the attempt; 9.0% whether there were previous attempts; 22.5% whether the patient was receiving mental health treatment at follow-up and 22.0% whether suicidal behaviour was repeated at follow-up. Relatively more patients≥65 years had no suicide risk evaluation (OR 3.54; 95% CI 1.11 to 11.26). As for quality of follow-up care, there was a GP-patient contact following 90.5% of the attempts, follow-up appointments were planned following 43.4% of the attempts and there was a GP contact with patient proxies following 62.8% of the attempts. Patient age ≥65 years (OR 4.09; 95% CI 1.79 to 9.33), a recent GP-patient contact preceding the attempt (OR 1.97; 95% CI 1.13 to 3.43), depression of patient (OR 1.96; 95% CI 1.14 to 3.37) and a suburban SGP area (OR 2.34; 95% CI 1.13 to 4.82) were determinants of an increased quality of care sum. GPs received patient care information from a hospital (ES) for 67.8% of eligible attempts, with SGP practice location being a determinant.

CONCLUSIONS

GPs are highly involved in the care of suicide attempters but there is room for improvement, also in informational continuity from hospital (ES) to GPs.

Recurrence and mortality 1 year after hospital admission for non-fatal self-harm: a nationwide population-based study

AIMS

A large number of people present each day at hospitals for non-fatal deliberate self-harm (DSH). Examination of the short-term risk of non-fatal recurrence and mortality at the national level is of major importance for both individual medical decision-making and global organisation of care.

METHODS

Following the almost exhaustive linkage (96%) of two national registries in France covering 45 million inhabitants (i.e. 70% of the whole population), information about hospitalisation for DSH in 2008-2009 and vital status at 1 year was obtained. Individuals who died during the index hospital stay were excluded from analyses.

RESULTS

Over 2 years, 136,451 individuals were hospitalised in medicine or surgery for DSH. The sample comprised 62.8% women, median age 38 in both genders, with two peaks at 16 and 44 years in women, and one peak at 37 years in men. The method used for DSH was drug overdose in 82.1% of cases. Admission to an intensive care unit occurred in 12.9%. Following index hospitalisation, 71.3% returned home and 23.7% were transferred to a psychiatric inpatient care unit. DSH recurrence during the following year occurred in 12.4% of the sample, within the first 6 months in 75.2%, and only once in 74.6%. At 1 year, 2.6% of the sample had died. The overall standardised mortality ratio was 7.5 but reached more than 20 in young adults. The causes were natural causes (35.7%), suicide (34.4%), unspecified cause (17.5%) and accident (12.4%). Most (62.9%) deaths by suicide occurred within the first 6 months following index DSH. Violent means (i.e. not drug overdose) were used in 70% of suicide cases. Concordance between means used for index DSH and for suicide was low (30% overall), except for drug overdose. Main suicide risk factors were older age, being male, use of a violent means at index DSH, index admission to an intensive care unit, a transfer to another medical department or to a psychiatric inpatient unit, and recurrence of DSH. However, these factors had low positive predictive values individually (below 2%).

CONCLUSIONS

Non-fatal DSH represent frequent events with a significant risk of short-term recurrence and death from various causes. The first 6 months following hospital discharge appear to be a critical period. Specific short-term aftercare programs targeting all people with a DSH episode have to be developed, along other suicide prevention strategies.

Patterns of self-harm methods over time and the association with methods used at repeat episodes of non-fatal self-harm and suicide: A systematic review

BACKGROUND

The risk of self-harm repetition and suicide may be influenced by self-harm method choice. However, there are mixed findings regarding whether there is a discernible pattern in self-harm methods over successive episodes of non-fatal self-harm, and if so, how these may be associated with self-harm repetition and/or suicide.

METHODS

A systematic review of five electronic databases was undertaken until 31 May 2018 to identify cohort studies on patterns of self-harm methods and their association with methods used either at repeat self-harm episodes and/or suicide.

RESULTS

15 studies were included reporting data on of 127,371 participants. Over an average follow-up period of 2.8 years, one-third (33.3%) switched methods between episodes of self-harm, most commonly from self-injury to self-poisoning. For suicide, almost one-half (42.1%) switched methods over an average follow-up period of 11.2 years.

LIMITATIONS

Studies were characterised by a moderate study quality. Studies tended to group all methods into self-injury and/or self-poisoning with little consideration as to the diverse range of self-harm methods included within these broad categories and the likely differences in potential lethality between these methods. Few investigated the role of alcohol and/or drug dependence and mental illness on self-harm method choice.

CONCLUSIONS

Given the frequency of method switching observed, and the lack of discernible patterns over time, all patients should be routinely assessed for risk and needs irrespective of the method used at the index episode of non-fatal self-harm.

The role of neuroticism in self-harm and suicidal ideation: results from two UK population-based cohorts

BACKGROUND

Self-harm is common, debilitating and associated with completed suicide and increased all-cause mortality, but there is uncertainty about its causal risk factors, limiting risk assessment and effective management. Neuroticism is a stable personality trait associated with self-harm and suicidal ideation, and correlated with coping styles, but its value as an independent predictor of these outcomes is disputed.

