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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TL;DR: In this paper, the clinical and demographic characteristics of patients who presented to the pediatric ED between 2012 and 2017 with non-suicidal self-harm (NSSH, n = 63, 60.3% female, M ǫ= 14.25 years), suicidal ideation (SI, n à 0, 75, 57.3%, M à à 14.83 years), and suicide attempts (SA, n n 0, 0, 82.9%, M Á 15.41 years).
Abstract: Self-harm presentations to emergency departments (ED) have become a growing concern, yet little is known about self-harm visits in pediatric EDs. This study aimed to investigate the clinical and demographic characteristics of patients who presented to the pediatric ED between 2012 and 2017 with non-suicidal self-harm (NSSH, n = 63, 60.3% female, M = 14.25 years), suicidal ideation (SI, n = 75, 57.3% female, M = 14.83 years), and suicide attempts (SA, n = 461, 82.9% female, M = 15.41 years). Also, predictors of SA were investigated. Of the patients, 79.4% had at least a psychiatric disorder. Depression was the most common diagnosis in the SI and SA groups, and autism spectrum disorder and intellectual disability were the leading diagnoses in the NSSH group. Self-poisoning was the most common method, and older age, female sex, having relational problems, and prior or current psychiatric admissions were the most important predictive factors of SA. NSSH, SI, and SA exhibit different features in early life. EDs provide an important opportunity for initiating developmentally appropriate interventions to reduce future risks.
5 citations
Dissertation•
01 Jan 2013
TL;DR: This book discusses the association between self-Cutting and Repetition, and the lived experience of Emergency Department Self-Harm patients.
Abstract: .........................................................................................9 Preface...........................................................................................15 Chapter 1: Introduction to Self-Harm.......................................................17 Chapter 2: Scope of the Current Research: The Association Between Self-Cutting and Repetition..................................................................................63 Chapter 3: Risk Factors for Repetition of Self-Harm: A Systematic Review of Prospective Hospital-Based Studies.........................................................97 Chapter 4: Factors Associated with Self-Cutting as a Method of Self-Harm: Findings from the Irish National Registry of Deliberate Self-Harm..............................195 Chapter 5: Severity of Hospital-Treated Self-Cutting and Risk of Future Self-Harm: A National Registry Study..................................................................223 Chapter 6: Are Individual Differences Related to Self-Harm Method and Repetition? A Cohort Study of Hospital Presentations of Self-Cutting and Overdose............241 Chapter 7: "Breaking Points" and “Turning Points": The Lived Experience of Emergency Department Self-Harm Patients..............................................291 Chapter 8: Discussion........................................................................325 Appendices....................................................................................367
5 citations
Cites background or methods or result from "Hospital care and repetition follow..."
...A multicentre study in England (Lilley et al., 2008) found that almost 60% of people presenting with self-poisoning to emergency departments were admitted to general hospital compared with 12....
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...Deliberate self harm in adolescents: self report survey in schools in England....
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...A multicentre study in England used emergency department records to explore repetition up to 18 months after an index self-harm presentation (Lilley et al., 2008)....
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...A study based in England also found that those who had presented with self-cutting were more likely to have follow-up arrangements made than those who had engaged in overdose (Gunnell et al., 2005)....
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...…have found that slightly more women present with self-cutting than men (Bennett, Coggan, Hooper, Lovell, & Adams, 2002; Horrocks et al., 2003; Lilley et al., 2008), while others have reported a male majority within self-cutting (Brakoulias, Ryan, & Byth, 2006; Harriss, Hawton, & Zahl, 2005;…...
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TL;DR: Ameliorating interpersonal problems and improving stress coping skills would benefit people who attempt suicide via overdose, as it is generally less fatal than other methods.
5 citations
Cites result from "Hospital care and repetition follow..."
...Participants’ median age was younger in the overdose group; this contrasts with previous research examining an emergency department (Lilley et al., 2008)....
