Association of Medicaid coverage with emergency department utilization after self-harm in Korea: A nationwide registry-based study.

BACKGROUND: Self-harm presents an important public health challenge. It imposes a notable burden on the utilization of emergency department (ED) services and medical expenses from patients and family. The Medicaid system is vital in providing financial support for individuals who struggle with medical expenses. This study explored the association of Medicaid coverage with ED visits following incidents of self-harm, utilizing nationwide ED surveillance data in Korea. METHODS: Data of all patients older than 14 years who presented to EDs following incidents of self-harm irrespective of intention to end their life, including cases of self-poisoning, were gathered from the National ED Information System (NEDIS). The annual self-harm visit rate (SHVR) per 100,000 people was calculated for each province and a generalized linear model analysis was conducted, with SHVR as a dependent variable and factors related to Medicaid coverage as independent variables. RESULTS: A 1% increase in Medicaid enrollment rate was linked to a significant decrease of 14% in SHVR. Each additional 1,000 Korean Won of Medicaid spending per enrollee was correlated with a 1% reduction in SHVR. However, an increase in Medicaid visits per enrollee and an extension of Medicaid coverage days were associated with an increase in SHVR. SHVR exhibited a stronger associated with parameters of Medicaid coverage in adolescents and young adults than in older adult population. CONCLUSION: Expansion of Medicaid coverage coupled with careful monitoring of shifts in Medicaid utilization patterns can mitigate ED overloading by reducing visits related to self-harm.

Brief admission by self-referral as an add-on to usual care for individuals with self-harm at risk of suicide: cost-effectiveness and 4-year health-economic consequences after a Swedish randomized controlled trial.

BACKGROUND: Brief Admission by self-referral (BA) is a crisis-management intervention standardized for individuals with self-harm at risk of suicide. We analyzed its health-economic consequences. MATERIALS AND METHODS: BA plus treatment as usual (TAU) was compared with TAU alone in a 12-month randomized controlled trial with 117 participants regarding costs for hospital admissions, coercive measures, emergency care and health outcomes (quality-adjusted life years; QALYs). Participants were followed from 12 months before baseline to up to five years after. RESULTS: Over one year BA was associated with a mean annual cost reduction of 4800 or incremental cost of 4600 euros, depending on bed occupancy assumption. Cost-savings were greatest for individuals with >180 admission days in the year before baseline. In terms of health outcomes BA was associated with a QALY gain of 0.078. Uncertainty analyses indicated a significant QALY gain and ambiguity in costs, resulting in BA either dominating TAU or costing 59 000 euros per gained QALY. CONCLUSION: BA is likely to produce QALY gains for individuals living with self-harm and suicidality. Cost-effectiveness depends on targeting high-need individuals and comparable bed utilization between BA and other psychiatric admissions. Future research should elaborate the explanatory factors for individual variations in the usage and benefit of BA.

Economic Cost of U.S. Suicide and Nonfatal Self-harm.

INTRODUCTION: The U.S. age-adjusted suicide rate is 35% higher than two decades ago and the COVID-19 pandemic era highlighted the urgent need to address nonfatal self-harm, particularly among youth. This study aimed to report the estimated annual economic cost of U.S. suicide and nonfatal self-harm. METHODS: In 2023 CDC's WISQARS Cost of Injury provided the retrospective number of suicides and nonfatal self-harm injury emergency department (ED) visits from national surveillance sources by sex and age group, as well as the estimated annual economic cost of associated medical spending, lost work productivity, reduced quality of life from injury morbidity, and avoidable mortality based on the value of statistical life during 2015-2020. RESULTS: The economic cost of suicide and nonfatal self-harm averaged $510 billion (2020 USD) annually, the majority from life years lost to suicide. Working-aged adults (aged 25-64 years) comprised nearly 75% of the average annual economic cost of suicide ($356B of $484B) and children and younger adults (aged 10-44 years) comprised nearly 75% of the average annual economic cost of nonfatal self-harm injuries ($19B of $26B). CONCLUSIONS: Suicide and self-harm have substantial societal costs. Measuring the consequences in terms of comprehensive economic cost can inform investments in suicide prevention strategies.

