Global prevalence of psychosocial assessment following hospital-treated self-harm: systematic review and meta-analysis.

BACKGROUND: Hospital-treated self-harm is common, costly and associated with repeated self-harm and suicide. Providing a comprehensive psychosocial assessment following self-harm is recommended by professional bodies and may improve outcomes. AIMS: To review the provision of psychosocial assessments after hospital-presenting self-harm and the extent to which macro-level factors indicative of service provision explain variability in these estimates. METHOD: We searched five electronic databases to 3 January 2023 for studies reporting data on the proportion of patients and/or events that were provided a psychosocial assessment. Pooled weighted prevalence estimates were calculated with the random-effects model. Random-effects meta-regression was used to investigate between-study variability. RESULTS: 119 publications (69 unique samples) were included. Across ages, two-thirds of patients had a psychosocial assessment (0.67, 95% CI 0.58-0.76). The proportion was higher for young people and older adults (0.75, 95% CI 0.36-0.99 and 0.83, 95% CI 0.48-1.00, respectively) compared with adults (0.64, 95% CI 0.54-0.73). For events, around half of all presentations had these assessments across the age range. No macro-level factor explained between-study heterogeneity. CONCLUSIONS: There is room for improvement in the universal provision of psychosocial assessments for self-harm. This represents a missed opportunity to review and tailor aftercare supports for those at risk. Given the marked unexplained heterogeneity between studies, the person- and system-level factors that influence provision of psychosocial assessments after self-harm should be studied further.

Global prevalence of psychiatric in- and out-patient treatment following hospital-presenting self-harm: a systematic review and meta-analysis.

Background: Hospital-treated self-harm is common, costly, and strongly associated with suicide. Whilst effective psychosocial interventions exist, little is known about what key factors might modify the clinical decision to refer an individual to psychiatric in- and/or out-patient treatment following an episode of hospital-treated self-harm. Methods: We searched five electronic databases (CENTRAL, CDSR, MEDLINE, Embase, and PsycINFO) until 3 January 2023 for studies reporting data on either the proportion of patients and/or events that receive a referral and/or discharge to psychiatric in- and/or outpatient treatment after an episode of hospital-treated self-harm. Pooled weighted prevalence estimates were calculated using the random effects model with the Freedman-Tukey double arcsine adjustment in R, version 4.0.5. We also investigated whether several study-level and macro-level factors explained variability for these outcomes using random-effects meta-regression. The protocol of this review was pre-registered with PROSPERO (CRD42021261531). Findings: 189 publications, representing 131 unique studies, which reported data on 243,953 individual participants who had engaged in a total of 174,359 episodes of self-harm were included. Samples were drawn from 44 different countries. According to World Bank classifications, most (83.7%) samples were from high income countries. Across the age range, one-quarter of persons were referred for inpatient psychiatric care and, of these, around one-fifth received treatment. Just over one-third were referred to outpatient psychiatric care, whilst around half of those referred received at least one treatment session across the age range. Event rate estimates were generally of a lower magnitude. Subgroup analyses found that older adults (mean sample age: ≥60 years) may be less likely than young people (mean sample age: ≤25 years) and adults (mean sample age: >25 years to <60 years) to be referred for outpatient psychiatric care following self-harm. More recent studies were associated with a small increase in the proportion of presentations (events) that were referred to, and received, psychiatric outpatient treatment. No macro-level factor explained between-study heterogeneity. Interpretation: There is considerable scope for improvement in the allocation and provision of both in- and out-patient psychiatric care following hospital-presenting self-harm, particularly considering that the period after discharge from general hospitals represents the peak risk period for repeat self-harm and suicide. Given the marked between-study heterogeneity, the basis for allocation of aftercare treatment is therefore not yet known and should be further studied. Funding: There was no specific funding for this review.

Suicides in Aboriginal and non-Aboriginal people following hospital admission for suicidal ideation and self-harm: A retrospective cohort data linkage study from the Northern Territory.

