Support for primary care prescribing for adult ADHD in England: national survey.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with effective pharmacological treatments that improve symptoms and reduce complications. NICE guidelines recommend primary care practitioners prescribe medication for adult ADHD under shared care agreements with adult mental health services (AMHS). However, provision remains uneven, with some practitioners reporting a lack of support. AIM: This study aimed to describe supportive elements (prescribing, shared care, AMHS availability) of primary care prescribing for adult ADHD medication in England, to inform service improvement and improve access for this underserved population. DESIGN AND SETTING: Three interlinked cross-sectional surveys asked every integrated care board (ICB) in England (Commissioners), and convenience samples of healthcare professionals (HP) and people with lived experience (LE), about elements supporting pharmacological treatment of ADHD in primary care. METHOD: Descriptive analyses used percentages and confidence intervals to summarise responses by stakeholder group. Variations in reported provision and practice were explored and displayed visually using mapping software. RESULTS: Data from 782 respondents (42 Commissioners; 331 HP; 409 LE) revealed differences in reported provision by stakeholder group, including for prescribing (94.6% of HP vs 62.6% of LE). Over 40% of respondents reported extended AMHS waiting times of two years or more. There was some variability by NHS region, for example London had highest rates of HP reported prescribing (100%), and lowest reported extended waiting times (25.0%). CONCLUSION: Elements supporting appropriate shared care prescribing of ADHD medication via primary care are not universally available in England. Co-ordinated approaches are needed to address these gaps.

Primary care provision for young people with ADHD: a multi-perspective qualitative study.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a highly prevalent neurodevelopmental disorder. UK guidance states that primary care has a vital role in effective ADHD management, including referral, medication prescribing and monitoring, and providing broader mental health and wellbeing support. However, many GPs feel unsupported to provide health care for young people with ADHD. Inadequate health care is associated with rising costs for patients and society. AIM: To investigate the experiences of young people with ADHD accessing primary care in England, from the perspectives of people with lived experience of ADHD and healthcare professionals (HCPs). DESIGN AND SETTING: A qualitative study. Interviews were conducted with HCPs (GPs, practice managers, and a wellbeing worker) and people with lived experience of ADHD (young people aged 16-25 years and their supporters) located in integrated care systems across England. METHOD: Semi-structured interviews were conducted with participants at five purposively selected general practices (varying by deprivation, ethnicity, and setting). Questions focused on experiences of accessing/providing health care for ADHD. Reflexive thematic analysis was undertaken within a critical realist framework to understand how provision works in practice and to explore potential improvements. RESULTS: In total, 20 interviews were completed with 11 HCPs and nine people with lived experience. Three themes were generated: a system under stress, incompatibility between ADHD and the healthcare system, and strategies for change in ADHD primary care provision. CONCLUSION: Standardisation of ADHD management in primary care, providing better information and support for HCPs, and advising on reasonable adjustments for people with lived experience could help improve access to effective treatments for young people living with ADHD.

Hospital-presenting self-harm among older adults living in Ireland: a 13-year trend analysis from the National Self-Harm Registry Ireland.

OBJECTIVES: To examine trends in rates of self-harm among emergency department (ED) presenting older adults in Ireland over a 13-year period. DESIGN: Population-based study using data from the National Self-Harm Registry Ireland. SETTING: National hospital EDs. PARTICIPANTS: Older adults aged 60 years and over presenting with self-harm to hospital EDs in Ireland between January 1, 2007 and December 31, 2019. MEASUREMENTS: ED self-harm presentations. RESULTS: Between 2007 and 2019, there were 6931 presentations of self-harm in older adults. The average annual self-harm rate was 57.8 per 100,000 among older adults aged 60 years and over. Female rates were 1.1 times higher compared to their male counterparts (61.4 vs 53.9 per 100,000). Throughout the study time frame, females aged 60-69 years had the highest rates (88.1 per 100,000), while females aged 80 years and over had the lowest rates (18.7 per 100,000). Intentional drug overdose was the most commonly used method (75.5%), and alcohol was involved in 30.3% of presentations. Between the austerity and recession years (2007-2012), self-harm presentations were 7% higher compared to 2013-2019 (incidence rate ratio (IRR): 1.07 95% CI 1.02-1.13, p = 0.01). CONCLUSIONS: Findings indicate that self-harm in older adults remains a concern with approximately 533 presentations per year in Ireland. While in younger age groups, females report higher rates of self-harm, this gender difference was reversed in the oldest age group (80 years and over), with higher rates of self-harm among males. Austerity/recession years (2007-2012) had significantly higher rates of self-harm compared to subsequent years.

