Hospital care and repetition following self-harm: multicentre comparison of self-poisoning and self-injury
TL;DR: Hospital services offer less to people who have cut themselves, although they are far more likely to repeat, than to those who have self-poisoned, and attendance at hospital should result in psychosocial assessment of needs regardless of method of self-harm.
Abstract: Background
Quantitative research about self-harm largely deals with self-poisoning, despite the high incidence of self-injury.
Aims
We compared patterns of hospital care and repetition associated with self-poisoning and self-injury.
Method
Demographic and clinical data were collected in a multicentre, prospective cohort study, involving 10 498 consecutive episodes of self-harm at six English teaching hospitals.
Results
Compared with those who self-poisoned, people who cut themselves were more likely to have self-harmed previously and to have received support from mental health services, but they were far less likely to be admitted to the general hospital or receive a psychosocial assessment. Although only 17% of people repeated self-harm during the 18 months of study, survival analysis that takes account of all episodes revealed a repetition rate of 33% in the year following an episode: 47% after episodes of self-cutting and 31% after self-poisoning ( P <0.001). Of those who repeated, a third switched method of self-harm.
Conclusions
Hospital services offer less to people who have cut themselves, although they are far more likely to repeat, than to those who have self-poisoned. Attendance at hospital should result in psychosocial assessment of needs regardless of method of self-harm.
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Dissertation•
11 May 2018
TL;DR: In this paper, the authors describe self-harm from a nursing perspective and describe the recovery process as a personal process, as well as a social process and as a lifelong learning process.
Abstract: s............................................................................................ i Norwegian abstract English abstract Original papers...................................................................................IIV 1.0 Introduction .................................................................................. 1 2.0 Background 2.1 Descriptions of self-harm................................................................ 4 2.2 Prevalence of self-harm.................................................................. 6 2.3 Biological vulnerability and self-harm ................................................ 8 2.4 Emotions and self-harm....................................................................9 2.5 Psycho-social perspective on self-harm..................................................11 3.0 Earlier research on recovery from self-harm 3.1 Recovery from self-harm from a nursing perspective..............................14 3.1.1 Nurses’ knowledge and attitudes toward persons who self-harm ............14 3.1.2 Meeting persons who self-harm with autonomy and/or paternalism......... 15 3.2 Personal experiences of the recovery process from self-harm .....................17 3.2.1 Personal experiences of what promotes a recovery process..................18 4.0 Theoretical perspective in the dissertation............................................... 20 4.1 Recovery from mental illness and suffering..........................................21 4.1.1 Recovery as a curing from illness.............................................. 21 4.1.2 Recovery as a personal process.................................................22 4.1.3 Recovery as a social process....................................................23 4.1.4 Recovery as lifelong learning ...................................................23 4.2 A person-centered perspective in nursing care................................... .....24 5.0 Rationale and aims 5.1 Rationale for the dissertation............................................................27 5.2 Aim of the dissertation................................................................... 28 6.0 Design and methods 6.1 The overall design........................................................................30
8 citations
TL;DR: A small-scale cohort study of 29 self-harm patients presenting to A&E and compared theoretically-derived psychological variables between 8 self-cutting and 21 overdose patients supports the hypothesis that the association between self- cutting and prospective repetition is at least partly due to pre-existing psychological vulnerabilities that increase both the likelihood of engaging inSelf-cutting as a method of self- Harm and the likelihoodof subsequent repetition of self -harm.
8 citations
Cites background from "Hospital care and repetition follow..."
...However, it is clear that, while self-cutting may have an initial positive effect of reducing tension, depersonalisation or other undesirable psychological states, it is certainly not ‘‘rewarded’’ in healthcare settings: those who present with self-cutting are less likely to receive admission or assessment than those who present with overdose [23] and some of the negative experiences of care in the emergency department seem to apply particularly to the treatment of self-cutting [29]....
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...The study’s prospective design allowed for the follow-up of patients during a period of the highest risk of repetition [5,23]....
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...Given that, in our sample, those presenting with self-cutting had higher levels of hopelessness than those presenting with overdose at baseline, it is plausible that the association between self-cutting and prospective repetition seen in several large-scale studies [5,23,24] may be related to hopelessness, a consistent predictor of repetition among those presenting to hospital with self-harm [13]....