PURPOSE: This study aimed to explore risk factors for suicide in Aboriginal and non-Aboriginal people following hospital admission for suicidal ideation and self-harm in the Northern Territory, Australia to help clarify opportunities for improved care and intervention for these population groups. METHODS: Individuals with at least one hospital admission involving suicidal ideation and/or self-harm between 1 July 2001 and 31 December 2013 were retrospectively recruited and followed up using linked mortality records to 31 December 2014. Survival analyses stratified by Indigenous status identified socio-demographic and clinical characteristics from index hospital admissions associated with suicide. RESULTS: Just over half of the 4391 cohort members identified as Aboriginal (n = 2304; 52.4%). By 2014, 281 deaths were observed comprising 68 suicides, representing a 2.6% and 2.0% probability of suicide for Aboriginal and non-Aboriginal people, respectively. After adjusting for other characteristics, a higher risk of suicide was associated with male sex (Aboriginal adjusted hazard ratio: 4.14; 95% confidence interval: [1.76, 9.75]; non-Aboriginal adjusted hazard ratio: 5.96; 95% confidence interval: [1.98, 17.88]) and repeat hospital admissions involving self-harm (Aboriginal adjusted hazard ratio: 1.37; 95% confidence interval: [1.21, 1.55]; non-Aboriginal adjusted hazard ratio: 1.29; 95% confidence interval: [1.10, 1.51]). Severe mental disorders were associated with a four times higher risk of suicide (adjusted hazard ratio: 4.23; 95% confidence interval: [1.93, 9.27]) in Aboriginal people only. CONCLUSION: The findings highlight non-clinical risk factors for suicide that suggest the need for comprehensive psychosocial assessment tailored to Aboriginal and non-Aboriginal people hospitalised with suicidal ideation or self-harm. Implementing appropriate management and aftercare within a broader public health framework is needed to support recovery and reduce long-term suicide risk in the community, especially for Aboriginal people and males.

Indigeneity and Likelihood of Discharge to Psychiatric Hospital in an Australian Deliberate Self-Poisoning Hospital-Treated Cohort.

Hospital-treated self-harm rates for Aboriginal and Torres Strait Islander (Indigenous) people are at least double those for other Australians. Despite this, limited research has explored the relationship between Indigeneity and the clinical management of hospital-treated deliberate self-harm. A retrospective clinical cohort study (2003-2012) at a regional referral centre (NSW) for deliberate self-poisoning was used to explore the magnitude and direction of the relationship between Indigeneity and discharge destination (psychiatric hospital vs. other) using a series of logistic regressions. There were 149 (4%) Indigenous and 3697 (96%) non-Indigenous deliberate self-poisoning admissions during the study period. One-third (31%) were referred to the psychiatric hospital at discharge; Indigenous 21% (n = 32) vs. non-Indigenous 32% (n = 1175). Those who identified as Indigenous were less likely to be discharged to the psychiatric hospital, OR 0.59 (0.40-0.87) at the univariate level, with little change after sequential adjustment; and AOR 0.34 (0.21-0.73) in the fully adjusted model. The Indigenous cohort had a lower likelihood of psychiatric hospital discharge even after adjustment for variables associated with discharge to the psychiatric hospital highlighting the need for further investigation of the reasons accounting for this differential pattern of clinical management and the effectiveness of differential after-care allocation.

Validity and reliability of resiliency measures trialled for the evaluation of a preventative Resilience-promoting social-emotional curriculum for remote Aboriginal school students.

PURPOSE: We aimed to test the reliability and validity of two brief measures of resilience adopted for the evaluation of a preventative social-emotional curriculum implemented for Aboriginal middle school students from socially disadvantaged remote communities in Australia's Northern Territory. The questionnaires chosen were intended to measure psychological resilience and socio-cultural resilience as complementary dimensions of the capacity to cope in circumstances of significant life stress and risk of self-harm. METHODS: Confirmatory factor analysis (CFA) was conducted to assess construct validity of the 10-item Connor-Davidson Resilience Scale (CD-RISC-10), a measure of psychological resilience, and the 12-item Child and Youth Resilience Measure (CYRM-12), a measure of socio-cultural resilience, with a sample of 520 students. Associations between resilience and psychological distress and emotional and behavioural difficulty were analysed in relation to life stressors to assess criterion validity of the scales. RESULTS: CFA provided support for the validity of the respective constructs. There was good fit for both scales. However, assessment of criterion validity of the scales suggested that the adapted measure of socio-cultural resilience (CYRM-12NT) showed higher reliability and a clearer indication of predictive validity than the measure of psychological resilience (CD-RISC-10). CONCLUSIONS: The CYRM-12NT appears to be a more useful measure of resilience among Aboriginal youth exposed to significant life stress and disadvantage. However, both measures may require further development to enhance their validity and utility among potentially at-risk adolescents in socially, culturally and linguistically diverse remote Aboriginal communities.

