The urban distribution of non-fatal deliberate self-harm

Self-harm in Oxford, England: epidemiological and clinical trends, 1996-2010

BACKGROUND

Self-harm is a major healthcare problem and changes in its prevalence and characteristics can have important implications for clinical services, treatment and prevention.

METHODS

We analysed data on all self-harm presentations to the general hospital in Oxford between 1996 and 2010 using the Oxford Monitoring System for Self-harm. We investigated trends in prevalence, methods and repetition of self-harm, and receipt of psychosocial assessment. For patients receiving a psychosocial assessment, we investigated trends in alcohol use and misuse, prior psychiatric treatment and self-harm, problems, and suicidal intent.

RESULTS

Rates of self-harm rose in both genders between 1996 and 2002/2003, after which they declined. There was evidence of a possible cohort effect, whereby higher rates in younger males in earlier years transferred over time to older age groups. Self-cutting, hanging and jumping became more common. Paracetamol was involved in 44.9 % of all self-poisoning episodes. Overdoses of antidepressants (particularly selective serotonin reuptake inhibitors) increased, as did those of mood stabilisers, non-opiate analgesics excluding paracetamol (e.g. non-steroidal anti-inflammatory drugs), and non-ingestible poisons. Alcohol use in relation to self-harm and alcohol-related problems became more common, as did history of prior psychiatric treatment and, especially, of self-harm, and employment problems from 2008. Despite national guidance, the proportion of patients undergoing psychosocial assessment declined.

CONCLUSIONS

Major changes in the extent and nature of self-harm occurred over the study period, some suggestive of increased psychopathology and others reflecting prescribing practices and changes in drinking patterns. The findings emphasise the need for psychosocial assessment following self-harm, to identify treatment needs and reduce repetition.

New Developments in the Understanding and Treatment of Suicidal Behaviour

Recent developments in the understanding, assessment and treatment of suicidal behaviour are reviewed. The accumulated social and demographic knowledge of suicidal populations has proved to be clinically useful in shaping the general level of concern, but at the individual level an understanding of the psychological processes involved in suicidal behaviour is required. Studies examining psychological processes involved in suicidal behaviour is required. Studies examining psychological processes in parasuicidal groups have revealed a number of deficits, including poor interpersonal problem solving, hopelessness about the future, and reduced ability to regulate affect. Research has also begun to look at some of the processes underlying these deficits, such as over-general retrieval of autobiographical memories and reduced anticipation of specific positive experiences. The clinical picture is now more optimistic, with therapies, such as Dialectical Behaviour Therapy, which focus on using problem solving strategies with those clients who are most vulnerable to repeat parasuicide episodes, producing demonstrable delays in parasuicide and reduced risk of repetition. The importance of the relationship between research and clinical practice is emphasized.

Characteristics and predictors of self-mutilation: a study of incarcerated women

BACKGROUND

Research on self-mutilating behaviour and incarcerated adults has found that nearly 50% of people in prison participated in it (Holley and Alborleda-Florez, 1988). This is an enormous liability for the criminal justice system as well as a human concern.

AIMS/HYPOTHESES

The research question for this study was to explore whether a history of childhood abuse in a sample of incarcerated women would increase their likelihood of self-mutilation.

METHODS

Participants were 256 female inmates from five prisons in a large southern state who volunteered to attend a 12-week trauma and abuse psychosocial intervention group. The participants were evaluated for childhood abuse, criminal history, risk-taking behaviour and self-mutilation. Data are presented regarding individual, criminal, abuse, family and risk-taking behaviours comparing self-mutilators (n = 109) with non-self-mutilators (n = 147).

RESULTS

The self-mutilation group was more likely to report higher rates of emotional, sexual and physical abuse and on clinical significance scales of anxiety, depression, dissociation, impaired self-reference, anger, tension reduction and intrusive experiences. The self-mutilation group was also younger and was more often Caucasian. The results of the regression model suggest that a history of suicide attempts, emotional abuse, sexual abuse, bingeing and vomiting and impaired self-reference are predictors of self-mutilation.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Recommendations and implications for practice are discussed.