Osteoporosis and fracture as risk factors for self-harm and suicide: a systematic review and meta-analysis.

BACKGROUND: Increase in presentations of self-harm to primary care, a risk factor of suicide, has led to a growing interest in identifying at-risk populations. AIM: To examine whether osteoporosis or fractures are risk factors for self-harm, suicidal ideation, and suicide. DESIGN AND SETTING: This was a systematic review of observational studies in adults (>18 years) that had examined the role of osteoporosis and/or fractures in subsequent self-harm, suicidal ideation, and/or suicide. METHOD: Six databases were searched from inception to July 2019. Additional citation tracking of eligible studies was undertaken in November 2022. Screening, data extraction, and quality assessment of full-text articles were performed independently by at least two authors. Where possible, meta-analysis was run on comparable risk estimates. RESULTS: Fifteen studies were included: two examined the outcome of self-harm, three suicidal ideation, and 10 suicide. In approximately half of studies on osteoporosis, the risk of suicidal ideation and suicide remained significant. However, pooling of adjusted odds ratios from three studies indicated no association between osteoporosis and suicide (1.14, 95% confidence interval = 0.88 to 1.49). Nine studies examined the risk of a mixture of fracture types across different outcomes, limiting comparisons. However, all studies examining vertebral fracture (n = 3) reported a significant adjusted negative association for self-harm and suicide. CONCLUSION: Patients with vertebral fractures, a risk potential factor for suicide, may benefit from clinical case finding for mood disorders with personalised primary care management. However, because of the limited number and quality of studies and mixed findings, further examination of these associations is warranted.

New guidance for self-harm: an opportunity not to be missed.

In this editorial we, as members of the 2022 NICE Guideline Committee, highlight and discuss what, in our view, are the key guideline recommendations (generated through evidence synthesis and consensus) for mental health professionals when caring for people after self-harm, and we consider some of the implementation challenges.

Protocol for the mixed methods, Managing young people (aged 16-25) with Attention deficit hyperactivity disorder in Primary care (MAP) study: mapping current practice and co-producing guidance to improve healthcare in an underserved population.

INTRODUCTION: Attention deficit hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder in children and adolescents, with an average worldwide prevalence of 5%. Up to 40% of young people continue to experience symptoms into adulthood. Young people with ADHD experience poorer outcomes than their peers across multiple domains, with treatment shown to reduce these risks. Primary care practitioners play an important role in healthcare provision for this group in the UK. However, many feel unsure about how best to provide support, reporting prescribing concerns and need for more evidence-based guidance. A lack of national data on primary care provision hinders efforts to improve access to care and optimise outcomes. This mixed-methods study aims to provide evidence that may be used to improve primary care services for young people aged 16-25 years with ADHD. METHODS AND ANALYSIS: There are three interlinked work packages: (a) a mapping study including a survey of stakeholders (healthcare professionals, people with ADHD and commissioners) will map ADHD prescribing practice, shared-care arrangements, available support and practitioner roles by geographic locations across England for different respondent groups; (b) a qualitative study involving semi-structured interviews with stakeholders (10-15 healthcare professionals and 10-15 people with ADHD) will explore experiences of 'what works' and 'what is needed' in terms of service provision and synthesise findings; (c) workshops will integrate findings from (a) and (b) and work with stakeholders to use this evidence to codevelop key messages and guidance to improve care. ETHICS AND DISSEMINATION: The protocol has been approved by Yorkshire and the Humber-Bradford Leeds Research Ethics Committee. Recruitment commenced in September 2022. Findings will be disseminated via research articles in peer-reviewed journals, conference presentations, public involvement events, patient groups and media releases. A summary of study findings will be shared with participants at the end of the study. TRIAL REGISTRATION NUMBER: NCT05518435.

Recent GP consultation before death by suicide in middle-aged males: a national consecutive case series study.

