Risk of suicide in patients who present to hospital after self-cutting according to site of injury: findings from the Multicentre Study of Self-harm in England.

BACKGROUND: We compared the risk of death by suicide following hospital presentation for self-harm according to site of self-cut/stab. METHOD: We included 54 999 self-harm presentations (involving 31 419 individuals) to hospitals in the Multicentre Study of Self-harm in England (1/1/2004-31/12/2014), with mortality follow-up to 31/12/2019. Information on method of self-harm was obtained through monitoring in hospitals. Information about mortality was obtained through linkage with NHS Digital. We assessed the association of site of self-cut with death by suicide using mixed effect models. RESULTS: In total, 10 790 (19.6%) hospital presentations involved self-cutting/stabbing, 7489 of which (69.4%) were due to laceration to the arm/wrist alone, 1846 episodes (17.1%) involved cutting elsewhere on the body, and 1455 (13.5%) were due to laceration to unknown site. Controlling for confounders, presentation to a hospital following self-cut/stab to bodily parts other than wrist/arm was associated with greater chance of subsequent suicide relative to presentation after self-poisoning alone [adjusted odds ratio (aOR) 1.75, 95% confidence interval (CI) 1.03-2.96, p = 0.038]. The likelihood of suicide after presentation for cutting/stabbing the wrist/arm alone was comparable to that of patients who had self-poisoned alone. Presentations after laceration involving the neck were associated with a four-fold greater chance of subsequent suicide relative to self-poisoning (aOR 4.09, 95% CI 1.80-9.30, p = 0.001). CONCLUSIONS: Patients who attend hospital after self-cutting/stabbing are a heterogeneous group in terms of characteristics, methods of cutting/stabbing and risk of subsequent suicide. Risk of suicide is greater in individuals who self-cut/stab to parts of the body other than the wrist or arm, especially the neck.

Socio-economic disparities in patients who present to hospital for self-harm: patients' characteristics and problems in the Multicentre Study of Self-harm in England.

BACKGROUND: We examined disparities in sociodemographic and clinical characteristics and in problems preceding self-harm across levels of socio-economic deprivation (SED) in persons who presented to hospital for self-harm. METHOD: 108,092 presentations to hospitals (by 57,306 individuals) following self-harm in the Multicentre Study of Self-harm in England (1/1/2000-31/12/2016). Information on area-level SED was based on the English Index of Multiple Deprivation. Information about patients' characteristics and problems was obtained from self-harm monitoring systems in the hospitals. We assessed the association of SED with the characteristics of interest using descriptive statistics. RESULTS: Overall, 45 % of the presentations were by individuals from areas ranked nationally as most deprived, while 13 % of episodes were by individuals from the least deprived areas. Males and non-white ethnic groups were over-represented in the most deprived SED stratum. Previous self-harm was more prevalent in the two most deprived groups. Relationships difficulties with partners and other family members were reported more commonly by individuals from less socio-economically deprived areas, as were problems pertaining to finances and employment or studies. Problems in relationships with friends were more prevalent in the most deprived group relative to other groups. LIMITATIONS: Information about problems which preceded self-harm was available only for patients who received psychosocial assessment. CONCLUSIONS: Patients vary considerably across area-level SED strata in terms of gender, ethnicity, and the problems which preceded their self-harm. These findings emphasise the need to use an individualised approach to patients in understanding the unique circumstances which contribute to their self-harm and their specific care needs.

Life problems in children and adolescents who self-harm: findings from the multicentre study of self-harm in England.

BACKGROUND: Self-harm, a significant and increasing global problem in children and adolescents, is often repeated and is associated with risk of future suicide. To identify potential interventions, we need to understand the life problems faced by children and adolescents, and by sub-groups of younger people who self-harm. Our aims were to include the following: (a) investigate the type and frequency of life problems in a large sample of children and adolescents who self-harmed. (b) Examine whether problems differ between those who repeat self-harm and those who do not. METHODS: We analysed data for 2000 to 2013 (follow up until 2014) from the Multicentre Study of Self-harm in England on individuals aged 11 to 18 years who presented to one of the five study hospitals following self-harm and received a psychosocial assessment including questions about problems, which precipitated self-harm. RESULTS: In 5648 patients (12,261 self-harm episodes), (75.5% female, mean age 16.1 years) the most frequently reported problems at first episode of self-harm were family problems. Problems around study/employment/study and relationships with friends also featured prominently. The types of problems that precede self-harm differed between late childhood/early adolescence. Abuse, mental health problems and legal problems significantly predicted repeat self-harm for females. CONCLUSION: The most common problems reported by both genders were social/interpersonal in nature, indicating the need for relevant services embedded in the community (e.g. in schools/colleges). Self-harm assessment and treatment choices for children and adolescents must take age and gender into account. To prevent future self-harm, individualised supports and services are particularly needed for abuse, mental health and legal problems.

Self-harm during the early period of the COVID-19 pandemic in England: Comparative trend analysis of hospital presentations.

