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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.
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Comportamento Autodestrutivo , Suicídio , Masculino , Humanos , Pessoa de Meia-Idade , Idoso , Feminino , Comportamento Autodestrutivo/epidemiologia , Suicídio/psicologia , Consumo de Bebidas Alcoólicas , Emprego , Inglaterra/epidemiologia , Etanol , Serviço Hospitalar de EmergênciaRESUMO
BACKGROUND: Self-harm, a significant and increasing global problem in children and adolescents, is often repeated and is associated with risk of future suicide. To identify potential interventions, we need to understand the life problems faced by children and adolescents, and by sub-groups of younger people who self-harm. Our aims were to include the following: (a) investigate the type and frequency of life problems in a large sample of children and adolescents who self-harmed. (b) Examine whether problems differ between those who repeat self-harm and those who do not. METHODS: We analysed data for 2000 to 2013 (follow up until 2014) from the Multicentre Study of Self-harm in England on individuals aged 11 to 18 years who presented to one of the five study hospitals following self-harm and received a psychosocial assessment including questions about problems, which precipitated self-harm. RESULTS: In 5648 patients (12,261 self-harm episodes), (75.5% female, mean age 16.1 years) the most frequently reported problems at first episode of self-harm were family problems. Problems around study/employment/study and relationships with friends also featured prominently. The types of problems that precede self-harm differed between late childhood/early adolescence. Abuse, mental health problems and legal problems significantly predicted repeat self-harm for females. CONCLUSION: The most common problems reported by both genders were social/interpersonal in nature, indicating the need for relevant services embedded in the community (e.g. in schools/colleges). Self-harm assessment and treatment choices for children and adolescents must take age and gender into account. To prevent future self-harm, individualised supports and services are particularly needed for abuse, mental health and legal problems.
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Comportamento Autodestrutivo , Suicídio , Adolescente , Criança , Emprego , Inglaterra/epidemiologia , Feminino , Humanos , Masculino , Instituições Acadêmicas , Comportamento Autodestrutivo/psicologia , Suicídio/psicologiaRESUMO
BACKGROUND: Patient and public involvement (PPI) is becoming more commonplace in mental health research. There are strong moral and ethical arguments for good quality PPI. Few studies have documented and evaluated PPI in self-harm and suicide research. Inconsistent reporting of PPI makes it difficult to discern practices that deliver quality, effective and meaningful involvement. It is important to understand and address emotional support needs of PPI members contributing to sensitive topics such as suicide and self-harm. Therefore, this study will examine the effect of PPI on self-harm and suicide research and explore patients', carers' and researchers' experiences and views in relation to the quality of PPI practice and provision of appropriate support for PPI members. METHODS: This protocol outlines the longitudinal, mixed methodological approach that will be taken. Qualitative and quantitative data will be collected via baseline and repeated questionnaires, document review and semi-structured interviews. Both PPI members and researchers will be invited to participate in this study. The two-year data collection period will enable evaluation of PPI throughout the entire research cycle. An integrated approach will be taken to data analysis, using inductive thematic analysis and descriptive and repeated measures analyses, to address specified study aims. DISSEMINATION: Findings from this study will inform practical guidance to support self-harm and suicide researchers in effectively involving people with experiential knowledge in their research. Analyses will offer insight into the effect of PPI throughout the research process and assess changes in PPI members' and researchers' experiences of involvement across a two-year period.
