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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Self-Harm by Nurses and Midwives - A Study of Hospital Presentations

Background: Nursing professionals are an occupational group at increased risk of suicide, but little is known about self-harm in this population. Aims: To investigate the characteristics of nurses and midwives who present to hospital following self-harm. Method: We used data from the Oxford Monitoring System for Self-Harm to identify nurses and midwives who presented to the general hospital in Oxford during 2010-2020 following an episode of self-harm and received a psychosocial assessment. Results: During the eleven-year study period, 107 presentations of self-harm involving 81 nurses and midwives were identified. Self-poisoning was the most common self-harm method (71.6%), with antidepressants and paracetamol most frequently involved. Many had consumed alcohol before (43.8%) or during (25.3%) the self-harm act. Some individuals had high or very high suicide intent scores (22/70, 31.4%). Common problems preceding self-harm included problems with a partner (46.9%), psychiatric disorder (29.6%), and problems with employment (27.2%), family (24.7%), and alcohol (23.5%). A range of aftercare options were offered following presentation. Limitations: This study was limited to data from a single hospital. Conclusion: Prevention and management of self-harm within this occupational group requires preventative strategies and availability of interventions addressing the range of factors that may contribute to self-harm, especially relationship problems, psychiatric disorders, employment problems, and alcohol misuse.

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.

The self-perceived needs of adolescents with suicidal behaviour: a scoping review

Suicidal behaviour in adolescents is a major public health problem. Much research on this issue has focused on epidemiology and risk factors for suicidal behaviour, paying less attention to the self-perceived needs of adolescents. However, to increase engagement in suicide prevention, it is important to include the views of adolescents. A scoping review was performed to identify the available empirical study findings, of any study design, related to the self-perceived needs of adolescents with suicidal behaviour. The literature databases Medline, Embase, Psycinfo, CINAHL, ERIC, Scopus, and Web of Science were searched. Twenty-nine studies from 14 predominantly Anglo countries were included in the scoping review. The review showed that girls were overrepresented and that studies predominantly used qualitative approaches. The identified needs of adolescents with suicidal behaviour can broadly be grouped into needs related to the following areas: the importance of connecting with other people; adolescents' self-help strategies and personal growth after self-harm; mental healthcare; school or study programs; and needs related to society in relation to taboo on suicidal behaviour. Prevention of suicidal behaviour in adolescents will need to focus on development and strengthening of interventions fitting the needs of adolescents in these areas.

Differences in the characteristics of people who purchase pesticides from shops for self-harm versus those who use pesticides available in the domestic environment in Sri Lanka

OBJECTIVE

Data from South Asia indicate that for 15%-20% of suicide attempts, pesticides are purchased from shops; otherwise, pesticides are obtained from an individual's house or nearby environment. We aimed to investigate the difference between individuals who directly purchase pesticides from shops for suicide attempts and suicide deaths versus those related to accessing the pesticides from an individual's house or nearby environment.

METHODS

We conducted two comparative studies in rural Sri Lanka: (1) non-fatal shop cases (n = 50) were survivors of self-poisoning with pesticides who ingested the pesticides after purchasing them from a shop; non-fatal domestic cases (n = 192) were survivors who accessed pesticides from their house or nearby environment. (2) fatal shop cases (n = 50) were individuals who died after ingesting pesticides they purchased for the act; fatal domestic cases (n = 102) were patients who died after ingesting pesticides they accessed at house or nearby environment. Logistic regression analysis was used to assess the characteristics which distinguished between the shop and domestic cases.

RESULTS

Data indicate that 20.7% and 32.9% of individuals who used pesticides for suicide attempts and suicide deaths had purchased them from shops, respectively. Being a non-farmer was the main distinguishing characteristic of shop cases: adjusted odds ratios (AOR) 8.9, 95% confidence intervals (CI) 3.2-24.4 for non-fatal shop cases, and AOR 4.0, 95% CI 1.5-10.6 for fatal shop cases. Non-fatal shop cases also had higher suicide intent (AOR 3.0, CI 1.0-8.9), and ingesting an insecticide (AOR 4.8, CI 1.8-1.0-8.9) than non-fatal domestic cases.

CONCLUSION

A high suicide intent of individuals who purchase pesticides for the event explains the high proportion of such fatal cases. Such high suicide intent makes the prevention implications difficult to spell out for those individuals who purchase pesticides for self-poisoning. However, our findings are valuable for clinicians to assess pesticide poisoning cases in hospitals.

Suicidal thoughts and behaviours among student nurses and midwives: A systematic review

AIM

To synthesize research investigating suicide, suicide attempts, self-harm and suicide ideation in nursing and midwifery students, a group of interest due to high rates of suicide among qualified nurses. Specific areas of interest for this review included prevalence, factors which may contribute to or mitigate risk and suicide prevention interventions.

DESIGN

A systematic review was conducted, and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

DATA SOURCES

Three electronic databases were searched, and additional articles identified using hand-searching. Studies were included if they examined suicide, suicide attempts, self-harm or suicide ideation in nursing or midwifery students.

REVIEW METHODS

Studies were deduplicated and assessed for inclusion. Data from included studies were extracted, quality of studies assessed and data synthesized, informed by study focus, design and assessed quality.

RESULTS

About 46 studies of largely moderate to low quality were identified. A high-quality study demonstrated increased risk of suicide in Swedish female nursing students, and increased risk of self-harm in nursing students of both sexes. Prevalence of suicide ideation did not appear to differ across course year, or between nursing students and students on other programmes. Psychiatric conditions, particularly depression, were associated with suicide ideation. Three studies related to suicide prevention interventions were identified. Integration of wellness initiatives into the curriculum and peer support were preferred interventions among nursing students and teaching staff.

CONCLUSIONS

To understand the extent of suicide and self-harm among nursing and midwifery students there is a need for further epidemiological research stratified by programme of study. To develop prevention interventions and initiatives for nursing students, high-quality longitudinal studies should examine characteristics associated with suicide and self-harm.

IMPACT

Current findings suggest interventions could include support for students experiencing mental health difficulties, foster peer support, and help develop wellness. No patient or public contribution.

Understanding Suicide Clusters Through Exploring Self-Harm Behaviors

Background: There is little information about characteristics and long-term outcomes of individuals who self-harm during a suicide cluster. Aims: To compare characteristics of individuals who self-harmed during a suicide cluster in South Wales (∼10 deaths between December 2007 and March 2008) with others who self-harmed prior to the cluster and to evaluate 10-year self-harm and mortality outcomes. Method: Using records from the hospital serving the catchment area of the suicide cluster, enhanced by national routinely collected linked data, we created the following two groups: individuals who self-harmed (a) during the suicide cluster and (b) 1 year before. We compared individuals' characteristics and performed logistic regression to compute odds ratios of 10-year self-harm and mortality outcomes. Results: Individuals who self-harmed during the cluster were less likely to be hospitalized or have a mental health history than those who self-harmed prior to the cluster. No significant group differences were found for 10-year self-harm outcomes, but all-cause mortality was higher for males. Limitations: Sample size was small, and data were lacking on psychological and social proximity to individuals who died during the suicide cluster. Conclusion: Our findings highlight the importance of long-term healthcare follow-up of those who self-harm during a suicide cluster, particularly males.

Experiences of clinical staff who work with patients who self-harm by ligature: An exploratory survey of inpatient mental health service staff

WHAT IS KNOWN ON THE SUBJECT

Self-harm by ligature is common within inpatient mental healthcare settings and is a dangerous method of self-harm. Most fatal and non-fatal suicidal behaviours in inpatient settings are a result of ligature use. There is a lack of research which has explored the experiences of staff members who work within inpatient settings where patients may self-harm by ligature.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

Key issues related to self-harm by ligature reported by staff included (1) understaffing increasing risk of ligature incidents, (2) spreading of self-harm by ligature within inpatient settings and (3) negative attitudes of staff related to patients who self-harm by ligature. Working with self-harm by ligature can have negative impacts on staff's personal (e.g. fear of blame) and professional lives (e.g. increased cautiousness). Many staff members currently feel underprepared by training related to working with self-harm by ligature, and unsupported after responding to a ligature incident.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

Training about self-harm by ligature needs to be improved and be accessible for all inpatient mental healthcare staff. Training should be coproduced, and could include practical components, education on potential reasons for self-harm, and acknowledgement of the emotional impact on staff. Support for staff members who respond to ligature incidents should be available for all staff members who respond to self-harm by ligature incidents. Stigma associated with accessing support should be challenged, alongside blame cultures within the workplace.

ABSTRACT

INTRODUCTION: Self-harm by ligature is a common form of self-harm within inpatient mental health services in England, where most suicides within inpatient settings involve hanging or suffocation. However, little research has examined the experiences of staff members working with this method of self-harm.

AIM

We explored the experiences of clinical staff who work with patients who self-harm by ligature.

METHOD

A staff survey was developed and disseminated to clinical staff working in inpatient settings in England. Quantitative data were analysed using descriptive statistics, and qualitative data using the framework approach. The study was STROBE checklist compliant.