Discrimination experienced by Aboriginal and Torres Strait Islander males in Australia: Associations with suicidal thoughts and depressive symptoms.

INTRODUCTION: Globally, Indigenous populations have higher rates of suicidal behavior and psychological distress compared to non-Indigenous populations. Indigenous populations also report high rates of exposure to discrimination, which could potentially contribute to poor mental health outcomes. The objectives of this paper were to estimate the prevalence of discrimination among Aboriginal and Torres Strait Islander males in Australia and to examine the role of discrimination in the association between Aboriginal and Torres Strait Islander status and suicidal thoughts and depressive symptoms. METHODS: We used cross-sectional data on 13,697 males aged 18-55 years from the Australian Longitudinal Study on Male Health. We undertook a Poisson regression with robust standard error analyses to examine Aboriginal and Torres Strait Islander status and self-perceived exposure to discrimination in the past 2 years as correlates of recent suicidal ideation. We used zero-inflated negative binomial regression to assess Aboriginal and Torres Strait Islander status and self-perceived exposure to discrimination as correlates of recent depressive symptoms. RESULTS: Aboriginal and Torres Strait Islander males have a twofold higher prevalence of self-perceived discrimination (39.2% vs 19.3%, p < 0.001), suicidal ideation (21.8% vs 9.4%, p < 0.001) and moderate or worse depressive symptoms (24.0% vs 12.2%, p < 0.001) as compared to their non-Indigenous counterparts. After adjusting for sociodemographics and substance use, Aboriginal and Torres Strait Islander status was significantly associated with suicidal thoughts (odds ratio = 1.49, p = 0.019) and depressive symptoms (prevalence rate ratio = 1.19, p = 0.018). About 15.3% and 28.7% of the association between Aboriginal and Torres Strait Islander status and suicidal thoughts and depressive symptoms, respectively, was explained by discrimination. CONCLUSION: Our analyses add to evidence that discrimination is a contributor to mental health disparities between Aboriginal and Torres Strait Islander and non-Indigenous populations in Australia. Reducing discrimination ought to be considered as part of strategies to improve the social and emotional well-being of Aboriginal and Torres Strait Islander people.

Opportunities for prevention: a data-linkage study to inform a public health response to youth offending in the Northern Territory, Australia.

BACKGROUND: Numerous studies have demonstrated a strong link between child maltreatment and subsequent youth offending, leading to calls for early intervention initiatives. However, there have been few whole-population studies into the dimensions of statutory child maltreatment responses that can inform these programs. The aim of this study was to investigate the sex-specific association between level and timing of child protection system (CPS) contact and youth offending. METHODS: This retrospective cohort study used linked individual-level records from multiple agencies, for 10,438Aboriginal children born in the Northern Territory between 1999 and 2006. The outcome measure was the first alleged offence. Key explanatory variables were level (no contact through to out-of-home care) and timing (0-4 years, 5-9 years, or both) of CPS contact. The Kaplan-Meier method was used to estimate cumulative incidence and a flexible parametric survival model to estimate hazard ratios (HR). RESULTS: Children with no record of CPS contact before age 10 had the lowest cumulative incidence of first alleged offence by age 18 (boys: 23.4% [95%CI:21.0-26.1]; girls: 6.6% [95%CI:5.3-8.2]) and those with a record of out-of-home care the highest CI (boys: 45.5% [95%CI:37.0-54.9]; girls: 18.6% [95%CI:13.0-26.2]). The association of CPS contact with the relative risk of a first alleged offence was greatest for children aged 10-13 years and decreased with age. Timing of CPS contact was also associated with increasing cumulative incidence. The relative risk for first alleged offence was generally higher for children with CPS contact, of any type, during both developmental phases including notifications during both phases (boys, HR at age 11: 8.9 [95%CI:4.2-17.2]; girls, HR at age 11: 13.7 [95%CI:3.8-48.9]) and substantiations during both phases (boys, HR at age 11: 17.0 [95%CI:9.6-30.0]; girls, HR at age 11: 54.1 [95%CI:18.1-162]). CONCLUSION: The increased risk of offending associated with level and timing of early CPS contact highlights opportunities for a differentiated public health response to improve life trajectories for children and to reduce youth crime. Although children with unsubstantiated notifications of maltreatment do not meet the criteria for a statutory CPS response, the higher risk of offending among these children supports their inclusion in targeted preventive interventions.

