Advancing early detection of suicide? A national study examining socio-demographic factors, antecedent stressors and long-term history of self-harm.

BACKGROUND: A range of factors including mental disorders, adverse events and history of self-harm are associated with suicide risk. Further examination is needed of the characteristics of suicides which occur without established risk factors, using national surveillance systems. METHODS: Data on all suicides in Ireland from 2015 to 2017 were drawn from the Irish Probable Suicide Deaths Study (IPSDS). Variables examined included socio-demographics, psychiatric history and precipitant stressors. Suicide data were linked with data on prior self-harm from the National Self-Harm Registry Ireland (NSHRI). Latent Class Analysis (LCA) was used to identify sub-groups of suicide cases. RESULTS: Of the 1809 individuals who died by suicide, 401 (22.2 %) had a history of hospital-treated self-harm. Four distinct profiles of suicides were identified. One group was marked by high levels of prior self-harm and mental health conditions. Two of the groups included few individuals with a history of self-harm but had notably high levels of mental health conditions. These two groups had relatively high levels of reported chronic pain or illness but differed in terms of socio-demographics. The final group, predominantly male, had markedly low levels of mental health conditions or self-harm but high levels of personal stressors and substance use. LIMITATIONS: The use of coronial data may be limited by bias in the collecting of information from the deceased's family members. CONCLUSIONS: A sub-group of suicide cases exists without any psychiatric or self-harm history but with salient occupational or health-related proximal stressors. Suicide prevention interventions should include occupational settings and should promote mental health literacy.

Evaluation of a national clinical programme for the management of self-harm in hospital emergency departments: impact on patient outcomes and the provision of care.

BACKGROUND: Emergency departments are important points of intervention, to reduce the risk of further self-harm and suicide. A national programme to standardise the management of people presenting to the emergency department with self-harm and suicidal ideation (NCPSHI) was introduced in Ireland in 2014. The aim of this study was to evaluate the impact of the NCPSHI on patient outcomes and provision of care. METHODS: Data on self-harm presentations were obtained from the National Self-Harm Registry Ireland from 2012 to 2017. The impacts of the NCPSHI on study outcomes (3-month self-harm repetition, biopsychosocial assessment provision, admission, post-discharge referral, and self-discharge) were examined at an individual and aggregate (hospital) level, using a before and after study design and interrupted time series analyses, respectively. The 15 hospitals that implemented the programme by January 2015 (of a total of 24 between 2015 and 2017) were included in the analyses. RESULTS: There were 31,970 self-harm presentations during the study period. In hospitals with no service for self-harm (n = 4), risk of patients not being assessed reduced from 31.8 to 24.7% following the introduction of the NCPSHI. Mental health referral in this hospital group increased from 42.2 to 59.0% and medical admission decreased from 27.5 to 24.3%. Signs of a reduction in self-harm repetition were observed for this hospital group, from 35.1 to 30.4% among individuals with a history of self-harm, but statistical evidence was weak. In hospitals with a pre-existing liaison psychiatry service (n = 7), risk of self-discharge was lower post-NCPSHI (17.8% vs. 14.8%). In hospitals with liaison nurse(s) pre-NCPSHI (n = 4), medical admission reduced (27.5% vs. 24.3%) and there was an increase in self-harm repetition (from 5.2 to 7.8%. for those without a self-harm history). CONCLUSION: The NCPSHI was associated with improvements in the provision of care across hospital groups, particularly those with no prior service for self-harm, highlighting the need to consider pre-existing context in implementation planning. Our evaluation emphasises the need for proper resourcing to support the implementation of clinical guidelines on the provision of care for people presenting to hospital with self-harm.

Real-Time Suicide Surveillance: Comparison of International Surveillance Systems and Recommended Best Practice.