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...We found that drug overdose was the most common method of self-harm, supporting previous research (Lilley et al., 2008; Perry et al., 2012)....
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TL;DR: Young males are at increased risk of repeat self-harm and method-switching following IDO and the type and quantity of drugs taken are further indicators of risk.
Abstract: Background: The incidence of hospital-presenting self-harm peaks among young people, who most often engage in intentional drug overdose (IDO). The risk of self-harm repetition is high among young people and switching methods between self-harm episodes is common. However, little is known about their patterns of repetition and switching following IDO. This study aimed to investigate repeat self-harm and method-switching following hospital-presenting IDO among young people. Methods: Data from the National Self-Harm Registry Ireland on hospital-presenting self-harm by individuals aged 10–24 years during 2009–2018 were examined. Cox proportional hazards regression models with associated hazard ratios (HRs), survival curves and Poisson regression models with risk ratios (RRs), were used to examine risk factors for repetition and method-switching. Results: During 2009–2018, 16,800 young people presented following IDO. Within 12 months, 2136 young people repeated self-harm. Factors associated with repetition included being male (HR = 1.13, 95% CI: 1.03–1.24), aged 10–17 years (HR = 1.29, 95% CI: 1.18–1.41), consuming ≥ 50 tablets (HR = 1.27, 95% CI: 1.07–1.49) and taking benzodiazepines (HR = 1.67, 95% CI: 1.40–1.98) or antidepressants (HR = 1.36, 95% CI: 1.18–1.56). The cumulative risk for switching method was 2.4% (95% CI: 2.2–2.7). Method-switching was most likely to occur for males (RR = 1.36; 95% CI: 1.09–1.69) and for those who took illegal drugs (RR = 1.63; 95% CI: 1.19–2.25). Conclusion: Young males are at increased risk of repeat self-harm and method-switching following IDO and the type and quantity of drugs taken are further indicators of risk. Interventions targeting IDO among young people are needed that ensure that mental health assessments are undertaken and which address access to drugs.
5 citations
TL;DR: The need to improve the integration of community mental health care for people who present to acute care following self-harm with a recent history of incarceration is highlighted, particularly for men and those with substance use disorder or dual diagnosis.
Abstract: The authors would like to acknowledge the Passports project team and the late Professor Konrad Jamrozik, for his pivotal role in conceiving and designing the Passports study. The authors also wish to acknowledge the Passports study participants for sharing their stories with us. The authors would like to acknowledge the assistance provided by Queensland Corrective Services to the Passports study. The views expressed herein are solely those of the authors, and in no way reflect the views or policies of Queensland Corrective Services. The Passports study was funded by National Health and Medical Research Council (NHMRC) Strategic Award APP409966 and NHMRC Project Grant APP1002463. Stuart Kinner is supported by NHMRC Senior Research Fellowship APP1078168. Rohan Borschmann is supported by NHMRC Early Career Fellowship APP1104644. Lisa Brophy receives salary support from Mind Australia Limited. Matthew Spittal is a recipient of an Australian Research Council Future Fellowship (project number FT180100075) funded by the Australian Government. Jesse T Young is supported by a Melbourne Research Scholarship (PhD) from the University of Melbourne. The funding source had no additional role in the research design; data collection, analysis, or interpretation; the writing of the manuscript; or the decision to submit the article for publication. Contributors: SK and EH developed the original research proposal and methodology. JY developed and conducted the statistical analysis. JY wrote the initial draft manuscript. JY, RB, EH, MS, LB, DP, GA, JO, PM, and SK contributed significantly to the interpretation and synthesis of results, and all authors were involved in the development of the final manuscript submitted. JY had full access to the data used in this study and takes responsibility for the integrity of the data and accuracy of the data analysis.
4 citations
Cites methods from "Hospital care and repetition follow..."
...Different patterns of mental healthcare referral for self-harm by poisoning have been observed (Lilley et al., 2008), thus we dichotomised self-harm by method, comparing self-harm by poisoning to self-harm by all other means....
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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