RESULTS

275 staff members participated. Challenges most frequently reported about working with self-harm by ligature included understaffing (210, 76.6%), spreading of ligature incidents (198, 72.8%) and negative attitudes held by clinical staff towards such patients (185, 68.5%). Participants' responses indicated that this work could have significant impacts on their professional and personal lives. Staff often reported inadequate training and lack of preparedness, alongside insufficient support opportunities following ligature incidents.

DISCUSSION

Staff had a diverse range of professional and personal experiences and identified multiple challenges associated with working with patients who have self-harmed by ligature.

IMPLICATIONS FOR PRACTICE

There is a need to improve accessibility, format and content of training and support for staff working within inpatient settings where patients may self-harm by ligature.

Real-Time Suicide Surveillance: Comparison of International Surveillance Systems and Recommended Best Practice

OBJECTIVE

Some countries have implemented systems to monitor suicides in real-time. These systems differ because of the various ways in which suicides are identified and recorded. The main objective of this study was to conduct an international comparison of major real-time suicide mortality surveillance systems to identify joint strengths, challenges, and differences, and thereby inform best-practice criteria at local, national, and international levels.

METHODS

Five major real-time suicide mortality surveillance systems of various coverage levels were identified and selected for review via an internet-based scoping exercise and prior knowledge of existing systems. Key information including the system components and practices was collated from those organizations that developed and operate each system using a structured template. The information was narratively and critically synthesized to determine similarities and differences between the systems.

RESULTS

The comparative review of the five established real-time suicide surveillance systems revealed more commonalities than differences overall. Commonalities included rapid, routine surveillance based on minimal, provisional data to facilitate timely intervention and postvention efforts. Identified differences include the timeliness of case submission and system infrastructure.

CONCLUSION

The recommended criteria could promote replicable components and practices in real-time suicide surveillance while offering flexibility in adapting to regional/local circumstances and resource availability.HIGHLIGHTSEvidence-informed recommendations for current best practice in real-time suicide surveillance.Proposed comprehensive framework can be adapted based on available resources and capacity.Real-time suicide mortality data facilitates rapid data-driven decision-making in suicide prevention.

Physical injuries as triggers for self-harm: a within-individual study of nearly 250 000 injured people with a major psychiatric disorder

BACKGROUND

Although there is robust evidence for several factors which may precipitate self-harm, the contributions of different physical injuries are largely unknown.

OBJECTIVE

To examine whether specific physical injuries are associated with risks of self-harm in people with psychiatric disorders.

METHODS

By using population and secondary care registers, we identified all people born in Finland (1955-2000) and Sweden (1948-1993) with schizophrenia-spectrum disorder (n=136 182), bipolar disorder (n=68 437) or depression (n=461 071). Falls, transport-related injury, traumatic brain injury and injury from interpersonal assault were identified within these subsamples. We used conditional logistic regression models adjusted for age and calendar month to compare self-harm risk in the week after each injury to earlier weekly control periods, which allowed us to account for unmeasured confounders, including genetics and early environments.

FINDINGS

A total of 249 210 individuals had been diagnosed with a psychiatric disorder and a physical injury during the follow-up. The absolute risk of self-harm after a physical injury ranged between transport-related injury and injury from interpersonal assault (averaging 17.4-37.0 events per 10 000 person-weeks). Risk of self-harm increased by a factor of two to three (adjusted OR: 2.0-2.9) in the week following a physical injury, as compared with earlier, unexposed periods for the same individuals.

CONCLUSIONS

Physical injuries are important proximal risk factors for self-harm in people with psychiatric disorders.

CLINICAL IMPLICATIONS

Mechanisms underlying the associations could provide treatment targets. When treating patients with psychiatric illnesses, emergency and trauma medical services should actively work in liaison with psychiatric services to implement self-harm prevention strategies.

Self-harm in university students: A comparative analysis of data from the Multicentre Study of Self-harm in England

BACKGROUND

Increases in poor mental health and suicide have been identified among university students in the UK. However, little is known about self-harm in this group.

AIMS

To describe and identify care needs of university aged-students who self-harm via comparisons with an age-equivalent non-student group who self-harm.

METHODS

Observational cohort data from The Multicentre Study of Self-harm in England were used to investigate students aged 18 to 24 years who presented to emergency departments for self-harm, 2003 to 2016. Data were collected via clinician reports and medical records from five hospitals in three English regions. Characteristics, rates, repetition, and mortality outcomes were investigated.

RESULTS

The student sample included 3491 individuals (983, 28.2 % men; 2507, 71.8 % women; 1 unknown) compared to 7807 (3342, 42.8 % men; 4465, 57.2 % women) non-students. Self-harm increased over time in students (IRR 1.08, 95%CI 1.06-1.10, p < 0.01) but not in non-students (IRR 1.01, 95%CI 1.00-1.02, p = 0.15). There were differences in monthly distribution of self-harm with more presentations by students in October, November, and February. Characteristics were broadly similar, but students reported more problems with studying and mental health. Repetition (HR 0.78, 95%CI 0.71-0.86, p < 0.01) and mortality (HR 0.51, 95%CI 0.33-0.80, p < 0.01) were lower in students than non-students.

CONCLUSIONS

Self-harm in students may be directly related the student experience, such as academic pressure, relocation, and the transition to independent living. Wellbeing initiatives targeting these factors, alongside mental health awareness training for academic and non-academic staff may help to support students at risk.

Association between SARS-CoV-2 infection and self-harm: Danish nationwide register-based cohort study

BACKGROUND

Case studies have linked SARS-CoV-2 infection to suicidal behaviour. However, conclusive evidence is lacking.

AIMS

To examine whether a history of SARS-CoV-2 infection or SARS-CoV-2-related hospital admission was associated with self-harm in the general population and in high-risk groups.

METHOD

A cohort design was applied to nationwide data on all people aged ≥15 years and living in Denmark between 27 February 2020 and 15 October 2021. Exposure was identified as having had a positive SARS-CoV-2 PCR test, and further assessed as SARS-CoV-2-related hospital admission. Rates of probable self-harm were examined using adjusted incidence rate ratios (aIRRs). The following subgroups were identified: (a) lower educational level, (b) chronic medical conditions, (c) disability pension, (d) mental disorders, (e) substance use disorders, and history of (f) homelessness and (g) imprisonment.

RESULTS

Among 4 412 248 included individuals, 260 663 (5.9%) had tested positive for SARS-CoV-2. Out of 5453 individuals presenting with self-harm, 131 (2.4%) had been infected. Individuals with a history of a positive SARS-CoV-2 test result had an aIRR for self-harm of 0.86 (95% CI 0.72-1.03) compared with those without. High rates were found after a SARS-CoV-2-related hospital admission (aIRR = 7.68; 95% CI 5.61-10.51) or a non-SARS-CoV-2-related admission (aIRR = 10.27; 95% CI 9.65-10.93) versus non-infected and not admitted. In sensitivity analyses with a more restrictive definition of self-harm, a positive PCR test was associated with lower rates of self-harm.

CONCLUSIONS

Individuals with a PCR-confirmed SARS-CoV-2 infection did not have higher rates of self-harm than those without. Hospital admission in general, rather than being SARS-CoV-2 positive. seemed to be linked to elevated rates of self-harm.

Research Review: Viewing self-harm images on the internet and social media platforms: systematic review of the impact and associated psychological mechanisms

BACKGROUND

Viewing self-harm and suicide-related images online can precede these behaviours. We reviewed studies of potential impacts and mechanisms associated with viewing self-harm-related images on the internet and social media.

METHOD

CINAHL, Cochrane Library, EMBASE, HMIC, MEDLINE, PsycArticles, PsycINFO, PubMed, Scopus, Sociological Abstracts and Web of Science Core Collection databases were searched for relevant studies from inception to 22 January 2022. Inclusion criteria were English language, peer-reviewed, empirical studies with data related to impacts of viewing self-harm images or videos on the internet or social media. Quality and risk of bias were assessed using Critical Appraisal Skills Programme tools. A narrative synthesis approach was used.

RESULTS

Of the 15 identified studies, all found harmful effects of viewing self-harm-related images online. These included escalation of self-harm, reinforcement of engagement behaviours (e.g. commenting and sharing images), encouragement of social comparison (comparing own self-harm with others), development of a self-harm identity, social connection perpetuating or escalating self-harm, and emotional, cognitive, and physiological impacts triggering self-harm urges and acts. Nine studies found protective effects, including self-harm mitigation or reduction, promotion of self-harm recovery, encouraging social connection and help-giving, and emotional, cognitive and physiological impacts mitigating or reducing self-harm urges and acts. Causality of impact was not determined in any study. Most of the studies did not explicitly evaluate or discuss potential mechanisms.

CONCLUSIONS

Viewing self-harm images online may have both harmful and protective effects, but harmful effects predominated in the studies. Clinically, it is important to assess individual's access to images relating to self-harm and suicide, and the associated impacts, alongside pre-existing vulnerabilities and contextual factors. Higher quality longitudinal research with less reliance on retrospective self-report is needed, as well as studies that test potential mechanisms. We have developed a conceptual model of the impact of viewing self-harm images online to inform future research.