OBJECTIVE: Some countries have implemented systems to monitor suicides in real-time. These systems differ because of the various ways in which suicides are identified and recorded. The main objective of this study was to conduct an international comparison of major real-time suicide mortality surveillance systems to identify joint strengths, challenges, and differences, and thereby inform best-practice criteria at local, national, and international levels. METHODS: Five major real-time suicide mortality surveillance systems of various coverage levels were identified and selected for review via an internet-based scoping exercise and prior knowledge of existing systems. Key information including the system components and practices was collated from those organizations that developed and operate each system using a structured template. The information was narratively and critically synthesized to determine similarities and differences between the systems. RESULTS: The comparative review of the five established real-time suicide surveillance systems revealed more commonalities than differences overall. Commonalities included rapid, routine surveillance based on minimal, provisional data to facilitate timely intervention and postvention efforts. Identified differences include the timeliness of case submission and system infrastructure. CONCLUSION: The recommended criteria could promote replicable components and practices in real-time suicide surveillance while offering flexibility in adapting to regional/local circumstances and resource availability.HIGHLIGHTSEvidence-informed recommendations for current best practice in real-time suicide surveillance.Proposed comprehensive framework can be adapted based on available resources and capacity.Real-time suicide mortality data facilitates rapid data-driven decision-making in suicide prevention.

Impact of female obesity and assisted reproduction on uncomplicated pregnancies and healthy births: a study of 428 336 births in Flanders.

STUDY QUESTION: What is the impact of BMI on uncomplicated pregnancies and healthy births in women who did or did not have medically assisted reproduction (MAR, i.e. ART or hormonal stimulation without manipulation of eggs or embryos) in the Flanders region (Belgium)? SUMMARY ANSWER: Women with a higher BMI who use MAR are at the highest risk of pregnancy and birth complications. WHAT WE KNOW ALREADY: Medically assisted reproduction (MAR) is used increasingly worldwide and is associated with increased risk of adverse perinatal outcomes. Obesity is also increasing globally and obese women are more likely to seek MAR since obesity is associated with infertility. When obese women undergo MAR, the risk of adverse outcomes may be enhanced but it is not clear to what extent. STUDY DESIGN, SIZE, DURATION: We conducted a registry-based study using the data from the Study Centre for Perinatal epidemiology database for years 2009-2015, region of Flanders, Belgium. This included 428 336 women. PARTICIPANTS/MATERIALS, SETTING, METHODS: The average age was 30.0 years (SD 4.78), 194 061 (45.31%) were nulliparous, and 6.3% (n = 26 971) conceived with MAR. We examined the association of BMI and MAR with the following composite primary outcomes: 'uncomplicated pregnancy and birth' and 'healthy baby'. We conducted Poisson regression and adjusted for maternal age, parity, gestational weight gain, smoking and previous caesarean section. MAIN RESULTS AND THE ROLE OF CHANCE: In our study, 36.80% (n = 157 623) of women had an uncomplicated pregnancy and birth according to the definition used. The predicted probability of having an uncomplicated pregnancy and birth for women with a BMI of 25 kg/m2 who conceived spontaneously was 0.33 (0.32 to 0.35), while it was 0.28 (0.24 to 0.32) for women who used hormonal stimulation and 0.26 (0.22 to 0.29) for women who used IVF/ICSI. This probability reduced with increasing BMI category for both MAR and non-MAR users. For women with a BMI of 30 kg/m2, the predicted probability of having an uncomplicated pregnancy and birth was 0.28 (0.26 to 0.30) for women who conceived spontaneously, and 0.22 (0.16 to 0.29) and 0.20 (0.14 to 0.26) for women who used hormonal stimulation only or IVF/ICSI, respectively. The predicted probability of having a healthy baby for women with a BMI of 25 kg/m2 who conceived spontaneously was 0.92 (0.91 to 0.93), 0.89 (0.87 to 0.92) for women who used hormonal stimulation only and 0.85 (0.84 to 0.87) for women who used IVF/ICSI. LIMITATIONS, REASONS FOR CAUTION: The database did not include data on socio-economic status, pre-pregnancy morbidities and paternal BMI. Subsequently, we could not adjust for these factors in the analysis. WIDER IMPLICATIONS OF THE FINDINGS: Obese women who use MAR are at the highest risk of pregnancy and birth complications. This increase in interventions also has cost and resource implications which is relevant for funding policies. Weight loss interventions prior to MAR seem plausible but their (cost-) effectiveness needs urgent investigation. STUDY FUNDING/COMPETING INTEREST(S): F.W. received an Erasmus Plus training grant to visit A.B., L.A. and R.D. and conducted this study during this visit. The authors have no competing interest to declare. TRIAL REGISTRATION NUMBER: N/A.

