The relationship between type, timing and duration of exposure to adverse childhood experiences and adolescent self-harm and depression: findings from three UK prospective population-based cohorts.

BACKGROUND: Adverse childhood experiences (ACEs) are well-established risk factors for self-harm and depression. However, despite their high comorbidity, there has been little focus on the impact of developmental timing and the duration of exposure to ACEs on co-occurring self-harm and depression. METHODS: Data were utilised from over 22,000 children and adolescents participating in three UK cohorts, followed up longitudinally for 14-18 years: the Avon Longitudinal Study of Parents and Children (ALSPAC), the Millennium Cohort Study (MCS) and the Environmental Risk (E-Risk) Longitudinal Twin Study. Multinomial logistic regression models estimated associations between each ACE type and a four-category outcome: no self-harm or depression, self-harm alone, depression alone and self-harm with co-occurring depression. A structured life course modelling approach was used to examine whether the accumulation (duration) of exposure to each ACE, or a critical period (timing of ACEs) had the strongest effects on self-harm and depression in adolescence. RESULTS: The majority of ACEs were associated with co-occurring self-harm and depression, with consistent findings across cohorts. The importance of timing and duration of ACEs differed across ACEs and across cohorts. For parental mental health problems, longer duration of exposure was strongly associated with co-occurring self-harm and depression in both ALSPAC (adjusted OR: 1.18, 95% CI: 1.10-1.25) and MCS (1.18, 1.11-1.26) cohorts. For other ACEs in ALSPAC, exposure in middle childhood was most strongly associated with co-occurring self-harm and depression, and ACE occurrence in early childhood and adolescence was more important in the MCS. CONCLUSIONS: Efforts to mitigate the impact of ACEs should start in early life with continued support throughout childhood, to prevent long-term exposure to ACEs contributing to risk of self-harm and depression in adolescence.

Parent-carer experiences using a peer support network: a qualitative study.

INTRODUCTION: Parent-carers of children and young people (CYP) with mental health problems are at greater risk of poor outcomes, such as poor physical and mental health. Peer interventions for parent-carers of CYP with disabilities may improve parent-carer outcomes. This qualitative study investigates parent-carer experiences of using Parental Minds (PM), a multi-component peer support service for parent-carers of CYP with disabilities. METHODS: Twelve current service-users and four staff/volunteers at PM participated in one-to-one semi-structured interviews. All participants were white females, except for one service-user who was male. All interviews were recorded and transcribed verbatim. Thematic analysis of results was used to explore perceived benefits and disadvantages of PM and possible behaviour change mechanisms. RESULTS: Three themes and eight subthemes were identified. Participants identified that internal and external factors influence their self-concept. The identification of themselves as a priority, and empowerment by reassurance and affirmation lead to improved parent-carer self-efficacy and agency to better care for their CYP. Participants described the difficulty of speaking honestly with friends and family about what they experience because it is perceived as different to what "normal" parents experience. From participant accounts, PM enables the construction of a support network and links external services to help manage family circumstances rather than offer curative treatment/intervention. Proactive and immediate advice which is constantly and consistently available was valued by participants. Participants expressed the need for a flexible range of service components which provide holistic support that encompasses both health and social care. CONCLUSIONS: PM was perceived to be beneficial as a multi-component peer support service which increases parenting self-efficacy and empowerment, reduces isolation, improves access to services, and is tailored to individual needs. Parent-carers reported benefits in parenting and wellbeing practices. The development of a refined logic model will inform a future study of the effectiveness of PM on parent-carer outcomes.

Self-harm in university students: A comparative analysis of data from the Multicentre Study of Self-harm in England.