Suicide, self-harm, and suicide ideation in nurses and midwives: A systematic review of prevalence, contributory factors, and interventions

BACKGROUND

Nurses have been identified as an occupational group at increased risk of suicide. This systematic review examines the prevalence of, and factors influencing, suicide and related behaviours among nurses and midwives (PROSPERO pre-registration CRD42021270297).

METHODS

MEDLINE, PsycINFO, and CINAHL were searched. Articles published from 1996 onwards exploring suicidal thoughts and behaviours among nurses and midwives were included. Quality of included studies was assessed. Articles were subjected to narrative synthesis informed by suicide data examined, study design, and quality. PRISMA guidelines were followed.

RESULTS

A total of 100 studies were eligible for inclusion in the review. Articles examining suicide exclusively among midwives were absent from the literature. Several studies confirmed that nursing professionals, especially female, are at increased risk of suicide, particularly by self-poisoning. Factors contributing to risk include psychiatric disorders, alcohol and substance misuse, physical health problems, and occupational and interpersonal difficulties. In studies of non-fatal suicidal behaviours, including during the COVID-19 pandemic, psychiatric, psychological, physical and occupational factors were contributory. There has been little investigation of interventions for prevention of suicide in nurses.

LIMITATIONS

Only articles published in English language were reviewed.

CONCLUSIONS

The findings highlight the risk of suicide in nurses. They also show a combination of factors contribute to suicide and non-fatal suicidal behaviour in nurses, with psychiatric, psychological, physical health, occupational and substance misuse (especially alcohol) problems being particularly important. The limited evidence regarding prevention measures indicates a major need to develop primary and secondary interventions for this at-risk occupational group, for example, education regarding enhancing wellbeing and safe alcohol use, alongside accessible psychological support.

Risk of suicide in patients who present to hospital after self-cutting according to site of injury: findings from the Multicentre Study of Self-harm in England

BACKGROUND

We compared the risk of death by suicide following hospital presentation for self-harm according to site of self-cut/stab.

METHOD

We included 54 999 self-harm presentations (involving 31 419 individuals) to hospitals in the Multicentre Study of Self-harm in England (1/1/2004-31/12/2014), with mortality follow-up to 31/12/2019. Information on method of self-harm was obtained through monitoring in hospitals. Information about mortality was obtained through linkage with NHS Digital. We assessed the association of site of self-cut with death by suicide using mixed effect models.

RESULTS

In total, 10 790 (19.6%) hospital presentations involved self-cutting/stabbing, 7489 of which (69.4%) were due to laceration to the arm/wrist alone, 1846 episodes (17.1%) involved cutting elsewhere on the body, and 1455 (13.5%) were due to laceration to unknown site. Controlling for confounders, presentation to a hospital following self-cut/stab to bodily parts other than wrist/arm was associated with greater chance of subsequent suicide relative to presentation after self-poisoning alone [adjusted odds ratio (aOR) 1.75, 95% confidence interval (CI) 1.03-2.96, p = 0.038]. The likelihood of suicide after presentation for cutting/stabbing the wrist/arm alone was comparable to that of patients who had self-poisoned alone. Presentations after laceration involving the neck were associated with a four-fold greater chance of subsequent suicide relative to self-poisoning (aOR 4.09, 95% CI 1.80-9.30, p = 0.001).

CONCLUSIONS

Patients who attend hospital after self-cutting/stabbing are a heterogeneous group in terms of characteristics, methods of cutting/stabbing and risk of subsequent suicide. Risk of suicide is greater in individuals who self-cut/stab to parts of the body other than the wrist or arm, especially the neck.

The characteristics, life problems and clinical management of older adults who self-harm: Findings from the multicentre study of self-harm in England

BACKGROUND

Older adults have a high risk of suicide following self-harm. Contemporary information on self-harm in this population is needed to inform care provision.

OBJECTIVES

To examine subgroup differences in the incidence of self-harm, sociodemographic and clinical characteristics, preceding life problems and outcomes in individuals aged 60 years and over presenting to hospital following self-harm.

METHOD

Data on Emergency Department (ED) presentations for self-harm from 2003 to 2016 from three centres in the Multicentre Study of Self-Harm in England were analysed. Changes in self-harm rates were examined using Poisson regression. Univariable logistic regression was used to investigate factors associated with 12-month self-harm repetition.

RESULTS

There were 3850 presentations for self-harm by 2684 individuals aged 60 years and over. Self-harm rates increased over time for 60-74-year-old men (Incident Rate Ratio = 1.04, 95% Confidence Interval 1.02-1.06, p < 0.0001). Problems most frequently reported to have preceded self-harm were mental health (40.5%) and physical health (38.3%) concerns. Problems with alcohol, finances, employment and relationship with partner were found more frequently in 60-74-year-olds compared with those aged over 74 years. Physical health problems were common with increasing age, as were problems with alcohol for men. One in ten (10.8%) individuals presented to hospital with self-harm within 12 months of their index presentation.

CONCLUSIONS

Self-harm-related ED attendances in older men have increased, particularly for men aged 60-74 years. Prevention and clinical management should involve a comprehensive psychosocial assessment to target common precipitants for the wide range of problems preceding self-harm and may include support with physical and mental wellbeing and advice on safer alcohol use.

Media coverage and speculation about the impact of the COVID-19 pandemic on suicide: a content analysis of UK news

OBJECTIVES

Since the start of the COVID-19 pandemic, there has been much concern and speculation about rises in suicide rates, despite evidence that suicides did not in fact increase in the first year of the pandemic in most countries with real-time suicide data. This public narrative is potentially harmful, as well as misleading, and is likely to be perpetuated by sensational news coverage.

METHOD

Using a bespoke database, we analysed the quality and content of print and online UK news (including opinion pieces) on the impact of COVID-19 on suicidality, based on adherence to international recommendations. χ² tests were conducted to examine variability in relation to key characteristics (eg, type of publication) and to four 'restriction phases' (based on UK government official lockdown measures) over the first 14 months of the pandemic.

RESULTS

We identified 372 stories about COVID-19 and suicidality in online and print news between the first UK lockdown (March 2020) and May 2021 (when restrictions were significantly eased in the UK). Throughout this period, over a third of articles (39.2%) and headlines (41.4%) claimed or predicted a rise in suicide, often attributed to feelings of entrapment and poor mental health (especially among young people) and fueled by expert commentary and speculation. Almost a third of reports were rated as being of negative quality (116, 31.2%), and at least half included no signposting to help and support. However, reporting improved in phases of less stringent COVID-19 restrictions and over time, with later articles and headlines including fewer negative statements and predictions about rises in suicides, and greater reliance on academic evidence.

CONCLUSIONS

As the longer-term consequences of the pandemic develop, and other national and global events unfold, it is increasingly important that the media, and the wider community of experts shaping its narratives, strive for a positive and evidence-informed approach to news coverage of suicide.

Establishing Self-Harm Registers: The Role of Process Mapping to Improve Quality of Surveillance Data Globally

Self-harm registers (SHRs) are an essential means of monitoring rates of self-harm and evaluating preventative interventions, but few SHRs exist in countries with the highest burden of suicides and self-harm. Current international guidance on establishing SHRs recommends data collection from emergency departments, but this does not adequately consider differences in the provision of emergency care globally. We aim to demonstrate that process mapping can be used prior to the implementation of an SHR to understand differing hospital systems. This information can be used to determine the method by which patients meeting the SHR inclusion criteria can be most reliably identified, and how to mitigate hospital processes that may introduce selection bias into these data. We illustrate this by sharing in detail the experiences from a government hospital and non-profit hospital in south India. We followed a five-phase process mapping approach developed for healthcare settings during 2019-2020. Emergency care provided in the government hospital was accessed through casualty department triage. The non-profit hospital had an emergency department. Both hospitals had open access outpatient departments. SHR inclusion criteria overlapped with conditions requiring Indian medicolegal registration. Medicolegal registers are the most likely single point to record patients meeting the SHR inclusion criteria from multiple emergency care areas in India (e.g., emergency department/casualty, outpatients, other hospital areas), but should be cross-checked against registers of presentations to the emergency department/casualty to capture less-sick patients and misclassified cases. Process mapping is an easily reproducible method that can be used prior to the implementation of an SHR to understand differing hospital systems. This information is pivotal to choosing which hospital record systems should be used for identifying patients and to proactively reduce bias in SHR data. The method is equally applicable in low-, middle- and high-income countries.