Understanding psychiatric nursing care with nonsuicidal self-harming patients in acute psychiatric admission units: the views of psychiatric nurses

Self-harm in the absence of suicidal intent is an underexplored area in psychiatric nursing research. This article reports on findings of a study undertaken in two acute psychiatric admission units in Ireland. The purpose of this study was to gain an understanding of the practices of psychiatric nurses in relation to people who self-harm but who are not considered suicidal. Semistructured interviews were held with eight psychiatric nurses. Content analysis revealed several themes, some of which will be presented and discussed in this article, namely, the participants' understanding of self-harm, their approach to care, and factors in the acute psychiatric admission setting, which impacted on their care. Recommendations for further research are offered.

Relation between parasuicide, suicide, psychiatric admissions, and socioeconomic deprivation

OBJECTIVE

To examine the relations between parasuicide, suicide, psychiatric inpatient admissions, and socioeconomic deprivation.

DESIGN

Ecological analysis with data from routine information systems and the 1991 census.

SETTING

24 localities in the area covered by the Bristol and District Health Authority (population 817,000), consisting of aggregations of neighbouring wards, with an average population of 34,000.

SUBJECTS

6089 subjects aged over 10 years admitted to hospital after parasuicide between April 1990 and March 1994; 997 suicides occurring 1982-91; 4763 subjects aged 10-64 years admitted with acute psychiatric illness between April 1990 and March 1994.

RESULTS

Localities varied significantly in standardised admission ratios for parasuicide and standardised mortality ratios for suicide (P < 0.001). Spearman's rank correlation coefficient between the standardised mortality ratio for suicide and standardised admission ratio for parasuicide was 0.73 (95% confidence interval 0.46 to 0.88). Correlation between parasuicide and Townsend score was 0.86 (0.70 to 0.94) and between suicide and Townsend score 0.73 (0.46 to 0.88). The partial correlation coefficient between suicide and parasuicide after the Townsend score was adjusted for was 0.29 (-0.13 to 0.62). The correlation between standardised admission ratio for parasuicide and standardised admission ratio for psychiatric illness was 0.76 (0.51 to 0.89) and between standardised mortality ratio for suicide and standardised admission ratio for psychiatric illness was 0.72 (0.45 to 0.87).

CONCLUSION

A strong ecological association exists between suicide and parasuicide, with socioeconomic deprivation accounting for much of this relation. This strong association provides supporting evidence for the importance of social policy measures in attaining Health of the Nation targets on mental health.

Attempted suicide in Hong Kong

In 1986, psychiatrists saw a total of 307 attempted suicide cases presented to a regional general hospital in Hong Kong, whether admitted or not. Compared with suicide attempts in Hong Kong in 1954 and those in Western countries, suicide attempts in Hong Kong in 1986 were significantly more likely to be precipitated by interpersonal conflicts, and significantly less likely to be precipitated by economic stress. Compared with the methods of attempted suicide in Hong Kong in 1986, those in Hong Kong in 1954 were significantly more likely to be fatal, while those in Western countries are significantly more likely to be ingestion of hyponotics and sedatives. Suicide attempters in Hong Kong are significantly more likely to be diagnosed as schizophrenics or paranoid psychotics than those in Western countries.

Parasuicide in an Arab industrial community: the Arabian-American Oil Company experience, Saudi Arabia

The parasuicide phenomena was investigated for the first time in a retrospective and prospective way in an Arab industrial community in the Eastern Province of Saudi Arabia during 1985 and 1986. Though the parasuicide rate of 20.7 per 100,000 is substantially lower from the reported rates in the West, underreporting and misdiagnosing of the phenomena may explain the low rate. The results of this study confirm that the act is predominantly the activity of young females, and disordered interpersonal relationships with spouses and parents stand out as precipitating factors. Acute reaction to stress was the commonest diagnosis followed by depression. Deliberate self-poisoning by analgesics and psychotropic drugs was the commonest method used. The findings of this study refute the hypothesis that parasuicide is rare in this part of the world, and time probably has come to amend the law in order to give the opportunity for distressed people to receive help.