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...Staff attitudes towards self-harm in general are often stigmatising [26], but self-cutting seems to be particularly undertreated [23] and maligned as ‘‘attention-seeking’’ in healthcare settings [27]....
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Journal Article•
TL;DR: Management of suicidal attempters and provision of risk assessment continue to be the major tasks of consultation-liaison psychiatrists and nurses in acute general hospitals in Hong Kong.
Abstract: Objective: To examine consultation-liaison psychiatric services in a general hospital in Hong Kong. Methods: All records of Tseung Kwan O Hospital psychiatric consultations from 1 July 2012 to 30 June 2013 were extracted from the database. Patients' demographic data, sources and reasons of referral, psychiatric and suicidal histories, current suicidal attempt, psychiatric diagnoses, psychiatric outcomes, as well as waiting times were analysed accordingly. Results: A total of 1392 psychiatric consultations were received, of which 82% were attended to within the same working day when the referral was received, and 99% were attended to by the end of the next working day. The commonest reasons of consultation were unstable emotion followed by suicidal / deliberate self-harm and aggression. There were 246 consultations with actual suicidal attempt. Overall, 270 (19%) patients who received consultation-liaison psychiatric services were admitted to the psychiatric wards. Follow-up in the psychiatric outpatient department was arranged for 691 (50%) patients while 57 (4%) required referral to the community psychiatric nursing service in addition to outpatient department arrangement. Conclusions: Management of suicidal attempters and provision of risk assessment continue to be the major tasks of consultation-liaison psychiatrists and nurses. A readily available on-site consultationliaison psychiatric service is an essential component of services provided in acute general hospitals.
7 citations
Dissertation•
01 Dec 2017
TL;DR: In this article, a study was conducted to determine whether any pre-existing, standardised instrument would be suitable to use for the purpose of assessing the risk of self-harm among the specific ACCT population.
Abstract: The reported incidence of self-harm is much higher among prisoners than in the general population. Along with the general increased risk among prisoners, there are also specific times of heightened vulnerability, such as on first reception into the prison environment. Currently in the UK, if an act of self-harm is carried out by a prisoner, if intent to do so is expressed, or if a prisoner is deemed vulnerable by a member of staff or a fellow prisoner, then this prisoner will be subject to a self-harm and suicide monitoring process known as an ACCT (Assessment, Care in Custody and Teamwork). As part of the ACCT process, a member of prison staff will carry out a prisoner assessment to ascertain the risk level of the prisoner, and whether the ACCT needs to remain open. However, there is currently no standardised risk assessment or clinical decision aid used as part of the ACCT process, which is perhaps largely owing to the paucity of validated risk assessment tools or clinical decision aids that are available to identify risk of self-harm in prisoner populations.
The primary aim of the study was therefore to determine whether any pre-existing, standardised instrument would be suitable to use for the purpose of assessing the risk of self-harm among the specific ACCT population.
This thesis describes various different elements of the study. Firstly, a scoping exercise was carried out in order to select the most appropriate pre-existing instruments that had the potential to predict self-harm events. A pilot study was then carried out to test the study process and to refine the instrument selection. Following this, a prospective cohort study was undertaken to assess the predictive validity of the selected instruments, where a six month follow-up determined self-harm occurrence since baseline, and area-under-the-curve (AUC) analysis examined the ability of the instruments to predict future self-harm. Alongside this, a thorough psychometric analysis of each of the instruments was carried out, in order to validate them among the specified ACCT population. Utilising the study dataset, an exploratory logistic regression analysis was carried out in order to identify individual background and instrument items that may prove effective in predicting future self-harm. Finally, structural equation modelling (SEM) was used to explore the relationships between some of the factors that influence self-harm, in order to contribute towards an understanding of the complexity of the issue of self-harm in prisons.