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Comportamento Autodestrutivo , Suicídio , Cuidadores , Humanos , Estudos Longitudinais , Saúde MentalRESUMO
BACKGROUND: Suicide is a leading cause of death globally. Suicide deaths are elevated in those experiencing severe mental health problems, including schizophrenia. Psychological talking therapies are a potentially effective means of alleviating suicidal thoughts, plans, and attempts. However, talking therapies need to i) focus on suicidal experiences directly and explicitly, and ii) be based on testable psychological mechanisms. The Cognitive AppRoaches to coMbatting Suicidality (CARMS) project is a Randomised Controlled Trial (RCT) which aims to investigate both the efficacy and the underlying mechanisms of a psychological talking therapy for people who have been recently suicidal and have non-affective psychosis. METHODS: The CARMS trial is a two-armed single-blind RCT comparing a psychological talking therapy (Cognitive Behavioural Suicide Prevention for psychosis [CBSPp]) plus Treatment As Usual (TAU) with TAU alone. There are primary and secondary suicidality outcome variables, plus mechanistic, clinical, and health economic outcomes measured over time. The primary outcome is a measure of suicidal ideation at 6 months after baseline. The target sample size is 250, with approximately 125 randomised to each arm of the trial, and an assumption of up to 25% attrition. Hence, the overall recruitment target is up to 333. An intention to treat analysis will be used with primary stratification based on National Health Service (NHS) recruitment site and antidepressant prescription medication. Recruitment will be from NHS mental health services in the North West of England, UK. Participants must be 18 or over; be under the care of mental health services; have mental health problems which meet ICD-10 non-affective psychosis criteria; and have experienced self-reported suicidal thoughts, plans, and/or attempts in the 3 months prior to recruitment. Nested qualitative work will investigate the pathways to suicidality, experiences of the therapy, and identify potential implementation challenges beyond a trial setting as perceived by numerous stake-holders. DISCUSSION: This trial has important implications for countering suicidal experiences for people with psychosis. It will provide definitive evidence about the efficacy of the CBSPp therapy; the psychological mechanisms which lead to suicidal experiences; and provide an understanding of what is required to implement the intervention into services should it be efficacious. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03114917), 14th April 2017. ISRCTN (reference ISRCTN17776666 https://doi.org/10.1186/ISRCTN17776666); 5th June 2017). Registration was recorded prior to participant recruitment commencing.
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Transtornos Psicóticos , Prevenção do Suicídio , Cognição , Inglaterra , Humanos , Intervenção Psicossocial , Transtornos Psicóticos/terapia , Resultado do TratamentoRESUMO
Parricide is a rare type of homicide in which mental illness is often an important factor. The aims of this study were (a) to describe the characteristics of parricide offenders with a focus on mental illness and clinical care and (b) to examine Heide's widely used typology of parricide through a data-driven approach. We analyzed all homicides in England and Wales between 1997 and 2014. Parricide offenders in our sample were most often male, unmarried, and unemployed, with a third of offenders diagnosed with schizophrenia; 28% had been in contact with mental health services before the offense. The latent class analysis resulted in three types of parricide offenders: middle-aged with affective disorder, previously abused, and seriously mentally Ill, which confirmed, to an extent, Heide's typology. Health and social care services should actively engage with carers of people with mental illness and support to those caring for older relatives and victims of abuse.
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Criminosos , Homicídio , Transtornos Mentais , Inglaterra/epidemiologia , Feminino , Humanos , Masculino , Transtornos Mentais/epidemiologia , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Suicide and non-fatal self-harm represent key patient safety events in mental healthcare services. However, additional important learning can also be derived by highlighting examples of optimal practice that help to keep patients safe. In this study, we aimed to explore clinicians' views of what constitutes good practice in mental healthcare services in the context of suicide prevention. METHODS: Data were extracted from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) database, a consecutive case series study of suicide by people in contact with mental healthcare services. A large national sample of clinicians' responses was analysed with a hybrid thematic analysis. RESULTS: Responses (n = 2331) were submitted by clinicians across 62 mental healthcare providers. The following five themes illustrated good practice that helps to: 1) promote safer environments, 2) develop stronger relationships with patients and families, 3) provide timely access to tailored and appropriate care, 4) facilitate seamless transitions, and 5) establish a sufficiently skilled, resourced and supported staff team. CONCLUSION: This study highlighted clinicians' views on key elements of good practice in mental health services. Respondents included practice specific to mental health services that focus on enhancing patient safety via prevention of self-harm and suicide. Clinicians possess important understanding of optimal practice but there are few opportunities to share such insight on a broader scale. A further challenge is to implement optimal practice into routine, daily care to improve patient safety and reduce suicide risk.