The development and validation of a dashboard prototype for real-time suicide mortality data.

Introduction/Aim: Data visualisation is key to informing data-driven decision-making, yet this is an underexplored area of suicide surveillance. By way of enhancing a real-time suicide surveillance system model, an interactive dashboard prototype has been developed to facilitate emerging cluster detection, risk profiling and trend observation, as well as to establish a formal data sharing connection with key stakeholders via an intuitive interface. Materials and Methods: Individual-level demographic and circumstantial data on cases of confirmed suicide and open verdicts meeting the criteria for suicide in County Cork 2008-2017 were analysed to validate the model. The retrospective and prospective space-time scan statistics based on a discrete Poisson model were employed via the R software environment using the "rsatscan" and "shiny" packages to conduct the space-time cluster analysis and deliver the mapping and graphic components encompassing the dashboard interface. Results: Using the best-fit parameters, the retrospective scan statistic returned several emerging non-significant clusters detected during the 10-year period, while the prospective approach demonstrated the predictive ability of the model. The outputs of the investigations are visually displayed using a geographical map of the identified clusters and a timeline of cluster occurrence. Discussion: The challenges of designing and implementing visualizations for suspected suicide data are presented through a discussion of the development of the dashboard prototype and the potential it holds for supporting real-time decision-making. Conclusions: The results demonstrate that integration of a cluster detection approach involving geo-visualisation techniques, space-time scan statistics and predictive modelling would facilitate prospective early detection of emerging clusters, at-risk populations, and locations of concern. The prototype demonstrates real-world applicability as a proactive monitoring tool for timely action in suicide prevention by facilitating informed planning and preparedness to respond to emerging suicide clusters and other concerning trends.

Maternal morbidity and mortality: an iceberg phenomenon.

OBJECTIVE: To apply the iceberg model, quantifying absolute and relative incidence, to the four main causes of maternal morbidity and mortality in Ireland: haemorrhage, hypertension, sepsis and thrombosis. DESIGN: Secondary analysis of national data on maternal morbidity and mortality. SETTING: Republic of Ireland. POPULATION OR SAMPLE: Approximately 715 000 maternities, 1 200 000 maternal hospitalisations, 2138 cases of severe maternal morbidity (SMM) and 54 maternal deaths. METHODS: Incidence rates and case-fatality ratios were calculated. MAIN OUTCOME MEASURES: Maternal death, SMM and hospitalisation. RESULTS: At the 'tip of the iceberg', the incidence of maternal death per 10 000 maternities was 0.09 (95% CI 0.03-0.20) due to thrombosis and 0.03 (95% CI 0-0.11) due to haemorrhage, hypertension disorders or sepsis. For one death due to thrombosis there were 35 cases of pulmonary embolism and 257 thrombosis hospitalisations. For one death due to eclampsia, there were 58 eclampsia cases, 13 040 hospitalisations with pre-existing hypertension and 40 781 hospitalisations with gestational hypertension. For one death due to pregnancy-related sepsis, there were 92 cases of septicaemic shock and 9005 hospitalisations with obstetric sepsis. For one maternal death due to haemorrhage, there were 1029 cases of major obstetric haemorrhage and 53 715 maternal hospitalisations with haemorrhage. For every 100 maternities, there were approximately 16 hospitalisations associated with haemorrhage, 12 associated with hypertension disorders, three with sepsis and 0.2 with thrombosis. CONCLUSIONS: Haemorrhage and hypertension disorders are leading causes of maternal morbidity in Ireland but they have very low case fatality. This indicates that these morbidities are managed effectively but their prevention requires more focus. TWEETABLE ABSTRACT: Study shows that haemorrhage and hypertension are main causes of #maternalmorbidity in Ireland. Timely interventions for #maternalhealth and focus on prevention of severe and non-severe morbidities are needed. @NPEC #maternityservices #clinicalaudit #qualityimprovement.

Real-time suicide surveillance supporting policy and practice.

Suicide mortality rates are a strong indicator of population mental-health and can be used to determine the efficacy of prevention measures. Monitoring suicide mortality rates in real-time provides an evidence-base to inform targeted interventions in a timely manner and accelerate suicide prevention responses. This paper outlines the importance of real-time suicide surveillance in the context of policy and practice, with a particular focus on public health and humanitarian crises.

