How can general practitioners help young people avoid future self-harm? a qualitative study.

Background Self-harm is a growing problem in young people. General practitioners (GPs) are usually the first point of healthcare contact for young people aged 16-25 years after self-harm. GPs can experience barriers to supporting young people and behaviour change theory can help to understand these barriers, and the influences on GP behaviour. Aim To explore and understand the capabilities, opportunities, and motivations (COM-B) of GPs, and their perceived training needs, to help young people aged 16-25 years avoid future self-harm. Design and setting A qualitative study in NHS general practice in England Method Semi-structured interviews were conducted with GPs and purposive sampling used to aim for a diverse sample. Interviews occurred in 2021. Data were analysed using reflexive thematic analysis and mapped onto COM-B model. The study patient and public involvement and community of practice groups supported data analysis. Results Fifteen interviews were completed (mean duration - 38 minutes). GPs described mixed capabilities, with many feeling they had the physical and psychological skills to support young people to avoid future self-harm, but some felt doing so was emotionally tiring. GPs identified opportunities to better support young people such as use of electronic consultation tools but cited lack of time as a concern. GPs reported motivation to help young people, but this was influenced by their daily workload. Unmet training needs around communication, knowledge, and optimising safety were identified. Conclusion Future GP-led interventions need to improve the capabilities, opportunities, and motivations of GPs to support young people to avoid future self-harm.

Reducing self-harm in adolescents: the RISA-IPD individual patient data meta-analysis and systematic review.

Background: Self-harm is common in adolescents and a major public health concern. Evidence for effective interventions is lacking. An individual patient data meta-analysis has the potential to provide more reliable estimates of the effects of therapeutic interventions for self-harm than conventional meta-analyses, to explore which treatments are best suited to certain groups. Method: A systematic review and individual patient data meta-analysis of randomised controlled trials of therapeutic interventions to reduce repeat self-harm in adolescents who had a history of self-harm and presented to clinical services. Primary outcome was repetition of self-harm. The methods employed for searches, study screening and selection, and risk of bias assessment are described, with an overview of the outputs of the searching, selection and quality assessment processes. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance is followed. Results: We identified a total 39 eligible studies, from 10 countries, where we sought Individual Patient Data (IPD), of which the full sample of participants were eligible in 18 studies and a partial sample of participants were eligible in 21 studies. We obtained IPD from 26 studies of 3448 eligible participants. For our primary outcome, repetition of self-harm, only 6 studies were rated as low risk of bias with 10 rated as high risk (although 2 of these were for secondary outcomes only). Conclusions: Obtaining individual patient data for meta-analyses is possible but very time-consuming, despite clear guidance from funding bodies that researchers should share their data appropriately. More attention needs to be paid to seeking appropriate consent from study participants for (pseudo) anonymised data-sharing and institutions need to collaborate on agreeing template data-sharing agreements. Researchers and funders need to consider issues of research design more carefully. Our next step is to analyse all the data we have collected to see if it will tell us more about how we might prevent repetition of self-harm in young people. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/117/11. A plain language summary of this research article is available on the NIHR Journals Library Website https://doi.org/10.3310/GTNT6331.

Self-harm is very common in young people and leads to an increased risk of death by suicide. Research so far has not provided clear evidence about which interventions can help to prevent self-harm repetition when young people present to services having harmed themselves. One way to understand what might help is to pool the results from lots of different clinical trials ­ this is known as a meta-analysis. This has already been done using the data published in research articles but has not led to clearer conclusions. In part this is because the information available in published articles is patchy and inconsistent which makes pooling the information and analysing it, difficult. A more useful approach is to ask researchers who led the clinical trials for their original 'raw' data and then pool and analyse all that data ­ this is known as an individual patient data meta-analysis. This has the added benefit that it is possible to include studies where only some of the participants are young people. We did this, and were able to identify many more study participants along with their data, compared to earlier meta-analyses. In this article, we describe how we searched for relevant research studies and the methods we used to obtain individual patient data from other researchers. We also describe our rating of the research quality of the studies we identified. We identified more studies, with many more participants in total, than in previous pooled study research. Gathering the data from other researchers was very time-consuming and not everyone was willing or able to share their data. When we rated the quality of the studies that we found, many were not of high quality. Our next step is to analyse all the data we have collected to see if it will tell us more about how we might prevent repetition of self-harm in young people.

Healthcare practitioners' views of self-harm management practices in older adults in Ireland: A qualitative study.

