Emergency department staff experiences of working with people who self-harm: A qualitative examination of barriers to optimal care.

For people who seek help for self-harm, emergency departments (ED) are often the first point of contact, making them a suitable setting for intervention. In Australia, base rates of self-harm presentations to ED are increasing, while the quality of care these people receive is often considered sub-optimal. This study used qualitative interviews to explore potential barriers ED staff face in delivering best possible self-harm care. Seventeen staff across two EDs in the state of Victoria, Australia, were interviewed regarding their perceptions of barriers to providing optimal self-harm care and suggestions for improvement. Three themes were identified: (1) system-related challenges when managing self-harm in ED, including the shortage of hospital resources, challenges of ED as a physical environment, and insufficient education, training and guidelines about self-harm care for staff; (2) human-related challenges regarding management of self-harm in ED, which encompassed the nature of a person's circumstances and presentation, and staff attitudes towards self-harm; and (3) staff suggestions for improving self-harm care in ED. Specific recommendations that were proposed based on these findings included introducing a separate ED area for mental health-related presentations, provision of specialised education and training about self-harm care to staff, better implementation of guidelines on treating self-harm in ED, and employing mental health educators to provide on-the-floor mentoring to nurses. The relevance of these barriers and recommendations to the wider healthcare sector is also discussed. Together, these findings may inform improvements to the quality of care provided to those who engage in self-harm.

Self-reported explanations for self-injury by people with intellectual disabilities: a systematic review of qualitative studies.

Background: Emotional distress has received less attention as an explanatory factor for self-injury in people with intellectual disabilities, with research and practice primarily focusing on biobehavioural factors. This systematic review examines the self-reported explanations for self-injury by people with mild or moderate intellectual disabilities, and discusses how the findings contrast with those from self-reported studies of people within the general population who self-harm. Methods: Five databases (PsychINFO, IBSS, CINAHL, Web of Science and Medline) were systematically searched to find qualitative, empirical research since 2000 about self-reported reasons for self-injury. Results: Four studies were found which conducted research with people with intellectual disabilities. Three primary themes are discussed: relief from overwhelming emotions; trauma and loss; and difficulty in articulating emotions. Conclusion: This review found a paucity of research asking people with intellectual disabilities about their own self-injury. However, the research available suggests that explanatory factors for self-injury typically reported in the general population should be considered for those with mild or moderate intellectual disabilities.

Characteristics of children with autism and unspecified intellectual developmental disorder (intellectual disability) presenting with severe self-injurious behaviours.

Objective: This study aims to delineate the characteristics of severe self-injurious behaviors (SIB) in a cohort of children with autism and unspecified intellectual developmental disorder (UIDD) (intellectual disability) and examine potential risk factors for developing SIB. Methods: A retrospective chart review studied characteristics of severe SIB in 30 children with autism spectrum disorder (ASD) and UIDD referred to a tertiary care center. Characteristics examined include genetic syndromes, brain MRI abnormalities, verbal ability, adaptive functioning, SIB frequency and severity, age of onset, number of psychopharmacological agents, irritability, hyperactivity, stereotypy, psychiatric and physical comorbidities, among others. Descriptive and bivariate analysis were applied to explore potential relationships between factors. Results: Children with severe SIB exhibit this behaviour with high frequency, inflicting moderate to severe injury. Most children in the study sample are non-verbal and have ASD (93.3%; n = 28) with psychiatric (96.7%; n = 29) and physical (90%; n = 27) comorbidities. Overall SIB improvement using the Clinical Global Impression, Improvement Score (CGI-I) was 3.0 (minimally improved). A minority were much or very much improved following appropriate intervention. Conclusions: The severity of SIB is much higher in this sample than previously noted in the literature. Severe SIB is associated with ADHD, early onset mood disorders, tics, avoidant restrictive food intake disorder and Obsessive-Compulsive Disorder.

Evaluation of a community-based brief intervention service for youth in crisis with suicidal ideation or self-harm.

AIM: To evaluate the implementation of a mixed virtual and in-person brief intervention for young people, aged 12-25 years, presenting to a large urban mental health service in crisis with suicidal ideation and/or self-harm. METHODS: A pragmatic, real-world evaluation was conducted on the Youth Brief Intervention Service between June 2021 (inception) and October 2022. Service users were offered four sessions over an approximate one-month period. Sessions focused on distress tolerance, safety plans and support systems. Implementation outcomes related to service uptake, retention, fidelity of the model and service user experience. Effectiveness outcomes were measured pre-post and included mental health-related hospital service utilization (primary outcome), functioning, mental health status, self-harm, suicidal ideation and quality of life. RESULTS: Of the 136 young people referred to the Youth Brief Intervention Service, 99 were accepted with 17 disengaging before the first session. Eighty percent of people who commenced, completed the package of care. Young persons' and parent/carers experience of service was high (97% and 88%, respectively). Mental health-related emergency department presentations and inpatient days decreased from 3 months pre-intake to 3 months post-intake (42 vs. 7 presentations, X2 = 25.3, p < .001; 11 vs. 0 inpatient days, X2 = 9.1, p = .01). There were significant improvements in mental health status, days engaging in self-harm, general health and functioning and quality of life. CONCLUSIONS: The Youth Brief Intervention Service is feasible, acceptable, subjectively beneficial and coincided with less mental health-related emergency department presentations and inpatient days, and improved mental health status and behaviour.