Patterns of child protection service involvement by Aboriginal children associated with a higher risk of self-harm in adolescence: A retrospective population cohort study using linked administrative data.

BACKGROUND: A history of child maltreatment is known to elevate the risk of self-harm in adolescence. However, this link has not been investigated for Aboriginal children who experience a greater burden of both. OBJECTIVE: Identify patterns of involvement with child protection services by Aboriginal children associated with a higher risk of self-harm in adolescence. PARTICIPANTS AND SETTING: A cohort study was established using linked administrative records of Aboriginal children born in the Northern Territory (NT) of Australia. METHODS: Survival analysis techniques were used to determine the risk of self-harm in adolescence associated with different levels and timing of child protection involvement throughout childhood. RESULT: The relative risk of self-harm was greatest for children with substantiated maltreatment in both early and middle childhood had nine times higher risk for self-harm (aHR: 9.11, 95% CI: 3.39-24.46,p < 0.001) and six times higher for children who experienced notifications in early childhood and substantiated maltreatment in middle childhood (aHR: 6.72, 95% CI:2.16-20.90, p < 0.001). Other patterns of child protection involvement observed in middle childhood alone also conferred a higher relative risk of self-harm in adolescence. CONCLUSION: This study confirms a higher risk of self-harm in adolescence is associated with child maltreatment, especially in middle childhood. Addressing the intergenerational trauma in Aboriginal families is crucial to preventing child maltreatment and informing reforms to child protection responses that can better identify and address the culturally-specific unmet needs of Aboriginal families. This would go some way to fostering the healthy growth and development of Aboriginal children and reduce self-harm risk.

School-Based Prevention in Very Remote Settings: A Feasibility Trial of Methods and Measures for the Evaluation of a Social Emotional Learning Program for Indigenous Students in Remote Northern Australia.

Purpose: Skills for Life (SFL) is a social-emotional curriculum for Indigenous middle school students that was co-developed with educators and community members in a remote community of northern Australia. This preliminary study aimed to test the feasibility of processes and methods of data-gathering, the reliability of youth self-report measures, and to identify the direction of effects for an evaluation of a longer-term pilot of the curriculum. Design/Methodology/Approach: Indigenous Students in years 7-9 of a remote school participated in SFL over 2 years. The Strengths and Difficulties Questionnaire (SDQ), Kessler 6 (K6), and a purpose-designed Connected Self Scale (CSS) were administered to 63 students pre- and post-program. Findings: Only the K6, Prosocial behavior (SDQ), and two CSS subscales showed sufficient internal consistency for analysis. Change was positive but non-significant for SDQ and CSS. There was evidence of a dosage effect: students receiving the intervention over 2 years showed greater reduction in psychological distress than other students. There was no evidence of iatrogenic effects. Conclusions: The feasibility pilot is a critically important phase in the development of evaluation design and cjhoice of evaluation measures for challenging remote settings. This study found that evaluation of SFL with culturally and linguistically distinct Indigenous middle school students using self-report measures is feasible. However, the SDQ may not be suitable for this project. High levels of psychological distress suggest the need to investigate sources of life stress and potential supports for adolescent resilience in this context. This preliminary pilot aimed to trial methods and measures for evaluation of a social-emotional curriculum developed specifically for remote Australian Indigenous students who are at risk of poor psychosocial outcomes. No studies have examined the appropriateness of standardized self-report measures for evaluation of SEL with this student population in remote school settings.

Developing best practice guidelines for the psychosocial assessment of Aboriginal and Torres Strait Islander people presenting to hospital with self-harm and suicidal thoughts.

OBJECTIVE: To develop guidelines for the culturally responsive psychosocial assessment of Aboriginal and Torres Strait Islander people presenting to hospital with self-harm and suicidal thoughts. METHOD: The Delphi method was used to establish expert consensus. A systematic search and review of relevant research literature, existing guidelines and grey literature was undertaken to develop a 286-item questionnaire. The questionnaire contained best practice statements to guide clinicians undertaking psychosocial assessment of Aboriginal and Torres Strait Islander people presenting to hospital with self-harm and suicidal thoughts. An expert panel comprising 28 individuals with clinical, community-based and lived experience in Aboriginal and Torres Strait Islander mental health and/or suicide prevention were recruited and independently rated the items over three rounds. Statements endorsed as essential or important by 90% or more of the expert panel were then synthesised into recommendations for the best practice guideline document. RESULTS: A total of 226 statements across all relevant areas of clinical practice were endorsed. No statements covering the use of structured assessment tools were endorsed. The endorsed statements informed the development of a set of underlying principles of culturally competent practice and recommendations for processes of effective and appropriate engagement; risks, needs and strengths to be assessed; formulation of psychosocial assessment; and recommendations specific to children and young people. CONCLUSION: The guidelines are based on recommendations endorsed across a range of expertise to address an important gap in the evidence-base for clinically effective and culturally responsive assessment of self-harm and suicidal thoughts by Aboriginal and Torres Strait Islander people in hospital settings. Further work is needed to develop an implementation strategy and evaluate the recommendations in practice.