Medicine, media and the law: The effect on training in obstetrics and gynaecology.

The inextricable link between medicine and the legal profession has flourished in the 21st century, with countless newspaper articles and social media content on medical cases visible at every juncture. This is particularly true in the speciality of obstetrics and gynaecology, with one of the highest rates of litigation of all medical specialities. We aimed to evaluate the influence of media and the legal environment on the career of trainees in obstetrics and gynaecology. Under the auspices of the Irish national training body, we distributed a 26-item questionnaire to doctors-in-training (DIT) working in obstetrics and gynaecology in the Republic of Ireland. Descriptive statistics and Chi-squared analyses were performed on the anonymised data. 151 DIT responded to the questionnaire, with a response rate of 86.2 % (sample size = 175). The majority were female (79.9 %, n = 121), Irish (85.5 %, n = 106) and had no children (67.0 %, n = 83). 86.7 % (n = 131) felt that the media did not have a positive impact on patients receiving care, and, further, unfairly represented the speciality (94.1 %; n = 142). Additionally, DIT felt that medico-legal issues had a negative impact on issues such as retention and recruitment. These two areas were implicated in over three quarters of DIT considering leaving the speciality. This study demonstrates that DIT perceive media scrutiny and litigation to have a negative effect on the speciality of obstetrics and gynaecology. Further support integrated into specialist training, is needed to ensure that trainees are adequately equipped to deal with both mainstream and social media as well as interactions they may have with the legal profession as they progress through their career.

Risk of repetition and subsequent self-harm following presentation to hospital with suicidal ideation: A longitudinal registry study.

BACKGROUND: Few studies have focused on those who present to hospital with suicidal thoughts (suicidal ideation). The aim of this study was to establish the risk of repeat presentation to hospital following suicidal ideation and to identify factors which were associated with further ideation or subsequent self-harm. METHODS: Data were obtained from the Northern Ireland Registry of Self-harm. Risk of repeat presentation following hospital-presenting ideation was analysed using Kaplan Meier analyses, specifically cox proportional hazard models. FINDINGS: During the period April 2014 to March 2019, a total of 14,695 presentations to hospital due to suicidal ideation were made in Northern Ireland. The cumulative incidence of repeat presentation to hospital was 40·5% within five years, with an 18·3% risk of subsequent self-harm. Previous ideation had the strongest association with repeat presentation. There was evidence of recidivism considering further ideation, with an increased risk according to number of previous presentations. In contrast, risk of subsequent self-harm was highest after the first or second presentation. Male gender and alcohol were associated with further ideation, while females and young people were more likely to re-present with self-harm. INTERPRETATION: The findings indicate that individuals who present to hospital with suicidal ideation are at risk of repeat presentation and future self-harm, however clinical guidelines do not specifically address hospital-presenting ideation. The transition from ideation to suicidal behaviour is important to consider and research could inform effective screening and early intervention measures. ROLE OF FUNDING: The Northern Ireland Registry of Self-harm is funded by the Public Health Agency, Northern Ireland.

High-flow Nasal Cannulae, Bronchopulmonary Dysplasia and Retinopathy of Prematurity

Aims To determine if HFNC use was associated with changes in incidence of BPD and ROP. Methods This retrospective study examined premature infants (<30 weeks GA or <1500g) in a tertiary neonatal unit from 2010- 2016. Patients were compared before and after introduction of HFNC. Further analysis of high-risk infants (<28 weeks GA or <750g or ventilated) compared those who received HFNC to those who did not across the whole period. Primary outcomes were incidence of BPD and ROP requiring surgery. Results Incidence of BPD rose following the introduction of HFNC (82/232 (35.3%) after vs 33/251 (13.1%) before, p<0.001). On multivariate analysis, the chance of developing BPD after HFNC introduction remained higher (OR 4.353, 95% CI 2.546-7.443). More infants received surgery for ROP following HFNC introduction (0/214 vs 11/205 (5.4%), p=<0.001). In the second analysis, the rate of BPD was higher in those who received HFNC (90/132 (68.1%) vs 33/153 (21.6%), p<0.001). Receiving HFNC demonstrated higher chance of BPD in multivariate analysis (OR 7.802, 95% CI 4.223-14.423). Rate of ROP surgery was higher in those who received HFNC (0/153 vs 13/134 (9.7%), p<0.001). Conclusions In this study, use of HFNC was associated with significantly increased risk of adverse outcomes.