Opening the black box of registration practice for self-harm and suicide attempts in emergency departments: a qualitative study.

BACKGROUND: The World Health Organization has called for improved surveillance of self-harm and suicide attempts worldwide to benefit suicide prevention programs. International comparisons of registrations are lacking, however, and there is a need for systematically collected, high-quality data across countries. The current study investigated healthcare professionals' perceptions of registration practices and their suggestions for ensuring high-quality registration of self-harm and suicide attempts. METHODS: Qualitative interviews (N = 20) were conducted among medical secretaries, medical doctors, nurses, and registration advisers from psychiatric and somatic emergency departments in all regions of Denmark between September 2022 and March 2023. Content analysis was performed using NVivo. RESULTS: Despite great efforts to standardize and assure the quality of registration in Denmark, almost all the healthcare professionals perceived registration practice as inconsistent and unreliable. Codes are often misclassified or unused due to insufficient time, non-standardized training, or insufficient information. The interview informants suggested that coding guidelines should be simplified and made more visible, alongside technical solutions in the electronic health record system. CONCLUSION: The study findings resulted in eight overall recommendations for clinical practice that aim at improving the registration of patients presenting with self-harm or suicide attempts. This would be expected to help improve surveillance and prevention programs.

Non-suicidal self-injury at a Canadian paediatric emergency department.

OBJECTIVE: Our primary objective was to determine agreement between non-suicidal self-injury recorded at triage and during subsequent mental health assessment. The secondary objective was to describe patients who reported non-suicidal self-injury. METHODS: This is a health records review of patients aged 12-18 years who had an Emergency Mental Health Triage form on their health record from an ED visit June 1, 2017-May 31, 2018. We excluded patients with diagnoses of autism spectrum disorder or schizophrenia. We abstracted data from the Mental Health Triage form, Emergency Mental Health and Addictions Service Assessment forms and Assessment of Suicide and Risk Inventory. We calculated Cohen's Kappa coefficient, sensitivity, and negative predictive value to describe the extent to which the forms agreed and the performance of triage for identifying non-suicidal self-injury. We compared the cohort who reported non-suicidal self-injury with those who did not, using t-tests, Wilcoxon rank-sum tests, and chi-square tests. RESULTS: We screened 955 ED visits and included 914 ED visits where 558 (58.4%) reported a history of non-suicidal self-injury. There were significantly more females in the group reporting non-suicidal self-injury (82.1%, n = 458) compared to the group not reporting non-suicidal self-injury (45.8%, n = 163). Patients reporting non-suicidal self-injury did so in triage and detailed Mental Health Assessment 64.7% of the time (Cohen's Kappa Coefficient 0.6); triage had sensitivity of 71.5% (95% CI 67.3-75.4) and negative predictive value of 71.2% (95% CI 68.2-74.0). Cutting was the most common method of non-suicidal self-injury (80.3%). CONCLUSION: Screening at triage was moderately effective in identifying non-suicidal self-injury compared to a detailed assessment by a specialised mental health team. More than half of children and adolescents with a mental health-related concern in our ED reported a history of non-suicidal self-injury, most of which were female. This symptom is important for delineating patients' coping strategies.