The actual, long-term cost of intentional injury care among a cohort of Maryland Medicaid recipients.

BACKGROUND: Intentional injury (both self-harm and interpersonal) is a major cause of morbidity and mortality, yet there are little data on the per-person cost of caring for these patients. Extant data focus on hospital charges related to the initial admission but does not include actual dollars spent or follow-up outpatient care. The Affordable Care Act has made Medicaid the primary payor of intentional injury care (39%) in the United States and the ideal source of cost data for these patients. We sought to determine the total and per-person long-term cost (initial event and following 24 months) of intentional injury among Maryland Medicaid recipients. METHODS: Retrospective cohort study of Maryland Medicaid claims was performed. Recipients who submitted claims after receiving an intentional injury, as defined by the International Classification of Diseases, Tenth Revision, between October 2015 and October 2017, were included in this study. Subjects were followed for 24 months (last participant enrolled October 2017 and followed to October 2019). Our primary outcome was the dollars paid by Medicaid. We examined subgroups of patients who harmed themselves and those who received repeated intentional injury. RESULTS: Maryland Medicaid paid $11,757,083 for the care of 12,172 recipients of intentional injuries between 2015 and 2019. The per-person, 2-year health care cost of an intentional injury was a median of $183 (SD, $5,284). These costs were highly skewed: min, $2.56; Q1 = 117.60, median, $182.80; Q3 = $480.82; and max, $332,394.20. The top 5% (≥95% percentile) required $3,000 (SD, $6,973) during the initial event and $8,403 (SD, $22,024) per served month thereafter, or 55% of the overall costs in this study. CONCLUSION: The long-term, per-person cost of intentional injury can be high. Private insurers were not included and may experience different costs in other states. LEVEL OF EVIDENCE: Economic and Value Based Evaluations; level III.

Cost-Effectiveness Analysis of Smoking Cessation Interventions in the United Kingdom Accounting for Major Neuropsychiatric Adverse Events.

OBJECTIVES: Smoking is a leading cause of death worldwide. Cessation aids include varenicline, bupropion, nicotine replacement therapy (NRT), and e-cigarettes at various doses (low, standard and high) and used alone or in combination with each other. Previous cost-effectiveness analyses have not fully accounted for adverse effects nor compared all cessation aids. The objective was to determine the relative cost-effectiveness of cessation aids in the United Kingdom. METHODS: An established Markov cohort model was adapted to incorporate health outcomes and costs due to depression and self-harm associated with cessation aids, alongside other health events. Relative efficacy in terms of abstinence and major adverse neuropsychiatric events was informed by a systematic review and network meta-analysis. Base case results are reported for UK-licensed interventions only. Two sensitivity analyses are reported, one including unlicensed interventions and another comparing all cessation aids but removing the impact of depression and self-harm. The sensitivity of conclusions to model inputs was assessed by calculating the expected value of partial perfect information. RESULTS: When limited to UK-licensed interventions, varenicline standard-dose and NRT standard-dose were most cost-effective. Including unlicensed interventions, e-cigarette low-dose appeared most cost-effective followed by varenicline standard-dose + bupropion standard-dose combined. When the impact of depression and self-harm was excluded, varenicline standard-dose + NRT standard-dose was most cost-effective, followed by varenicline low-dose + NRT standard-dose. CONCLUSION: Although found to be most cost-effective, combined therapy is currently unlicensed in the United Kingdom and the safety of e-cigarettes remains uncertain. The value-of-information analysis suggested researchers should continue to investigate the long-term effectiveness and safety outcomes of e-cigarettes in studies with active comparators.

The economic burden of deliberate self-poisoning: insight from a tertiary hospital in the Free State Province, South Africa.