Effects of patient deaths by suicide on clinicians working in mental health: A survey

In the UK, at least a quarter of suicides occurs in patients whilst under the care of mental health services. This study investigated the effects of such deaths on non-medical mental health clinicians. An online survey was conducted within a single NHS mental health Trust to elicit both quantitative and qualitative responses from staff across a range of professions. The survey focused on personal and professional impacts and available support. Participants reported significant negative emotional and professional effects that were long-lasting for some. These included mental health difficulties, loss of confidence regarding clinical responsibilities, and actual or contemplated career change. However, there was also some evidence of positive effects and professional growth. Support from colleagues and line managers is clearly important following deaths of patients by suicide. Clinicians' experiences of the support they had received in the workplace were polarized, suggesting that there is no single nor ideal approach that will meet everyone's needs. Participants made recommendations for the types of support that may be helpful. Most commonly, clinicians desired opportunities for focused reflection and support and help with the formal processes following the death. Sensitivity around how clinicians are notified about the death was highlighted as being particularly important. Conclusions are drawn as to how training institutions and employers can help staff to be better prepared for the potential occurrence of patient suicides and the formal processes that follow, with a view to mitigating risks of more serious harm to staff and hence indirectly to patients, and potential loss of highly trained clinicians to the workforce.

Police-led real-time surveillance system for suspected suicides in Great Britain

It has become increasingly apparent that rapidly available information about the occurrence of suicides is needed, particularly to support suicide prevention efforts. Concerns about the potential impact of the COVID-19 pandemic on vulnerability to suicide highlighted the need for such early data internationally. Here, we set out the nature, current status and content of a real-time suicide monitoring system in Great Britain (England, Scotland and Wales), and explore its potential to contribute to timely and targeted suicide prevention initiatives. We also discuss the challenges to successful implementation.

Socio-economic disparities in patients who present to hospital for self-harm: patients' characteristics and problems in the Multicentre Study of Self-harm in England

BACKGROUND

We examined disparities in sociodemographic and clinical characteristics and in problems preceding self-harm across levels of socio-economic deprivation (SED) in persons who presented to hospital for self-harm.

METHOD

108,092 presentations to hospitals (by 57,306 individuals) following self-harm in the Multicentre Study of Self-harm in England (1/1/2000-31/12/2016). Information on area-level SED was based on the English Index of Multiple Deprivation. Information about patients' characteristics and problems was obtained from self-harm monitoring systems in the hospitals. We assessed the association of SED with the characteristics of interest using descriptive statistics.

RESULTS

Overall, 45 % of the presentations were by individuals from areas ranked nationally as most deprived, while 13 % of episodes were by individuals from the least deprived areas. Males and non-white ethnic groups were over-represented in the most deprived SED stratum. Previous self-harm was more prevalent in the two most deprived groups. Relationships difficulties with partners and other family members were reported more commonly by individuals from less socio-economically deprived areas, as were problems pertaining to finances and employment or studies. Problems in relationships with friends were more prevalent in the most deprived group relative to other groups.

LIMITATIONS

Information about problems which preceded self-harm was available only for patients who received psychosocial assessment.

CONCLUSIONS

Patients vary considerably across area-level SED strata in terms of gender, ethnicity, and the problems which preceded their self-harm. These findings emphasise the need to use an individualised approach to patients in understanding the unique circumstances which contribute to their self-harm and their specific care needs.

News reporting of suicide in nurses: A content analysis study

Media impact on suicide is well-established. Groups at heightened risk of suicide, such as nurses, may be particularly influenced by poor news reporting. This study aimed to examine UK newspaper reporting of suicide of nurses and student nurses, including during the COVID-19 pandemic. Print and online newspaper reports about suicide in nurses (including students) published in the UK between January 2018 and August 2021 were obtained and data extracted for analysis in collaboration with Samaritans' media advisory team. Content and quality of newspaper reports were examined using a content analysis approach. The study was compliant with the STROBE checklist. Nurse or student nurse suicides were reported in 134 articles, including 50 individual suicides. Most articles were acceptable against Samaritans' media guidelines. However, common problems included absence of signposting to support organizations and lack of suicide prevention messages. A minority of articles included methods of suicide within article headlines (18, 13.4%) and sensationalist or romanticizing language (14, 10.7%). Most contained occupation-related content. Many named the individual's specific hospital or university and a substantial proportion included occupation-related images. Working on the frontline was the most reported link between COVID-19 and nurse suicide. While reporting on suicide among nurses and students was largely acceptable, quality of reporting was variable. Occupation was often discussed, and most articles published during COVID-19 linked suicide to the pandemic. The research findings can help shape guidance on reporting of suicide in specific professions and occupations, including nursing, to encourage responsible reporting and reduce inadvertent promotion of suicide.

Life problems in children and adolescents who self-harm: findings from the multicentre study of self-harm in England

BACKGROUND

Self-harm, a significant and increasing global problem in children and adolescents, is often repeated and is associated with risk of future suicide. To identify potential interventions, we need to understand the life problems faced by children and adolescents, and by sub-groups of younger people who self-harm. Our aims were to include the following: (a) investigate the type and frequency of life problems in a large sample of children and adolescents who self-harmed. (b) Examine whether problems differ between those who repeat self-harm and those who do not.

METHODS

We analysed data for 2000 to 2013 (follow up until 2014) from the Multicentre Study of Self-harm in England on individuals aged 11 to 18 years who presented to one of the five study hospitals following self-harm and received a psychosocial assessment including questions about problems, which precipitated self-harm.

RESULTS

In 5648 patients (12,261 self-harm episodes), (75.5% female, mean age 16.1 years) the most frequently reported problems at first episode of self-harm were family problems. Problems around study/employment/study and relationships with friends also featured prominently. The types of problems that precede self-harm differed between late childhood/early adolescence. Abuse, mental health problems and legal problems significantly predicted repeat self-harm for females.

CONCLUSION

The most common problems reported by both genders were social/interpersonal in nature, indicating the need for relevant services embedded in the community (e.g. in schools/colleges). Self-harm assessment and treatment choices for children and adolescents must take age and gender into account. To prevent future self-harm, individualised supports and services are particularly needed for abuse, mental health and legal problems.

Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management

Suicide prevention in psychiatric practice has been dominated by efforts to predict risk of suicide in individual patients. However, traditional risk prediction measures have been shown repeatedly in studies from high income countries to be ineffective. Several factors might contribute to clinicians' preoccupation with risk prediction, which can have negative effects on patient care and also on clinicians where prediction is seen as failing. The model of therapeutic risk assessment, formulation, and management we outline in this article regards all patients with mental health problems as potentially at increased risk of suicide. It is aimed at reducing risk through use of a person-centred approach. We describe how a move towards therapeutic risk assessment, formulation, and risk management, including collaborative safety planning, could help clinicians develop a more tailored approach to managing risk for all patients, incorporating potentially therapeutic effects as well as helping to identify other risk reduction interventions. Such an approach could lead to enhanced patient safety and quality of care, which is more acceptable to patients.

The impact of the COVID-19 pandemic on presentations to health services following self-harm: systematic review

BACKGROUND

Evidence on the impact of the pandemic on healthcare presentations for self-harm has accumulated rapidly. However, existing reviews do not include studies published beyond 2020.

AIMS

To systematically review evidence on presentations to health services following self-harm during the COVID-19 pandemic.

METHOD

A comprehensive search of databases (WHO COVID-19 database; Medline; medRxiv; Scopus; PsyRxiv; SocArXiv; bioRxiv; COVID-19 Open Research Dataset, PubMed) was conducted. Studies published from 1 January 2020 to 7 September 2021 were included. Study quality was assessed with a critical appraisal tool.

RESULTS

Fifty-one studies were included: 57% (29/51) were rated as 'low' quality, 31% (16/51) as 'moderate' and 12% (6/51) as 'high-moderate'. Most evidence (84%, 43/51) was from high-income countries. A total of 47% (24/51) of studies reported reductions in presentation frequency, including all six rated as high-moderate quality, which reported reductions of 17-56%. Settings treating higher lethality self-harm were overrepresented among studies reporting increased demand. Two of the three higher-quality studies including study observation months from 2021 reported reductions in self-harm presentations. Evidence from 2021 suggests increased numbers of presentations among adolescents, particularly girls.

CONCLUSIONS

Sustained reductions in numbers of self-harm presentations were seen into the first half of 2021, although this evidence is based on a relatively small number of higher-quality studies. Evidence from low- and middle-income countries is lacking. Increased numbers of presentations among adolescents, particularly girls, into 2021 is concerning. Findings may reflect changes in thresholds for help-seeking, use of alternative sources of support and variable effects of the pandemic across groups.

Associations between treatment with melatonin and suicidal behavior: a nationwide cohort study

STUDY OBJECTIVES

Melatonin is often prescribed to patients with sleep disorders who are known to have elevated suicide risks, yet melatonin's association with suicidal behavior remains to be examined. We investigated whether individuals prescribed melatonin had higher rates of suicide and suicide attempts when compared to individuals who were not prescribed this drug, including both those with and without known mental disorders.

METHODS

A cohort design was applied to longitudinal, register data on all persons aged ≥ 10 years in Denmark during 2007-2016. Based on data from the National Prescription Registry, periods of being in treatment with melatonin were defined using information on the number of tablets and the daily defined dose. We calculated incidence rate ratios for suicide and suicide attempts, as identified in register records, comparing those in treatment with melatonin to those not in treatment.