RéSUMé: OBJECTIFS: Notre objectif principal était de déterminer l'accord entre les blessures non suicidaires enregistrées au triage et lors de l'évaluation subséquente de la santé mentale. L'objectif secondaire était de décrire les patients qui ont déclaré une automutilation non suicidaire. MéTHODES: Il s'agit d'un examen des dossiers de santé de patients âgés de 12 à 18 ans qui avaient un formulaire de triage d'urgence en santé mentale dans leur dossier de santé à la suite d'une visite à l'urgence du 1er juin 2017 au 31 mai 2018. Nous avons exclu les patients présentant un diagnostic de trouble du spectre autistique ou de schizophrénie. Nous avons extrait des données du formulaire de triage en santé mentale, des formulaires d'évaluation des services d'urgence en santé mentale et en toxicomanie et de l'évaluation du suicide et de l'inventaire des risques. Nous avons calculé le coefficient de Kappa de Cohen, la sensibilité et la valeur prédictive négative pour décrire la mesure dans laquelle les formes étaient d'accord et la performance du triage pour identifier l'automutilation non suicidaire. Nous avons comparé la cohorte qui a déclaré une automutilation non suicidaire avec celles qui ne l'ont pas fait, en utilisant des tests t-tests, des tests Wilcoxon rank-sum et des tests chi-carrés. RéSULTATS: Nous avons examiné 955 visites à l'urgence et inclus 914 visites à l'urgence où 558 (58,4 %) ont signalé des antécédents d'automutilation non suicidaire. Il y avait beaucoup plus de femmes dans le groupe déclarant une automutilation non suicidaire (82,1 %, n = 458) que dans le groupe ne déclarant pas une automutilation non suicidaire (45,8 %, n = 163). Les patients ayant déclaré une automutilation non suicidaire l'ont fait dans le cadre du triage et de l'évaluation détaillée de la santé mentale 64,7 % du temps (coefficient de Kappa de Cohen 0,6); le triage avait une sensibilité de 71,5 % (IC à 95 % 67,3­75,4) et une valeur prédictive négative de 71,2 % (IC à 95 % 68,2­74,0). La coupe était la méthode la plus courante d'automutilation non suicidaire (80,3 %). CONCLUSION: Le dépistage au triage a été modérément efficace pour identifier les blessures non suicidaires comparativement à une évaluation détaillée par une équipe spécialisée en santé mentale. Plus de la moitié des enfants et des adolescents ayant un problème de santé mentale à notre DE ont signalé des antécédents d'automutilation non suicidaire, dont la plupart étaient des femmes. Ce symptôme est important pour délimiter les stratégies d'adaptation des patients.

When the time is right: Men's experiences of recovery in self-harm.

Previous research has mainly focused on self-harm among women, defining what it is, what functions it has, how to manage and prevent self-harm, and how to recover from it. A recent review of the literature on self-harm among men concluded that research need to consider both clinical and personal aspects of recovery and pointed out the need to explore recovery from men's point of view. This study aimed to describe men's experiences of recovery in self-harm. Data were collected in Sweden in 2020 using semi-structured interviews. Eleven men who had recovered in self-harm were interviewed. Interviews were analysed using an abductive approach to qualitative content analysis. The analysis involved the application of an established framework for personal recovery in mental illness: connectedness, hope, identity, meaning, and empowerment (CHIME). The analysis identified one main theme: when the time is right, and five sub-themes: finding support in others; trusting that change is possible; getting to know yourself; reaching a new understanding; and developing new strategies to manage life. While the cessation of self-harm might both be a sign of and contribute to recovery, it is not the defining feature of recovery. Mental health professionals should be persistent in providing person-centred, recovery-oriented care for men who self-harm. The CHIME framework can be applied in the context of men's recovery in self-harm. This study is reported in accordance with the COREQ guidelines.

Development and evaluation of a de-escalation training intervention in adult acute and forensic units: the EDITION systematic review and feasibility trial.