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Pessoal de Saúde/psicologia , Serviços de Saúde Mental/normas , Qualidade da Assistência à Saúde/normas , Prevenção do Suicídio , Humanos , Segurança do Paciente/normas , Pesquisa QualitativaRESUMO
BACKGROUND: Bipolar and other psychiatric disorders are associated with considerably increased risk of suicidal behaviour, which may include self-poisoning with medication used to treat the disorder. Therefore, choice of medication for treatment should include consideration of toxicity, especially for patients at risk. The aim of this study was to estimate the relative toxicity of specific drugs within two drug categories, antipsychotics and mood stabilizers, using large-scale databases to provide evidence that could assist clinicians in making decisions about prescribing, especially for patients at risk of suicidal behaviour. METHOD: Two indices were used to assess relative toxicity of mood stabilisers and antipsychotics: case fatality (the ratio between rates of fatal and non-fatal self-poisoning) and fatal toxicity (the ratio between rates of fatal self-poisoning and prescription). Mood stabilisers assessed included lithium [reference], sodium valproate, carbamazepine, and lamotrigine, while antipsychotics included chlorpromazine [reference], clozapine, olanzapine, quetiapine and risperidone. Fatal self-poisoning (suicide) data were provided by the Office for National Statistics (ONS), non-fatal self-poisoning data by the Multicentre Study of Self-harm in England, and information on prescriptions by the Clinical Practice Research Datalink. The primary analysis focussed on deaths due to a single drug. Cases where the drug of interest was listed as the likely primary toxic agent in multiple drug overdoses were also analysed. The study period was 2005-2012. RESULTS: There appeared to be little difference in toxicity between the mood stabilisers, except that based on case fatality where multiple drug poisonings were considered, carbamazepine was over twice as likely to result in death relative to lithium (OR 2.37 95% CI 1.16-4.85). Of the antipsychotics, clozapine was approximately18 times more likely to result in death when taken in overdose than chlorpromazine (single drug case fatality: OR 18.53 95% CI 8.69-39.52). Otherwise, only risperidone differed from chlorpromazine, being less toxic (OR 0.06 95% CI 0.01-0.47). CONCLUSIONS: There was little difference in toxicity of the individual mood stabilisers. Clozapine was far more toxic than the other antipsychotics. The findings are relevant to prescribing policy, especially for patients at particular risk of suicidal behaviour.
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Antipsicóticos , Overdose de Drogas , Conduta do Tratamento Medicamentoso , Transtornos Mentais , Risco Ajustado/métodos , Comportamento Autodestrutivo , Prevenção do Suicídio , Suicídio , Tranquilizantes , Adulto , Antipsicóticos/administração & dosagem , Antipsicóticos/efeitos adversos , Antipsicóticos/classificação , Overdose de Drogas/etiologia , Overdose de Drogas/prevenção & controle , Overdose de Drogas/psicologia , Inglaterra , Feminino , Humanos , Transtornos Mentais/complicações , Transtornos Mentais/tratamento farmacológico , Transtornos Mentais/psicologia , Padrões de Prática Médica , Comportamento Autodestrutivo/prevenção & controle , Comportamento Autodestrutivo/psicologia , Suicídio/psicologia , Suicídio/estatística & dados numéricos , Tranquilizantes/administração & dosagem , Tranquilizantes/efeitos adversos , Tranquilizantes/classificaçãoRESUMO
BACKGROUND: Individuals who do not adhere to their treatment regimens may be at greater risk of suicide but these issues are relatively unexplored in primary care services. AIM: To explore GPs' views and perspectives on the reasons why patients who were in contact with mental health services in the year prior to suicide was non-adherent to treatment prior to their death. METHOD: In total, 198 semi-structured face-to-face interviews with GPs of people who had died by suicide. Interviews were transcribed verbatim and analyzed using a thematic approach. RESULTS: The following themes were conceptualized from GP interviews: (i) "Lack of insight or denial?" relates to what GPs perceived as their patients lack of insight into their psychiatric illness; (ii) "Lack of treatment choices" discusses GPs' understanding of patient treatment choices; (iii) "Services for comorbidity and dual diagnosis" refers to treatment availability for suicidal patients with two or more mental health diagnoses. CONCLUSIONS: For suicide prevention, it is crucial for health professionals to assess patients and manage the possible causes of non-adherence. Policies for increasing treatment adherence, improving services for dual diagnosis, or providing alternative treatments to meet individual patient needs may help to achieve the best health outcomes and could potentially prevent suicide.