Social determinants of self-poisoning

The non-fatal deliberate taking of overdoses in Cork city during 1982 was investigated from records in the general hospitals. In one of the hospitals, those attending after an overdose were personally interviewed. For both sexes, the greatest incidence of overdoses was in the younger groups; for females, there was a seasonal variation. Those taking overdoses were grouped by electoral wards, and the social characteristics of these wards determined. The frequency varied greatly throughout the city; some wards, particularly in corporation northern estates and part of the city centre, showed a rate of up to three times the average; these areas were the most likely to show social deprivation.

Developmental aspects of adolescent problem disclosure in England and Ireland

Adolescents in England and Ireland completed a problem checklist and results showed that problem experience varied systematically with age, sex and culture. Boys were less mature than girls in their problem experience, and were more concerned with authority, self-image and behavioural problems. Girls showed more worries in personal and emotional areas. In both sexes concern about unemployment and feelings of self inadequacy increased with age, while concerns in in other areas showed a general decrease. Irish adolescents had a less mature problem pattern than English, and they admitted to more worries. Cultural differences were specifically reflected in the adolescents' problem experience.

Psychiatric hospital admissions in Bristol. I. Geographical and ethnic factors

The distribution of in-patient psychiatric admissions throughout the city of Bristol during the period 1978-1981 is described. High rates were found from the central urban areas of low social class and with a high concentration of immigrants. The findings suggest that immigrant groups (mainly of West Indian origin) are no more likely than others living in the city centre to become psychiatric hospital in-patients, but when they do so, they are more likely to require compulsory admission.

Proposal for a distinctive diagnosis: the deliberate self-harm syndrome (DSH)

Self-destructive behavior is a major clinical problem in psychiatry. A review of the literature reveals the existence of enough clinical data to identify a diagnostic entity, "The Deliberate Self-Harm Syndrome" (DSH). The authors present a diagnostic formulation of the DSH syndrome (in the DSM-III format) which consists of four essential clinical features, a group of associated features, clinical features, a group of associated features, a clinical course of typical onset in late adolescence, with multiple recurrent episodes, with multiple methods of low lethality physical self-injury, extending over many years. On the basis of relatively exclusive association of clinical signs and symptoms a heuristic clinical entity is proposed.

Fatal ingestions in Edinburgh 1974-78

A retrospective survey of 275 fatal ingestions in Edinburgh is reported. There was only one accidental death in a child; the remainder comprised 113 men and 161 women. There were significant differences as to sex and age relationship. Single men and divorced or separated persons of both sexes were most strongly represented. Barbiturates comprised the group of drugs most often responsible for death, but common analgesics caused as many deaths as did tricyclic antidepressants and tranquillizers combined. The significance of alcohol was less than was anticipated, as was the association of significant organic disease. At least half of those who died were under treatment for psychiatric disease, and the evidence is that toxic ingestion is the commonest mode of suicide in the area. The limitations of a retrospective study are stressed and it is suggested that a central review of potential suicidal deaths as they occur would be useful.

Acute and chronic drug abuse emergencies in Metropolitan Toronto

From 3,548 drug overdose or abuse cases presenting at 21 Metropolitan Toronto hospitals' Emergency departments, data concerning demographic and medical characteristics, investigative and management procedures, drug analysis services, and disposition of patients were collected. Of the 3,548 cases, 2,723 (77%) were acute overdose and 816 (23%) were drug abuse. Drug overdose was more common than drug abuse for both sexes, but was more characteristic of females. The drugs most frequently alleged ingested were benzodiazepines (34%), ethanol (32%), salicylates (16%), and barbiturates (14%). The frequency with which particular classes of drugs are alleged in overdose corresponds closely to the frequency of prescribing these drugs in Ontario.