RESULTS

Among 5,798,923 individuals, 10,577 (0.2%) were treated with melatonin (mean treatment length, 50 days) during the study period. Of those, 22 died by suicide and 134 had at least 1 suicide attempt. People in treatment with melatonin had a 4-fold higher rate of suicide (incidence rate ratio, 4.8; 95% CI, 3.0-7.5) and a 5-fold higher rate of suicide attempt (incidence rate ratio, 5.9; 95% CI, 4.4-8.0) than those not in treatment and when adjusting for sex and age group.

CONCLUSIONS

Treatment with melatonin was associated with suicide and suicide attempt. Although there are several possible explanations, attention to suicide risk is particularly warranted for people with mental comorbidity who are in treatment with melatonin.

CITATION

Høier NK, Madsen T, Spira AP, et al. Associations between treatment with melatonin and suicidal behavior: a nationwide cohort study. J Clin Sleep Med. 2022;18(10):2451-2458.

Loneliness and self-harm in adolescents during the first national COVID-19 lockdown: results from a survey of 10,000 secondary school pupils in England

Adolescents' loneliness and self-harm have received considerable attention during the COVID-19 pandemic with concerns that the socioecological changes taking place would contribute to an escalation of both loneliness and self-harm. However, empirical evidence is scant. We estimated the prevalence of loneliness and self-harm in adolescent school pupils and investigated the association of loneliness and change in loneliness during the UK's first lockdown with self-harm during lockdown in a cross-sectional school survey (OxWell) involving 10,460 12-18-year-olds from south England. Loneliness was measured with four items. Self-harm was ascertained through a detailed questionnaire. The prevalence of loneliness and self-harm were estimated applying post-stratification weights to account for differences between the study sample and the target population. The associations between indicators of loneliness and self-harm were examined using mixed effect models. 1,896 of 10,460 adolescents (18.1%) reported feeling lonely 'often' (weighted proportion 16.8%). 3,802/10,460 (36.4%; weighted proportion 35%) felt more lonely since lockdown. Self-harm during lockdown was reported by 787/10,460 adolescents (7.5%; weighted proportion 6.7%). Controlling for confounders, adolescents who reported feeling lonely 'often' [adjusted odds ratio (aOR) 2.8, 95% CI 2.1-3.9, p < 0.0001] or 'sometimes' (aOR 2.2, 95% CI 1.5-3.2, p < 0.0001) were more likely to self-harm during lockdown relative to adolescents who reported 'never' or 'hardly ever' feeling lonely. Exacerbation in loneliness during lockdown was associated with an increase in the odds of self-harm during lockdown. Loneliness, heightened loneliness and self-harm were common during lockdown and closely linked. It is important to support schools in address loneliness and self-harm as part of efforts to improve well-being as the long tail of the pandemic continues to impact on child and adolescent mental health. Understanding how loneliness and self-harm may co-vary could be important for future self-harm reduction strategies in young persons.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-022-03651-5.

Suicide numbers during the first 9-15 months of the COVID-19 pandemic compared with pre-existing trends: An interrupted time series analysis in 33 countries

BACKGROUND

Predicted increases in suicide were not generally observed in the early months of the COVID-19 pandemic. However, the picture may be changing and patterns might vary across demographic groups. We aimed to provide a timely, granular picture of the pandemic's impact on suicides globally.

METHODS

We identified suicide data from official public-sector sources for countries/areas-within-countries, searching websites and academic literature and contacting data custodians and authors as necessary. We sent our first data request on 22nd June 2021 and stopped collecting data on 31st October 2021. We used interrupted time series (ITS) analyses to model the association between the pandemic's emergence and total suicides and suicides by sex-, age- and sex-by-age in each country/area-within-country. We compared the observed and expected numbers of suicides in the pandemic's first nine and first 10-15 months and used meta-regression to explore sources of variation.

FINDINGS

We sourced data from 33 countries (24 high-income, six upper-middle-income, three lower-middle-income; 25 with whole-country data, 12 with data for area(s)-within-the-country, four with both). There was no evidence of greater-than-expected numbers of suicides in the majority of countries/areas-within-countries in any analysis; more commonly, there was evidence of lower-than-expected numbers. Certain sex, age and sex-by-age groups stood out as potentially concerning, but these were not consistent across countries/areas-within-countries. In the meta-regression, different patterns were not explained by countries' COVID-19 mortality rate, stringency of public health response, economic support level, or presence of a national suicide prevention strategy. Nor were they explained by countries' income level, although the meta-regression only included data from high-income and upper-middle-income countries, and there were suggestions from the ITS analyses that lower-middle-income countries fared less well.

INTERPRETATION

Although there are some countries/areas-within-countries where overall suicide numbers and numbers for certain sex- and age-based groups are greater-than-expected, these countries/areas-within-countries are in the minority. Any upward movement in suicide numbers in any place or group is concerning, and we need to remain alert to and respond to changes as the pandemic and its mental health and economic consequences continue.

FUNDING

None.

Temporal trends in calls for suicide attempts to poison control centers in France during the COVID-19 pandemic: a nationwide study

Concerns have been raised about early vs. later impacts of the COVID-19 pandemic on suicidal behavior. However, data remain sparse to date. We investigated all calls for intentional drug or other toxic ingestions to the eight Poison Control Centers in France between 1st January 2018 and 31st May 2022. Data were extracted from the French National Database of Poisonings. Calls during the study period were analyzed using time trends and time series analyses with SARIMA models (based on the first two years). Breakpoints were determined using Chow test. These analyses were performed together with examination of age groups (≤ 11, 12–24, 25–64, ≥ 65 years) and gender effects when possible. Over the studied period, 66,589 calls for suicide attempts were received. Overall, there was a downward trend from 2018, which slowed down in October 2019 and was followed by an increase from November 2020. Number of calls observed during the COVID period were above what was expected. However, important differences were found according to age and gender. The increase in calls from mid-2020 was particularly observed in young females, while middle-aged adults showed a persisting decrease. An increase in older-aged people was observed from mid-2019 and persisted during the pandemic. The pandemic may therefore have exacerbated a pre-existing fragile situation in adolescents and old-aged people. This study emphasizes the rapidly evolving situation regarding suicidal behaviour during the pandemic, the possibility of age and gender differences in impact, and the value of having access to real-time information to monitor suicidal acts.

Impact of the COVID-19 Pandemic on the Global Delivery of Mental Health Services and Telemental Health: Systematic Review

BACKGROUND

The COVID-19 pandemic required mental health services around the world to adapt quickly to the new restrictions and regulations put in place to reduce the risk of transmission. As face-to-face contact became difficult, virtual methods were implemented to continue to safely provide mental health care. However, it is unclear to what extent service provision transitioned to telemental health worldwide.

OBJECTIVE

We aimed to systematically review the global research literature on how mental health service provision adapted during the first year of the pandemic.

METHODS

We searched systematically for quantitative papers focusing on the impact of the COVID-19 pandemic on mental health services published until April 13, 2021, in the PubMed, Embase, medRxiv, and bioXriv electronic bibliographic databases, using the COVID-19 Open Access Project online platform. The screening process and data extraction were independently completed by at least two authors, and any disagreement was resolved by discussion with a senior member of the team. The findings were summarized narratively in the context of each country's COVID-19 Stringency Index, which reflects the stringency of a government's response to COVID-19 restrictions at a specific time.

RESULTS

Of the identified 24,339 records, 101 papers were included after the screening process. Reports on general services (n=72) showed that several countries' face-to-face services reduced their activities at the start of the pandemic, with reductions in the total number of delivered visits and with some services forced to close. In contrast, telemental health use rapidly increased in many countries across the world at the beginning of the pandemic (n=55), with almost complete virtualization of general and specialistic care services by the end of the first year. Considering the reported COVID-19 Stringency Index values, the increased use of virtual means seems to correspond to periods when the Stringency Index values were at their highest in several countries. However, due to specific care requirements, telemental health could not be used in certain subgroups of patients, such as those on clozapine or depot treatments and those who continued to need face-to-face visits.

CONCLUSIONS

During the pandemic, mental health services had to adapt quickly in the short term, implementing or increasing the use of telemental health services across the globe. Limited access to digital means, poor digital skills, and patients' preferences and individual needs may have contributed to differences in implementing and accessing telemental health services during the pandemic. In the long term, a blended approach, combining in-person and virtual modalities, that takes into consideration the needs, preferences, and digital skills of patients may better support the future development of mental health services. It will be required to improve confidence with digital device use, training, and experience in all modalities for both clinicians and service users.

Utilization and Acceptability of Formal and Informal Support for Adolescents Following Self-Harm Before and During the First COVID-19 Lockdown: Results From a Large-Scale English Schools Survey

Background

Little is known about the perceived acceptability and usefulness of supports that adolescents have accessed following self-harm, especially since the onset of the COVID-19 pandemic.

Aims

To examine the utilization and acceptability of formal, informal, and online support accessed by adolescents following self-harm before and during the pandemic.

