Consultation-liaison psychiatric services among patients presenting to the hospital with deliberate self-harm: A retrospective record-based study

Abstract:- Background: Deliberate Self Harm (DSH) is a complex event, associated with psychosomatic, biological, social factors and psychiatric disorders. Current literature shows that, there is rise in DSH in psychiatric disorders and it has been recognised as major public health problem in India. So, objective of this study was to assess the underlying risk factors for DSH in patients with Bipolar Affective Disorder (BPAD). Methods: This cross-sectional study was conducted on 150 patients diagnosed with BPAD as per International Classification of Diseases; tenth revision (ICD-10). Semi-structured socio-demographic proforma was used to record basic profile. Deliberate self harm inventory (DSHI) was administered to assess the type of DSH. Young Mania Rating scale and Beck Depression Inventory were used to assess severity of symptoms. Results: Prevalence of DSH in present study was 33%. In socio-demographic profile, younger age group, lower education levels and being single were significant risk factors for DSH (p- value <.001, .016 and <.001 respectively) and among clinical variables, early years of disorder, severe mania, moderate and severe depressive episode in presence of medium to high suicidal intent, family history of mood disorders and co-morbid substance use and medical disorder were significant risk factors for DSH in BPAD with statistical significance (p<.0001). Conclusion: DSH is considered to be the significant predictor of suicide. BPAD is associated with high risk of DSH, which can be present in either depressive or manic episode. Patients with BPAD in early years of illness, should be evaluated thoroughly for risk factors, so that DSH risk can be minimised

Background: Mental disorders are among the strongest predictors of suicide attempts. However, little is known regarding which disorders that is uniquely associated with suicidal behavior because of high levels of psychiatric co-morbidity. The present study was planned to undertake on suicidal intent in such deliberate self-harm patients. Aims: The aim is to determine the suicidal intent and to assess the relationship with psychiatric morbidity in patients of deliberate self-harm Settings: Patients of deliberate self-harm. Design: Cross-sectional study. Materials and Methods: The sample consisted of 50 patients of deliberate self-harm admitted during study period of 6 months in appropriate in-patient unit for observation and necessary intervention, who fulfils inclusion criteria. A semi structured pro forma was used for collection of socio-demographic data, case history and Beck's Suicide intent scale was used which is designed to assess the severity of intention to die associated with an episode of deliberate self-harm. Statistical Analysis Used: Descriptive statistics such as mean, standard deviation, and percentage was used to present the data. To assess the relationship between the suicidal intent and psychiatric morbidity, Chi-square test was used. A P < 0.05 were considered significant. Data analysis was performed using software SPSS v20.0. Results: Self poisoning (80%) was found to be the most common method employed in deliberate self-harm. 74% of the deliberate self-harm attempts were impulsive in nature. Altercation with the spouse (30%) was the most common precipitating factor. Psychiatric morbidity was found to be associated with suicidal intent (P = 0.0068). Conclusions: In conclusion, even with low intent to harm self we have to be careful while examining the patients of psychiatric morbidity. They are at risk of attempting harm to self. We cannot ignore the patients just on the basis of low intent to harm self.

Deliberate Self-harm and Relationship to Alcohol Use at an Emergency Department In Eastern Taiwan

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. 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 (15-24years, 25-54years and 55+ years) and according to whether or not they lived alone. 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 25-54years 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 12months. 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. 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.

This study examines the efficacy of a short-term individual therapy, Manual Assisted Cognitive Treatment (MACT), which was developed to treat parasuicidal (suicidal or self-harming) patients. In this trial, MACT was modified to focus on deliberate self-harm (DSH) in patients with borderline personality disorder (BPD). Thirty BPD patients who were engaged in DSH while in ongoing treatments, i.e., treatment-as-usual (TAU), were randomly assigned to receive MACT (N = 15) or not. DSH and level of suicide ideation were assessed at the baseline, at completion of the MACT intervention, and six months later. Results indicated that MACT was associated with significantly less frequent DSH upon completion of the intervention and with significantly decreased DSH frequency and severity at the six months follow-up. Moreover, MACT's contribution to reducing DSH frequency and severity was greater than the contribution by the amount of concurrent treatments. In contrast, MACT did not affect the level of suicide ideation and time-to-repeat of DSH. In conclusion, MACT seems to be a promising intervention for DSH in patients with BPD. More definitive studies are needed.

Suicide is a leading cause of death among Korean adolescents. Many suicide attempting adolescents often are discharged against medical advice in the emergency department. The aim of the present study was to determine the risk factors for discharge against medical advice (DAMA) after self-inflicted injury or attempted suicide in the emergency department. We extracted data on adolescents (10-19 yr old) from the national emergency department information system; we used data from 2007 and 2011. A total of 6,394 adolescents visited EDs after self-inflicted injury or attempted suicide. Among these patients, the median age was 17 yr (Interquatile range, 15-18 yr), 83.2% were between 15-19 yr of age, and 63.3% were female. Poisoning was the most common method of attempted suicide, while hanging and fall were the most common methods of fatality. The rate of DAMA from the ED was 22.8%. Independent risk factors for DAMA included female gender (odds ratio [OR], 1.49), older age adolescents (OR, 1.96), residence in a metropolitan/large city area (OR, 1.49), and discharge at night (OR, 1.38). These risk factors should be considered in establishing management and counseling plans for patients discharged against medical advice by community services and EDs.