BACKGROUND: Increases in poor mental health and suicide have been identified among university students in the UK. However, little is known about self-harm in this group. AIMS: To describe and identify care needs of university aged-students who self-harm via comparisons with an age-equivalent non-student group who self-harm. METHODS: Observational cohort data from The Multicentre Study of Self-harm in England were used to investigate students aged 18 to 24 years who presented to emergency departments for self-harm, 2003 to 2016. Data were collected via clinician reports and medical records from five hospitals in three English regions. Characteristics, rates, repetition, and mortality outcomes were investigated. RESULTS: The student sample included 3491 individuals (983, 28.2 % men; 2507, 71.8 % women; 1 unknown) compared to 7807 (3342, 42.8 % men; 4465, 57.2 % women) non-students. Self-harm increased over time in students (IRR 1.08, 95%CI 1.06-1.10, p < 0.01) but not in non-students (IRR 1.01, 95%CI 1.00-1.02, p = 0.15). There were differences in monthly distribution of self-harm with more presentations by students in October, November, and February. Characteristics were broadly similar, but students reported more problems with studying and mental health. Repetition (HR 0.78, 95%CI 0.71-0.86, p < 0.01) and mortality (HR 0.51, 95%CI 0.33-0.80, p < 0.01) were lower in students than non-students. CONCLUSIONS: Self-harm in students may be directly related the student experience, such as academic pressure, relocation, and the transition to independent living. Wellbeing initiatives targeting these factors, alongside mental health awareness training for academic and non-academic staff may help to support students at risk.

Childhood predictors of self-harm, externalised violence and transitioning to dual harm in a cohort of adolescents and young adults.

BACKGROUND: The aetiology of dual harm (co-occurring self-harm and violence towards others) is poorly understood because most studies have investigated self-harm and violence separately. We aimed to examine childhood risk factors for self-harm, violence, and dual harm, including the transition from engaging in single harm to dual harm. METHODS: Data from the Avon Longitudinal Study of Parents and Children, a UK-based birth cohort study, were used to estimate prevalence of self-reported engagement in self-harm, violence, and dual harm at ages 16 and 22 years. Risk ratios were calculated to indicate associations across various self-reported childhood risk factors and risks of single and dual harm, including the transition from single harm at age 16 years to dual harm at age 22. RESULTS: At age 16 years, 18.1% of the 4176 cohort members had harmed themselves, 21.1% had engaged in violence towards others and 3.7% reported dual harm. At age 22 the equivalent prevalence estimates increased to 24.2, 25.8 and 6.8%, respectively. Depression and other mental health difficulties, drug and alcohol use, witnessing self-harm and being a victim of, or witnessing, violence were associated with higher risks of transitioning from self-harm or violence at age 16 to dual harm by age 22. CONCLUSIONS: Prevalence of dual harm doubled from age 16 to 22 years, highlighting the importance of early identification and intervention during this high-risk period. Several childhood psychosocial risk factors associated specifically with dual harm at age 16 and with the transition to dual harm by age 22 have been identified.

The characteristics, life problems and clinical management of older adults who self-harm: Findings from the multicentre study of self-harm in England.

BACKGROUND: Older adults have a high risk of suicide following self-harm. Contemporary information on self-harm in this population is needed to inform care provision. OBJECTIVES: To examine subgroup differences in the incidence of self-harm, sociodemographic and clinical characteristics, preceding life problems and outcomes in individuals aged 60 years and over presenting to hospital following self-harm. METHOD: Data on Emergency Department (ED) presentations for self-harm from 2003 to 2016 from three centres in the Multicentre Study of Self-Harm in England were analysed. Changes in self-harm rates were examined using Poisson regression. Univariable logistic regression was used to investigate factors associated with 12-month self-harm repetition. RESULTS: There were 3850 presentations for self-harm by 2684 individuals aged 60 years and over. Self-harm rates increased over time for 60-74-year-old men (Incident Rate Ratio = 1.04, 95% Confidence Interval 1.02-1.06, p < 0.0001). Problems most frequently reported to have preceded self-harm were mental health (40.5%) and physical health (38.3%) concerns. Problems with alcohol, finances, employment and relationship with partner were found more frequently in 60-74-year-olds compared with those aged over 74 years. Physical health problems were common with increasing age, as were problems with alcohol for men. One in ten (10.8%) individuals presented to hospital with self-harm within 12 months of their index presentation. CONCLUSIONS: Self-harm-related ED attendances in older men have increased, particularly for men aged 60-74 years. Prevention and clinical management should involve a comprehensive psychosocial assessment to target common precipitants for the wide range of problems preceding self-harm and may include support with physical and mental wellbeing and advice on safer alcohol use.