Suicide rate in South Africa is contentiously rated among the top ten highest in the world. Deliberate self-poisoning (DSP) remains one of the common methods for suicide. The management of DSP often impose a significant economic burden on health services with a growing loss of resources. However, studies on the financial implications associated with the management of DSP cases in South Africa are scarce and no known study has investigated the financial implication of managing DSP in a resource strained health system as obtained in the Free State Department of Health (FSDoH). This present study investigated the financial implication of managing DSP in a state regional hospital in the Free State province and proffer efficient ways of utilizing limited available resources in DSP management. This was a descriptive, retrospective cross-sectional study in which clinical records of 212 DSP cases which presented during an 18-month period at the emergency department of a state regional hospital were reviewed. The incidence of DSP was higher among individuals who are females (66% females vs 34% males), unemployed (65.6%) in the age group 20-29 years (44.8%). DSP management cost an average of R50, 000 per month. Wasteful expenditures such as blanket requests for laboratory investigation accounted for 19% of the cost. These findings agree with prior studies that have reported that managing DSP could pose a huge direct financial burden on hospital expenditure and health service delivery. If future cost containment and quality of care are to be achieved in the Free State province, efforts must be made by healthcare personnel to combat wasteful and unnecessary expenditure during patient management. We hope that recommendations proffered by this current study will alleviate the financial burden of DSP management in the province.

A One Year Cost Analysis of Acute Paediatric Mental Health Presentations.

Aim Examine costs associated with acute mental health presentations (AMHP) to a paediatric emergency department (ED) in 2016 and 2018. Methods Case identification and bed costs were calculated. Results In 2018, 163 youths attended the ED with AMHP, 122 (75%) were admitted (average 8 days), representing a yearly cost to the hospital of €1,028,020, average cost per patient €8,426. This marks an increase of €425,320 or €2,686 per patient compared to 2016. Arriving out of hours, presence of self-harm (SH) and discharge to an inpatient psychiatry bed were all associated with greater costs. Conclusion Despite increasing hospital costs associated with out of hours psychiatric emergencies, dedicated funding is not yet in place. All children should have access to urgent MH assessment. Work force planning and creation of pathways of care for young people with MH needs, including dedicated funding from HSE mental health division must be a priority.

Emergency Department Use and Inpatient Admissions and Costs Among Adolescents With Deliberate Self-Harm: A Five-Year Follow-Up Study.

OBJECTIVE: Self-harm rates among U.S. adolescents have risen substantially. Health and social outcomes among contemporary self-harming youths are infrequently tracked and poorly understood. This study investigated long-term health service utilization (emergency department [ED] visits and inpatient admissions) and inpatient costs among a recent cohort of adolescents with deliberate self-harm. METHODS: This retrospective cohort study used statewide, all-payer, longitudinally linked discharge data from California. All residents ages 10-19 presenting to EDs in 2010 with deliberate self-harm (N=5,396) were compared with two control groups: a random sample of adolescent ED patients with other complaints, matched on sex, age, residential zip code, and month of index visit (general control patients, N=14,921), and matched ED patients with psychiatric complaints but no self-harm (psychiatric control patients, N=15,835). Outcomes included 5-year rates of ED visits, inpatient admissions, and inpatient costs, overall and for psychiatric and nonpsychiatric complaints separately. RESULTS: Self-harm patients' ED use, inpatient admissions, and inpatient costs were significantly higher than those of general control patients (by 39%, 81%, and 21%, respectively), when the analysis controlled for confounding demographic and utilization characteristics. Associations mostly persisted, although smaller in magnitude, in comparisons between self-harm and psychiatric control patients. Psychiatric and nonpsychiatric complaints contributed to self-harming adolescents' excess health service utilization and costs. CONCLUSIONS: Deliberate self-harm among adolescents was found to be associated with long-lasting and costly patterns of health service utilization, often but not exclusively for psychiatric complaints. Future research should investigate the pathways underlying these associations and incorporate service utilization as a key patient outcome.

The cost of hospitalisation for youth self-harm: differences across age groups, sex, Indigenous and non-Indigenous populations.