Method

Cross-sectional survey (OxWell) of 10,560 secondary school students aged 12-18 years in the south of England. Information on self-harm, support(s) accessed after self-harm, and satisfaction with support received were obtained via a structured, self-report questionnaire. No tests for significance were conducted.

Results

1,457 (12.5%) students reported having ever self-harmed and 789 (6.7%) reported self-harming during the first national lockdown. Informal sources of support were accessed by the greatest proportion of respondents (friends: 35.9%; parents: 25.0%). Formal sources of support were accessed by considerably fewer respondents (Child and Adolescent Mental Health Services: 12.1%; psychologist/ psychiatrist: 10.2%; general practitioner: 7.4%). Online support was accessed by 8.6% of respondents, and 38.3% reported accessing no support at all. Informal sources of support were rated as most helpful, followed by formal sources, and online support. Of the respondents who sought no support, 11.3% reported this as being helpful.

Conclusions

More than a third of secondary school students in this sample did not seek any help following self-harm. The majority of those not seeking help did not find this to be a helpful way of coping. Further work needs to determine effective ways of overcoming barriers to help-seeking among adolescents who self-harm and improving perceived helpfulness of the supports accessed.

The association between melatonin and suicide: a nationwide cohort study

Introduction

Melatonin is often prescribed to patients experiencing sleep disturbances, which has been linked to elevated risks of suicide. However, it remains to be assessed whether melatonin is associated with suicide and suicide attempts.

Objectives

We aimed to investigate whether individuals in treatment with melatonin had higher rates of suicide and suicide attempt when compared to individuals not in treatment.

Methods

Using longitudinal data on all persons aged 10+ years living in Denmark between 2007-2016 were obtained. Data from the National Prescription Register was used to identify periods of being in treatment with melatonin based on number of tablets and daily defined dose. Suicide and suicide attempt were identified in hospital and cause of death registries.

Results

Among 5,798,923 included individuals, 10,577 (0.18%) were in treatment with melatonin (mean treatment length 50 days). Out of 5,952 individuals who died by suicide, 22 (0.37%) were in melatonin treatment, while 134 (0.53%) out of 25,136 had a first suicide attempt. After adjustment for sex and age-group, people in treatment with melatonin were found to have a higher rate of suicide (IRR: 4.2; 95% CI, 2.7-6.4) and suicide attempt (IRR: 6.7-fold (95% CI, 5.7-7.9) when compared to those not in treatment.

Conclusions

Treatment with melatonin was associated with higher rates of suicide and suicide attempt. The association might be explained through mediators, such as psychiatric comorbidity and sleep disorders. Our findings indicate that attention towards these issues might be warranted.

Disclosure

No significant relationships.

The association between benzodiazepine and non-benzodiazepine and suicide: a nationwide cohort study

Introduction

Benzodiazepines and non-benzodiazepines have been linked to a variety of adverse effects including addiction. Long term use of these drugs has been associated with an increased risk of suicide.

Objectives

We assessed if individuals in treatment with non-benzodiazepine (n-BZD) and benzodiazepine (BZD) had higher rates of suicide when compared to individuals not in treatment with these drugs.

Methods

We utilized a cohort design and national longitudinal data on all individuals aged 10 or above who lived in Denmark between 1995 and 2018. Treatment with either n-BZD or BZD was identified via the Danish National Prescription Registry and suicide deaths were identified in the national cause of death registries.

Results

In a total of 6,494,206 individuals, 10,862 males and 4,214 females died by suicide. Of these, 1,220 (11.2%) males and 792 (18.8%) females had been in treatment with n-BZD, resulting in adjusted IRR for suicide of 4.2 (95% CI, 4.0 – 4.5) and 3.4 (95% CI, 3.1 – 3.7) for males and females, respectively, when compared to those not in treatment. In all, 529 (4.8%) males and 395 (9.3%) females who died by suicide had been in treatment with BZD. The IRRs for suicide were 2.4 (95% CI, 2.2 – 2.6) and 2.5 (95% CI, 2.3 – 2.8) for males and females, respectively, and compared to those not in treatment.

Conclusions

In this study we find that those in treatment experienced higher suicide rates than those not in treatment, this persisted when also adjusting for a large variety of covariates.

Disclosure

No significant relationships.

Association of hospital-diagnosed sleep disorders with suicide: a nationwide cohort study

Introduction

Sleep disorders and psychiatric disease are closely related, and psychiatric diseases are associated with elevated suicide risks. Yet, the association between sleep disorders and suicide remains to be assessed using a consistent measure of sleep disorders.

Objectives

The aim of this study was to examine whether people with a hospital-diagnosis of sleep disorders had higher suicide rates than people with no diagnosis.

Methods

In a cohort study, nationwide data on all persons aged 15+ years living in Denmark during 1980-2016 were analysed. Sleep disorders were identified through diagnoses recorded during contacts to somatic hospitals. Incidence Rate Ratios (IRR) were estimated using Poisson regression models and adjusted for relevant covariates.

Results

In all, 3,674,563 males and 3,688,164 females were included, of whom 82,223 (2.2%, mean age: 50.2, SD: 17.5) males and 40,003 (1.1%, mean age: 50.6, SD: 19.9) females had sleep disorder diagnoses. Compared to those with no sleep disorders, the adjusted IRRs for suicide were 1.6 (95% CI, 1.4-1.7) and 2.2 (95% CI, 1.8-2.6) for males and females with sleep disorders, respectively. Excess rates for narcolepsy were found for males (IRR:1.2, 95% CI, 1.0-1.5) and females (IRR:3.3, 95% CI, 3.0-4.1), and for sleep apnea in males (IRR:1.8, 95% CI, 1.5-2.2). Males and females had IRRs of 4.1 (95% CI, 3.1-5.5) and 7.0 (95% CI, 4.8-10.1), respectively, 6 months after being diagnosed with a sleep disorder.

Conclusions

Sleep disorders were associated with higher suicide rates even after adjusting for pre-existing mental disorders. Our findings suggest attention towards suicidal ideation in patients suffering from sleep disorders is warranted.

Disclosure

Disclosures and Acknowledgements: Adam Spira has received honoraria for serving as a consultant to Merck and from Springer Nature Switzerland AG for guest editing special issues of Current Sleep Medicine Reports. The other authors report no conflict of in

The early impact of the COVID-19 pandemic on patients with severe mental illness: An interrupted time series study in South-East England

Background

Deterioration in general population mental health since the start of the COVID-19 pandemic has been reported, but the impact of the pandemic on people with severe mental illness (SMI) has received less attention.

Aims

To understand the impact of the early stages of the pandemic on the patients with SMI, in terms of provision of mental health care and patient outcomes.

Method

We examined records of 34,446 patients with SMI in Oxford Health Foundation Trust between March 2016 and July 2020. We used interrupted time-series analysis to estimate the immediate and subsequent changes in weekly rates of the use of community mental health services, hospitalization, and patient outcomes (as measured by Health of the Nation Outcome Scales, or HoNOS, scores) during the weeks of lockdown between March 23, 2020 and July 3, 2020.

Results

Mean total HoNOS scores for all patients deteriorated in the weeks subsequent to lockdown (0.060 per week; 95%CI: 0.033, 0.087). Scores for patients with a history of psychosis deteriorated immediately (0.63; 95% CI: 0.26, 1.0). There was an immediate decrease in weekly referrals to community and outpatient services (−196; 95%CI: −300, −91) and no immediate change in weekly inpatient admissions (−4.2; 95%CI: −9.9, 1.5) or weekly total contacts (−26; 95%CI: −475, 423).

Conclusions

Patients with SMI were negatively impacted during the early stages of the COVID-19 pandemic. Patients with a history of psychosis experienced distinct and immediate impacts. During the same period, referrals to community and outpatient services fell with no consequent impact on inpatient admissions.

Youth Culturally adapted Manual Assisted Problem Solving Training (YCMAP) in Pakistani adolescent with a history of self-harm: protocol for multicentre clinical and cost-effectiveness randomised controlled trial

INTRODUCTION

Suicide is a global health concern. Sociocultural factors have an impact on self-harm and suicide rates. In Pakistan, both self-harm and suicide are considered as criminal offence's and are condemned on both religious and social grounds. The proposed intervention 'Youth Culturally Adapted Manual Assisted Problem Solving Training (YCMAP)' is based on principles of problem-solving and cognitive-behavioural therapy. YCMAP is a brief, culturally relevant, scalable intervention that can be implemented in routine clinical practice if found to be effective.

METHOD AND ANALYSIS

A multicentre rater blind randomised controlled trial to evaluate the clinical and cost-effectiveness of YCMAP including a sample of 652 participants, aged 12-18 years, presenting to general physicians/clinicians, emergency room after self harm or self referrals. We will test the effectiveness of 8-10 individual sessions of YCMAP delivered over 3 months compared with treatment as usual. Primary outcome measure is repetition of self-harm at 12 months. The seconday outcomes include reduction in suicidal ideation, hopelessness and distress and improvement in health related quality of life. Assessments will be completed at baseline, 3, 6, 9 and 12 months postrandomisation. The nested qualitative component will explore perceptions about management of self-harm and suicide prevention among adolescents and investigate participants' experiences with YCMAP. The study will be guided by the theory of change approach to ensure that the whole trial is centred around needs of the end beneficiaries as key stakeholders in the process.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the Ethics Committee of University of Manchester, the National Bioethics Committee in Pakistan. The findings of this study will be disseminated through community workshops, social media, conference presentations and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04131179.

