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.
Citations
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TL;DR: What self-harm research can tell us about the concept of NSSI is considered and the potential pitfalls of introducing N SSI into clinical practice are examined.
Abstract: Non-suicidal self-injury (NSSI) is a term that is becoming popular especially in North America and it has been proposed as a new diagnosis in DSM-5. In this paper we consider what self-harm research can tell us about the concept of NSSI and examine the potential pitfalls of introducing NSSI into clinical practice.
322 citations
TL;DR: There was a significant treatment effect for CBT-based psychotherapy compared to TAU at final follow-up in terms of fewer participants repeating SH, but for interventions typically delivered to individuals with a history of multiple episodes of SH/probable personality disorder, group-based emotion-regulation psychotherapy and mentalisation were associated with significantly reduced repetition.
Abstract: Background: Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and associated with suicide. This is an update of a broader Cochrane review first published in 1998, previously updated in 1999, and now split into three separate reviews. This review focuses on psychosocial interventions in adults who engage in self-harm.
Objectives: To assess the effects of specific psychosocial treatments versus treatment as usual, enhanced usual care or other forms of psychological therapy, in adults following SH.
Search methods: The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) trials coordinator searched the CCDAN Clinical Trials Register (to 29 April 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date).
Selection criteria: We included RCTs comparing psychosocial treatments with treatment as usual (TAU), enhanced usual care (EUC) or alternative treatments in adults with a recent (within six months) episode of SH resulting in presentation to clinical services.
Data collection and analysis: We used Cochrane's standard methodological procedures.
230 citations
TL;DR: This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH and finds that mentalisation therapy was associated with fewer adolescents scoring above the cut-off for repetition of SH based on the Risk-Taking and Self-Harm Inventory 12 months post-intervention.
Abstract: Self-harm (SH; intentional self-poisoning or self-injury) is common in children and adolescents, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for SH published in 1998 and updated in 1999. We have
215 citations
TL;DR: A substantial increase in self-injury occurred in the latter part of the study period, especially marked for self-cutting/stabbing and hanging/asphyxiation.
Abstract: Objectives Self-harm is a major health problem in many countries, with potential adverse outcomes including suicide and other causes of premature death. It is important to monitor national trends in this behaviour. We examined trends in non-fatal self-harm and its management in England during the 13-year period, 2000–2012. Design and setting This observational study was undertaken in the three centres of the Multicentre Study of Self-harm in England. Information on all episodes of self-harm by individuals aged 15 years and over presenting to five general hospitals in three cities (Oxford, Manchester and Derby) was collected through face-to-face assessment or scrutiny of emergency department electronic databases. We used negative binomial regression models to assess trends in rates of self-harm and logistic regression models for binary outcomes (eg, assessed vs non-assessed patients). Participants During 2000–2012, there were 84 378 self-harm episodes (58.6% by females), involving 47 048 persons. Results Rates of self-harm declined in females (incidence rate ratio (IRR) 0.98; 95% CI 0.97 to 0.99, p Conclusions Trends in rates of self-harm and suicide may be closely related; therefore, self-harm can be a useful mental health indicator. Despite national guidance, many patients still do not receive psychosocial assessment, especially those who self-injure.
180 citations
Cites result from "Hospital care and repetition follow..."
...The increase in self-cutting is also concerning given our earlier finding that the proportion of patients who receive psychosocial assessment is especially low for individuals who self-cut.(28) The increase in other methods of self-injury, especially hanging/asphyxiation, is also worrying....
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TL;DR: It is difficult to find predictors for repetition of nonfatal suicide attempts, and even more difficult to identify predictors of completed suicide.
Abstract: OBJECTIVES: This review aimed to identify the evidence for predictors of repetition of suicide attempts, and more specifically for subsequent completed suicide. METHODS: We conducted a literature search of PubMed and Embase between January 1, 1991 and December 31, 2009, and we excluded studies investigating only special populations (eg, male and female only, children and adolescents, elderly, a specific psychiatric disorder) and studies with sample size fewer than 50 patients. RESULTS: The strongest predictor of a repeated attempt is a previous attempt, followed by being a victim of sexual abuse, poor global functioning, having a psychiatric disorder, being on psychiatric treatment, depression, anxiety, and alcohol abuse or dependence. For other variables examined (Caucasian ethnicity, having a criminal record, having any mood disorders, bad family environment, and impulsivity) there are indications for a putative correlation as well. For completed suicide, the strongest predictors are older age, suicide ideation, and history of suicide attempt. Living alone, male sex, and alcohol abuse are weakly predictive with a positive correlation (but sustained by very scarce data) for poor impulsivity and a somatic diagnosis. CONCLUSION: It is difficult to find predictors for repetition of nonfatal suicide attempts, and even more difficult to identify predictors of completed suicide. Suicide ideation and alcohol or substance abuse/dependence, which are, along with depression, the most consistent predictors for initial nonfatal attempt and suicide, are not consistently reported to be very strong predictors for nonfatal repetition. Language: en
173 citations
References
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TL;DR: Multicentre monitoring of self-harm in England has demonstrated similar overall patterns ofSelf- Harm in Oxford, Manchester and Leeds, with some differences reflecting local suicide rates.