Attempted suicide: an ethological perspective

Attempted suicides are complex phenomena. Examination of the observed and described behavior permits an analogy to be drawn between them and the biological concept of "conservation withdrawal." This cognizance of innate of innate responses, individual differences and changing socio-cultural standards. Such a formulation more readily allows a non-judgemental approach to the patient, with acceptance of both the appeal and wish to die components. In addition, it offers a different view of the nosological debate, rendering the differences more apparent than real.

Patterns of health care in non-fatal deliberate self-harm

A series of 80 patients who had deliberately but not fatally harmed themselves and had been admitted to hospital was examined with special reference to their use of available services during the period of distress prior to the episode. They were followed up for 4 months and the ways in which they subsequently made use of helping agencies were also monitored.

Three broad groups of patient attitudes to help and its utilization are described. ‘General practitioner help-seekers’ (29) defaulted least often and appeared to have more positive attitudes towards seeking help for their problem. The ‘psychiatric help-seekers’ (17) appeared to be a chronically disorganized group who, though previously often in treatment, seemed unable to cooperate: they defaulted frequently and apparently gained little. ‘Non-help-seekers’ (34) had been reluctant to ask for help concerning psychological problems and subsequently defaulted just as frequently as did the ‘psychiatric help seekers’.

The need to take into account variation in patient attitude to help and its utilization in designing services for the primary prevention of non-fatal deliberate self-harm is emphasized.

Suicide attempts 1970--75: updating a United States study and comparisons with international trends

This paper brings up to date a 1970 study of suicide attempters coming to a major emergency room in an United States urban community and reviews international trends in suicide attempts. Results of the study and the review of the international literature indicate that the high rates of suicide attempts that were observed in 1970 are continuing into 1975. The incidence of suicide attempts continues to be a public health problem primarily amoung young women. Pill ingestion, usually barbiturates and psychotropic drugs, continues to be the most common method used.

Psychiatric illness, maladjustment and juvenile delinquency: an ecological study in a London borough

Patterns of adult psychiatric referral, of child guidance referral and of juvenile delinquency in a metropolitan borough were examined. The 3 sets of rates showed parallel trends among the 20 electoral wards of the borough, all 3 being similarly related to socio-demographic indices. A cluster analysis technique was used to combine the 450 enumeration districts of the borough into 22 clusters defined by social characteristics rather than by geographical boundaries. Ecological correlates of treated psychiatric disorder and of delinquency, based on these clusters, were found to be similar to those derived from the electoral ward data. The findings suggest that it may be possible to demarcate relatively small urban areas with high concentrations of psychiatric disorder, maladjustment and delinquency.

Parasuicide in Edinburgh--a seven-year review 1968-74

Parasuicide admissions to the Regional Poisoning Treatment Centre in Edinburgh are reviewed over the seven year period 1968-74. Special emphasis is given to trends in parasuicide rates for Edinburgh City, but social and clinical data are also described. Though the mean annual increase for admissions is 10-6 per cent, recent years have shown a fall in the rates for men and a levelling off for women. There have been increases in the rates for the young, for men in social classes 4 and 5 and for divorced women, and in poisonings with psychotropic drugs and alcohol consumption among women. At the same time it is important to note variables which have not changed: the relative risks by age and sex, repetition rates, the diagnostic picture, poisoning with non-prescribed drugs, and the rank order of municipal ward rates: and variables which have diminished: the rates for divorced men, overcrowding, domestic gas and barbiturate poisoning, and drug misuse. A comprehensive explanation of parasuicide in the contemporary scene would have to explain both the consistencies and the changing trends. The answer to the central question of why parasuicide is changing remains elusive.

