Self-harm in Oxford, England: epidemiological and clinical trends, 1996-2010.

BACKGROUND: Self-harm is a major healthcare problem and changes in its prevalence and characteristics can have important implications for clinical services, treatment and prevention. METHODS: We analysed data on all self-harm presentations to the general hospital in Oxford between 1996 and 2010 using the Oxford Monitoring System for Self-harm. We investigated trends in prevalence, methods and repetition of self-harm, and receipt of psychosocial assessment. For patients receiving a psychosocial assessment, we investigated trends in alcohol use and misuse, prior psychiatric treatment and self-harm, problems, and suicidal intent. RESULTS: Rates of self-harm rose in both genders between 1996 and 2002/2003, after which they declined. There was evidence of a possible cohort effect, whereby higher rates in younger males in earlier years transferred over time to older age groups. Self-cutting, hanging and jumping became more common. Paracetamol was involved in 44.9 % of all self-poisoning episodes. Overdoses of antidepressants (particularly selective serotonin reuptake inhibitors) increased, as did those of mood stabilisers, non-opiate analgesics excluding paracetamol (e.g. non-steroidal anti-inflammatory drugs), and non-ingestible poisons. Alcohol use in relation to self-harm and alcohol-related problems became more common, as did history of prior psychiatric treatment and, especially, of self-harm, and employment problems from 2008. Despite national guidance, the proportion of patients undergoing psychosocial assessment declined. CONCLUSIONS: Major changes in the extent and nature of self-harm occurred over the study period, some suggestive of increased psychopathology and others reflecting prescribing practices and changes in drinking patterns. The findings emphasise the need for psychosocial assessment following self-harm, to identify treatment needs and reduce repetition.

Medicines management: an interview study of nurses at a secure psychiatric hospital.

AIMS: To explore mental health nurses' knowledge, attitudes and clinical judgement concerning medicines management in an inpatient setting with a view to enhancing training. BACKGROUND: Medicines management is a key role of mental health nurses, but little research has been conducted into their training needs. DESIGN: An exploratory mixed-methods design was used involving individual interviews with participants to investigate their responses to hypothetical medicine administration scenarios. METHODS: Interviews were held with a convenience sample of 50 Registered Nurses working in a specialist mental health hospital between November 2012-February 2013. Participants were presented with clinical vignettes describing eight scenarios they might encounter as part of their medicines management role and asked about how they would respond. Responses were assessed by two independent raters against ten quality standards underpinning the vignettes. RESULTS: The median number of responses that were judged to demonstrate adequate awareness of associated quality standards was 4 (range 1-7), indicating that many participants did not appear to be aware of, or compliant with, current UK medicines management guidance and local policy. Many would not report a 'near miss' or medicines administration error. There was a lack of awareness of guidance on verbal prescribing, consent to treatment rules and the administration of off-label/unlicensed drugs. Past year attendance on a medicines management course, time since registration and self-reported knowledge of national standards for medicines administration did not discriminate between total score on the 10 quality standards. CONCLUSION: The medicines management training needs of participants appeared not to be fully met by the existing learning sources. The use of vignettes to assess nurses' training needs requires evaluation in other settings.

A study of the prescription and administration of sedative PRN medication to older adults at a secure hospital.

BACKGROUND: There is a paucity of research into PRN medication use in older psychiatric inpatients. This is an important topic given the risks of polypharmacy, adverse drug reactions, and high dose medication. METHOD: In 2013, we carried out a cross-sectional survey of the prescription and administration of sedative PRN medication to older adult inpatients on seven wards at a UK tertiary referral centre. We compared them with 242 patients of working age. RESULTS: Of the 92 patients studied, 56 (60.9%) were prescribed PRN sedation and 25 (27.2%) had received one or more doses in the previous fortnight. In total, 70 doses had been administered; all by mouth and all but one as single doses. Lorazepam was by far the most commonly prescribed and administered PRN drug. Agitation was the main indication, although violence was the most commonly cited reason for administration but documentation of antecedents, non-pharmacological strategies and outcome including side effects was uniformly poor with only 37 (52.9%) doses recorded in the case notes. Those with organic disorders were just as likely to receive PRN as those with functional illnesses. Patients very rarely actually received high dose antipsychotics or antipsychotic polypharmacy as a result of PRN prescriptions. Older patients were less likely than adults of working age to be prescribed PRN and dosages were smaller. CONCLUSION: Prospective studies of PRN prescription and administration are needed to better understand the reasons underpinning its use and to gain objective data upon its effectiveness or otherwise in this vulnerable patient group.

Living alone and deliberate self-harm: a case-control study of characteristics and risk factors.