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Clínicos Gerais/psicologia , Adesão à Medicação , Prevenção do Suicídio , Atitude do Pessoal de Saúde , Feminino , Humanos , MasculinoRESUMO
BACKGROUND: Self-harm in young people is a common reason for contact with clinical services. However, there is little research focusing on parents' perspectives of care following self-harm. The aim of this study was to explore parents' experiences of treatment and support for the young person and for themselves. METHODS: A qualitative design was used to explore parents' perspectives. Semi-structured narrative interviews were conducted across the UK with 37 parents of young people who had self-harmed. Thematic analysis was undertaken to identify themes relating to how parents experienced the help and treatment received. RESULTS: Parents reported differing reactions to contact with helping services. Many found these helpful, particularly in keeping the young person safe, developing a trusting relationship with the young person, encouraging skills in managing self-harm and giving them an opportunity to talk about and find solutions to their difficulties. They spoke about the importance of practical help including prompt access to care, the right intensity of care, practical strategies and information and support. Some aspects of services were perceived as unhelpful, particularly a judgmental approach by professionals, lack of early access to treatment, inadequate support or failure to listen to the perspective of parents. CONCLUSIONS: Parents' views highlight the need for clinicians to consider carefully the perspective of parents, involving them wherever possible and providing practical help and support, including written information. The need for training of clinicians in communicating with young people and parents following self-harm is also highlighted.
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Self-harm is common in young people, and can have profound effects on parents and other family members. We conducted narrative interviews with 41 parents and other family members of 38 young people, aged up to 25, who had self-harmed. Most of the participants were parents but included one sibling and one spouse. This article reports experiences of the parent participants. A cross-case thematic analysis showed that most participants were bewildered by self-harm. The disruption to their worldview brought about by self-harm prompted many to undergo a process of "sense-making"-by ruminative introspection, looking for information, and building a new way of seeing-to understand and come to terms with self-harm. Most participants appeared to have been successful in making sense of self-harm, though not without considerable effort and emotional struggle. Our findings provide grounds for a deeper socio-cultural understanding of the impact of self-harm on parents.
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Emoções , Pais/psicologia , Comportamento Autodestrutivo/psicologia , Adolescente , Criança , Maus-Tratos Infantis/psicologia , Família/psicologia , Feminino , Culpa , Humanos , Relações Interpessoais , Masculino , Transtornos Mentais/psicologia , Pesquisa Qualitativa , Apoio SocialRESUMO
BACKGROUND: Patient suicide can be a devastating event for some general practitioners (GPs). Few guidelines exist to aid or support GPs in the aftermath of patient suicide. AIM: To explore GPs views on how they are affected by a patient suicide and the formal support available to them following a patient suicide. DESIGN: Questionnaires and semi-structured interviews. SETTING: General practices in the northwest of England. METHODS: About 198 semi-structured interviews were conducted as part of a retrospective study. Interviews were transcribed verbatim and analysed using descriptive statistics and a framework thematic approach. RESULTS: GPs were aged between 31 and 67 years, 144 (73%) were male and the number of years in practice varied between 8 and 40 years (median = 24 years). GPs were based at 133 (67%) urban and 65 (33%) rural practices, 30 (15%) were single-handed GP practices and 168 (85%) practices had two or more GPs. About 131 (66%) GPs reported being affected by patient suicide through feelings of grief, guilt and self-scrutiny. A greater number of years in practice may have been protective against these effects. About 54 (27%) GPs reported having mostly 'informal' support from peers or colleagues and support was less available to younger and single handed GPs. CONCLUSIONS: Our findings suggest that the majority of GPs are affected by patient suicide and most seek informal support from their peers and colleagues. Although many indicated that informal support systems were adequate and provided a protective environment, procedures should be developed to ensure the availability of guidelines for those who may require formal support.