Abstract: Background
Self-harm is a major healthcare problem in the United Kingdom, but monitoring of hospital presentations has largely been done separately in single centres Multicentre monitoring of self-harm has been established as a result of the National Suicide Prevention Strategy for England
348 citations
TL;DR: The aim of the paper is to determine which models are appropriate for recurrent event data using the key components of the Cox proportional hazards approach, and concludes that PWP-GT and TT-R are useful models for analysing recurrent eventData.
Abstract: Many extensions of survival models based on the Cox proportional hazards approach have been proposed to handle clustered or multiple event data. Of particular note are five Cox-based models for recurrent event data: Andersen and Gill (AG); Wei, Lin and Weissfeld (WLW); Prentice, Williams and Peterson, total time (PWP-CP) and gap time (PWP-GT); and Lee, Wei and Amato (LWA). Some authors have compared these models by observing differences that arise from fitting the models to real and simulated data. However, no attempt has been made to systematically identify the components of the models that are appropriate for recurrent event data. We propose a systematic way of characterizing such Cox-based models using four key components: risk intervals; baseline hazard; risk set, and correlation adjustment. From the definitions of risk interval and risk set there are conceptually seven such Cox-based models that are permissible, five of which are those previously identified. The two new variant models are termed the 'total time - restricted' (TT-R) and 'gap time - unrestricted' (GT-UR) models. The aim of the paper is to determine which models are appropriate for recurrent event data using the key components. The models are fitted to simulated data sets and to a data set of childhood recurrent infectious diseases. The LWA model is not appropriate for recurrent event data because it allows a subject to be at risk several times for the same event. The WLW model overestimates treatment effect and is not recommended. We conclude that PWP-GT and TT-R are useful models for analysing recurrent event data, providing answers to slightly different research questions. Further, applying a robust variance to any of these models does not adequately account for within-subject correlation.
330 citations
TL;DR: The measurement of suicidal intent in the assessment of self-harm patients is beneficial for the evaluation of future suicide risk and a shortened measuring scale might be useful in clinical practice.
Abstract: Background Self-harm is associated with a high risk of suicide. It is unclear whether suicidal intent at the time of self-harm is a risk factor for future suicidal behaviour.
Aims To investigate the relationship between suicidal intent and patient characteristics, repetition of self-harm, and suicide.
Method Clinical and demographic data on 4415 patients presenting to hospital following self-harm between 1993 and 2000 were analysed. Suicidal intent was measured using the Beck Suicide Intent Scale (SIS). Follow-up information on repetition of self-harm and suicide was investigated for 2489 patients presenting between 1993 and 1997.
Results Suicidal intent at the time of self-harm was associated with risk of subsequent suicide, especially within the first year and among female patients. Suicide was more strongly associated with scores on the circumstances section of the SIS than the self-report section. The association between repetition of self-harm and SIS scores was different for male and female patients.
Conclusions The measurement of suicidal intent in the assessment of self-harm patients is beneficial for the evaluation of future suicide risk. A shortened measuring scale might be useful in clinical practice.
248 citations
TL;DR: ED visits for attempted suicide and self-inflicted injury are relatively common, serious, and most frequent among adolescents and young adults, and the high prevalence of psychiatric and substance abuse disorders in this population suggests these issues should be considered during management and disposition.
241 citations
TL;DR: On a population level, this study suggests that the most important strategies to reduce repetition might include primary prevention of suicidal behavior, targeting psychiatric illness, and tackling social factors such as unemployment.
Abstract: OBJECTIVES: To determine the proportion of individuals who repeated nonfatal suicidal behavior within 12 months of an index episode, to investigate the timing of repetition, and to investigate risk factors associated with repetition and their population impact. METHOD: We carried out a prospective cohort study (1997-2002) in 4 large hospitals in North West England. We included subjects aged 15 years and over who attended with "self-harm" (an act of intentional self-poisoning or injury irrespective of the apparent purpose of the act). Following the episode, a standard assessment form, which included detailed demographic and clinical data, was completed by a clinician. RESULTS: 9213 individuals presented during the study period. The incidence of repetition within 12 months of the index episode was 13.6% (95% CI: 12.9% to 14.4%). The median time to first repetition was 73.5 days (interquartile range, 20 to 187 days). One in 10 subjects repeated within 5 days of the index episode. Independent risk factors for repetition included previous suicidal behavior, psychiatric treatment, being unemployed or registered sick, self-injury, alcohol misuse, and reporting suicidal plans or hallucinations at the time of the index episode. The combined population attributable fraction (an indicator of the potential population impact) for these variables was 65%. CONCLUSION: The repetition of suicidal behavior is common and occurs quickly. On a population level, our study suggests that the most important strategies to reduce repetition might include primary prevention of suicidal behavior, targeting psychiatric illness, and tackling social factors such as unemployment. Specific interventions may be required for individual subgroups.
173 citations