BACKGROUND: An increasing proportion of the UK population live alone. Little is known about deliberate self-harm (DSH) patients who live alone. We conducted a study of the characteristics of DSH patients who live alone using data from the Oxford Monitoring System for Attempted Suicide. METHOD: Data on patients presenting to the general hospital in Oxford with an episode of DSH between 1993 and 2006 were analysed by gender and age group (15-24 years, 25-54 years and 55+ years) and according to whether or not they lived alone. RESULTS: In total, 1,163/7,865 (14.8%) patients lived alone. Having a problem with social isolation was more common in those living alone compared with those living with others, especially in those aged 55+ years. In the 25-54 years age group several variables concerning psychiatric problems were more common in those living alone, as was higher suicide intent associated with the current DSH episode and past DSH, and for females, repetition of DSH within 12 months. In patients aged 55+ years those living alone were more likely to have problems due to bereavement. Significantly more individuals living alone died from any cause. More also died by suicide, although the difference between the groups was non-significant after adjusting for age. CONCLUSIONS: These results have implications for psychiatric services assessing DSH patients who live alone, since, depending on the patient's age and living circumstances, different psychiatric and social interventions may be needed. Middle-aged DSH patients who live alone appear to be particularly vulnerable. DSH patients who live alone may not have supportive social networks and may be at increased risk of repetition of DSH and suicide.

Problem drug use, drug misuse and deliberate self-harm: trends and patient characteristics, with a focus on young people, Oxford, 1993-2006.

BACKGROUND: Drug misuse is related to self-harm and suicide. However, relatively little is known about deliberate self-harm (DSH) in patients with drug problems and whether drug misuse by DSH patients is increasing. METHODS: We used data collected by the Oxford Monitoring System for Attempted Suicide to study the characteristics of DSH patients with drug problems who presented to the general hospital in Oxford between 1993 and 2006, and who underwent psychosocial assessment at their first presentation in the study period. We also studied trends in problem drug use and drugs misused over this period. RESULTS: During the 14-year study period, 11,426 patients presented of whom 9,248 underwent psychosocial assessment and it was known whether or not they had a drug problem. Problem drug use was present in 805/9,248 (8.7%) patients. Problem drug use was more common in males (13.6%) than in females (5.3%). Problem drug users were younger, more likely to be socially disadvantaged, to have a personality disorder and comorbid alcohol problems and to have a further episode of DSH within a year. Problem drug use in young females was associated with higher suicidal intent scale (SIS) scores. During the study period, problem drug use and drug misuse increased in females, but not in males. Cannabis and cocaine misuse increased with time. CONCLUSIONS: Provision of help for DSH patients with problem drug use is particularly challenging due to their complex social and clinical characteristics and increased risk of further self-harm, suicide and accidental death. It may require extensive liaison between different services. The increasing misuse of drugs by female DSH patients and the higher SIS scores of young females are of concern.

Medication for borderline personality disorder: a survey at a secure hospital.

OBJECTIVES: To study the use of medication in the treatment of inpatients with borderline personality disorder (BPD). To survey clinicians' views on the UK National Institute for Health and Clinical Excellence (NICE) Guideline on BPD. METHODS: Cross-sectional survey of the use of psychotropics purely for BPD at a large secure UK psychiatric hospital, together with interviews with the treating psychiatrists. RESULTS: A total of 79 patients had a DSM diagnosis of BPD, of whom 80% were receiving one or more psychotropics and 48% were receiving two or more. Most prescriptions were off-label. Antipsychotics followed by antidepressants were the most frequent class of drug prescribed for BPD. Clozapine was the most commonly prescribed drug and according to the treating psychiatrists the one most likely to lead to a major improvement in target symptoms. Other psychotropics were generally rated as resulting in minor improvement or no change. Clinicians were aware they were prescribing contrary to NICE but justified this on the basis of having to treat severe and complex cases. CONCLUSIONS: Use of psychotropics (especially clozapine), off-label prescribing and polypharmacy were very common in these inpatients with BPD. Randomised controlled trials of the use of clozapine in severe BPD are needed.

Guidance on the Use of Antidepressants for Depression in Young People: A Survey of the Views of Consultants in Child and Adolescent Psychiatry.

BACKGROUND: The Committee on Safety of Medicines (CSM) and National Institute for Health and Clinical Excellence have issued guidance on antidepressant use in depression in young people. METHOD: An anonymous survey was sent to 692 UK consultants in child and adolescent psychiatry; the response rate was 70.1%. RESULTS: Almost all (95.1%) respondents said fluoxetine was their antidepressant of first choice (29.9% only prescribed fluoxetine), although use of sertraline and citalopram was common. The CSM advice had resulted in 68.4% switching to fluoxetine only, or mostly. CONCLUSIONS: Clinicians appear to be adhering national guidance. Guidance needs to be regularly updated to reflect current evidence.