Aims:To study the presence of personality disorder in cases of deliberate self harm (DSH) in young (15–24 years) and elderly (45–74 years) and compare.Materials and Methods:Deliberate self harm cases admitted in Medical and surgical departments and cases attending psychiatry department of R.G. Kar Medical College, Kolkata were studied. For diagnosis of personality disorder ICD 10 International Personality Disorder Examination (IPDE) questionnaire was used.Results:Percentage of elderly patients having personality disorder (64%) was higher compared to young DSH patients (58.5%). In young group, most common disorder was emotionally unstable personality disorder (28.6%) and in elderly group most common was anankastic type of personality disorder (36%). Schizoid, dissocial, histrionic, and anxious-avoidant personality disorders were found in small percentages of cases.Conclusion:Among DSH patients, the most common personality disorder found in young age was Emotionally unstable (Impulsive and Borderline) personality disorder, but most common personality disorder found in elderly patients was Anankastic personality disorder.

Objective: The aim of this paper is to assess the level of agreement between clinical estimates of suicidal intent based entirely on information recorded in the Accident and Emergency acute assessment and Beck's Suicide Intent Scale (SIS) scores.Method: As part of the WHO/EURO Multicentre Study of Parasuicide, cases of deliberate self-harm (DSH) in Cork city hospitals were monitored. Over the period 1995-1997, the information recorded in the Accident and Emergency acute assessment was examined by a psychiatrist and, if possible on the available evidence, clinical estimates were made at three levels of suicidal intent: minimal, moderate and definite. Seventy-nine of these cases had fully completed Beck's SIS. Statistical comparison was made between the results of the SIS and the clinical estimate of suicide intent.Results: The agreement (Kappa = 0.146, p = 0.046) and concordance (Lin's concordance coefficient = 0.330, p = 0.001) between the two ratings are statistically significant but both are low. The overlap between those identified as high or low intent is low.Conclusions: These findings indicate low agreement between a clinician's rating of suicide intent based on clinical records and Beck's SIS. This is especially relevant given the increasing reliance on psychometric instruments in assessment in psychiatry. However, further investigation is necessary to clarify which is the more valid method.

Deliberate self harm patients with depressive disorders: treatment and outcome

Marked differences have been found in the characteristics of people dying by suicide in Western and Asian countries. However, there is less information available on possible differences for deliberate self-harm (DSH). To compare the characteristics of people presenting to hospital in Hong Kong and Oxford (UK) with DSH, and to assess the outcome of those persons in Hong Kong. A sample of DSH patients admitted to the accident and emergency (A&E) department of a regional hospital in Hong Kong was assessed and followed up 6 months later to assess the risk of repetition of DSH, and was then compared with such patients in Oxford. The majority of patients in Hong Kong were female (male:female ratio of 1:2.4), young (59% were under 35), and had used self-poisoning (78%). Over one-third were single (37%) and one-fourth unemployed (26%). About half (49%) scored in the high or very high categories of the Beck's Suicide Intent Scale, considerably more so than in Oxford; 44.6% of patients defaulted psychiatric outpatient service during the 6-month follow-up period. The repetition rate within the following 6 months was 16.7%. The number of self-reported adverse life problems, history of childhood sexual and physical abuse, and repetitive self-mutilation were shown to be the factors most strongly correlated with the risk of re-attempt. Alcohol problems were much lower than in Oxford. The findings show that DSH patients in Hong Kong show some marked differences compared to those in Oxford. Implications for the prevention of repeated DSH in Hong Kong are discussed.

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. 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. 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. 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.

Deliberate self-harm (DSH) patients with alcohol problems present a considerable challenge for clinical services. In a study of a sample of 150 DSH patients who were representative of all such patients seen at a general hospital during the study period, 40 patients with an ICD-10 diagnosis of alcohol dependence or harmful use of alcohol were compared with the remainder of the sample. The treatment of the patients with alcohol disorders before and after the episode of DSH and the outcome 12-20 months later were also investigated. Compared with other DSH patients, those with an alcohol diagnosis were older and more often male, living alone, unemployed, sick, disabled, or with a past history of DSH. They also had higher scores on measures of anger, aggression, and impulsivity. Comorbid psychiatric disorder was present in 37 (92.5%) patients, this being depression in three-quarters of those cases. Fourteen (35.0%) patients were receiving treatment from the psychiatric services prior to DSH, and 33 (82.5%) were subsequently offered treatment. Of the patients who were followed up, 37.9% remained in contact with psychiatric services, 55.2% showed poor compliance with treatment and 44.8% reported a further episode of DSH. All patients presenting after DSH need to be carefully screened for alcohol disorders and for comorbid psychiatric diagnoses. Treatment of DSH patients with alcohol disorders should include the treatment of any comorbid depressive illness.

Problems relating to alcohol use are very common among deliberate self-harm (DSH) patients, and alcohol abuse increases the risk of both DSH and suicide. In the UK, per capita consumption of alcohol has risen by 50% since 1970. The proportion of women (but not men) drinking in excess of government-recommended limits has also increased. We investigate trends, by gender and age group, in alcohol problems and usage among DSH patients. Data collected by the Oxford Monitoring System for Attempted Suicide were used to examine trends in alcohol disorders and alcohol consumption shortly before, or at, the time of self-harm by patients aged 15 years or over between 1989 and 2002. Data were available on 10,414 patients who were involved in 17,511 episodes of DSH. The annual numbers of both male and female DSH patients rose progressively over the study period. Although rates of alcohol disorders and consumption remained higher in males than females, substantial increases were seen in females of all ages in rates of alcohol problems, excessive drinking and consumption of alcohol within 6 h of DSH and as part of the act of DSH. Rates for males largely remained unchanged. There has been a significant increase in excessive drinking and consumption of alcohol around the time of DSH by females but not males. These changes may relate to increases in the affordability and availability of alcohol and to social changes in drinking patterns. They have implications for services for DSH patients and may have an impact on future patterns of suicidal behaviour.

Validation of Brief Screening Tools for Mental Disorders Among New Zealand Prisoners

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