METHODS

Prior history of hospital-treated self-harm was obtained by record-linkage to administrative health data in Generation Scotland:Scottish Family Health Study (N = 15,798; self-harm cases = 339) and by a self-report variable in UK Biobank (N = 35,227; self-harm cases = 772). Neuroticism in both cohorts was measured using the Eysenck Personality Questionnaire-Short Form. Associations of neuroticism with self-harm were tested using multivariable regression following adjustment for age, sex, cognitive ability, educational attainment, socioeconomic deprivation, and relationship status. A subset of GS:SFHS was followed-up with suicidal ideation elicited by self-report (n = 3342, suicidal ideation cases = 158) and coping styles measured by the Coping Inventory for Stressful Situations. The relationship of neuroticism to suicidal ideation, and the role of coping style, was then investigated using multivariable logistic regression.

RESULTS

Neuroticism was positively associated with hospital-associated self-harm in GS:SFHS (per EPQ-SF unit odds ratio 1.2 95% credible interval 1.1-1.2, p_FDR 0.0003) and UKB (per EPQ-SF unit odds ratio 1.1 95% confidence interval 1.1-1.2, p_FDR 9.8 × 10^-17). Neuroticism, and the neuroticism-correlated coping style, emotion-oriented coping (EoC), were also associated with suicidal ideation in multivariable models.

CONCLUSIONS

Neuroticism is an independent predictor of hospital-treated self-harm risk. Neuroticism and emotion-orientated coping styles are also predictive of suicidal ideation.

Is It Rational to Pursue Zero Suicides Among Patients in Health Care?

Suicide prevention is a major health care responsibility in need of new perspectives. This study reviews Zero Suicide, an emerging approach to suicide prevention that embraces the aspirational goal of zero suicides among patients treated in health care systems or organizations. Zero Suicide is gaining international momentum while at the same time evoking objections and concerns. Fundamental to Zero Suicide is a multilevel system view on suicide prevention, with three core elements: a direct approach to suicidal behaviors; continual improvement of the quality and safety of care processes; and an organizational commitment to the aspirational goal of zero suicides. The rationale and evidence for these components are clarified and discussed against the backdrop of concerns and objections that focus on possible undesired consequences of the pursuit of zero suicide, in particular for clinicians and for those who are bereaved by suicide. It is concluded that it is rational to pursue zero suicides as an aspirational goal, provided the journey toward zero suicides is undertaken in a systemic and sustained manner, in a way that professionals feel supported, empowered, and protected against blame and inappropriate guilt.

Looking to the Future: A Synthesis of New Developments and Challenges in Suicide Research and Prevention

Suicide and attempted suicide are major public health concerns. In recent decades, there have been many welcome developments in understanding and preventing suicide, as well as good progress in intervening with those who have attempted suicide. Despite these developments, though, considerable challenges remain. In this article, we explore both the recent developments and the challenges ahead for the field of suicide research and prevention. To do so, we consulted 32 experts from 12 countries spanning four continents who had contributed to the International Handbook of Suicide Prevention (2nd edition). All contributors nominated, in their view, (i) the top 3 most exciting new developments in suicide research and prevention in recent years, and (ii) the top 3 challenges. We have synthesized their suggestions into new developments and challenges in research and practice, giving due attention to implications for psychosocial interventions. This Perspective article is not a review of the literature, although we did draw from the suicide research literature to obtain evidence to elucidate the responses from the contributors. Key new developments and challenges include: employing novel techniques to improve the prediction of suicidal behavior; testing and applying theoretical models of suicidal behavior; harnessing new technologies to monitor and intervene in suicide risk; expanding suicide prevention activities to low and middle-income countries; moving toward a more refined understanding of sub-groups of people at risk and developing tailored interventions. We also discuss the importance of multidisciplinary working and the challenges of implementing interventions in practice.

Suicide and all-cause mortality following routine hospital management of self-harm: Propensity score analysis using multicentre cohort data

BACKGROUND

Observational studies are suited to examining links between the routine hospital management of self-harm and future suicide and all-cause mortality due to their large scale. However, care must be taken when attempting to infer causal associations in non-experimental settings.

METHODS

Data from the Multicentre Study of Self-Harm in England were used to examine associations between four types of hospital management (specialist psychosocial assessment, general hospital admission, psychiatric outpatient referral and psychiatric admission) following self-harm and risks of suicide and all-cause mortality in the subsequent 12 months. Missing data were handled by multiple imputation and propensity score (PS) methods were used to address observed differences between patients at baseline. Unadjusted, PS stratified and PS matched risk ratios (RRs) were calculated.

RESULTS

The PSs balanced the majority of baseline differences between treatment groups. Unadjusted RRs showed that all four treatment types were associated with either increased risks or no change in risks of suicide and all-cause mortality within a year. None of the four types of hospital management were associated with lowered risks of suicide or all-cause mortality following propensity score stratification (psychosocial assessment and medical admission) and propensity score matching (psychiatric outpatient referral and psychiatric admission), though there was no longer an increased risk among people admitted to a psychiatric bed. Individuals who self-cut were at an increased risk of death from any cause following psychosocial assessment and medical admission. Medical admission appeared to be associated with reduced risk of suicide in individuals already receiving outpatient or GP treatment for a psychiatric disorder.

CONCLUSIONS

More intensive forms of hospital management following self-harm appeared to be appropriately allocated to individuals with highest risks of suicide and all-cause mortality. PS adjustment appeared to attenuate only some of the observed increased risks, suggesting that either differences between treatment groups remained, or that some treatments had little impact on reducing subsequent suicide or all-cause mortality risk. These findings are in contrast to some previous studies that have suggested psychosocial assessment by a mental health specialist reduces risk of repeat self-harm. Future observational self-harm studies should consider increasing the number of potential confounding variables collected.