Administration of medicines in food and drink: a study of older inpatients with severe mental illness.

BACKGROUND: Difficulties in administering medicines to older people are common, and medicines are sometimes mixed with food and drink to aid administration. Little is known about this practice or that of covert administration. This study aims to examine the nature, frequency, safety, reasons for and documentation of the administration of medicines in food and drink. METHODS: A cross-sectional survey of mainly older adults, who were inpatients at a U.K. tertiary referral centre, was carried out, and nursing staff and consultant psychiatrists were interviewed. RESULTS: Of the 110 patients, 34 (30.9%) were receiving medication mixed with food or drink, although for only 52.9% was the procedure documented in the patient's care plan and for 64.7% was it documented on the medication chart. No associated safety issues were identified. The main reasons for this practice were swallowing difficulties (61.8%) and refusal to swallow tablets (47.1%). Thirteen out of 110 (11.8%) patients were receiving covert medication, most commonly antipsychotics and anxiolytics or hypnotics. All were detained and lacked capacity to consent. Most had dementia but a few had chronic schizophrenia. For only 46.2% was covert administration documented in the care plan and for 69.2% on the medication chart. CONCLUSIONS: Administration of medication in food or drink and covert medication were common in this group of hospitalized patients with severe mental illness. Before administering medication covertly it is important to discuss the matter with the multidisciplinary team and, where appropriate, with the patient's relatives. It is also important to ensure that supporting documentation has been completed in order to avoid medico-legal difficulties.

Patients' complaints at a large psychiatric hospital: can they lead to better patient services?

PURPOSE: Little is known about complaints made by psychiatric patients. The aim of this study is to analyse complaints made by, or behalf of, inpatients at a large independent psychiatric hospital. DESIGN/METHODOLOGY/APPROACH: The hospital's complaints register was used to identify and study complaints made during 2006. A descriptive analysis was performed. FINDINGS: Of the 392 complaints, 39 per cent related to staff behaviour, 26 per cent to clinical matters, 18 per cent to the behaviour of other patients and the remaining 16 per cent to the physical environment and facilities. Action as a result of complaints was mainly taken at unit level but in 9 per cent of cases organisation-wide improvements were made, for example to enrich patient treatment programmes, rectify staff shortages and improve the quality of meals. RESEARCH LIMITATIONS/IMPLICATIONS: The study took place in a specialist hospital and so the findings cannot be generalised to the wider NHS. Important differences exist between complaints made in psychiatric as opposed to general hospital settings. PRACTICAL IMPLICATIONS: Complaints are a valuable source of organisational learning for mental health services. ORIGINALITY/VALUE: Given the paucity of literature on complaints in psychiatry, this study describes some in detail the nature of patients' complaints and one organisation's actions to improve patient services as a result of these complaints.

Life problems and deliberate self-harm: associations with gender, age, suicidal intent and psychiatric and personality disorder.

BACKGROUND: Deliberate self-harm (DSH) may occur in response to negative life events and life problems. High suicidal intent may be a risk factor for subsequent suicide but little is known about how life problems and suicidal intent are related. The aims of this study were to examine life problems according to age, gender, suicidal intent and other patient characteristics in DSH patients. METHODS: Data from the Oxford Monitoring System for Attempted Suicide were used to investigate life problems contributing to DSH and their relationship to patient variables including Suicide Intent Scale (SIS) scores in DSH patients presenting to the general hospital in Oxford between 1993 and 2000. Of 4391 persons included in the study 80.6% reported multiple life problems, the most common being in the relationship with spouse or partner. The nature of the most frequent problems changed over the life-span and there were gender differences. Females, but not males, with high suicidal intent had more problems than those with low intent and for females with no past history of DSH there was a weak positive correlation between the number of life problems and total SIS score. Patients with high intent more frequently experienced psychiatric and social isolation problems than those with low intent. Females with high intent more frequently reported bereavement or loss and eating problems. LIMITATIONS: The study population was not entirely representative of all DSH patients presenting to hospital. CONCLUSIONS: Most DSH patients have multiple life problems and the type of problems may be associated with varying degrees of suicidal intent. Patients should be offered interventions individually tailored according to their specific problems.

Delegation of medication administration: an exploratory study.