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.

Self-harm in people experiencing homelessness: investigation of incidence, characteristics and outcomes using data from the Multicentre Study of Self-Harm in England.

BACKGROUND: People who experience homelessness are thought to be at high risk of suicide, but little is known about self-harm in this population. AIMS: To examine characteristics and outcomes in people experiencing homelessness who presented to hospital following self-harm. METHOD: Data were collected via specialist assessments and/or hospital patient records from emergency departments in Manchester, Oxford and Derby, UK. Data were collected from 1 January 2000 to 31 December 2016, with mortality follow-up via data linkage with NHS Digital to 31 December 2019. Trend tests estimated change in self-harm over time; descriptive statistics described characteristics associated with self-harm. Twelve-month repetition and long-term mortality were analysed using Cox proportional hazards models and controlled for age and gender. RESULTS: There were 4841 self-harm presentations by 3270 people identified as homeless during the study period. Presentations increased after 2010 (IRR = 1.09, 95% CI 1.04-1.14, P < 0.001). People who experienced homelessness were more often men, White, aged under 54 years, with a history of previous self-harm and contact with psychiatric services. Risk of repetition was higher than in domiciled people (HR = 2.05, 95% CI 1.94-2.17, P < 0.001), as were all-cause mortality (HR = 1.45, 95% CI 1.32-1.59. P < 0.001) and mortality due to accidental causes (HR = 2.93, 95% CI 2.41-3.57, P < 0.001). CONCLUSIONS: People who self-harm and experience homelessness have more complex needs and worse outcomes than those who are domiciled. Emergency department contact presents an opportunity to engage people experiencing homelessness with mental health, drug and alcohol, medical and housing services, as well as other sources of support.

Self-harm in children 12 years and younger: characteristics and outcomes based on the Multicentre Study of Self-harm in England.

BACKGROUND: Very little is known about self-harm in children. We describe the characteristics and outcomes of children under 13 years who presented following self-harm to five hospitals in England. METHODS: We included children under 13 years who presented after self-harm to hospitals in the Multicentre Study of Self-harm in England. Information on patients' characteristics and method of self-harm was available through monitoring of self-harm in the hospitals. Area level of socioeconomic deprivation was based on the English Index of Multiple Deprivation (IMD). RESULTS: 387 children aged 5-12 years presented to the study hospitals in 2000-2016, 39% of whom were 5-11 years. Boys outnumbered girls 2:1 at 5-10 years. The numbers of boys and girls were similar at age 11, while at 12 years there were 3.8 girls to every boy. The proportion of study children living in neighbourhoods ranked most deprived (43.4%) was twice the national average. 61.5% of children self-poisoned, 50.6% of them by ingesting analgesics. Of children who self-injured, 45.0% self-cut/stabbed, while 28.9% used hanging/asphyxiation. 32% of the children had a repeat hospital presentation for self-harm, 13.5% re-presented within a year. CONCLUSIONS: Gender patterns of self-harm until age 11 years are different to those of adolescents, with a male preponderance, especially in 5-10 years, and hanging/suffocation being more common. The frequent use of self-poisoning in this age group highlights the need for public health messages to encourage safer household storage of medicines. Self-harm in children is strongly associated with socioeconomic deprivation; understanding the mechanisms involved could be important in effective prevention.

Self-harm in children and adolescents by ethnic group: an observational cohort study from the Multicentre Study of Self-Harm in England.