Background: Containment (e.g. physical restraint and seclusion) is used frequently in mental health inpatient settings. Containment is associated with serious psychological and physical harms. De-escalation (psychosocial techniques to manage distress without containment) is recommended to manage aggression and other unsafe behaviours, for example self-harm. All National Health Service staff are trained in de-escalation but there is little to no evidence supporting training's effectiveness. Objectives: Objectives were to: (1) qualitatively investigate de-escalation and identify barriers and facilitators to use across the range of adult acute and forensic mental health inpatient settings; (2) co-produce with relevant stakeholders an intervention to enhance de-escalation across these settings; (3) evaluate the intervention's preliminary effect on rates of conflict (e.g. violence, self-harm) and containment (e.g. seclusion and physical restraint) and understand barriers and facilitators to intervention effects. Design: Intervention development informed by Experience-based Co-design and uncontrolled pre and post feasibility evaluation. Systematic reviews and qualitative interviews investigated contextual variation in use and effects of de-escalation. Synthesis of this evidence informed co-design of an intervention to enhance de-escalation. An uncontrolled feasibility trial of the intervention followed. Clinical outcome data were collected over 24 weeks including an 8-week pre-intervention phase, an 8-week embedding and an 8-week post-intervention phase. Setting: Ten inpatient wards (including acute, psychiatric intensive care, low, medium and high secure forensic) in two United Kingdom mental health trusts. Participants: In-patients, clinical staff, managers, carers/relatives and training staff in the target settings. Interventions: Enhancing de-escalation techniques in adult acute and forensic units: Development and evaluation of an evidence-based training intervention (EDITION) interventions included de-escalation training, two novel models of reflective practice, post-incident debriefing and feedback on clinical practice, collaborative prescribing and ward rounds, practice changes around admission, shift handovers and the social and physical environment, and sensory modulation and support planning to reduce patient distress. Main outcome measures: Outcomes measured related to feasibility (recruitment and retention, completion of outcome measures), training outcomes and clinical and safety outcomes. Conflict and containment rates were measured via the Patient-Staff Conflict Checklist. Clinical outcomes were measured using the Attitudes to Containment Measures Questionnaire, Attitudes to Personality Disorder Questionnaire, Violence Prevention Climate Scale, Capabilities, Opportunities, and Motivation Scale, Coercion Experience Scale and Perceived Expressed Emotion in Staff Scale. Results: Completion rates of the proposed primary outcome were very good at 68% overall (excluding remote data collection), which increased to 76% (excluding remote data collection) in the post-intervention period. Secondary outcomes had high completion rates for both staff and patient respondents. Regression analyses indicated that reductions in conflict and containment were both predicted by study phase (pre, embedding, post intervention). There were no adverse events or serious adverse events related to the intervention. Conclusions: Intervention and data-collection procedures were feasible, and there was a signal of an effect on the proposed primary outcome. Limitations: Uncontrolled design and self-selecting sample. Future work: Definitive trial determining intervention effects. Trial registration: This trial is registered as ISRCTN12826685 (closed to recruitment). Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/101/02) and is published in full in Health Technology Assessment; Vol. 28, No. 3. See the NIHR Funding and Awards website for further award information. Context: Conflict (a term used to describe a range of potentially unsafe events including violence, self-harm, rule-breaking, medication refusal, illicit drug and alcohol use and absconding) in mental health settings causes serious physical and psychological harm. Containment interventions which are intended to minimise harm from violence (and other conflict behaviours) such as restraint, seclusion and rapid tranquilisation can result in serious injuries to patients and, occasionally, death. Involvement in physical restraint is the most common cause of serious physical injury to National Health Service mental health staff in the United Kingdom. Violence to staff results in substantial costs to the health service in sickness and litigation payments. Containment interventions are also expensive (e.g. physical restraint costs mental health services £6.1 million and enhanced observations £88 million per annum). Despite these harms, recent findings indicate containment interventions such as seclusion and physical restraint continue to be used frequently in mental health settings. Clinical trials have demonstrated that interventions can reduce containment without increasing violence and other conflict behaviours (e.g. verbal aggression, self-harm). Substantial cost-savings result from reducing containment use. De-escalation, as an intervention to manage aggression and potential violence without restrictive practices, is a core intervention. 'De-escalation' is a collective term for a range of psychosocial techniques designed to reduce distress and anger without the need to use 'containment' interventions (measures to prevent harm through restricting a person's ability to act independently, such as physical restraint and seclusion). Evidence indicates that de-escalation involves ensuring conditions for safe intervention and effective communication are established, clarifying and attempting to resolve the patient's concern, conveyance of respect and empathy and regulating unhelpful emotions such as anxiety and anger. Despite featuring prominently in clinical guidelines and training policy domestically and internationally and being a component of mandatory National Health Service training, there is no evidence-based model on which to base training. A systematic review of de-escalation training effectiveness and acceptability conducted in 2015 concluded: (1) no model of training has demonstrated effectiveness in a sufficiently rigorous evaluation, (2) the theoretical underpinning of evaluated models was often unclear and (3) there has been inadequate investigation of the characteristics of training likely to enhance acceptability and uptake. Despite all National Health Service staff being trained in de-escalation there have been no high-quality trials evaluating the effectiveness and cost-effectiveness of training. Feasibility studies are needed to establish whether it is possible to conduct a definitive trial that can determine the clinical, safety and cost-effectiveness of this intervention.

Mental health hospitals are stressful places for patients and staff. Patients are often detained against their will, in places that are noisy, unfamiliar and frightening. Violence and self-injury happen quite frequently. Sometimes staff physically restrain patients or isolate patients in locked rooms (called seclusion). While these measures might sometimes be necessary to maintain safety, they are psychologically and physically harmful. To help reduce the use of these unsafe measures, staff are trained in communication skills designed to reduce anger and distress without using physical force. Professionals call these skills 'de-escalation'. Although training in de-escalation is mandatory, there is no good evidence to say whether it works or not, or what specific techniques staff should be trained in. The Enhancing de-escalation techniques in adult acute and forensic units: Development and evaluation of an evidence-based training intervention (EDITION) project aimed to develop and evaluate a de-escalation training programme informed by research evidence. We interviewed over one hundred people who either worked in or received treatment in a mental health hospital. These people were clear that the training should target key sources of interpersonal and environmental stress that prevent de-escalation from working. We also reviewed all the scientific studies on de-escalation and training, aiming to identify the elements of training that are most likely to increase use of de-escalation. Then, in partnership with current mental health service users and clinical staff, we developed the training programme. Training was delivered to more than 270 staff working in 10 different wards in mental health hospitals. We measured rates of violence, self-injury and use of physical restraint and seclusion 8 weeks before staff received training and 16 weeks after they received training (24 weeks of data collection in total). Analysis of these data showed that these unsafe events were occurring significantly less frequently after training than they were before training, which raised the possibility that the training was helping to reduce harm.

Exposure to patient aggression and health outcomes for forensic mental health nurses: A cross-sectional survey.