OBJECTIVE: To report the comparative rates, average length of stay and cost per episode of hospital management for self-harm in three age cohorts: 15-19 years, 20-24 years and 25-29 years; by sex and indigeneity. DESIGN, SETTING, PARTICIPANTS: A secondary data analysis of the Australian Institute of Health and Welfare (AIHW) dataset between 1st January 2014 and 31st December 2014 inclusive. MAIN OUTCOME MEASURES: Cost per episode of hospitalised self-harm and rates by age group, sex and Indigenous status. RESULTS: The rate of hospitalised self-harm among Australian youth was 254.0 per 100,000 population. This rate resulted in an annual cost to the healthcare system of AU$55 million or an average cost per episode of $4649 (95% CI $4488:$4810). Hospitalised self-harm was 21 times higher than the rate of suicide (11,820 episodes of hospitalised self-harm/564 suicides). Indigenous youth had on average a 1.4 times higher rate of hospitalised self-harm and 2.2 times higher rate of suicide than non-Indigenous counterparts. When controlling for age and sex, the average cost per episode was significantly lower for Indigenous youth compared to non-Indigenous youth, estimated marginal means $4538 and $4954, respectively (p < 0.001). CONCLUSIONS: Hospitalised self-harm among Australian youth resulted in a substantial cost to the healthcare system. This cost is only part of the overall burden associated with self-harm. The rate of hospitalised self-harm was significantly higher in Indigenous youth, but the associated cost per episode was significantly lower.

Risk assessment scales to predict risk of hospital treated repeat self-harm: A cost-effectiveness modelling analysis.

BACKGROUND: Risk scales are used widely for assessing individuals presenting to Emergency Departments (EDs) following self-harm. There is growing evidence that risk scales have limited clinical utility in identifying episodes at highest risk of repeat self-harm. However, their cost-effectiveness in terms of treatment allocation and subsequent repeat self-harm is unknown. We aimed to examine the cost-effectiveness of five risk scales (SAD PERSONS Scale, Modified SAD PERSONS Scale, ReACT Self-Harm Rule, Manchester Self-Harm Rule, Barratt Impulsivity Scale) and single item clinician and patient ratings of risk. METHOD: Quality-Adjusted Life Years were estimated for each episode. The five risk scales and the patient rating were compared to the clinician rating. Incremental cost-effectiveness ratios (ICERs) were estimated for each scale, using a range of ICER thresholds. Sensitivity analysis explored different model assumptions. RESULTS: The formal scales were less cost-effective than the clinician and patient ratings across a range of ICER thresholds (£0-£30,000). The five scales were also less cost-effective than the clinician rating in most alternative scenario analyses. However, the clinician rating would be likely to result in unnecessary treatment costs for over half of patients identified as high risk. LIMITATIONS: Our primary model depended on the assumption that high-intensity care reduced patients' risk of further self-harm. CONCLUSION: The use of formal assessment tools for managing self-harm presentations to EDs did not appear to be cost-effective. While the judgement of a mental health clinician was found to be slightly more cost-effective, it still resulted in incorrect allocation of costs and missed treatment opportunities.

Self-inflicted burn injuries: Etiologies, risk factors and impact on institutional resources.