Aboriginal and Non-Aboriginal Emergency Department Presentations Involving Suicide-Related Thoughts and Behaviors.

Background: Rates of hospital admission for suicide-related thoughts and behaviors (SRTBs) are elevated in the Northern Territory (NT) of Australia, especially by Aboriginal people, but very little is known about emergency department (ED) presentations. Aim: We aimed to profile ED presentations in the NT involving SRTBs by Indigenous status and compare discharge arrangements. Method: Logistic regression analyses were performed on data from electronic patient records of consecutive ED presentations involving SRTBs. Results: During the study period, 167 presentations were observed. Aboriginal patients were more likely to present from remote areas and to report substance misuse and family conflict or violence compared with non-Aboriginal patients. In both groups, males were more likely than females to be admitted as were persons presenting with self-harm compared with those who had suicidal thoughts only. No differences in discharge arrangements were identified by Indigenous status. Limitations: The small scale of the study and use of administrative records points to the need for further research to improve the quality of the evidence. Conclusion: While presentations by high-risk groups are more likely to be admitted for further care, the assessment of psychosocial risks and needs in EDs is vital to informing decisions for aftercare that support recovery in the community for Aboriginal patients and patients discharged from EDs.

Enhancing Social and Emotional Wellbeing of Aboriginal Boarding Students: Evaluation of a Social and Emotional Learning Pilot Program.

Boarding schools can provide quality secondary education for Aboriginal students from remote Aboriginal Australian communities. However, transition into boarding school is commonly challenging for Aboriginal students as they need to negotiate unfamiliar cultural, social and learning environments whilst being separated from family and community support. Accordingly, it is critical for boarding schools to provide programs that enhance the social and emotional skills needed to meet the challenges. This study evaluated a 10-session social and emotional learning (SEL) program for Aboriginal boarders and identified contextual factors influencing its effectiveness. The study combined a pre-post quantitative evaluation using diverse social and emotional wellbeing measures with 28 students between 13-15 years (10 female, 11 male, 7 unidentified) and qualitative post focus groups with 10 students and episodic interviews with four staff delivering the program. Students' social and emotional skills significantly improved. The qualitative findings revealed improvements in students seeking and giving help, working in groups, managing conflict, being assertive and discussing cultural issues. The focus groups and interviews also identified program elements that worked best and that need improvement. Secure relationships with staff delivering the program and participation in single sex groups stood out as critical enablers. The findings lend evidence to the critical importance of collaborative design, provision and evaluation of SEL programs with Aboriginal peoples.

Trends in hospital admissions involving suicidal behaviour in the Northern Territory, 2001-2013.

OBJECTIVE: To investigate trends in hospital admissions involving suicidal behaviour in the Northern Territory (NT) resident population over the period 2001-2013. METHODS: Estimates of age-standardised rates and average changes in the annual rate of hospital admissions involving suicidal behaviour were calculated by socio-demographic characteristics and types of suicidal behaviour. RESULTS: Overall rates for Indigenous admissions were 2.7 times higher than non-Indigenous admissions and had increased by almost twice as much. While male and female rates of admission were similar for both Indigenous and non-Indigenous residents, the average annual change in rates was greater for Indigenous females (13.4%) compared to males (8.8%) and for non-Indigenous males (7.7%) compared to females (5.2%). Younger and middle-aged Indigenous admissions experienced increasing rates of admissions, whilst trends were similar across age groups for non-Indigenous admissions. Admissions with a diagnosis of suicidal ideation increased the most across all groups. Trends in intentional self-harm admissions differed according to Indigenous status and sex. CONCLUSIONS: There have been substantial increases in hospital admissions involving suicidal behaviour in the NT, most markedly for Indigenous residents. Indigenous females and youth appear to be at increasing risk. The steep increase in suicidal ideation across all groups warrants further investigation.