AIMS: The aims of the study were to determine the types and prevalence of forensic mental health nurse exposure to patient aggression and explore the impact of these exposures on their physical and mental health and work absences. DESIGN: Cross-sectional survey conducted January to April 2020. METHODS: All 205 nurses working in an Australian high-security inpatient forensic mental health hospital were invited to participate. An online survey included the Perception of Prevalence of Aggression Scale to measure respondent exposure to types of patient aggression, and the SF-36v2 to measure mental and physical health. Absence from work and other work and individual characteristics were also explored. RESULTS: Sixty-eight respondents completed the survey. Verbal abuse was the most experienced aggression type, followed by physical violence and observing violence, patient self-harming behaviours and sexual violence. Nurses who worked in acute units experienced significantly more exposure to overall aggression than nurses in non-acute units. Higher level of aggression was associated with number of days sick leave taken and days off due to aggression or violence. Higher level of aggression was associated with poorer mental health, and patient self-harming behaviour was associated with poorer physical health. CONCLUSIONS: Nurses in acute units experience higher levels of inpatient aggression and are therefore at increased risk of being impacted by the exposure. Findings indicate a psychological impact of exposure to frequent aggression and potential for an accumulative effect of exposure to traumatic events on nurse well-being. Nurses who are victim of, or witness, physical violence are most likely to take time off work. IMPACT: This study provides further evidence that forensic mental health nurses are frequently exposed to various forms of patient aggression. For some nurses, this exposure to patient aggression negatively impacted their mental and physical health. Employing organizations should therefore prioritize provision of formal support for nurses. No patient or public contribution.

Parental attachment and childhood trauma in adolescents engaged in non-suicidal self-injury.

AIM: In this study, it was aimed to compare parental attachment and childhood traumas in adolescents with NSSI with healthy peers. METHODS: Fifty adolescents aged 14-18 years with lifetime NSSI and 56 healthy peers were included in the study. Inventory of Statements About Self-injury (ISAS), The Parental Bonding Instrument (PBI) and Child Trauma Questionnaire (CTQ-28) scales were used. RESULTS: Eighty-two percentage of the NSSI group and 70% of the control group were girls. The mean age was 15.6 ± 1.1 years in the NSSI group and 15.3 ± 0.9 years in the control group. There was no significant difference between the groups in terms of age and gender. The NSSI group had more negative scores than the control group in terms of childhood traumas and attachment characteristics to both mother and father. The analyses showed that mother PBI care/control and sexual abuse score had a relationship with both ISAS Autonomic Functions and ISAS Social Functions scores. CONCLUSIONS: These results suggest that secure attachment with the mother may be protective for both the autonomic and social functions of the NSSI. Therefore, interventions for dysfunctional parental attachment may prevent the development of NSSI.

The influence of peer non-suicidal self-harm on young adults' urges to self-harm: experimental study.

OBJECTIVE: To test the hypothesis that exposure to peer self-harm induces adolescents' urges to self-harm and that this is influenced by individual suggestibility. METHODS: We recruited 97 UK-based adults aged 18-25 years with a recent history of self-harm, measuring baseline suggestibility (Resistance to Peer Influence; RPI) and perceived ability to control urges to self-harm (using an adapted item from the Self-Efficacy to Resist Suicidal Action scale; SEASA) before and after two self-harm vignettes featuring named peers from the participant's social network (to simulate exposure to peer non-suicidal self-harm) and after a wash-out exposure. We used paired t-tests to compare mean SEASA scores pre- and post-exposure, and linear regression to test for an association between RPI and change in SEASA scores pre- and post-exposure. RESULTS: Perceived ability to control urges to self-harm was significantly reduced following exposure to peer self-harm (t(96) = 4.02, p < 0.001, mean difference = 0.61; 95% CI = 0.31, 0.91), but was not significantly different from baseline after exposure to a wash-out. We found no association between suggestibility and change in urges to self-harm after exposure to peer self-harm. CONCLUSION: Our findings support social influences on self-harm in a sample of young adults, regardless of their individual degree of suggestibility.

Review: Systematic review and metasynthesis of qualitative literature on young people's experiences of going to A&E/emergency departments for mental health support.

BACKGROUND: There has been an increase in children and young people attending emergency departments for mental health reasons, including self-harm. Patients often report having poor experiences when attending emergency departments for mental health support. However, there has yet to be a review exploring the experiences of young people. Our aim in this study was to synthesise qualitative literature on young people's experiences of going to emergency departments for mental health support. METHODS: A systematic review and metasynthesis were conducted. Five databases and grey literature were searched for relevant studies. Five articles met study criteria and were analysed using an iterative process of thematic synthesis. RESULTS: The synthesis yielded four overarching themes: (a) emergency departments' inability to meet the mental health needs of young people, (b) emergency departments exacerbating patient distress, (c) patients feeling like a burden or undeserving of treatment and (d) consequences of poor emergency department experiences. CONCLUSIONS: These findings (based on a still very limited literature) highlight the role that emergency departments have in relation to being a key point of contact with young people who self-harm. To properly engage with patients, emergency departments need to have the resources to provide compassionate care and follow clinical guidelines regarding assessments.