INTRODUCTION: Self-inflicted burns are a rare cause of injury, accounting for only 1.0% of burns in the United States. While rare, the physical and psychosocial ramifications of these injuries are lasting. The goal of this study was to examine the etiologies, risk factors and outcomes of self-inflected burns in an urban setting. METHODS: Records of all patients presented to a regional burn center from July 2011 to June 2015 were reviewed. Those who sustained a self-inflected burn were identified and included in this study. Demographic data, psychiatric history, previous self-harm records, insurance status, injury circumstance, burn characteristic [location and total body surface area (TBSA)], need for excision and grafting, graft-take and duration of hospital stay and costs were reviewed. This group was then compared to a cohort of 166 patients with non-intentional burn during the same time frame matched for age and TBSA%. RESULTS: There were 34 patients with a mean (SD) age of 31 (15.2) who sustained a self-inflicted burn during the study period. The mean TBSA% was 2.8 (SD=5.1), with most injuries in the upper and lower extremities. Fifty three percent of the patients presented with altered mental status secondary to either psychiatric illness or intoxication. Twenty-four percent of incidents were claimed as suicide attempts and suicidal ideation was present in 47% of cases. Twenty-six percent of patients with a previous psychiatric diagnosis were not on a psychiatric medication prior to incident. There was record of previous self-harm in 26% of patients. When compared to control group of 166 patient with non-intentional burn, patients with self-inflicted burn had higher rates of substance abuse (35% vs. 13%, p<0.05), longer stay in the hospital (11.3 vs. 5.3 days, p<0.01), longer stay in the intensive care unit (1.8 vs. 0.2 days, p<0.01), and lower rates of insurance (15% vs. 42%, p<0.001). These patients also exhibited a higher need for excision and grafting (41% vs. 20%, p<0.01). CONCLUSIONS: Patients with self-inflected burn have a higher rate of previous self-harm behavior, psychiatric comorbidities and substance abuse. These patients are more likely to require surgical excision and grafting and expanded institutional resources compared to those with non-intentional burn with similar degree and size of burn. Increased counseling of at-risk populations may help to decrease this potentially preventable method of injury.

Disease burden and government spending on mental, neurological, and substance use disorders, and self-harm: cross-sectional, ecological study of health system response in the Americas.

BACKGROUND: Disorders affecting mental health are highly prevalent, can be disabling, and are associated with substantial premature mortality. Yet national health system responses are frequently under-resourced, inefficient, and ineffective, leading to an imbalance between disease burden and health expenditures. We estimated the disease burden in the Americas caused by disorders affecting mental health. This measure was adjusted to include mental, neurological, and behavioural disorders that are frequently not included in estimates of mental health burden. We propose a framework for assessing the imbalance between disease burden and health expenditures. METHODS: In this cross-sectional, ecological study, we extracted disaggregated disease burden data from the Global Health Data Exchange to produce country-level estimates for the proportion of total disease burden attributable to mental disorders, neurological disorders, substance use disorders, and self-harm (MNSS) in the Americas. We collated data from the WHO Assessment Instrument for Mental Health Systems and the WHO Mental Health Atlas on country-level mental health spending as a proportion of total government health expenditures, and of psychiatric hospital spending as a proportion of mental health expenditures. We used a metric capturing the imbalance between disease burden and mental health expenditures, and modelled the association between this imbalance and real (ie, adjusted for purchasing power parity) gross domestic product (GDP). FINDINGS: Data were collected from July 1, 2016, to March 1, 2017. MNSS comprised 19% of total disability-adjusted life-years in the Americas in 2015. Median spending on mental health was 2·4% (IQR 1·3-4·1) of government health spending, and median allocation to psychiatric hospitals was 80% (52-92). This spending represented an imbalance in the ratio between disease burden and efficiently allocated spending, ranging from 3:1 in Canada and the USA to 435:1 in Haiti, with a median of 32:1 (12-170). Mental health expenditure as a proportion of government health spending was positively associated with real GDP (ß=0·68 [95% CI 0·24-1·13], p=0·0036), while the proportion allocated to psychiatric hospitals (ß=-0·5 [-0·79 to -0·22], p=0·0012) and the imbalance in efficiently allocated spending (ß=-1·38 [-1·97 to -0·78], p=0·0001) were both inversely associated with real GDP. All estimated coefficients were significantly different from zero at the 0·005 level. INTERPRETATION: A striking imbalance exists between government spending on mental health and the related disease burden in the Americas, which disproportionately affects low-income countries and is likely to result in undertreatment, increased avoidable disability and mortality, decreased national economic output, and increased household-level health spending. FUNDING: Weatherhead Center for International Affairs, Harvard University.