Psychosocial, psychiatric and work-related risk factors associated with suicide in Ireland: optimised methodological approach of a case-control psychological autopsy study.

BACKGROUND: Suicide has profound effects on families and communities, but is a statistically rare event. Psychological autopsies using a case-control design allow researchers to examine risk factors for suicide, using a variety of sources to detail the psychological and social characteristics of decedents and to compare them to controls. The Suicide Support and Information System Case Control study (SSIS-ACE) aimed to compare psychosocial, psychiatric and work-related risk factors across three groups of subjects: suicide decedents, patients presenting to hospital with a high-risk self-harm episode, and general practice controls. METHODS: The study design includes two inter-related studies; one main case-control study: comparing suicide cases to general practice (GP) controls, and one comparative study: comparing suicide cases to patients presenting with high-risk self-harm. Consecutive cases of suicide and probable suicide are identified through coroners' registration of deaths in the defined region (Cork City and County, Ireland) and are frequency-matched for age group and gender with GP patient controls recruited from the same GP practice as the deceased. Data sources for suicide cases include coroners' records, interviews with health care professionals and proxy informants; data sources for GP controls and for high-risk self-harm controls include interviews with control, with proxy informants and with health care professionals. Interviews are semi-structured and consist of quantitative and qualitative parts. The quantitative parts include a range of validated questionnaires addressing psychiatric, psychosocial and occupational factors. The study adopts several methodological innovations, including accessing multiple data sources for suicide cases and controls simultaneously, recruiting proxy informants to examine consistency across sources. CONCLUSIONS: The study allows for the investigation of consistency across different data sources and contributes to the methodological advancement of psychological autopsy research. The study will also inform clinical and public health practice. The comparison between suicide cases and controls will allow investigation of risk and protective factors for suicide more generally, while the comparison with high-risk self-harm patients will help to identify the factors associated specifically with a fatal outcome to a self-harm episode. A further enhancement is the particular focus on specific work-related risk factors for suicide.

Method of self-harm and risk of self-harm repetition: findings from a national self-harm registry.

BACKGROUND: Risk of self-harm repetition has consistently been shown to be higher following self-cutting compared to intentional drug overdose (IDO) and other self-harm methods. The utility of previous evidence is limited due to the large heterogeneous method categories studied. This study examined risk of hospital presented self-harm repetition according to specific characteristics of self-harm methods. METHODS: Data on consecutive self-harm presentations to hospital emergency departments (2010-2016) were obtained from the National Self-Harm Registry Ireland. Associations between self-harm method and repetition were analysed using survival analyses. RESULTS: Overall, 65,690 self-harm presentations were made involving 46,661 individuals. Self-harm methods associated with increased repetition risk included minor self-cutting, severe self-cutting, multiple drug IDOs involving psychotropic drugs and self-harm by blunt object. Minor self-cutting was the method associated with highest repetition risk (adjusted hazard ratio (AHR) 1.38, 95% CI 1.31-1.45). Risk of repetition was comparable following IDOs of four or more drugs involving psychotropic drugs (AHR = 1.29, 95% CI 1.20-1.39), severe self-cutting (AHR 1.25, 95% CI 1.16-1.34) and blunt object (AHR = 1.23, 95% CI 1.07-1.42). LIMITATIONS: Information was not available on suicide or other causes of mortality. CONCLUSIONS: Self-harm method and the associated risk of repetition should form a core part of biopsychosocial assessments and should inform follow-up care for self-harm patients. The observed differences in repetition associated with specific characteristics of IDO underline the importance of safety planning and monitoring prescribing for people who have engaged in IDO.

Factors associated with different smoking status in European adolescents: results of the SEYLE study.

