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•
29 Apr 2013
TL;DR: It is demonstrated that there are risk factors associated with repeated DSH that can be used to identify DSH patients at risk for repetition and that both clinical decision rules, the Södersjukhuset Self-harm Rule (SoS-4) and the Manchester Self-Harm Rule (MSHR) can be useful in the clinical assessment of D SH patients in conjunction with psychiatric assessment.
Abstract: Each year approximately ten million people deliberately harm themselves and one million people commit suicide across the world. Deliberate self-harm (DSH) is a major cause of individual suffering and a burden on the healthcare system. An attendance at an emergency department (ED) due to DSH increases the risk for subsequent suicide with 50 to 100 times compared to the general population. Repetition of DSH is very common (15−25%) and often occurs within a short period of time. The aim of this thesis was to gain a better knowledge of DSH patients in the somatic ED and to find ways of reducing the high repetition rate among this group of patients. The aims of the studies were to investigate risk factors associated with repeated DSH and suicide, to stratify a DSH population according to the risk of repetition, to develop and validate clinical decision rules that predict repetition of DSH and to investigate follow-up care for DSH patients and its impact on repeated DSH. Study I: In this study risk factors associated with repeated DSH among 1524 patients attending the ED due to DSH were identified and the patients were stratified into risk categories. New DSH or suicide was identified via national registers. A model for risk stratification for repeated DSH describing groups of low-risk (18%), medianrisk (28% to 32%) and high-risk (47% to 72%) was presented. Study II: The aim was to develop a clinical decision rule, the Södersjukhuset Self-harm Rule (SoS-4), based on factors found to be associated with repeated DSH in Study I and also to validate an existing clinical tool for assessing risk after DSH, i.e., the Manchester Self-Harm Rule (MSHR). The SoS-4 uses five clinical correlates: gender, antidepressant treatment, history of self-harm, admission to a psychiatric clinic and current psychiatric treatment. The MSHR uses four clinical correlates: history of self-harm, previous psychiatric treatment, selfpoisoning with benzodiazepines and current psychiatric treatment. The SoS-4 yielded a sensitivity of 90% and a specificity of 18% when applied to the DSH population in Study I and application of the MSHR yielded a sensitivity of 89% and a specificity of 21%. Study III: The aim was to prospectively validate the ability of the two clinical decision rules, SoS-4 and MSHR, to predict repetition of DSH in a new population and new setting. Included were 325 DSH patients in the EDs of Södersjukhuset and Karolinska University Hospital Huddinge who were followed for six months. Application of the SoS-4, to this new DSH population, yielded a sensitivity of 89% and a specificity of 12% and application of the MSHR a sensitivity of 95% and a specificity of 18%. Study IV: The aim was to investigate follow-up care of DSH patients and its impact on repetition, which was done in the same study population as in Study III. A visit to a psychiatric consultant within 10 days was registered as an early follow-up. When adjusting for risk factors known to be associated with repetition there was an indication of early followed-up patients being less inclined to repeat their DSH actions. Conclusions: This thesis, focusing on DSH patients in a somatic ED, demonstrated that there are risk factors associated with repeated DSH that can be used to identify DSH patients at risk for repetition and that both clinical decision rules, the SoS-4 and the MSHR, can be useful in the clinical assessment of DSH patients in conjunction with psychiatric assessment. This thesis also demonstrated that there was an indication of early followed-up patients being less inclined to repeat their DSH actions after adjusting for risk factors known to be associated
2 citations
TL;DR: The low comparative repetition rates in rural Sri Lanka was not explained by higher rates of suicide or access to more lethal means or differences in methodology.
Abstract: Repetition of deliberate self harm is an important predictor of subsequent suicide. Repetition rates in Asian countries appear to be significantly lower than in western high income countries. The reason for these reported differences is not clear and has been suggested to due methodological differences or the impact of access to more lethal means of self harm.
This prospective study determines the rates and demographic pattern of deliberate self-poisoning, suicide and fatal and non fatal repeated deliberate self-poisoning in rural Sri Lanka.
Details of deliberate self poisoning admission in all hospitals (n=46) and suicides reported to all the police stations (n=28) of a rural district were collected for 3 years, 2011-2013. Demographic details of the cohort of deliberate self-poisoning patients admitted to all hospitals in 2011 (N=4022), were screened to link with patient records and police reports of successive two years with high sensitivity using a computer program and manual matching was performed with higher specificity. Life time repetition was assessed in a randomly selected subset of DSP patients (n=438).
There were 15,914 DSP admissions and 1078 suicides during the study period. Within the study area the deliberate self poisoning and suicide population incidences were, 248.3/100,000 and 20.7/100,000 in 2012. Repetition rate for four weeks, one-year and two-years were 1.9% (95% CI 1.5-2.3%), 5.7% (95% CI 5.0 to 6.4) and 7.9% (95% CI 7.1 to 8.8) respectively. The median interval between two attempts were 92 (IQR 10 - 238) and 191 (IQR 29 - 419.5) days for the one and two-year repetition groups. The majority of patients used the same poison in the repeat attempt. Age and hospital stay of individuals with repetitive events were not significantly different from those who had no repetitive events. The two-year rate for suicide following DSP was 0.7% (95% CI 0.4-0.9%). Reported life time history of deliberate self harm attempts was 9.5% (95% CI 6.7-12.2%).