AIM: To examine the delegation of medication administration, including the frequency of delegation, whether delegation was to a care worker or a registered nurse (RN) and whether care workers were directly supervised when administering medication. METHOD: Administration of 1313 medication doses was observed on two inpatient psychiatric wards for older people. RESULTS: Administration was delegated by the nurse preparing the medication for four out of every five doses, usually to another registered nurse (78% of delegated doses), but also to care workers (22%). Care workers were more likely to administer medications to confused and aggressive patients than were registered nurses. CONCLUSION: Care workers who undertake delegated medication administration should receive regular training to ensure safety. Nurses remain accountable for delegated medication administration.

Benzodiazepines--a necessary evil? A survey of prescribing at a specialist UK psychiatric hospital.

Guidelines on the prescription of benzodiazepines recommend their use be limited to the short-term relief of severe anxiety or insomnia. However, clinical experience suggests that in psychiatry these drugs may be being prescribed more widely. The aim of this survey was to investigate benzodiazepine prescribing in a specialist UK psychiatric hospital using a structured interview with consultant psychiatrists. Prescribers were also asked their views on the UK CSM guidance on benzodiazepines (1988). Of 412 inpatients, 77 (18.7%) were receiving 90 benzodiazepine prescriptions for psychiatric indications. Most prescriptions were for anxiety (45/90; 50.0%), aggression (23/90; 25.6%) and agitation (13/90; 14.4%). Use was commonest for acquired brain injury, schizophrenia and personality disorders. Much usage was chronic (only 4/90 (4.4%) prescriptions had been initiated within the previous 4 weeks) and off-label (85/90; 94.4%). Prescribers were concerned about the addictive nature of benzodiazepines for these patients and to a lesser extent about their abuse potential. Most consultants believed the UK CSM guidance was too restrictive in relation to their clinical practice and needed modification to encompass new indications, for example rapid tranquillization, and specialist prescribing. In psychiatry benzodiazepines are quite frequently used in the management of a number of groups of difficult-to-treat patients. Although largely not evidence based, some psychiatrists report a favourable risk-benefit ratio for benzodiazepines in the treatment of certain patients.

Repetition of deliberate self-harm: a study of the characteristics and subsequent deaths in patients presenting to a general hospital according to extent of repetition.

Repetition of deliberate self-harm (DSH) is common. Some patients repeat multiple times. We have investigated the characteristics of repeaters, and mortality in three groups of DSH patients by repetition status. Data collected by the Oxford Monitoring System for Attempted Suicide were used to examine the pattern of repetition of DSH patients presenting to a general hospital between 1990 and 1997. Each patient was tracked through the monitoring system with regard to repetition. Patients traceable through National Death Registers were followed up until 2000 with respect to mortality. A total of 4,167 patients were studied of which 1,022 (24.5%) repeated at least once during follow-up. Using multinomial regression, past history of DSH was the variable most strongly associated with frequent (4+) and less frequent (1-3) repetitions. Risk of suicide was significantly increased in females with frequent repetition (7.7% dying by suicide), compared with both those with 1-3 repetitions (2.3%) and those not repeating (1.0%). The analyses were repeated for the 2,167 patients with no past history of DSH at their first presentation. Using multinomial regression, personality disorder was the only variable that was associated with 4+ repetitions compared with no repetitions, although a number of variables distinguished between patients with 1-3 repetitions and no repeat episodes. For clinicians assessing DSH patients, past history of DSH is the best predictor of infrequent and frequent repetition. In patients with no past history of DSH the presence of personality disorder increases the risk of frequent repetition of DSH.

Prescription errors in psychiatry - a multi-centre study.

Medication errors are an important cause of patient morbidity and mortality, of which there have been few reports in psychiatry, especially in the UK. Our aim was to examine the nature, frequency and potential severity of prescribing errors in UK mental health units in a prospective, 1 week survey of errors detected by pharmacy staff in nine NHS trusts. Pharmacists checked 22036 prescription items. In total, 523 errors meeting the study definition were detected (2.4% of prescription items checked). Prescription writing errors (77.4%) were most common, while decision-making errors accounted for 22.6% of errors. In 280 (53.5%) cases the prescribed drug had been administered before the error was detected. Most errors were of doubtful or minor importance but 22 (4.3%) were deemed likely to result in serious adverse effects or death. The error detection rate varied fourfold between trusts. Prescribing errors are fairly common in psychiatry. A small proportion of errors have the potential for serious harm. Pharmacy staff have an important role to play in their management.

Suicide and Self-Harm by Drowning: A Review of the Literature.