What utility scores do mental health service users, healthcare professionals and members of the general public attribute to different health states? A co-produced mixed methods online survey.

BACKGROUND: Utility scores are integral to health economics decision-making. Typically, utility scores have not been scored or developed with mental health service users. The aims of this study were to i) collaborate with service users to develop descriptions of five mental health states (psychosis, depression, eating disorder, medication side effects and self-harm); ii) explore feasibility and acceptability of using scenario-based health states in an e-survey; iii) evaluate which utility measures (standard gamble (SG), time trade off (TTO) and rating scale (RS)) are preferred; and iv) determine how different participant groups discriminate between the health scenarios and rank them. DESIGN AND METHODS: This was a co-produced mixed methods cross-sectional online survey. Utility scores were generated using the SG, TTO and RS methods; difficulty of the completing each method, markers of acceptability and participants' preference were also assessed. RESULTS: A total of 119 participants (58%) fully completed the survey. For any given health state, SG consistently generated higher utility scores compared to RS and for some health states higher also than TTO (i.e. SG produces inflated utility scores relative to RS and TTO). Results suggest that different utility measures produce different evaluations of described health states. The TTO was preferred by all participant groups over the SG. The three participant groups scored four (of five) health scenarios comparably. Psychosis scored as the worst health state to live with while medication side-effects were viewed more positively than other scenarios (depression, eating disorders, self-harm) by all participant groups. However, there was a difference in how the depression scenario was scored, with service users giving depression a lower utility score compared to other groups. CONCLUSION: Mental health state scenarios used to generate utility scores can be co-produced and are well received by a broad range of participants. Utility valuations using SG, TTO and RS were feasible for use with service users, carers, healthcare professionals and members of the general public. Future studies of utility scores in psychiatry should aim to include mental health service users as both co-investigators and respondents.

Intentional injuries in the Eastern Mediterranean Region, 1990-2015: findings from the Global Burden of Disease 2015 study.

OBJECTIVES: We used GBD 2015 findings to measure the burden of intentional injuries in the Eastern Mediterranean Region (EMR) between 1990 and 2015. METHODS: The Global Burden of Disease (GBD) study defines intentional injuries as a combination of self-harm (including suicide), interpersonal violence, collective violence (war), and legal intervention. We estimated number of deaths, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs) for each type of intentional injuries. RESULTS: In 2015, 28,695 individuals (95% UI: 25,474-37,832) died from self-harm, 35,626 (95% UI: 20,947-41,857) from interpersonal violence, and 143,858 (95% UI: 63,554-223,092) from collective violence and legal interventions. In 2015, collective violence and legal intervention was the fifth-leading cause of DALYs in the EMR and the leading cause in Syria, Yemen, Iraq, Afghanistan, and Libya; they account for 49.7% of total DALYs in Syria. CONCLUSIONS: Our findings call for increased efforts to stabilize the region and assist in rebuilding the health systems, as well as increasing transparency and employing preventive strategies to reduce self-harm and interpersonal injuries.

General hospital costs in England of medical and psychiatric care for patients who self-harm: a retrospective analysis.