Definitions and incidence rates of self-harm and suicide attempts in Europe: A scoping review.

INTRODUCTION: European countries use various terminologies for self-harm and attempted suicide, which are sometimes used interchangeably. This complicates cross-country comparisons of incidence rates. This scoping review aimed to examine the definitions used and the possibilities to identify and compare incidence rates of self-harm and attempted suicide in Europe. METHODS: A literature search was conducted in Embase, Medline and PsycINFO for studies published from 1990 to 2021, followed by grey literature searches. Data were collected for total populations originating from health care institutions or registries. Results were presented in tabular form supplemented by a qualitative summary by area. RESULTS: A total of 3160 articles were screened, resulting in 43 studies included from databases and further 29 studies from other sources. Most studies used the term 'suicide attempt' rather than 'self-harm' and reported person-based rates with annual incidence rates from age 15+. None of the rates were considered comparable due to different reporting traditions related to classification codes and statistical approaches. CONCLUSION: The present extensive literature on self-harm and attempted suicide cannot be used to compare findings between countries because of the high degree of heterogeneity among studies. International agreement on definitions and registration practices is needed to improve knowledge and understanding of suicidal behaviour.

Estudio Transdiagnóstico de la Impulsividad y de la Conducta Autolítica en los Trastornos Impulsivos e Inestables / Transdiagnostic study of impulsivity and self-injurious behavior in unstable and impulsive disorders

Introducción. La elevada comorbilidad entre el trastorno límite de la personalidad (TLP) y los trastornos de la conducta alimentaria (TCA) pone de manifiesto la necesidad de establecer modelos transdiagnósticos, donde la impulsividad podría tener un papel relevante en las manifestaciones dela conducta autolítica. Objetivos: 1) Comparar los niveles de impulsividad y conducta autolítica entre personas con TLP, personas con TCA y controles. 2) Predecir la presencia de conductas autolíticas a partir de la impulsividad y otras variables clínicas relevantes, como la vivencia de acontecimientos traumáticos y la sensibilidad al rechazo. Método. 108 mujeres (23 controles; 29 con diagnóstico de TCA restrictivo (TCAr); 21 con diagnóstico de TCA purgativo (TCAp); y 35 con diagnóstico de TLP) fueron evaluadas a través de la Escala de Impulsividad de Barratt, el Cuestionario para Experiencias Traumáticas y el Cuestionario de Sensibilidad al Rechazo. La información sobre conducta autolítica fue recogida a través de entrevista e historia clínica. Resultados. Se encontraron diferencias en las puntuaciones de impulsividad y conducta autolítica entre los grupos, encontrándose mayor impulsividad en los grupos TLP y TCAp, y mayores índices de conducta autolítica en el grupo TLP seguido de ambos grupos de TCA. Por otro lado, la impulsividad predecía los intentos de suicidio, y junto con la sensibilidad al rechazo interpersonal predecía las autolesiones no suicidas (ANS).Conclusión. La impulsividad es una variable dimensional en el TLP y en los TCA, que a su vez juega un papel relevante en la predicción de las conductas autolíticas. (AU)

Introduction. High comorbidity between borderline personality disorder (BPD) and eating disorders (ED) shows the necessity of developing transdiagnostic models, where impulsivity could play a relevant role in the manifestations ofself-injurious behaviour. Objectives: 1) To compare the levelsof impulsivity and self-injurious behaviour among peoplewith BPD, people with ED and controls. 2) To predict the presence of self-injurious behaviour based on impulsivity andother relevant clinical variables, such as the experience oftraumatic events and sensitivity to rejection. Methods. 108 women (23 controls; 29 with a diagnosis of restrictive ACT (rED); 21 with a diagnosis of purgative ACT(pED); and 35 with a diagnosis of BPD) were assessed usingthe Barratt Impulsivity Scale, the Traumatic Experiences Questionnaire and the Sensitivity to Rejection Questionnaire. Information about self-injurious behaviour was collectedthrough interview and clinical history. Results. Differences in impulsivity and self-injurious behaviour scores were found between the groups, with higherimpulsivity in the BPD and pED groups, and higher rates ofself-injurious behaviour in the BPD group followed by both ED groups. On the other hand, impulsivity predicted suicideattempts, and together with sensitivity to interpersonal rejection predicted nonsuicidal self-harm (NSSH). Conclusion. Impulsivity is a dimensional variable in BPD and ED, which in turn plays a relevant role in the prediction of self-injurious behaviour. (AU)

Maternal incarceration increases the risk of self-harm but not suicide: a matched cohort study.