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Atitude do Pessoal de Saúde , Clínicos Gerais/psicologia , Sistemas de Apoio Psicossocial , Suicídio , Adulto , Idoso , Inglaterra , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Estudos Retrospectivos , Inquéritos e QuestionáriosRESUMO
PURPOSE: Self-harm is a major clinical problem and is strongly linked to suicide. It is important to understand the problems faced by those who self-harm to design effective clinical services and suicide prevention strategies. We investigated the life problems experienced by patients presenting to general hospitals for self-harm. METHODS: Data for 2000-2010 from the Multicentre Study of Self-harm in England were used to investigate life problems associated with self-harm and their relationship to patient and clinical characteristics, including age, gender, repeat self-harm and employment status. RESULTS: Of 24,598 patients (36,431 assessed episodes), 57% were female and with a mean age of 33.1 years (SD 14.0 years), 92.6% were identified as having at least one contributing life problem. The most frequently reported problems at first episode of self-harm within the study period were relationship difficulties (especially with partners). Mental health issues and problems with alcohol were also very common (especially in those aged 35-54 years, and those who repeated self-harm). Those who repeated self-harm were more likely to report problems with housing, mental health and dealing with the consequences of abuse. CONCLUSIONS: Self-harm usually occurs in the context of multiple life problems. Clinical services for self-harm patients should have access to appropriate care for provision of help for relationship difficulties and problems concerning alcohol and mental health issues. Individualised clinical support (e.g. psychological therapy, interventions for alcohol problems and relationship counselling) for self-harm patients facing these life problems may play a crucial role in suicide prevention.
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Comportamento Autodestrutivo/epidemiologia , Comportamento Autodestrutivo/psicologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Alcoolismo/epidemiologia , Emprego/estatística & dados numéricos , Inglaterra/epidemiologia , Feminino , Habitação/estatística & dados numéricos , Humanos , Relações Interpessoais , Masculino , Transtornos Mentais/epidemiologia , Pessoa de Meia-Idade , Abuso Físico/psicologia , Fatores de Risco , Adulto Jovem , Prevenção do SuicídioRESUMO
BACKGROUND: There has been little previous research on self-harm among people of Chinese origin living in the UK, although this population has grown substantially in recent years and China is now the largest source of international students at UK universities. METHODS: We conducted a prospective cohort study using self-harm presentation data (1997-2011) collected from three hospitals in the City of Manchester, which has the largest Chinese population across all UK Local Authorities. Rate ratios between the Chinese and White groups were calculated using Poisson regression models. Chi-square tests (or Fisher's exact tests), logistic regression, and log-binomial regression were used to examine differences in characteristics and clinical management between groups. RESULTS: Ethnicity was known in the study cohort for 23,297 (87%) amongst 26,894 individuals aged 15 years and above. A total number of 97/23,297 (0.4%) people of Chinese ethnic origin presented with self-harm over the study period and 20,419 (88%) were White people. Incidence of self-harm in the Chinese group (aged 16-64 years) was less than one fifth of that found in White people (0.6 versus 3.2 per 1000 person-years; rate ratio 0.18, 95% confidence interval 0.13-0.24), and was particularly low amongst men of Chinese origin. Individuals of Chinese origin who presented with self-harm were younger, more likely to be female and students, and more likely to self-injure and describe relationship problems as a precipitant than White people. They were less likely to have clinical risk factors such as drug/alcohol misuse and receiving psychiatric treatment, and were rated to have lower risk of self-harm repetition by treating clinicians. CONCLUSION: Future research needs to investigate whether the low incidence of self-harm presenting to hospitals amongst people of Chinese origin truly reflects a lower frequency of self-harm, or alternatively is due to markedly different post-episode help-seeking behaviours or student overrepresentation in this ethnic group. Relevant healthcare professionals need to be aware of the risk characteristics of people of Chinese origin who self-harm.