The key findings from this programme of work can be summarised as follows:
i. Self-harm is a common occurrence among the prison ACCT population, with 29.1% of the study participants deliberately self-harming during the follow up period, although this varied considerably across gender and participating prisons.
ii. Four of the five selected instruments did display a certain level of psychometric validity among the study population; therefore validating the cut-points for the predictive analysis. However, all instruments required some refinement to meet the strict measurement criteria of the Rasch model.
iii. Of the five pre-existing instruments that were selected for the study, none of these displayed a meaningful predictive validity.
iv. Logistic regression analysis did reveal gender-specific item sets, producing predictive algorithms which were statistically significant in predicting future self-harm; however, the operational functionality of these item sets may be limited.
v. Structural equation modelling revealed an insightful explanatory model of the process that may be involved in the culmination of self-harm in prison. Path analysis models supported the view that self-harm capacity and self-harm propensity are integral elements to the self-harm pathway, although the complete explanatory model is likely to be more complex.
7 citations
Cites background from "Hospital care and repetition follow..."
...(110) The repetition of self-harm events tends to occur quickly, with a quarter of repetitions occurring within 3 weeks, with the median time to repetition being 12 weeks....
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TL;DR: Short-term fluctuations in self-reported mental health may provide an indication of when an individual is at-risk of self-harm, andModifiable risk factors identified in the current study may be targeted during interventions to minimise risk of self.
Abstract: Background Self-harm is a significant public health issue, and both our understanding and ability to predict adverse outcomes are currently inadequate. The current study explores how preventative efforts could be aided through short-term prediction and modelling of risk factors for self-harm. Methods
Patients (72% female, Mage = 40.3 years) within an inpatient psychiatric facility self-reported their psychological distress, interpersonal circumstances, and wish to live and die on a daily basis during 3690 unique admissions. Hierarchical logistic regressions assessed whether daily changes in self-report and history of self-harm could predict self-harm, with machine learning used to train and test the model. To assess interrelationships between predictors, network and cross-lagged panel models were performed. Results
Increases in a wish to die (β = 1.34) and psychological distress (β = 1.07) on a daily basis were associated with increased rates of self-harm, while a wish to die on the day prior [odds ratio (OR) 3.02] and a history of self-harm (OR 3.02) was also associated with self-harm. The model detected 77.7% of self-harm incidents (positive predictive value = 26.6%, specificity = 79.1%). Psychological distress, wish to live and die, and interpersonal factors were reciprocally related over the prior day. Conclusions
Short-term fluctuations in self-reported mental health may provide an indication of when an individual is at-risk of self-harm. Routine monitoring may provide useful feedback to clinical staff to reduce risk of self-harm. Modifiable risk factors identified in the current study may be targeted during interventions to minimise risk of self-harm.
7 citations
References
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TL;DR: Subjects who received dialectical behavior therapy had fewer incidences of parasuicide and less medically severe parasuicides, were more likely to stay in individual therapy, and had fewer inpatient psychiatric days.
Abstract: A randomized clinical trial was conducted to evaluate the effectiveness of a cognitive-behavioral therapy, ie, dialectical behavior therapy, for the treatment of chronically parasuicidal women who met criteria for borderline personality disorder. The treatment lasted 1 year, with assessment every 4 months. The control condition was "treatment as usual" in the community. At most assessment points and during the entire year, the subjects who received dialectical behavior therapy had fewer incidences of parasuicide and less medically severe parasuicides, were more likely to stay in individual therapy, and had fewer inpatient psychiatric days. There were no between-group differences on measures of depression, hopelessness, suicide ideation, or reasons for living although scores on all four measures decreased throughout the year.
1,979 citations
TL;DR: In this article, Dialectical behavior therapy (DBT) was shown to be more effective in reducing suicidal behavior and borderline personality disorder compared with non-behavioral psychotherapy experts.