The low comparative repetition rates in rural Sri Lanka was not explained by higher rates of suicide or access to more lethal means or differences in methodology.
2 citations
Dissertation•
01 Jun 2012
TL;DR: Over half of those making their first-ever self-harm presentation had no mental health contact with a physician within 30 days of discharge, and several demographic, clinical and health service variables were associated with follow-up.
Abstract: Objective: Describe emergency department (ED) presentations for self-harm by youth (12-17 yearolds), including the mental health follow-up they receive after their first-ever presentation, and analyze the association between this mental health follow-up and repeat presentation(s). Methods: Population-based health services data from Ontario, Canada, covering April 2002 to March 2009, were used to ascertain ED presentations for self-harm by youth (n=16,835). These data were used to create a retrospective cohort (n=3,497) of those making their first-ever presentation, and individually-linked to inpatient admission and ambulatory physician contact data. Mental health follow-up within 30-days of discharge, either from a psychiatrist or from any physician specialty, was assessed. The associations between follow-up and repeat self-harm presentation(s) within the following year were then analyzed. Results: Conservatively, the overall incidence rate for ED presentations for self-harm by Ontario youth was 239.0 per 100,000 person-years. Rates were higher in girls, increased with age and inversely related to neighbourhood income and community size (population). Self-harm made up a small but severe proportion of ED use by youth. Over half (57.2%) making their first-ever self-harm presentation had no mental health contact with a physician within 30 days of discharge (and several demographic, clinical and health service variables were associated with follow-up). However, mental health follow-up was not associated with reduced odds of repetition or fewer repeat presentations.
2 citations
Cites result from "Hospital care and repetition follow..."
...Individuals who use self-cutting as a method of self-harm have been shown to be less likely to receive a psychosocial assessment or be admitted, despite their risk of negative outcomes.(143) The results presented here corroborate this finding as it appears these individuals may also be less likely to receive mental health follow-up....
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08 Nov 2010
TL;DR: Self-harm is commonly used to describe a wide range of behaviours and intentions including attempted hanging, impulsive self-poisoning and superficial cutting in response to intolerable tension.
Abstract: This paper explores self-harm and examines some of the management strategies that may be used to plan care interventions effectively. Self-harm The term self-harm is commonly used to describe a wide range of behaviours and intentions including attempted hanging, impulsive self-poisoning and superficial cutting in response to intolerable tension (Skegg, 2005).
2 citations
Cites background from "Hospital care and repetition follow..."
...There is also evidence that cutting is repeated more often than other forms of self-harm (Lilley et al, 2008)....
[...]
Dissertation•
13 Jun 2011
TL;DR: In this paper, the authors investigated the experience of taking part in a psychosocial assessment following an episode of self-harm from the service user perspective and found that the interaction with staff had the power to reinforce or challenge hopelessness and negative self-evaluations.
Abstract: University of Manchester - Cheryl Hunter ? Degree of Doctor of Philosophy in the Faculty of Medical and Human Sciences - 2011A Qualitative Investigation into the Lived Experience of Psychosocial Assessment following Self-harmThis thesis investigated the experience of taking part in a psychosocial assessment following an episode of self-harm from the service user perspective. Psychosocial assessments are a key aspect of self-harm management in secondary care, designed to identify needs and risk and determine further care. This study utilised interpretative phenomenological analysis to privilege the voices of service users and produce in-depth, contextualised understandings of the experience of assessment and its impact on future help-seeking and engagement with services. Data collection consisted of semi-structured interviews with thirteen participants soon after their hospital attendance; follow-up semi-structured interviews were also completed with seven participants three months later, to explore patient-derived outcomes from assessment and hospital attendance.The lived experiences of participants were characterised by two main features: experiences of life as a struggle and of the self as ?less than?. As a result of these struggles and experiences of powerlessness and devaluation, participants mostly saw self-harm and suicide as a natural progression in their narratives. Expressions of suicidal intent reflected a struggle between a desperate desire for change and hopelessness in the face of current circumstances. The key message gained from participants? accounts of assessment was that the interaction with staff had the power to reinforce or challenge hopelessness and negative self-evaluations. In addition, the way an assessment was conducted had influence beyond the hospital: as an experience which created or reinforced expectations for future instances of help-seeking; as a deterrent or an encouragement to seek help; and as the first step along the path to change. Unfortunately, participants? experiences of aftercare were dominated by a sense of stagnation due to the failure of services to follow through with promises of aftercare, which affected their attitudes towards future help-seeking and towards themselves.This thesis is the first study to utilise an in-depth idiographic methodology to explore and contextualise the service user experience of psychosocial assessment following self-harm within the wider circumstances of their lives. It demonstrates how patient-staff interactions within the hospital and after discharge can affect future help-seeking through reinforcing or challenging the hopelessness and self-negativity of patients.
2 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