AIMS: Children of incarcerated mothers are at increased risk of experiencing multiple adversity such as poverty, mental illness and contact with child protection services (CPS), including being taken into out of home care (OOHC). However, little is known about whether these children are at increased risk of suicide or self-harm compared to children not exposed to maternal incarceration or about the factors that may contribute to this. We aimed to investigate differences in the risk of suicide and self-harm between children exposed to maternal incarceration and those not exposed and examine how socio-demographic factors, maternal mental illness and CPS contact (with or without OOHC) may affect these outcomes. METHODS: We used a retrospective matched cohort study design, comparing 7674 children exposed to maternal incarceration with 7674 non-exposed children. We used multivariable Cox proportional hazards regression to compare the risk of suicide and self-harm between exposed and non-exposed groups, controlling for geographical remoteness, CPS contact and maternal mental illness. RESULTS: There was no significant difference in the rate of suicide (rate ratio [RR] = 1.49; 95% confidence interval [CI]: 0.78, 2.87) or risk of suicide (adjusted hazard ratio [aHR] = 0.92; 95% CI: 0.43, 1.96) between the two groups. However, the exposed group had a significantly higher rate of self-harm (RR = 2.83; 95% CI: 2.50, 3.21) and a significantly higher risk of self-harm (aHR = 1.74; 95% CI: 1.45, 2.09) compared to those non-exposed. CPS contact with or without OOHC was independently associated with an increased risk of self-harm for both groups. CONCLUSION: Children exposed to maternal incarceration are at an increased risk of self-harm and should be prioritized to receive targeted, multimodal support that continues after the mother's release from prison. The association between CPS contact and self-harm warrants further research.

A systematic review and meta-analysis of suicidality in autistic and possibly autistic people without co-occurring intellectual disability.

BACKGROUND: Suicidality is highly prevalent in autistic people without co-occurring intellectual disabilities, and high autistic traits are found in adults who have attempted suicide. However, prevalence rates for both autistic and possibly autistic people have not been synthesised meta-analytically. AIMS: To (1) calculate pooled prevalence estimates of suicidality in autistic people and possibly autistic people without co-occurring intellectual disability; (2) evaluate the influence of participant and study level characteristics on heterogeneity; and (3) determine the quality of evidence. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. PsycINFO, Embase, MEDLINE and Web of Science were systematically searched from 1992 to January 25, 2022. Empirical quantitative studies reporting prevalence of suicidal ideation, suicide plans, or suicide attempts and behaviours were considered for inclusion. Random effects models were used to estimate pooled prevalence of each suicidality outcome with 95% confidence intervals. Heterogeneity was explored using sensitivity and moderator analyses. RESULTS: Data from 48,186 autistic and possibly autistic participants in 36 primary studies were meta-analysed. Pooled prevalence of suicidal ideation was 34.2% (95% CI 27.9-40.5), suicide plans 21.9% (13.4-30.4), and suicidal attempts and behaviours 24.3% (18.9-29.6). High levels of heterogeneity (I2 > 75) were observed in all three analyses. Estimates did not differ between autistic or possibly autistic samples. Geographical location (p = 0.005), transgender or gender non-conforming samples (p < 0.001) and type of report (p < 0.001) significantly moderated suicidal ideation, whereas age group (p = 0.001) and measure of suicidality (p = 0.001) significantly moderated suicide plans. There was a significant association between the proportion of male participants and prevalence of suicide plans, with a decrease in the proportion of males for every unit change of suicide plan prevalence (p = 0.013). No variables were found to moderate estimates of suicide attempts and behaviours. CONCLUSIONS: The results confirm suicidality is highly prevalent in both autistic and possibly autistic people without co-occurring intellectual disability and highlights potential moderators. Possibly autistic individuals require more attention in clinical and research considerations going forward to further understand and prevent suicide in both groups.

The functions of self-harm in young people and their perspectives about future general practitioner-led care: A qualitative study.

BACKGROUND: Self-harm in young people is a serious concern but a deeper understanding of the functions of self-harm in young people can tailor care and inform new clinical interventions to reduce repeat self-harm and suicide risk. General practitioners (GPs), as frontline healthcare professionals, have an important role in managing self-harm in young people. This study aimed to explore the functions of self-harm in young people and their perspectives on future GP-led care. METHODS: A qualitative study using interviews with young people aged between 16 and 25 years with a personal history of self-harm was conducted. Interviews were transcribed and analysed using reflexive thematic analysis. FINDINGS: Four distinct functions were identified: (1) handling emotional states; (2) self-punishment; (3) coping with mental illness and trauma; and (4) positive thoughts and protection. Young people valued GP-led support and felt future GP interventions should include self-help and be personalised. CONCLUSIONS: These findings support clinicians, including GPs, to explore the functions of self-harm in young people aged 16-25 in a personalised approach to self-harm care. It should be noted that self-harm may serve more than one function for a young person and thus interventions should recognise this. PATIENT AND PUBLIC CONTRIBUTION: A group consisting of young people with lived experience of self-harm, carers, the public, and those who work with young people who harm themselves conceived this study idea, informed recruitment methods and the interview topic guide, and supported the interpretation of findings.