The objectives of this study were to carry out a comprehensive review of the worldwide literature on suicidal behaviour by drowning. Systematic electronic searches of databases using various search terms were carried out. Recent trends in suicide and undetermined deaths due to drowning in England and Wales are described. The characteristics of patients presenting to the general hospital in Oxford, UK following attempted drowning are compared with self-poisoning patients. A total of 20 studies containing empirical data about suicide by drowning were identified, mainly concerning Western countries. Drowning suicides have declined in most countries in recent years. The proportion of undetermined deaths remains high. Drowning suicides and self-harm patients tend to be older, with only a small excess of males compared to those using other methods. This is an under-researched area that deserves good quality studies focusing upon prevention.

Suicide and attempted suicide in bipolar disorder: a systematic review of risk factors.

OBJECTIVE: To determine the main risk factors for suicide and nonfatal suicidal behavior in patients with bipolar disorder through a systematic review of the international literature. DATA SOURCES: Studies were identified through electronic searches of MEDLINE (1966-December 2003), EMBASE (1980-December 2003), PsycINFO (1872-November 2003), and Biological Abstracts (1985-December 2003) using index and free-text search terms for bipolar disorder, bipolar depression, manic depression, mania, and affective disorders; combined with terms for self-harm, self-injury, suicide, attempted suicide, automutilation, self-mutilation, self-poisoning, and self-cutting; and combined with terms for risk, case control, cohort, comparative, longitudinal, and follow-up studies. No language restrictions were applied to the search. STUDY SELECTION: Included studies were cohort, case-control, and cross-sectional investigations of patients with bipolar disorder in which suicide (13 studies) or attempted suicide (23 studies) was reported as an outcome. The selected studies also used diagnostic tools including the DSM, International Classification of Diseases, and Research Diagnostic Criteria. DATA SYNTHESIS: Meta-analysis of factors reported in more than 1 study identified the main risk factors for suicide as a previous suicide attempt and hopelessness. The main risk factors for nonfatal suicidal behavior included family history of suicide, early onset of bipolar disorder, extent of depressive symptoms, increasing severity of affective episodes, the presence of mixed affective states, rapid cycling, comorbid Axis I disorders, and abuse of alcohol or drugs. CONCLUSIONS: Prevention of suicidal behavior in patients with bipolar disorder should include attention to these risk factors in assessment and treatment, including when deciding whether to initiate treatment aimed specifically at reducing suicide risk.

A survey of the off-label use of mood stabilizers in a large psychiatric hospital.

The term 'off-label' prescribing refers to the use of a drug outside the terms of its Marketing Authorization, including prescribing for an unlicensed indication. The aims of the study were to determine the frequency of off-label prescriptions for mood stabilizers (lithium and antiepileptics) among inpatients of a large psychiatric hospital, the nature of the off-label clinical indications in use and whether patients had been informed about the off-label usage.A cross-sectional survey of inpatients aged 18-65 years at St Andrew's Hospital, Northampton, UK and interviews with consultant psychiatrists about off-label usage of mood stabilizers were carried out. Of the 249 patients studied, 75 (30.1%) were receiving one or more mood stabilizers, of which 71 (94.7%) were off-label. The most frequently cited off-label indications for mood stabilizers were: prophylaxis of mood swings (48 cases), treatment of aggression (31), manic symptoms (10), antipsychotic augmentation in treatment-resistant schizophrenia (7) and post-traumatic stress disorder (6). Lithium was prescribed infrequently. The reasons for this are discussed. Although in most instances the psychiatrist was aware the drug was being used off-label, in less than one-third of cases had the patient been informed of this, partly because of anticipated difficulties in their understanding the off-label concept, but also because of concerns that this information could adversely affect compliance. The off-label prescription of mood stabilizers is very common in psychiatry and such usage benefits patients. When prescribing off-label, psychiatrists should consider the evidence that the drug is likely to be effective for the unlicensed indication. Where there is limited evidence of benefit, a trial of the drug, with clinical monitoring, may be indicated. Patients should be fully informed about their medication, and this includes information that the prescription is off-label. Pharmacists can assist this process. The off-label concept may be difficult for some patients to understand.

A review of medication administration errors reported in a large psychiatric hospital in the United kingdom.

A retrospective analysis of reports of medication administration errors over a period of three and a half years was carried out in a UK psychiatric hospital. A total of 112 errors and "near misses" were studied. The reporting rate increased over time. Psychotropic, intramuscular, and as-needed medications were overrepresented in the error reports. Fifteen percent of the errors had the potential to cause moderate or severe harm to patients. The two most common factors cited by nurses as contributing to error causation were a busy, noisy environment and personal factors, such as feeling tired or unsupported. Physicians were cited as having contributed to some errors.