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Povo Asiático , Comportamento Autodestrutivo/etnologia , Estudantes , População Branca , Adolescente , Adulto , Povo Asiático/psicologia , Povo Asiático/estatística & dados numéricos , Estudos de Coortes , Inglaterra/epidemiologia , Etnopsicologia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Comportamento Autodestrutivo/terapia , Estudantes/psicologia , Estudantes/estatística & dados numéricos , Universidades , População Branca/psicologia , População Branca/estatística & dados numéricosRESUMO
OBJECTIVES: Alcohol use and misuse are strongly associated with self-harm and increased risk of future self-harm and suicide. The UK general population prevalence of alcohol use, misuse and alcohol-attributable harm has been rising. We have investigated the prevalence of and trends in alcohol use and misuse in self-harm patients and their associations with repeat self-harm and subsequent death. METHODS: We used patient data from the Multicentre Study of Self-Harm in England for 2000-2009 and UK mortality data for patients presenting from 2000 to 2007 who were followed up to the end of 2009. RESULTS: Alcohol involvement in acts of self-harm (58.4%) and alcohol misuse (36.1%) were somewhat higher than found previously in self-harm patients. Alcohol involvement and misuse were most frequent in men, those aged 35-54 years and those from white ethnicities. The frequency of alcohol misuse increased between 2000 and 2009, especially in women. Repetition of self-harm was associated with alcohol involvement in self-harm and particularly with alcohol misuse. Risk of suicide was increased significantly in women misusing alcohol. CONCLUSIONS: Alcohol use and misuse in self-harm patients appears to have increased in recent years, particularly in women. The association of alcohol with greater risk of self-harm repetition and mortality highlights the need for clinicians to investigate alcohol use in self-harm patients. Ready availability of alcohol treatment staff in general hospitals could facilitate appropriate aftercare and the prevention of adverse outcomes.
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Consumo de Bebidas Alcoólicas/epidemiologia , Alcoolismo/epidemiologia , Comportamento Autodestrutivo/epidemiologia , Suicídio/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Inglaterra/epidemiologia , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prevalência , Fatores de Risco , Comportamento Autodestrutivo/mortalidade , Fatores Sexuais , Adulto JovemRESUMO
Background: Suicide-related internet use (SRIU) has been shown to be linked to suicide. However, there is limited research on SRIU among mental health patients, who are at 4 to 7 times increased risk of suicide compared to the general population. This study aims to address this gap by exploring the prevalence of SRIU among mental health patients who died by suicide in the UK and describing their characteristics. Methods: The study was carried out as part of the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH). Data were collected on sociodemographic, clinical, suicide characteristics and engagement in SRIU of patients who died by suicide between 2011 and 2021. The study utilised a case-control design to compare patients who engaged in suicide-related internet use with those who did not. Findings: The presence or absence of SRIU was known for 9875/17,347 (57%) patients; SRIU was known to be present in 759/9875 (8%) patients. The internet was most often used to obtain information on suicide methods (n = 523/759, 69%) and to visit pro-suicide websites (n = 250/759, 33%) with a significant overlap between the two (n = 152/759, 20%). Engaging in SRIU was present across all age groups. The case-control element of the study showed patients who were known to have engaged in SRIU were more likely to have been diagnosed with autism spectrum disorder (OR = 2.13, 95% CI: 1.43-3.18), have a history of childhood abuse (OR = 1.70, 95% CI: 1.36-2.13) and to have received psychological treatment (OR = 1.43, 95% CI: 1.18-1.74) than controls. Additionally, these patients were more likely to have died on or near a salient date (OR = 2.11, 95% CI: 1.61-2.76), such as a birthday or anniversary. Interpretation: The findings affirm SRIU as a feature of suicide among patients of all ages and highlight that clinicians should inquire about SRIU during assessments. Importantly, as the most common type of SRIU can expand knowledge on suicide means, clinicians need to be aware of the association between SRIU and choice of methods. This may be particularly relevant for patients approaching a significant calendar event. Funding: The Healthcare Quality Improvement Partnership.