OBJECTIVES: To explore healthcare practitioners' views on management practices of self-harm in older adults. METHODS: Semi-structured interviews were conducted with healthcare practitioners, including consultant psychiatrists, general practitioners, clinical psychologists, psychotherapists, clinical nurse specialists and social workers. Purposeful sampling was used to recruit participants in the Republic of Ireland ensuring diverse perspectives of healthcare practitioners were included. Healthcare practitioners were recruited advertising via professional and clinical research networks, social media, and snowballing methods. Interviews were audio-recorded, transcribed verbatim, and analysed using reflexive thematic analysis. RESULTS: We conducted interviews with 20 healthcare practitioners from April to July 2023. Three main themes were generated: first, a perceived greater risk of suicide, and increased awareness of complexity in older adults' self-harm presentations. Second, integrated care as an avenue for improving the management of self-harm in older adults. Third, the importance of safety planning in risk assessments of older adults. CONCLUSIONS: Healthcare practitioners viewed self-harm in older adults as complex, challenging, and associated with high suicide risk, approaching patients with care and caution. The need for integrated support and improved collaboration between relevant healthcare practitioners was identified. Suggestions were made for primary care having a lead role in identifying and managing older adults after self-harm. Increased mental health promotion and awareness of mental health and self-harm in this age group would help address current stigma and shame.

Primary care contact, clinical management and suicide risk following discharge from inpatient mental health care.

BACKGROUND: Evidence is sparse regarding service usage and the clinical management of people recently discharged from inpatient psychiatric care who die by suicide. AIM: To improve understanding of how people discharged from inpatient mental health care are supported by primary care during this high-risk transition. DESIGN & SETTING: A nested case-control study utilising interlinked primary and secondary care records in England for people who died within a year of discharge between 2001 and 2019, matched on age, sex, practice-level deprivation and region with up to 20 living discharged people. METHOD: We described patterns of consultation, prescription of psychotropic medication and continuity of care for people who died by suicide and those who survived. Mutually adjusted relative risk estimates were generated for a range of primary care and clinical variables. RESULTS: Over 40% of patients who died within 2 weeks and 80% who died later had at least one primary care consultation. Evidence of discharge communication from hospital was infrequent. Within-practice continuity of care was relatively high. Those who died by suicide were less likely to consult within two weeks of discharge, AOR 0.61 (0.42-0.89), more likely to consult in the week before death, AOR 1.71 (1.36-2.15), to be prescribed multiple types of psychotropic medication, (AOR 1.73, 1.28-2.33), to experience readmission and have a diagnosis outside of the 'Severe Mental Illness' definition. CONCLUSION: Primary care clinicians have opportunities to intervene and should prioritise patients experiencing transition from inpatient care. Clear communication and liaison between services is essential to provide timely support.

Involvement of propranolol in suicides: cross-sectional study using coroner-reported data.

BACKGROUND: Propranolol is a beta-blocker medication indicated mostly for heart rhythm conditions and for physical symptoms of anxiety. Prescriptions for propranolol in the UK have increased since 2008. Recently, there have been concerns about the involvement of propranolol in intentional poisonings, but such deaths are not routinely reported. Therefore, use of coroner-reported and toxicology data enables unique investigation into the scale of involvement of propranolol in suicide. AIMS: To describe the extent to which propranolol is involved in suicides, including patterns over time and characteristics of people whose suicide involved propranolol compared with other suicides. METHOD: Data were derived from the National Programme on Substance Use Mortality (NPSUM). All suicides and deaths of undetermined intent between 2010 and 2021 in England, Wales and Northern Ireland were extracted, and a subset was identified where propranolol was involved in death. RESULTS: There were 4473 suicides of which 297 (6.6%) involved propranolol, with the proportion involving propranolol nearly quadrupling during the study period (3.4% v. 12.3%). Compared with all other suicides, a greater proportion of propranolol suicides were in women (56.6% v. 37.1%) and in people with diagnoses of depression (39.1% v. 27.1%) and anxiety (22.2% v. 8.6%). When suicide involved propranolol, an antidepressant was detected at post-mortem in 81.8% of deaths, most commonly a selective serotonin reuptake inhibitor (SSRIs) (51.5%), and most often citalopram (24.6%). CONCLUSIONS: A small number, but increasing proportion, of suicides reported to the NPSUM involve propranolol. Vigilance to the combined toxicity profile of medicines used alongside propranolol may be pertinent.

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.