BACKGROUND: Self-harm is an extremely common reason for hospital presentation. However, few estimates have been made of the hospital costs of assessing and treating self-harm. Such information is essential for planning services and to help strengthen the case for investment in actions to reduce the frequency and effects of self-harm. In this study, we aimed to calculate the costs of hospital medical care associated with a self-harm episode and the costs of psychosocial assessment, together with identification of the key drivers of these costs. METHODS: In a retrospective analysis, we estimated hospital resource use and care costs for all presentations for self-harm to the John Radcliffe Hospital (Oxford, UK), between April 1, 2013, and March 31, 2014. Episode-related data were provided by the Oxford Monitoring System for Self-harm and we linked these with financial hospital records to quantify costs. We assessed time and resources allocated to psychosocial assessments through discussion with clinical and managerial staff. We then used generalised linear models to investigate the associations between hospital costs and methods of self-harm. FINDINGS: Between April 1, 2013, and March 31, 2014, 1647 self-harm presentations by 1153 patients were recorded. Of these, 1623 (99%) presentations by 1140 patients could be linked with hospital finance records. 179 (16%) patients were younger than 18 years. 1150 (70%) presentations were for self-poisoning alone, 367 (22%) for self-injury alone, and 130 (8%) for a combination of methods. Psychosocial assessments were made in 75% (1234) of all episodes. The overall mean hospital cost per episode of self-harm was £809. Costs differed significantly between different types of self-harm: self-injury alone £753 (SD 2061), self-poisoning alone £806 (SD 1568), self-poisoning and self-injury £987 (SD 1823; p<0·0001). Costs were mainly associated with the type of health-care service contact such as inpatient stay, intensive care, and psychosocial assessment. Mean costs of psychosocial assessments were £228 for adults and £392 for individuals younger than 18 years. INTERPRETATION: If our findings are extrapolated to England, the estimated overall annual cost of general hospital management of self-harm is £162 million per year. More use of psychosocial assessment and other preventive measures, especially for young people and against self-poisoning, could potentially lower future costs at a time of major cost pressures in the NHS. FUNDING: National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research, Care Oxford at Oxford Health NHS Foundation Trust, and Department of Health.

Extending the liaison psychiatry service in a large hospital in the UK: a before and after evaluation of the economic impact and patient care following ED attendances for self-harm.

OBJECTIVES: To evaluate the impact of an expansion of liaison psychiatry services (LPS) on patient management, outcomes and treatment costs for emergency department (ED) attendances for self-harm. DESIGN: Retrospective before and after cohort study using routinely collected Self-Harm Surveillance Register data. SETTING: A large hospital in South West England. SUBJECTS: Patients attending the ED for self-harm. INTERVENTIONS: Extension of the LPS' working hours from 9:00 to 17:00, Monday to Friday to 8:00 to 22:00, 7 days a week, following a £250 000 annual investment MAIN OUTCOME MEASURES: Number and characteristics of ED attendances for self-harm. The before and after cohorts were compared in terms of key process measures, including proportion of patients receiving a psychosocial assessment, average length of hospital stay, waiting times for assessment, proportion of patients who self-discharged without an assessment, levels of repeat self-harm attendances and mean cost per patient attendance. RESULTS: 298 patients attended ED for self-harm on 373 occasions between January and March 2014, and 318 patients attended on 381 occasions between January and March 2015. The proportion of ED attendances where patients received a psychosocial assessment increased from 57% to 68% (p=0.003), median waiting time decreased by 3 hours and 14 min (p=0.017), and the proportion of episodes where patients self-discharged without a psychosocial assessment decreased from 20% to 13% (p=0.022). The mean cost per patient attendance was marginally lower after the intervention (-£84; 95% CI -£254 to £77). CONCLUSIONS: The extended LPS seems to have had a favourable effect on the management and outcomes of self-harm patients. The cost of extending the LPS' working hours might be partially offset by more efficient assessment and discharge. The impact of the extended LPS on the care of hospitalised patients with mental health problems other than self-harm requires further evaluation.

Stock Market Fluctuations and Self-Harm among Children and Adolescents in Hong Kong.

Although a few studies investigated the impact of stock market fluctuations on population health, the question of whether stock market fluctuations have an impact on self-harm in children and adolescents remain unanswered. This study therefore investigated the association between stock market fluctuations and self-harm among children and adolescents in Hong Kong. Daily self-harm attendance records were retrieved from all 18 local Accident and Emergency Departments (AED) from 2001 to 2012. 4931 children and adolescents who committed self-harm were included. The results indicated positive correlation between daily change in stock market index, Hang Seng Index (∇HSI, per 300 points), and daily self-harm incident risk of children and adolescents, without time lag between the two. The incident risk ratio for ∇HSI was 1.09 (p = 0.0339) in children and 1.06 (p = 0.0246) in adolescents. Importantly, non-trading days were found to impose significant protective effect in both groups against self-harm risk. Our results showed that stock market fluctuations were related to self-harm behaviors in children and adolescents. Parents and professionals should be educated about the potential harm of stock market fluctuations and the importance of effective parenting in reducing self-harm among children and adolescents.