Association between hospital-diagnosed sleep disorders and suicide: a nationwide cohort study

STUDY OBJECTIVES

Sleep disorders are related to mental disorders. Yet few studies have examined their association with suicide. We examined whether males and females diagnosed with sleep disorders had higher rates of suicide than individuals not diagnosed with sleep disorders.

METHODS

In a cohort study, nationwide data on all males and females aged over 15 years living in Denmark during 1980-2016 were analyzed. Sleep disorders were identified through diagnoses recorded during contacts to somatic hospitals. Incidence rate ratios (IRR) were estimated using Poisson regression models and adjusted for covariates.

RESULTS

In all, 3 674 563 males and 3 688 164 females were included, of whom 82 223 (2.2%, mean age: 50.2 years, SD: 17.5) males and 40 003 (1.1%, mean age: 50.6 years, SD: 19.9) females had sleep disorder diagnoses. Compared with those with no sleep disorders, the adjusted IRR for suicide were 1.6 (95% CI, 1.4 to 1.7) and 2.2 (95% CI, 1.8 to 2.6) for males and females with sleep disorders, respectively. Excess rates for narcolepsy were found for males (IRR: 1.2, 95% CI, 1.0 to 1.5) and females (IRR: 3.3, 95% CI, 3.0 to 4.1), and for sleep apnea in males (IRR: 1.8, 95% CI, 1.5 to 2.2). A difference with respect to age and sex was observed (p < 0.001) between males and females. Males and females had IRR of 4.1 (95% CI, 3.1 to 5.5) and 7.0 (95% CI, 4.8 to 10.1), during the first 6 months after being diagnosed with a sleep disorder.

CONCLUSIONS

Sleep disorders were associated with higher suicide rates even after adjusting for preexisting mental disorders. Our findings suggest attention toward suicidality in patients with sleep disorders is warranted.

Transgenerational concordance in parent-to-child transmission of suicidal behaviour: a retrospective, nationwide, register-based cohort study of 4 419 642 individuals in Denmark

BACKGROUND

Suicidal behaviour runs in families, but the nature of transgenerational concordance needs elucidation. The aim of this study was to examine parent-to-child transmission by investigating whether presence and nature of parental suicidal behaviour was associated with suicidal behaviour in children.

METHODS

We did a retrospective, nationwide, register-based cohort study in Demark using register data. We included all individuals born after 1953 who were 10 years or older and who were recorded as living in Denmark at some point between Jan 1, 1980, and Dec 31, 2016. Adults listed as living with their child at first registration in the Civil Registration System were considered as parents; later records of different legal parents allowed identification of potential step-parents. Self-reported ethnicity data were not available. Exposure to parental suicide attempt and suicide was identified using information from hospital contacts and causes of death from national registers. The examined outcomes were suicide attempt and death by suicide. We calculated incidence rate ratios (IRRs) and cumulative hazards for children's suicide attempt and suicide, taking into account type of parental suicidal behaviour, child's age of exposure, and sex.

FINDINGS

In total, 4 419 642 individuals aged 10-63 years were observed during 1980-2016. Of these individuals, 150 222 (3·4%) were exposed to one or more parents with a suicide attempt, 31 564 (0·7%) to at least one parent who died by suicide, and 12 834 (0·3%) to both events. Individuals exposed to parental suicide attempt had higher rates of suicide attempt (IRR 2·72 [95% CI 2·33-3·17]) than individuals exposed to parental suicide (1·77 [1·50-2·09]) when compared with unexposed individuals. Higher rates of suicide were found for individuals exposed to parental suicide (IRR 3·18 [95% CI 2·84-3·58]) than for those exposed to parental suicide attempt (2·37 [2·19-2·57]). The cumulative hazard of suicide attempt was 0·07 for individuals exposed to parental suicide attempt, and the cumulative hazard of suicide was 0·009 for individuals exposed to parental suicide. Individuals exposed to parental suicide had higher odds of violent suicidal methods than those exposed to suicide attempt alone (odds ratio 2·0 [95% CI 1·7-2·3]).

INTERPRETATION

A concordant pattern of higher rates of the same type of suicidal behaviour as the one of the parents was observed, including type of suicide method. Preventive, family-oriented interventions are warranted to mitigate familial transmission of risk, as are clinical considerations of familial exposure in risk assessment of patients.

FUNDING

Mental Health Services, Capital Region of Denmark.

Effectiveness of medical treatment for bipolar disorder regarding suicide, self-harm and psychiatric hospital admission: between- and within-individual study on Danish national data

BACKGROUND

Mood stabilisers are the main treatment for bipolar disorder. However, it is uncertain which drugs have the best outcomes.

AIMS

To investigate whether rates of suicide, self-harm and psychiatric hospital admission in individuals with bipolar disorder differ between mood stabilisers.

METHOD

A cohort design was applied to people aged ≥15 years who were diagnosed with bipolar disorder and living in Denmark during 1995-2016. Treatment with lithium, valproate, other mood stabilisers and antipsychotics were compared in between- and within-individual analyses, and adjusted for sociodemographic characteristics and previous self-harm.

RESULTS

A total of 33 337 individuals with bipolar disorder were included (266 900 person-years). When compared with individuals not receiving treatment, those receiving lithium had a lower rate of suicide (hazard ratio 0.40, 95% CI 0.31-0.51). When comparing treatment and non-treatment periods in the same individuals, lower rates of self-harm were found for lithium (hazard ratio 0.74, 95% CI 0.61-0.91). Lower rates of psychiatric hospital admission were found for all drug categories compared with non-treatment periods in within-individual analyses (P<0.001). The low rates of self-harm and hospital admission for lithium in within-individual analyses were supported by results of between-individual analyses.

CONCLUSIONS

Lithium was associated with lower rates of suicide, self-harm and psychiatric hospital readmission in all analyses. With respect to suicide, lithium was superior to no treatment. Although confounding by indication cannot be excluded, lithium seems to have better outcomes in the treatment of bipolar disorder than other mood stabilisers.

Have News Reports on Suicide and Attempted Suicide During the COVID-19 Pandemic Adhered to Guidance on Safer Reporting?

Background: Associations between sensational news coverage of suicide and increases in suicidal behavior have been well documented. Amid growing concern over the impact of the COVID-19 pandemic on suicide rates, it is especially important that news coverage adheres to recommended standards. Method: We analyzed the quality and content of print and online UK news reports of possible COVID-19-related suicides and suicide attempts in the first 4 months of the pandemic (N = 285). Results: The majority of reports made explicit links between suicidal behavior and the COVID-19 pandemic in the headline (65.5%), largely based on statements by family, friends, or acquaintances of the deceased (60%). The impact of the pandemic on suicidal behavior was most often attributed to feelings of isolation (27.4%), poor mental health (14.7%), and entrapment due to government-imposed restrictions (14.4%). Although rarely of poor overall quality, reporting was biased toward young people, frontline staff, and relatively unusual suicides and, to varying degrees, failed to meet recommended standards (e.g., 41.1% did not signpost readers to sources of support). Limitations: This analysis cannot account for the impact of reporting on suicide. Conclusion: Careful attention must be paid to the quality and content of reports, especially as longer-term consequences of the pandemic develop.

Gatekeeper training for vendors to reduce pesticide self-poisoning in rural South Asia: a study protocol for a stepped-wedge cluster randomised controlled trial

INTRODUCTION

Pesticide self-poisoning kills an estimated 110 000-168 000 people worldwide annually. Data from South Asia indicate that in 15%-20% of attempted suicides and 30%-50% of completed suicides involving pesticides these are purchased shortly beforehand for this purpose. Individuals who are intoxicated with alcohol and/or non-farmers represent 72% of such customers. We have developed a 'gatekeeper' training programme for vendors to enable them to identify individuals at high risk of self-poisoning (gatekeeper function) and prevent such individuals from accessing pesticides (means restriction). The primary aim of the study is to evaluate the effectiveness of the gatekeeper intervention in preventing pesticide self-poisoning in Sri Lanka. Other aims are to identify method substitution and to assess the cost and cost-effectiveness of the intervention.

METHODS AND ANALYSIS

A stepped-wedge cluster randomised trial of a gatekeeper intervention is being conducted in rural Sri Lanka with a population of approximately 2.7 million. The gatekeeper intervention is being introduced into 70 administrative divisions in random order at each of 30 steps over a 40-month period. The primary outcome is the number of pesticide self-poisoning cases identified from surveillance of hospitals and police stations. Secondary outcomes include: number of self-poisoning cases using pesticides purchased within the previous 24 hours, total number of all forms of self-harm and suicides. Intervention effectiveness will be estimated by comparing outcome measures between the pretraining and post-training periods across the divisions in the study area. The original study protocol has been adapted as necessary in light of the impact of the COVID-19.