Early onset and long-term smoking are associated with physical and psychological health problems. The aim of the presented analysis was to investigate risk and influencing factors for different smoking status in a big sample of European adolescents. In the context of the "saving and empowering young lives in Europe" (SEYLE) study we surveyed 12,328 adolescents at the age of 13-17 from 11 countries. The survey took place in a school-based context using a questionnaire. Overall 58% reported the onset of ever-smoking under the age of 14 and 30.9% smoke on a daily basis. Multinomial logistic regression model showed significant positive associations between adolescent smoking and internalizing problems (suicidal behavior, direct self-injurious behavior, anxiety), externalizing problems (conduct problems, hyperactivity, substance consumption) and family problems (parental substance consumption, broken home). Our data show that smoking among adolescents is still a major public health problem and adolescents who smoke are at higher risk for mental problems. Further, adolescent smoking is associated with broken home families and parental behaviors. Therefore, early preventive measures are necessary not only for adolescents, but also for their parents.

Experience of miscarriage: an interpretative phenomenological analysis.

OBJECTIVE: The objective of the study was to explore the experiences of those who have experienced miscarriage, focusing on men's and women's accounts of miscarriage. DESIGN: This was a qualitative study using a phenomenological framework. Following in-depth semistructured interviews, analysis was undertaken in order to identify superordinate themes relating to their experience of miscarriage. SETTING: A large tertiary-level maternity hospital in Ireland. PARTICIPANTS: A purposive sample of 16 participants, comprising 10 women and 6 men, was recruited. RESULTS: 6 superordinate themes in relation to the participant's experience of miscarriage were identified: (1) acknowledgement of miscarriage as a valid loss; (2) misperceptions of miscarriage; (3) the hospital environment, management of miscarriage; (4) support and coping; (5) reproductive history; and (6) implications for future pregnancies. CONCLUSIONS: One of the key findings illustrates a need for increased awareness in relation to miscarriage. The study also indicates that the experience of miscarriage has a considerable impact on men and women. This study highlights that a thorough investigation of the underlying causes of miscarriage and continuity of care in subsequent pregnancies are priorities for those who experience miscarriage. Consideration should be given to the manner in which women who have not experienced recurrent miscarriage but have other potential risk factors for miscarriage could be followed up in clinical practice.

Surgical Site Infection after Caesarean Section? There Is an App for That: Results from a Feasibility Study On Costs and Benefits.

Surgical site infections (SSIs) are one of the most common and, yet, preventable healthcare associated infections. In Ireland, the rate of Caesarean section (CS) is increasing, while postpartum hospital stay is decreasing, adversely affecting SSI among women. There is much need to develop post-discharge surveillance which can effectively monitor, detect, and arrange treatment for affected women. The use of modern technology to survey SSI following discharge from hospital remains unexplored. We report the results of a feasibility study which investigates whether an integrated mobile application (hereafter, app) is more cost-beneficial than a stand-alone app or telephone helpline at surveying SSI following CS. We find women prefer the integrated app (47.5%; n=116/244) over the stand-alone app (8.2%; n=20/244) and telephone helpline (18.0%; 44/244), although there is no significant difference in women's valuation of these services using willingness to pay techniques. The stand-alone app is the only cost-beneficial service due to low labour costs. Future research should employ alternative measures when evaluating the benefits of the health technology. The use of a mobile app as a mechanism for postpartum care could represent a considerable advancement towards technological health care.

Variation between hospitals in inpatient admission practices for self-harm patients and its impact on repeat presentation.

PURPOSE: Self-harm patient management varies markedly between hospitals, with fourfold differences in the proportion of patients who are admitted to a medical or psychiatric inpatient bed. The current study aimed to investigate whether differences in admission practices are associated with patient outcomes (repeat self-harm) while accounting for differences in patient case mix. METHODS: Data came from the National Self-Harm Registry Ireland. A prospective cohort of 43,595 self-harm patients presenting to hospital between 2007 and 2012 were included. As well as conventional regression analysis, instrumental variable (IV) methods utilising between hospital differences in rates of hospital admission were used in an attempt to gain unbiased estimates of the association of admission with risk of repeat self-harm. RESULTS: The proportion of self-harm patients admitted to a medical bed varied from 10 to 74 % between hospitals. Conventional regression and IV analysis suggested medical admission was not associated with risk of repeat self-harm. Psychiatric inpatient admission was associated with an increased risk of repeat self-harm in both conventional and IV analyses. This increased risk persisted in analyses stratified by gender and when restricted to self-poisoning patients only. CONCLUSIONS: No strong evidence was found to suggest medical admission reduces the risk of repeat self-harm. Models of health service provision that encourage prompt mental health assessment in the emergency department and avoid unnecessary medical admission of self-harm patients appear warranted. Psychiatric inpatient admission may be associated with a heightened risk of repeat self-harm in some patients, but these findings could be biased by residual confounding and require replication.