BACKGROUND: Reducing suicide risk in middle-aged males (40-54 years) is a national priority. People have often presented to their GP within 3 months before suicide thus highlighting an opportunity for early intervention. AIM: To describe the sociodemographic characteristics and identify antecedents in middle-aged males who recently consulted a GP before dying by suicide. DESIGN AND SETTING: This study was a descriptive examination of suicide in a national consecutive sample of middle-aged males in 2017 in England, Scotland, and Wales. METHOD: General population mortality data were obtained from the Office for National Statistics and National Records of Scotland. Information was collected about antecedents considered relevant to suicide from data sources. Logistic regression examined associations with final recent GP consultation. Males with lived experience were consulted during the study. RESULTS: In 2017, a quarter (n = 1516) of all suicide deaths were in middle-aged males. Data were attained on 242 males: 43% had their last GP consultation within 3 months of suicide; and a third of these males were unemployed and nearly half were living alone. Males who saw a GP recently before suicide were more likely to have had recent self-harm and work-related problems than males who had not. Having a current major physical illness, recent self-harm, presenting with a mental health problem, and recent work-related issues were associated with having a last GP consultation close to suicide. CONCLUSION: Clinical factors were identified that GPs should be alert to when assessing middle-aged males. Personalised holistic management may have a role in preventing suicide in these individuals.

The functions of self-harm in young people and their perspectives about future general practitioner-led care: A qualitative study.

BACKGROUND: Self-harm in young people is a serious concern but a deeper understanding of the functions of self-harm in young people can tailor care and inform new clinical interventions to reduce repeat self-harm and suicide risk. General practitioners (GPs), as frontline healthcare professionals, have an important role in managing self-harm in young people. This study aimed to explore the functions of self-harm in young people and their perspectives on future GP-led care. METHODS: A qualitative study using interviews with young people aged between 16 and 25 years with a personal history of self-harm was conducted. Interviews were transcribed and analysed using reflexive thematic analysis. FINDINGS: Four distinct functions were identified: (1) handling emotional states; (2) self-punishment; (3) coping with mental illness and trauma; and (4) positive thoughts and protection. Young people valued GP-led support and felt future GP interventions should include self-help and be personalised. CONCLUSIONS: These findings support clinicians, including GPs, to explore the functions of self-harm in young people aged 16-25 in a personalised approach to self-harm care. It should be noted that self-harm may serve more than one function for a young person and thus interventions should recognise this. PATIENT AND PUBLIC CONTRIBUTION: A group consisting of young people with lived experience of self-harm, carers, the public, and those who work with young people who harm themselves conceived this study idea, informed recruitment methods and the interview topic guide, and supported the interpretation of findings.

Social services utilisation and referrals after seeking help from health services for self-harm: a systematic review and narrative synthesis.

Objectives: Suicide prevention is a major public health challenge. Appropriate aftercare for self-harm is vital due to increased risks of suicide following self-harm. Many antecedents to self-harm involve social factors and there is strong rationale for social services-based self-harm aftercare. We aimed to review evidence for social service utilisation and referrals among people seeking help following self-harm. Design: Systematic review with narrative synthesis. Data sources: PubMed, PsycINFO, AMED, Social Policy and Practice, EMBASE, Medline, Web of Science, Social Care Online, citation lists of included articles and grey literature. Eligibility criteria: Studies of people of any age in contact with health services following self-harm, with study outcomes including referrals to or utilisation of social workers and social services. Data extraction and synthesis: Information was extracted from each included study using a proforma and quality was critically assessed by two reviewers. Narrative synthesis was used to review the evidence. Results: From a total of 3414 studies retrieved, 10 reports of 7 studies were included. Study quality was generally high to moderate. All studies were based in emergency departments (EDs) and most were UK based. In studies based solely on ED data, low proportions were referred to social services (in most studies, 1%-4%, though it was up to 44% when social workers were involved in ED assessments). In one study using linked data, 15% (62/427) were referred to social services and 21% (466/2,205) attended social services over the subsequent 3-year period. Conclusions: Overall, few patients were referred to social services after self-harm. Higher reported referral rates may reflect greater service availability, involvement of social workers in psychosocial assessments or better capture of referral activity. Social services-based and integrated approaches for self-harm aftercare are important future directions for suicide prevention. Improved links between social services and health services for people seeking support after self-harm are recommended.