BACKGROUND: The COVID-19 pandemic and public health measures necessary to address it may have major effects on mental health, including on self-harm. We have used well-established monitoring systems in two hospitals in England to investigate trends in self-harm presentations to hospitals during the early period of the pandemic. METHOD: Data collected in Oxford and Derby on patients aged 18 years and over who received a psychosocial assessment after presenting to the emergency departments following self-harm were used to compare trends during the three-month period following lockdown in the UK (23rd March 2020) to the period preceding lockdown and the equivalent period in 2019. RESULTS: During the 12 weeks following introduction of lockdown restrictions there was a large reduction in the number of self-harm presentations to hospitals by individuals aged 18 years and over compared to the pre-lockdown weeks in 2020 (mean weekly reduction of 13.5 (95% CI 5.6 - 21.4) and the equivalent period in 2019 (mean weekly reduction of 18.0 (95% CI 13.9 - 22.1). The reduction was greater in females than males, occurred in all age groups, with a larger reduction in presentations following self-poisoning than self-injury. CONCLUSIONS: A substantial decline in hospital presentations for self-harm occurred during the three months following the introduction of lockdown restrictions. Reasons could include a reduction in self-harm at the community level and individuals avoiding presenting to hospital following self-harm. Longer-term monitoring of self-harm behaviour during the pandemic is essential, together with efforts to encourage help-seeking and the modification of care provision.

Self-harm on roads: Register-based study of methods and characteristics of individuals involved.

BACKGROUND: Suicide on roads is receiving increased attention. However, there has been little research on non-fatal road-related self-harm. This study was conducted in order to investigate the characteristics of such acts. METHOD: Information on non-fatal road self-harm was extracted from a self-harm monitoring system database of self-harm presentations to a major general hospital in England during 2005-2017. Patients were identified through being referred for psychosocial assessment by a clinical service and through scrutiny of medical records. RESULTS: During the 13-year study period 110 individuals (67 males, 43 females) presented to the hospital with road-related self-harm: 38 (34.5%) jumped from bridges, 34 (30.9%) jumped or lay in front of vehicles, 27 (24.5%) crashed vehicles and 11 (10.0%) jumped from moving vehicles. Crashing vehicles was more common in males and jumping from vehicles more common in females. In patients who received a psychosocial assessment, their most frequent problems were with a partner, employment and family members. Over half had been in psychiatric care and nearly two-thirds had a history of previous self-harm. Suicide intent was often high, especially in those who crashed a vehicle or jumped from a bridge. LIMITATION: The study was based on presentations to a single hospital. Some data were not available for non-assessed patients. CONCLUSIONS: Road-related self-harm, while not common, more frequently involves males and the acts are often of high suicidal intent. The range of problems preceding this method of self-harm indicates that there needs to be a variety of aftercare interventions, adapted to each individual's situation.

Paracetamol self-poisoning: Epidemiological study of trends and patient characteristics from the multicentre study of self-harm in England.

BACKGROUND: Paracetamol is frequently used for intentional self-poisoning, especially in the UK, despite pack size restrictions introduced in 1998. Knowing more about paracetamol self-poisoning may identify further approaches to prevention. METHODS: We used data from the Multicentre Study of Self-harm in England for 2004-2014 to calculate incidence rates of presentations to Emergency Departments following self-poisoning with pure paracetamol alone. National estimates for England for 2011-2014 were extrapolated using indirect age-standardised rates. The characteristics of individuals taking paracetamol overdoses and the size of the overdoses were investigated. RESULTS: A third of 54,863 intentional overdoses presenting to the five Emergency Departments involved paracetamol without other drugs (N = 18,011), taken by 13,171 individuals (63.4% female).  The proportion of paracetamol self-poisonings was similar in the three centres. Extrapolation suggested there were approximately 50,000 paracetamol overdoses in England annually during 2011-2014. Females had higher rates of paracetamol overdose than males.  Males and older individuals took larger overdoses.  Nearly a quarter of individuals (24.2%) consumed more than 32 tablets. Alcohol was involved in 53.7% of paracetamol overdoses. LIMITATIONS: Data were collected in three centres with predominantly urban populations. Extrapolation from local to national rates should be interpreted with caution. CONCLUSIONS: Paracetamol overdose remains a major problem in the UK. It is more common in females and younger patients, but males and older patients consume larger overdoses. Consideration should be given to further restriction in pack sizes and sources of sales, in keeping with those of several other European countries.

Comparing short-term risk of repeat self-harm after psychosocial assessment of patients who self-harm by psychiatrists or psychiatric nurses in a general hospital: Cohort study.