ETHICS AND DISSEMINATION

The Ethical Review Committee of the Faculty of Medicine and Allied Sciences, Rajarata University, Sri Lanka (ERC/2018/30), and the ACCORD Medical Research Ethics Committee, Edinburgh University (18-HV-053) approved the study. Results will be disseminated in scientific peer-reviewed journals.

TRIAL REGISTRATION NUMBER

SLCTR/2019/006, U1111-1220-8046.

Direct costs of hospital care of self-harm: A national register-based cohort study

OBJECTIVE

To estimate national direct hospital costs associated with treatment of self-harm and to analyse whether costs differ with respect to demographic and clinical characteristics.

METHODS

A cohort design was applied to register data on all people living in Denmark (5.8 million inhabitants) from Jan 1, 2012 to Dec 31, 2016. Self-harm presentations at all hospitals by persons aged 10 years and older were included. Total costs and costs related to somatic and psychiatric care and treatment setting (inpatient, emergency department and outpatient) were calculated (in US dollars). The association between specific characteristics and somatic inpatient costs was analysed adjusted using generalized linear models and expressed as Odds Ratios (OR).

RESULTS

In all, 42,634 (97.3%) self-harm presentations by 30,366 persons were included. Annual somatic and psychiatric costs amounted to $25,241,518 and $34,696,388, respectively, and the median cost per episode was $2248 (IQR: $1553-$4138). Predictors of high somatic inpatient costs were: admission to intensive care (OR = 15.6; 95% CI, 13.7-17.9), particularly dangerous methods of self-harm, such as being hit by moving objects (OR = 6.5; 95% CI, 2.7-15.7) and shooting (OR = 6.0; 95% CI, 3.4-10.7), and age ≥75 years (OR = 1.8; 95% CI, 1.5-2.2). A small group of persons (0.7%) with ≥10 presentations accounted for 8.2% of somatic and 15.3% of total hospital costs.

CONCLUSION

Substantial hospital costs were noted for inpatient treatment. Although one-time presenters accounted for the major share of costs, smaller patient groups accounted for considerable shares. Hospital costs of self-harm should be included in evaluation of initiatives for prevention and treatment.

Self-harm, somatic disorders and mortality in the 3 years following a hospitalisation in psychiatry in adolescents and young adults

Background

There is limited recent information regarding the risk of self-harm, somatic disorders and premature mortality following discharge from psychiatric hospital in young people.

Objective

To measure these risks in young people discharged from a psychiatric hospital as compared with both non-affected controls and non-hospitalised affected controls.

Methods

Data were extracted from the French national health records. Cases were compared with two control groups. Cases: all individuals aged 12–24 years, hospitalised in psychiatry in France in 2013–2014. Non-affected controls: matched for age and sex with cases, not hospitalised in psychiatry and no identification of a mental disorder in 2008–2014. Affected controls: unmatched youths identified with a mental disorder between 2008 and 2014, never hospitalised in psychiatry. Follow-up of 3 years. Logistic regression analyses were conducted with these confounding variables: age, sex, past hospitalisation for self-harm, past somatic disorder diagnosis.

Findings

The studied population comprised 73 300 hospitalised patients (53.6% males), 219 900 non-affected controls and 9 683 affected controls. All rates and adjusted risks were increased in hospitalised patients versus both non-affected and affected controls regarding a subsequent hospitalisation for self-harm (HR=105.5, 95% CIs (89.5 to 124.4) and HR=1.5, 95% CI (1.4 to 1.6)), a somatic disorder diagnosis (HR=4.1, 95% CI (3.9–4.1) and HR=1.4, 95% CI (1.3–1.5)), all-cause mortality (HR=13.3, 95% CI (10.6–16.7) and HR=2.2, 95% CI (1.5–3.0)) and suicide (HR=9.2, 95% CI (4.3–19.8) and HR=1.7, 95% CI (1.0–2.9)).

Conclusions

The first 3 years following psychiatric hospital admission of young people is a period of high risk for self-harm, somatic disorders and premature mortality.

Clinical implications

Attention to these negative outcomes urgently needs to be incorporated in aftercare policies.

Self-harm in people experiencing homelessness: investigation of incidence, characteristics and outcomes using data from the Multicentre Study of Self-Harm in England

BACKGROUND

People who experience homelessness are thought to be at high risk of suicide, but little is known about self-harm in this population.

AIMS

To examine characteristics and outcomes in people experiencing homelessness who presented to hospital following self-harm.

METHOD

Data were collected via specialist assessments and/or hospital patient records from emergency departments in Manchester, Oxford and Derby, UK. Data were collected from 1 January 2000 to 31 December 2016, with mortality follow-up via data linkage with NHS Digital to 31 December 2019. Trend tests estimated change in self-harm over time; descriptive statistics described characteristics associated with self-harm. Twelve-month repetition and long-term mortality were analysed using Cox proportional hazards models and controlled for age and gender.

RESULTS

There were 4841 self-harm presentations by 3270 people identified as homeless during the study period. Presentations increased after 2010 (IRR = 1.09, 95% CI 1.04-1.14, P < 0.001). People who experienced homelessness were more often men, White, aged under 54 years, with a history of previous self-harm and contact with psychiatric services. Risk of repetition was higher than in domiciled people (HR = 2.05, 95% CI 1.94-2.17, P < 0.001), as were all-cause mortality (HR = 1.45, 95% CI 1.32-1.59. P < 0.001) and mortality due to accidental causes (HR = 2.93, 95% CI 2.41-3.57, P < 0.001).

CONCLUSIONS

People who self-harm and experience homelessness have more complex needs and worse outcomes than those who are domiciled. Emergency department contact presents an opportunity to engage people experiencing homelessness with mental health, drug and alcohol, medical and housing services, as well as other sources of support.

Non-presentation at hospital following a suicide attempt: a national survey

BACKGROUND

A few previous studies suggest that a large number of individuals do not present at hospital following a suicide attempt, complicating recurrence prevention and prevalence estimation.

METHODS

Data were extracted from a regular phone survey in representative samples of the French population aged 18-75 years old. Five surveys between 2000 and 2017 collected data about the occurrence of a previous suicide attempt and subsequent care contacts. A total of 102,729 individuals were surveyed. Among them, 6,500 (6.4%) reported a lifetime history of suicide attempt.

RESULTS

Following their last suicide attempt, 39.3% reported they did not present to hospital (53.4% in 18-24 year-olds), with limited changes in rates with time. Risk factors for non-presentation were being male [adjusted odds ratio = 1.3, 95% confidence interval (1.1-1.5)], living with someone [1.2 (1.0-1.4)], being a non-smoker [1.4 (1.2-1.6)], and being younger at time of attempt [0.97 (0.96-0.98) per year]. Of those who did not present to hospital, only 37.7% reported visiting a doctor or a psychiatrist/psychologist after their act v. 67.1% in those who presented to hospital (as a second health contact). In both cases, half disclosed their act to someone else. Prevalence rates of suicide attempts reported in community were 4.6 times higher than those in hospital administrative databases.

CONCLUSIONS

This survey at a national level confirmed that a large proportion of individuals does not go to the hospital and does not meet any health care professionals following a suicidal act. Assessment of unmet needs is necessary.

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.

Self-harm in children 12 years and younger: characteristics and outcomes based on the Multicentre Study of Self-harm in England

BACKGROUND

Very little is known about self-harm in children. We describe the characteristics and outcomes of children under 13 years who presented following self-harm to five hospitals in England.

METHODS

We included children under 13 years who presented after self-harm to hospitals in the Multicentre Study of Self-harm in England. Information on patients' characteristics and method of self-harm was available through monitoring of self-harm in the hospitals. Area level of socioeconomic deprivation was based on the English Index of Multiple Deprivation (IMD).

RESULTS

387 children aged 5-12 years presented to the study hospitals in 2000-2016, 39% of whom were 5-11 years. Boys outnumbered girls 2:1 at 5-10 years. The numbers of boys and girls were similar at age 11, while at 12 years there were 3.8 girls to every boy. The proportion of study children living in neighbourhoods ranked most deprived (43.4%) was twice the national average. 61.5% of children self-poisoned, 50.6% of them by ingesting analgesics. Of children who self-injured, 45.0% self-cut/stabbed, while 28.9% used hanging/asphyxiation. 32% of the children had a repeat hospital presentation for self-harm, 13.5% re-presented within a year.

CONCLUSIONS

Gender patterns of self-harm until age 11 years are different to those of adolescents, with a male preponderance, especially in 5-10 years, and hanging/suffocation being more common. The frequent use of self-poisoning in this age group highlights the need for public health messages to encourage safer household storage of medicines. Self-harm in children is strongly associated with socioeconomic deprivation; understanding the mechanisms involved could be important in effective prevention.