BACKGROUND: Studies report an increasing incidence of self-harm in children and adolescents, but the extent to which this is seen in different ethnic groups is unclear. We aimed to investigate rates of emergency department presentations for self-harm in children and adolescents by ethnicity, as well as to examine their demographic characteristics, clinical characteristics, and outcomes. METHODS: In this observational cohort study, we used data on hospital emergency department presentations for self-harm in children and adolescents aged 10-19 years between 2000 and 2016 from the Multicentre Study of Self-harm in England. This study collects data from five general hospitals in Manchester, Oxford, and Derby in the UK, and defines self-harm as any act of intentional self-injury or self-poisoning, regardless of intent. All children and adolescents aged 10-19 years for whom ethnicity data were available were included. Mortality follow-up was available through linkage with mortality records from the Office for National Statistics. Rates of self-harm over time, demographic and clinical characteristics, and self-harm methods were investigated by ethnic group. Risk of repeat self-harm and mortality following an initial presentation for self-harm was compared by ethnic group using Kaplan-Meier curves and Cox proportional hazards models. FINDINGS: Of 14 894 individuals who presented at hospitals with self-harm, 11 906 had data for ethnicity, of whom 10 211 (85·8%) were White, 344 (2·9%) were Black, 619 (5·2%) were South Asian, and 732 (6·1%) were other non-White. Rates of self-harm were highest in White children and adolescents but increased between 2009 and 2016 in all ethnicities. Mean annual rates of self-harm per 100 000 population were 574 for White, 225 for Black, 260 for South Asian, and 344 for other non-White groups. Increases in rates of self-harm between 2009 and 2016 appeared slightly greater in Black groups (incidence rate ratio 1·07 [95% CI 1·03-1·11]), South Asian groups (1·05 [1·01-1·09]), and other non-White groups (1·11 [1·06-1·16]) than in White groups (1·02 [1·00-1·03]). Children and adolescents from a minority ethnic background were more likely to live in areas of high deprivation and were less likely to receive a specialist psychosocial assessment than were White children and adolescents. Children and adolescents from minority ethnic groups were also less likely to repeat self-harm. However, there were no differences in suicide mortality by ethnic group, although the numbers were small. INTERPRETATION: Minority ethnic children and adolescents accounted for an increased proportion of self-harm presentations to hospital over time compared with White ethnic groups. The minority ethnic groups also tended to be more socioeconomically disadvantaged and were less likely to receive a psychosocial assessment. Socioeconomic disparities need to be addressed, and equitable access to culturally sensitive comprehensive psychosocial assessments must be ensured. FUNDING: UK Department of Health and Social Care.

Exploring characteristics and risk of repetition in people who fail to report previous hospital presentations for self-harm: A case-control study using data from The Manchester Self-Harm Project.

BACKGROUND: As a risk factor for future self-harm and suicide, questions about past self-harm are typically included in assessments that help inform management of people who self-harm. However, little is known about people with a history of self-harm who do not report it. This study aimed to describe and compare (i) characteristics of people who did or did not accurately report previous self-harm, and (ii) 12-month repetition of self-harm. METHODS: Data on all self-harm presentations to three hospital emergency departments in England were collected from 2003 to 2015. A 1:5 matched case-control design included 374 cases where previous self-harm was not reported and 1,870 controls where previous self-harm was reported. Data were analysed using conditional logistic regression and survival analysis. RESULTS: Cases were more likely to be male (OR 1.42; 95% CI 1.13-1.77), middle-aged (OR 1.41; 95% CI 1.08-1.83), employed (OR 1.51; 95% CI 1.15-1.98), and less likely be referred to psychiatric services (OR 0.53; 95% CI 0.35-0.80). Twelve-month repetition was similar in cases and controls (30% vs 31%). LIMITATIONS: Self-harm not resulting in a hospital presentation could not be verified and individuals with a single episode in the study database were therefore excluded. CONCLUSIONS: Previous self-harm is an important risk factor for repetition in people who accurately recall and report it and those who fail to report it. Those who do not report previous self-harm are less likely to be referred to psychiatric services, emphasising the need for careful assessment of every self-harm presentation to emergency departments.