BACKGROUND: There is mixed evidence for whether psychosocial assessment following hospital presentation for self-harm reduces self-harm repetition. A possible reason is the differences in professional background of assessors (primarily psychiatrists and psychiatric nurses) due to variability in training and therapist style. METHODS: Using data from the Oxford Monitoring System for Self-harm, we analysed data on patients making their first emergency department (ED) presentation for self-harm between 2000 and 2014, followed-up until 2015. Using logistic regression, we estimated the probability of repeat self-harm within 12 months, comparing: (i) patients receiving psychosocial assessment versus none, adjusting for age, gender, self-harm method, past self-harm presentation, and general hospital admission; and (ii) patients assessed by a psychiatric nurse versus those assessed by a psychiatrist, adjusting for age, self-harm method, time and year of presentation. RESULTS: The 12,652 patients who had an index ED presentation for self-harm during the study period accounted for 24,450 presentations, in 17,303 (71%) of which a psychosocial assessment was conducted; in 9318 (54%) by a psychiatric nurse and in 7692 (45%) by a psychiatrist. We found a reduced probability of repeat self-harm presentation among patients receiving psychosocial assessment versus none (adjusted odds ratio [AOR] = 0.70; 95% CI = 0.65-0.75; p < 0.001), but no differences between patients assessed by a psychiatric nurse or a psychiatrist (AOR = 1.05; 95% CI = 0.98-1.13; p = 0.129). LIMITATIONS: Findings from a single hospital may not be generalizable to other settings. CONCLUSIONS: Short-term risk of repeat self-harm after psychosocial assessment for self-harm may not differ by the assessor's professional background.

Medication use in people with late stage Parkinson's disease and parkinsonism living at home and in institutional care in north-east England: A balance of symptoms and side-effects?

BACKGROUND: People with Parkinson's disease (PD) and parkinsonism living in care homes (residential or nursing care) in the UK represent around 10-15% of all people with PD and 3-5% of all care home residents. There are few previous data on medication use in those living in care homes with PD. In this study we aimed to compare medication use in a representative cohort of people with PD living in care homes in north-east England with those living in their own homes. METHOD: All people with late stage (Hoehn and Yahr III-V) idiopathic PD, PD dementia, or atypical parkinsonian syndromes under the care of the Northumbria Healthcare NHS Foundation Trust PD service on 1st January 2015 were identified. Demographic, disease characteristics and medication use data were collected from an audit of medical notes of all those identified. RESULTS: We identified 377 people who met the inclusion criteria, 91 (24.1%) of whom were living in a care home. Disease stage, age and age at disease onset were all significantly higher and levodopa equivalent dose significantly lower in those living in care homes, although disease duration and levodopa dose were not. Greater age, lower levodopa equivalent dose and higher disease stage were independently associated with being in a care home. CONCLUSIONS: Although people in care homes had more advanced disease, they were on a significantly lower levodopa equivalent dose. This is likely to be due to the requirement to balance symptom management with drug side-effects.

Alcohol dependence, excessive drinking and deliberate self-harm: trends and patterns in Oxford, 1989-2002.

BACKGROUND: Problems relating to alcohol use are very common among deliberate self-harm (DSH) patients, and alcohol abuse increases the risk of both DSH and suicide. In the UK, per capita consumption of alcohol has risen by 50% since 1970. The proportion of women (but not men) drinking in excess of government-recommended limits has also increased. We investigate trends, by gender and age group, in alcohol problems and usage among DSH patients. METHOD: Data collected by the Oxford Monitoring System for Attempted Suicide were used to examine trends in alcohol disorders and alcohol consumption shortly before, or at, the time of self-harm by patients aged 15 years or over between 1989 and 2002. RESULTS: Data were available on 10,414 patients who were involved in 17,511 episodes of DSH. The annual numbers of both male and female DSH patients rose progressively over the study period. Although rates of alcohol disorders and consumption remained higher in males than females, substantial increases were seen in females of all ages in rates of alcohol problems, excessive drinking and consumption of alcohol within 6 h of DSH and as part of the act of DSH. Rates for males largely remained unchanged. CONCLUSIONS: There has been a significant increase in excessive drinking and consumption of alcohol around the time of DSH by females but not males. These changes may relate to increases in the affordability and availability of alcohol and to social changes in drinking patterns. They have implications for services for DSH patients and may have an impact on future patterns of suicidal behaviour.

Self-cutting: patient characteristics compared with self-poisoners.

A large ( n = 14,892) consecutive sample of deliberate self-harm (attempted suicide) patients who presented to a general hospital in the United Kingdom during a 23-year study period was examined (over two consecutive time periods) in order to compare the characteristics of those who used self-cutting ( n = 428) and those who self-poisoned ( n = 11,065). Patients who used different methods on other occasions, or were not assessed by the psychiatric service, were excluded. In the first time period (January 1976-June 1988), the self-cutters were distinguished from the self-poisoners by more often being male, single, not employed, and having a history of previous deliberate self-harm. In the second time period (July 1988-December 1998) the self-cutters were again distinguished by more often being male and having a history of previous deliberate self-harm, but also by being more likely to live alone, misuse alcohol, and have low suicidal intent scores. The finding of an excess of males among the self-cutters is contrary to the impression in the literature that self-cutting presentations to general hospitals more often involve females. It also indicates that the treatment needs of those who deliberately cut themselves are likely to differ from those of self-poisoners.