Application of a Modified Garbage Code Algorithm to Estimate Cause-Specific Mortality and Years of Life Lost in Korea.

Years of life lost (YLLs) are estimated based on mortality and cause of death (CoD); therefore, it is necessary to accurately calculate CoD to estimate the burden of disease. The garbage code algorithm was developed by the Global Burden of Disease (GBD) Study to redistribute inaccurate CoD and enhance the validity of CoD estimation. This study aimed to estimate cause-specific mortality rates and YLLs in Korea by applying a modified garbage code algorithm. CoD data for 2010-2012 were used to calculate the number of deaths. The garbage code algorithm was then applied to calculate target cause (i.e., valid CoD) and adjusted CoD using the garbage code redistribution. The results showed that garbage code deaths accounted for approximately 25% of all CoD during 2010-2012. In 2012, lung cancer contributed the most to cause-specific death according to the Statistics Korea. However, when CoD was adjusted using the garbage code redistribution, ischemic heart disease was the most common CoD. Furthermore, before garbage code redistribution, self-harm contributed the most YLLs followed by lung cancer and liver cancer; however, after application of the garbage code redistribution, though self-harm was the most common leading cause of YLL, it is followed by ischemic heart disease and lung cancer. Our results showed that garbage code deaths accounted for a substantial amount of mortality and YLLs. The results may enhance our knowledge of burden of disease and help prioritize intervention settings by changing the relative importance of burden of disease.

The Influence of Posttraumatic Stress Disorder on Treatment Outcomes of Patients With Borderline Personality Disorder.

The aim of this study was to determine the influence of posttraumatic stress disorder (PTSD) on treatment outcomes in patients with borderline personality disorder (BPD). Participants were 180 individuals diagnosed with BPD enrolled in a randomized controlled trial that compared the clinical and cost effectiveness of dialectical behavior therapy (DBT) and general psychiatric management (GPM). Multilevel linear models and generalized linear models were used to compare clinical outcomes of BPD patients with and without PTSD. BPD patients with comorbid PTSD reported significantly higher levels of global psychological distress at baseline and end of treatment compared to their non-PTSD counterparts. Both groups evidenced comparable rates of change on suicide attempts and non-suicidal self-injury (NSSI), global psychological distress, and BPD symptoms over the course of treatment and post-treatment follow-up. DBT and GPM were effective for BPD patients with and without PTSD across a broad range of outcomes.

Epidemiology and financial implications of self-inflicted burns.

INTRODUCTION: The cost of the treatment of burns is high especially in self-inflicted burns with prolonged treatment. We performed a retrospective review of the self-inflicted burns at our regional burns centre to determine the costs incurred in their management and to identify factors which could reduce the financial burden in the future. METHODS: The data was collected retrospectively of all the inpatient and outpatient self-inflicted burns presenting to our regional burns centre in the year 2011. RESULTS: Twenty one patients (out of a total of 870 patients) presented with self-inflicted burns to our centre in 2011. Five (23.8%) were major burns with an average of 53.2% Total Body Surface Area (TBSA) and 16 (76.2%) were minor burns with an average of 0.5% TBSA. 11 (52.4%) patients had flame burns including 4 self-immolation burns. The mortality rate was 4.8% (n=1). Five (23.8%) patients underwent surgical treatment. Seven (33.3%) patients were treated in intensive care and with average stay of 46.85 days. Critical care and theatre attendances made up most of the costs with average ICU stay per patient calculated at £313,131/day. The total cost of all 21 patients was £1,581,856. CONCLUSION: Burns are preventable injuries, early detection and intervention in patients with propensity to self-inflict burns can possibly reduce the costs of treatment in the future.