Suicide following presentation to hospital for non-fatal self-harm in the Multicentre Study of Self-harm: a long-term follow-up study.

BACKGROUND: Self-harm is the strongest risk factor for subsequent suicide, but risk may vary. We compared the risk of suicide following hospital presentation for self-harm according to patient characteristics, method of self-harm, and variations in area-level socioeconomic deprivation, and estimated the incidence of suicide by time after hospital attendance. METHODS: In this ongoing Multicentre Study of Self-harm in England, the study population consists of individuals aged at least 15 years who had attended the emergency department of five general hospitals in Oxford, Manchester, and Derby after non-fatal self-harm between Jan 1, 2000, and Dec 31, 2013. Information on method of self-harm was obtained through systematic monitoring in hospitals. Level of socioeconomic deprivation was based on the Index of Multiple Deprivation (IMD) characterising the area where patients lived, grouping them according to IMD quintiles. Mortality follow-up was up to Dec 31, 2015, resulting in up to 16 years of follow-up. We calculated incidence of suicide since first hospital presentation by follow-up period and estimated the association between individual factors (age, gender, method of self-harm, IMD, and number of non-fatal self-harm presentations to hospital) and suicide using mixed-effect models. FINDINGS: Between Jan 1, 2000, and Dec 31, 2013, there were 92 177 presentations to the study hospitals by 51 108 individuals. 1325 patients involved in 1563 self-harm episodes were excluded from the study because they had missing information on gender, age, or mortality. The resulting study sample consisted of 90 614 hospital presentations by 49 783 individuals. By the end of follow-up on Dec 31, 2015, 703 patients had died by suicide. The overall incidence of suicide was 163·1 (95% CI 151·5-175·6) per 100 000 person-years, and 260·0 (237·4-284·8) per 100 000 person-years in men and 94·6 (83·3-107·4) per 100 000 person-years in women. The incidence of suicide was highest in the year following discharge from hospital (511·1 [451·7-578·2] per 100 000 person-years), particularly in the first month (1787·1 [1423·0-2244·4] per 100 000 person-years). Based on all presentations to hospital, men were three times more likely than women to die by suicide after self-harm (OR 3·36 [95% CI 2·77-4·08], p<0·0001). Age was positively related to suicide risk in both genders, with a 3% increase in risk for every one-year increase in age at hospital presentation (OR 1·03 [1·03-1·04], p<0·0001). Relative to hospital presentations after self-poisoning alone, presentations involving both self-injury and self-poisoning were associated with higher suicide risk (adjusted OR 2·06 [95% CI 1·42-2·99], p<0·0001], as were presentations after self-injury alone (adjusted OR 1·36 [1·09-1·70], p=0·007). Similarly, relative to self-harm by self-poisoning alone, attempted hanging or asphyxiation (adjusted OR 2·70 [1·53-4·78], p=0·001) and traffic-related acts of self-injury (adjusted OR 2·99 [1·17-7·65], p=0·022) were associated with greater risk of suicide. Self-cutting combined with self-poisoning was also associated with increased suicide risk (adjusted OR 1·36, [1·08-1·71], p=0·01). Compared with those patients living in the most deprived areas, those who lived in the least deprived areas (first national IMD quintile) had a greater risk of dying by suicide (adjusted OR 1·76 [1·32-2·34], p<0·0001) after adjusting for gender, age, previous self-harm, and psychiatric treatment, as did those living in the second least deprived areas (adjusted OR 1·64 [1·20-2·25], p=0·002). INTERPRETATION: Patients attending hospital for self-harm are at high risk of suicide, especially immediately after hospital attendance. Certain patient characteristics and methods of self-harm, together with living in areas of low socioeconomic deprivation, can increase patients' subsequent suicide risk. However, while specific risk factors can be usefully integrated into the assessment process, individual factors have poor utility in predicting suicide, so the needs and risks of all patients should be assessed to develop appropriate aftercare plan, including early follow-up. FUNDING: UK Department of Health and Social Care.