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BACKGROUND: People under the care of mental health services are at increased risk of suicide. Existing studies are small in scale and lack comparisons. AIMS: To identify opportunities for suicide prevention and underpinning data enhancement in people with recent contact with mental health services. METHOD: This population-based study includes people who died by suicide in the year following a mental health services contact in Wales, 2001-2015 (cases), paired with similar patients who did not die by suicide (controls). We linked the National Confidential Inquiry into Suicide and Safety in Mental Health and the Suicide Information Database - Cymru with primary and secondary healthcare records. We present results of conditional logistic regression. RESULTS: We matched 1031 cases with 5155 controls. In the year before their death, 98.3% of cases were in contact with healthcare services, and 28.5% presented with self-harm. Cases had more emergency department contacts (odds ratio 2.4, 95% CI 2.1-2.7) and emergency hospital admissions (odds ratio 1.5, 95% CI 1.4-1.7), but fewer primary care contacts (odds ratio 0.7, 95% CI 0.6-0.9) and out-patient appointments (odds ratio 0.2, 95% CI 0.2-0.3) than controls. Odds ratios were larger in females than males for injury and poisoning (odds ratio: 3.3 (95% CI 2.5-4.5) v. 2.6 (95% CI 2.1-3.1)). CONCLUSIONS: We may be missing existing opportunities to intervene, particularly in emergency departments and hospital admissions with self-harm presentations and with unattributed self-harm, especially in females. Prevention efforts should focus on strengthening routine care contacts, responding to emergency contacts and better self-harm care. There are benefits to enhancing clinical audit systems with routinely collected data.
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BACKGROUND: Research investigating which aspects of mental health service provision are most effective in prevention of suicide is scarce. We aimed to examine the uptake of key mental health service recommendations over time and to investigate the association between their implementation and suicide rates. METHODS: We did a descriptive, cross-sectional, and before-and-after analysis of national suicide data in England and Wales. We collected data for individuals who died by suicide between 1997 and 2006 who were in contact with mental health services in the 12 months before death. Data were obtained as part of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. When denominator data were missing, we used information from the Mental Health Minimum Data Set. We compared suicide rates for services implementing most of the recommendations with those implementing fewer recommendations and examined rates before and after implementation. We stratified results for level of socioeconomic deprivation and size of service provider. FINDINGS: The average number of recommendations implemented increased from 0·3 per service in 1998 to 7·2 in 2006. Implementation of recommendations was associated with lower suicide rates in both cross-sectional and before-and-after analyses. The provision of 24 h crisis care was associated with the biggest fall in suicide rates: from 11·44 per 10â000 patient contacts per year (95% CI 11·12-11·77) before to 9·32 (8·99-9·67) after (p<0·0001). Local policies on patients with dual diagnosis (10·55; 10·23-10·89 before vs 9·61; 9·18-10·05 after, p=0·0007) and multidisciplinary review after suicide (11·59; 11·31-11·88 before vs 10·48; 10·13-10·84 after, p<0·0001) were also associated with falling rates. Services that did not implement recommendations had little reduction in suicide. The biggest falls in suicide seemed to be in services with the most deprived catchment areas (incidence rate ratio 0·90; 95% CI 0·88-0·92) and the most patients (0·86; 0·84-0·88). INTERPRETATION: Our findings suggest that aspects of provision of mental health services can affect suicide rates in clinical populations. Investigation of the relation between new initiatives and suicide could help to inform future suicide prevention efforts and improve safety for patients receiving mental health care. FUNDING: National Patient Safety Agency, UK.