Healthcare visits for mental disorders and use of psychotropic medications before and after self-harm in a cohort aged 75.

OBJECTIVES: Non-fatal self-harm (SH) is a major risk factor for late-life suicide. A better knowledge of the clinical management of older adults who self-harm is needed to establish where improvements could be made for the implementation of effective suicide prevention interventions. We therefore assessed contacts with primary and specialised care for mental disorders and psychotropic drug use during the year before and after a late-life non-fatal SH episode. METHOD: Longitudinal population-based study in adults aged ≥75 years with SH episode between 2007 and 2015 retrieved from the regional database VEGA. Healthcare contacts for mental disorders and psychotropic use were assessed during the year before and after the index SH episode. RESULTS: There were 659 older adults who self-harmed. During the year before SH, 33.7% had primary care contacts with a mental disorder, 27.8% had such contacts in specialised care. Use of specialised care increased sharply after the SH, reaching a maximum of 68.9%, but this figure dropped to 19.5% by the end of the year. Use of antidepressants increased from 41% before to 60% after the SH episode. Use of hypnotics was extensive before and after SH (60%). Psychotherapy was rare in both primary and specialised care. CONCLUSION: The use of specialised care for mental disorders and antidepressant prescribing increased after SH. The drop in long-term healthcare visits should be further explored to align primary and specialised healthcare to the needs of older adults who self-harmed. The psychosocial support of older adults with common mental disorders needs to be strengthened.

Experiences of dialectical behaviour therapy for adolescents: A qualitative analysis.

OBJECTIVES: To explore how former patients in dialectical behaviour therapy for adolescents (DBT-A) experience their treatment, and specifically if there were aspects of the treatment that they retrospectively identify as particularly meaningful, helpful or unhelpful. DESIGN: From a larger sample of 75 former DBT-A patients 19 were selected for a qualitative semi-structured interview study. METHODS: Young adults (N = 19; 18 females, one male), who as adolescents had been enrolled in DBT-A due to self-harming behaviours and features of borderline personality disorder, were interviewed up to 8 years (median 6.0; min 1.3; max 8.2) after end of treatment, at mean age 23 years (SD 2.5). Reflexive thematic analysis was implemented. RESULTS: Six key themes were revealed; (1) The need to be seen, listened to and believed in, (2) the importance of teamwork between patient and therapist, (3) the value of group and structure, (4) therapy as lifesaving and life-changing, (5) the risks of feeling misplaced and (6) the risks of abrupt endings. CONCLUSION: A trusting relationship with the therapist promoted commitment and motivation for treatment. This relationship was facilitated by the therapist showing explicit care and belief in the patient's own competence in changing their destructive behaviours. Meeting peers in group skill training offered a salient form of validation and was reported to be of particular value. The format of meeting peers and the importance of the dialectical therapeutic stance need to be studied further. Not all youth experienced DBT-A as suitable and the need for sufficient treatment dose was emphasized.

Conducta suicida y autolesiva en adolescentes, un problema sin resolver. Una revisión comprensiva / Suicidal and self-injurious behaviour among adolescents, an unresolved problem. A comprehensive review

En los últimos años se ha observado un aumento de la prevalencia de la conducta suicida y de los suicidios consumados en la población infantojuvenil. Entendiendo la adolescencia como una ventana sensible en la que implementaractuaciones de promoción de bienestar emocional, consideramos pertinente el análisis de la conducta suicida en estapoblación. A tal efecto este trabajo realiza una revisión comprensiva sobre el tema de interés, estructurando el trabajoen los siguientes epígrafes: conceptualización del fenómeno,factores de riesgo, modelos explicativos, instrumentos deevaluación, intervenciones psicoterapéuticas eficaces y planes actuales de prevención. Se concluye que aún habiendodiseñado múltiples estrategias de intervención, el aumentode prevalencia del suicidio justifica el diseño de nuevos programas con contenidos apropiados, concretos y factibles. (AU)

In recent years, an increase in the prevalence of suicidal behaviour and completed suicides among children andyoung people have been observed. Considering adolescenceas a sensitive point where actions to promote emotional wellbeing can be implemented, we consider relevant the analysis of suicidal behaviour in this population. For this purpose,this paper carries out a comprehensive review of the topic ofinterest, structuring the work under the following headings:phenomenon conceptualization, risk factors, explanatorymodels, assessment instruments, effective psychotherapeutic interventions and current prevention plans. The conclusion isthat while multiple intervention strategies have been developed, the increase in the prevalence of suicide justifies theimplementation of new programs with appropriate, concreteand feasible content. (AU)