Social geography of suicidal behaviour in Hobart

Psychological notions are required to explain geographical patterns. Mapping and statistical analysis for years 1971, 1973, 1974 and half of 1975 revealed that attempted suicide occurs commonly in the area surrounding the central business area of urban Hobart and also in the older housing department areas. Physical patterns and social structure are related in a tangible way for the expression of suicidal behaviour in a spatial pattern.

Socio-cultural determinants of attempted suicide among West Indians in Birmingham: ethnic origin and immigrant status

The author studied the significance of ethnic origin and immigrant status in attempted suicide. Epidemiological data (1969-72) indicated that self-poisoning among West Indian immigrants in Birmingham was less prevalent than among natives there but more prevalent than in the West Indies. The association of recent pregnancy with attempted suicide among young immigrant patients was noteworthy. Attempted suicide among immigrants was often relatively benign; few abused alcohol or drugs or made repeated attempts. The markedly lower male rate of attempted suicide, and its rarity in older persons, confirms previous findings.

A small area analysis of self-poisoning and self-injury in the region of Oxford

The number of persons attempting suicide in 1972–3 was related to the 1971 Census data by enumeration district in a defined area centred on Oxford City. Variations among enumeration districts in the number of attempters was partly explined by the age and marital state distribution of the population, but a few areas were identified where the high rates were not accounted for in this way. These included areas on council estates, both in the City and outside it, with marked indications of social disadvantage, and a socially mixed and probably rapidly changing inner city area. Persons attempting suicide were predominantly young and included relatively more women and more single people, but otherwise appeared to resemble the population of their immediate areas in terms of distribution by socio-economic group, housing conditions and indicators of social disadvantage. A model was fitted to the 1972–3 data to ‘predict’ the number of attempters in an enumeration district from the Census information. The fit was not entirely satisfactory, and suggested that there was a sub-group of districts with a near zero probability of producing an attempter which was not identifiable from the Census data. When fitted retrospectively to attempted suicide data for 1969 the performance of the model was poor. It was not possible to distinguish the effect of random variation from that of systematic change, but there was some evidence that certain areas with high attempted suicide rates in the City also showed a rapid increase in rates.

Deliberate self-harm: a follow-up study of 279 patients

Two-hundred-and-seventy-nine patients (103 men, 176 women) were followed-up 1-2 years after an act of non-fatal deliberate self-harm. Of 155 patients offered a psychiatric out-patient appointment at the time, only 68 completed the treatment. A further act of deliberate self-harm was committed by 26 men and 41 women within twelve months. The factors most highly associated with repetition were previous psychiatric treatment, a previous act of deliberate self-harm, and a criminal record. These factors held good for a separate series of patients. Significantly more repeaters received prolonged psychiatric care after the initial episode of deliberate self-harm. The implications of these findings for the clinical management of such patients are discussed.

Deliberate self-harm: clinical and socio-economic characteristics of 368 patients

In this study 368 patients were interviewed after they had attended the Bristol Royal Infirmary Accident and Emergency Department following a non-fatal act of deliberate self-harm. There were twice as many women (247) as men (121), and two thirds of the patients were in the 15-35 age group. Ninety-five per cent had taken a drug overdose, most commonly one or more of the tranquillizers, antidepressants, hypnotics or analgesics. Seventy-eight per cent had taken drugs prescribed by a doctor. Half the patients mentioned interpersonal conflict as a major precipitating factor in the episode. A psychiatric diagnosis was completed for all admitted patients, of whom 52 per cent were considered to be suffering from neurotic depression, 29 per cent from personality disorder, 12 per cent from functional psychosis and 10 per cent from alcohol addiction. Almost half had deliberately harmed themselves on a previous occasion. The series showed a greater than average incidence of unemployment, overcrowded living conditions, divorce and antisocial behaviour. The implications of these findings for the clinical management and prevention of non-fatal deliberate self-harm are discussed.