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Serviços de Saúde Mental , Suicídio/estatística & dados numéricos , Inglaterra/epidemiologia , Humanos , Serviços de Saúde Mental/normas , Melhoria de Qualidade , País de Gales/epidemiologia , Prevenção do SuicídioRESUMO
BACKGROUND: People who self-harm have an increased risk of premature death. The aim of this study was to investigate cause-specific premature death in individuals who self-harm, including associations with socioeconomic deprivation. METHODS: We undertook a cohort study of patients of all ages presenting to emergency departments in Oxford, Manchester, and Derby, UK, after self-poisoning or self-injury between Jan 1, 2000, and Dec 31, 2007. Postcodes of individuals' place of residence were linked to the Index of Multiple Deprivation 2007 in England. Mortality information was supplied by the Medical Research Information Service of the National Health Service. Patients were followed up to the end of 2009. We calculated age-standardised mortality ratios (SMRs) and years of life lost (YLL), and we tested for associations with socioeconomic deprivation. FINDINGS: 30â950 individuals presented with self-harm and were followed up for a median of 6·0 years (IQR 3·9-7·9). 1832 (6·1%) patients died before the end of follow-up. Death was more likely in patients than in the general population (SMR 3·6, 95% CI 3·5-3·8), and occurred more in males (4·1, 3·8-4·3) than females (3·2, 2·9-3·4). Deaths due to natural causes were 2-7·5 times more frequent than was expected. For individuals who died of any cause, mean YLL was 31·4 years (95% CI 30·5-32·2) for male patients and 30·7 years (29·5-31·9) for female patients. Mean YLL for natural-cause deaths was 25·9 years (25·7-26·0) for male patients and 25·5 years (25·2-25·8) for female patients, and for external-cause deaths was 40·2 years (40·0-40·3) and 40·0 years (39·7-40·5), respectively. Disease of the circulatory (13·1% in males; 13·0% in females) and digestive (11·7% in males; 17·8% in females) systems were major contributors to YLL from natural causes. All-cause mortality increased with each quartile of socioeconomic deprivation in male patients (χ(2) trend 39·6; p<0·0001), female patients (13·9; p=0·0002), and both sexes combined (55·4; p<0·0001). Socioeconomic deprivation was related to mortality in both sexes combined from natural causes (51·0; p<0·0001) but not from external causes (0·30; p=0·58). Alcohol problems were associated with death from digestive-system disease, drug misuse with mental and behavioural disorders, and physical health problems with circulatory-system disease. INTERPRETATION: Physical health and life expectancy are severely compromised in individuals who self-harm compared with the general population. In the management of self-harm, clinicians assessing patients' psychosocial problems should also consider their physical needs. FUNDING: Department of Health Policy Research Programme.
Assuntos
Mortalidade Prematura , Comportamento Autodestrutivo/mortalidade , Acidentes/mortalidade , Adolescente , Adulto , Causalidade , Criança , Estudos de Coortes , Doenças do Sistema Digestório/mortalidade , Feminino , Nível de Saúde , Humanos , Masculino , Intoxicação/mortalidade , Classe Social , Doenças Vasculares/mortalidade , Adulto JovemRESUMO
Non-suicidal self-injury (NSSI) is a term that is becoming popular especially in North America and it has been proposed as a new diagnosis in DSM-5. In this paper we consider what self-harm research can tell us about the concept of NSSI and examine the potential pitfalls of introducing NSSI into clinical practice.
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Comportamento Autodestrutivo/diagnóstico , Terminologia como Assunto , HumanosRESUMO
Studies of therapeutic contact following self-harm have had mixed results. We carried out a pilot randomised controlled trial comparing an intervention (information leaflet listing sources of help, two telephone calls soon after presentation and a series of letters over 12 months) to usual treatment alone in 66 adults presenting with self-harm to two hospitals. We found that our methodology was feasible, recruitment was challenging and repeat self-harm was more common in those who received the intervention (12-month repetition rate 34.4% v. 12.5%).