The area level association between suicide, deprivation, social fragmentation and population density in the Republic of Ireland: a national study.

PURPOSE: Numerous studies have examined the ecological relationship between suicide and area level determinants such as deprivation and social fragmentation. In Ireland, there is considerable geographic variation in the rates of suicide. However, there is a dearth of Irish studies investigating the geographic variability of suicide. METHODS: The Irish Central Statistics Office (CSO) provided data relating to all deaths by suicide and deaths of undetermined intent that occurred from 2009 to 2011. Negative binomial regression was used to examine the relationship between area level suicide rates and measures of deprivation, social fragmentation and population density that were taken from the 2011 National Census. RESULTS: Overall deprivation had the strongest independent effect on small-area rates of suicide, with the most deprived areas showing the greatest risk of suicide (risk ratio = 2.1; 95 % CI 1.70-2.52). Low population density (rurality) was associated with an increased risk suicide in males across both age groups and among females in the older 40-64-year age group. Conversely, a weak association between high population density (urbanicity) and increased suicide risk was found among females in the 15-39-year age group. Associations with social fragmentation only became apparent in the sub group analysis. Social fragmentation was associated with an elevated risk of suicide in the older 40-64 age group, with this effect being most pronounced among females. CONCLUSION: The findings of this study demonstrate marked geographical inequalities in the distribution of suicide in Ireland and highlight the importance of targeting suicide prevention resources in the most deprived areas.

Reasons for Attempted Suicide in Europe: Prevalence, Associated Factors, and Risk of Repetition.

To examine the prevalence of specific reasons for attempted suicide, factors associated with them, and whether reasons for attempted suicide influence risk of repetition. As part of the Monitoring Suicide in Europe (MONSUE) project, data on 4,683 suicide attempters from nine European countries were collected. Independence tests were used to study the influence of age, gender, and other factors on reported reasons. We examined risk of repetition using logistic regression analysis. Interpersonal conflict was common for all patients except those widowed, living alone, or retired. Mental health problems were prevalent among over 45 year-olds, patients unable to work, and patients with a history of at least three suicide attempts. Financial difficulties were cited more often by patients who were 45-64 years old, divorced or separated, living with children only, and unemployed. Close bereavement/serious illness and own physical illness were associated with those over 65 years of age. Two reasons for suicide attempt, interpersonal conflict and mental health problems, were associated with increased risk of repetition independent of other factors. Suicide attempters have a multitude of problems of varying prevalence depending on age, gender, and other factors. They present a range of clinical profiles that require a multidisciplinary response.

Characteristics of small areas with high rates of hospital-treated self-harm: deprived, fragmented and urban or just close to hospital? A national registry study.

BACKGROUND: Previous research has shown an inconsistent relationship between the spatial distribution of hospital treated self-harm and area-level factors such as deprivation and social fragmentation. However, many of these studies have been confined to urban centres, with few focusing on rural settings and even fewer studies carried out at a national level. Furthermore, no previous research has investigated if travel time to hospital services can explain the area-level variation in the incidence of hospital treated self-harm. METHODS: From 2009 to 2011, the Irish National Registry of Deliberate Self Harm collected data on self-harm presentations to all hospital emergency departments in the country. The Registry uses standard methods of case ascertainment and also geocodes patient addresses to small area geographical level. Negative binomial regression was used to explore the ecological relationship between area-level self-harm rates and various area-level factors. RESULTS: Deprivation, social fragmentation and population density had a positive linear association with self-harm, with deprivation having the strongest independent effect. Furthermore, self-harm incidence was found to be elevated in areas that had shorter journey times to hospital. However, while this association became attenuated after controlling for other area-level factors it still remained statistically significant. A subgroup analysis examining the effect of travel time on specific methods of self-harm, found that this effect was most marked for self-harm acts involving minor self-cutting. CONCLUSIONS: Self-harm incidence was influenced by proximity to hospital services, population density and social fragmentation; however, the strongest area-level predictor of self-harm was deprivation.