Abstract: Context Dialectical behavior therapy (DBT) is a treatment for suicidal behavior and borderline personality disorder with well-documented efficacy. Objective To evaluate the hypothesis that unique aspects of DBT are more efficacious compared with treatment offered by non–behavioral psychotherapy experts. Design One-year randomized controlled trial, plus 1 year of posttreatment follow-up. Setting University outpatient clinic and community practice. Participants One hundred one clinically referred women with recent suicidal and self-injurious behaviors meeting DSM-IV criteria, matched to condition on age, suicide attempt history, negative prognostic indication, and number of lifetime intentional self-injuries and psychiatric hospitalizations. Intervention One year of DBT or 1 year of community treatment by experts (developed to maximize internal validity by controlling for therapist sex, availability, expertise, allegiance, training and experience, consultation availability, and institutional prestige). Main Outcome Measures Trimester assessments of suicidal behaviors, emergency services use, and general psychological functioning. Measures were selected based on previous outcome studies of DBT. Outcome variables were evaluated by blinded assessors. Results Dialectical behavior therapy was associated with better outcomes in the intent-to-treat analysis than community treatment by experts in most target areas during the 2-year treatment and follow-up period. Subjects receiving DBT were half as likely to make a suicide attempt (hazard ratio, 2.66; P = .005), required less hospitalization for suicide ideation (F 1,92 =7.3; P = .004), and had lower medical risk (F 1,50 =3.2; P = .04) across all suicide attempts and self-injurious acts combined. Subjects receiving DBT were less likely to drop out of treatment (hazard ratio, 3.2; P 1,92 =6.0; P = .007) and psychiatric emergency department visits (F 1,92 =2.9; P = .04). Conclusions Our findings replicate those of previous studies of DBT and suggest that the effectiveness of DBT cannot reasonably be attributed to general factors associated with expert psychotherapy. Dialectical behavior therapy appears to be uniquely effective in reducing suicide attempts.
1,760 citations
TL;DR: In this paper, a systematic review of published follow-up data from observational and experimental studies was conducted to estimate rates of fatal and non-fatal repetition of self-harm.
Abstract: Background Non-fatal self-harm frequently leads to non-fatal repetition and sometimes to suicide. We need to quantify these two outcomes of self-harm to help us to develop and test effective interventions.
Aims To estimate rates of fatal and non-fatal repetition of self-harm.
Method A systematic review of published follow-up data, from observational and experimental studies. Four electronic databases were searched and 90 studies met the inclusion criteria.
Results Eighty per cent of studies found were undertaken in Europe, over one-third in the UK. Median proportions for repetition 1 year later were: 16% non-fatal and 2% fatal; after more than 9 years, around 7% of patients had died by suicide. The UK studies found particularly low rates of subsequent suicide.
Conclusions After 1 year, non-fatal repetition rates are around 15%. The strong connection between self-harm and later suicide lies somewhere between 0.5% and 2% after 1 year and above 5% after 9 years. Suicide risk among self-harm patients is hundreds of times higher than in the general population.
1,024 citations
01 Jan 2004
TL;DR: Deliberate self harm defined according to strict criteria is common in adolescents, especially females Associated factors include recent awareness of self harm in peers, self harm by family members, drug misuse, depression, anxiety, impulsivity, and low self esteem.
929 citations
TL;DR: In this article, the prevalence of deliberate self harm in adolescents and the factors associated with it was found to be more common in females than it was in males (11.2% v 3.2%) and only 12.6% of episodes had resulted in presentation to hospital.
Abstract: Objective: To determine the prevalence of deliberate self harm in adolescents and the factors associated with it.
Design: Cross sectional survey using anonymous self report questionnaire.
Setting: 41 schools in England.
Participants: 6020 pupils aged 15 and 16 years.
Main outcome measure: Deliberate self harm.
Results: 398 (6.9%) participants reported an act of deliberate self harm in the previous year that met study criteria. Only 12.6% of episodes had resulted in presentation to hospital. Deliberate self harm was more common in females than it was in males (11.2% v 3.2%; odds ratio 3.9, 95% confidence interval 3.1 to 4.9). In females the factors included in a multivariate logistic regression for deliberate self harm were recent self harm by friends, self harm by family members, drug misuse, depression, anxiety, impulsivity, and low self esteem. In males the factors were suicidal behaviour in friends and family members, drug use, and low self esteem.
Conclusions: Deliberate self harm is common in adolescents, especially females. School based mental health initiatives are needed. These could include approaches aimed at educating school pupils about mental health problems and screening for those at risk.
#### What is already known on this topic
What is already known on this topic Deliberate self harm is a common reason for presentation of adolescents to hospital
Community studies from outside the United Kingdom have shown much greater prevalence of self harm in adolescents than hospital based studies
#### What this study adds
What this study adds Deliberate self harm defined according to strict criteria is common in adolescents, especially females
Associated factors include recent awareness of self harm in peers, self harm by family members, drug misuse, depression, anxiety, impulsivity, and low self esteem
908 citations