Has the COVID-19 pandemic influenced suicide rates differentially according to socioeconomic indices and ethnicity? More evidence is needed globally.

The COVID-19 pandemic has harmed many people's mental health globally. Whilst the evidence generated thus far from high-income countries regarding the pandemic's impact on suicide rates is generally reassuring, we know little about its influence on this outcome in lower- and middle-income countries or among marginalised and disadvantaged people. There are some signals for concern regarding the pandemic's potentially unequal impact on suicide rates, with some of the affected demographic subgroups and regions being at elevated risk before the pandemic began. However, the evidence-base for this topic is currently sparse, and studies conducted to date have generally not taken account of pre-pandemic temporal trends. The collection of accurate, complete and comparable data on suicide rate trends in ethnic minority and low-income groups should be prioritised. The vulnerability of low-income groups will likely be exacerbated further by the current energy supply and cost-of-living crises in many countries. It is therefore crucial that reassuring messaging highlighting the stability of suicide rates during the pandemic does not lead to complacency among policymakers.

Supporting general practitioners in the assessment and management of suicide risk in young people: an evaluation of an educational resource in primary care.

AIM: To conduct a local evaluation of the use of the educational resource: Suicide in Children and Young People: Tips for GPs, in practice and its impact on General Practitioners (GPs)' clinical decision making. BACKGROUND: This Royal College of General Practitioners (RCGP) resource was developed to support GPs in the assessment and management of suicide risk in young people. METHOD: The dissemination of the educational resource took place over a nine month period (February 2018-October 2018) across two Clinical Commissioning Groups in West Midlands. Subsequently, a survey questionnaire on GPs' experiences of using the resource was sent to GPs in both Clinical Commissioning Groups (CCGs). FINDINGS: Sixty-two GPs completed the survey: 21% reported that they had used the resource; most commonly for: (1) information; (2) assessing a young person; and (3) signposting themselves and young people to relevant resources. Five out of thirteen GPs (38.5%), who responded to the question about whether the resource had an impact on their clinical decision making, reported that it did; four (30.7%) responded that it did not; and four (30.7%) did not answer this question. Twenty out of thirty-two GPs (62.5%) agreed that suicide prevention training should be part of their NHS revalidation cycle. The generalizability of the findings is limited by the small sample size and possible response and social desirability bias. The survey questionnaire was not validated. Despite the limitations, this work can be useful in informing a future large-scale evaluation of the RCGP online resource to identify barriers and facilitators to its implementation.

Harm minimisation for self-harm: a cross-sectional survey of British clinicians' perspectives and practices.

OBJECTIVE: Harm minimisation for self-harm is an alternative to preventive strategies and focuses on maximising safety when self-harming. We explored the views of clinicians on harm minimisation for self-harm to describe reported use and acceptability in clinical practice. DESIGN: A cross-sectional study using an online survey consisting of fixed-choice and open-ended questions. SETTING: Primary and secondary care practices in England, Scotland and Wales. PARTICIPANTS: Snowball sampling of UK-based clinicians (n=90; 67% female) working with people who self-harm and who have or have not previously recommended harm minimisation methods to patients. RESULTS: Of the 90 clinicians sampled, 76 (84%) reported having recommended harm minimisation techniques to people in their care who self-harm. Commonly recommended techniques were snapping rubber bands on one's wrist and squeezing ice. Other techniques, such as teaching use of clean instruments when self-harming, were less likely to be recommended. Perceived client benefits included harm reduction and promotion of the therapeutic relationship. Perceived potential limitations of a harm minimisation approach for self-harm were (a) potential worsening of self-harm outcomes; (b) ethical reservations; (c) doubts about its effectiveness and appropriateness; and (d) lack of training and clear policies within the workplace. CONCLUSIONS: In our sample of UK-based clinicians in various settings, harm minimisation for self-harm was broadly recommended for clients who self-harm due to perceived client benefits. However, future policies on harm minimisation must address clinicians' perceived needs for training, well-defined guidelines, and clear evidence of effectiveness and safety to mitigate some clinician concerns about the potential for further harm.