Deliberate Self Research Articles

Web focus.

This regular feature highlights websites with information on clinical subjects. This edition focuses on deliberate self harm.

The psychosocial assessment of deliberate self harm: using clinical audit to improve the quality of the service

Objectives—To determine whether simple service initiatives resulted in an improvement in the quality of the psychosocial assessment of adults presenting with deliberate self harm (DSH) by accident and emergency (A&E)...

Reducing self-harm.

Deliberate self poisoning is one of the commonest reasons for admission to hospital in the UK. Up to 15 per cent of patients who poison themselves eventually kill themselves. Despite this, there are no interventions of proved efficacy. The objective of this randomised controlled trial was to determine the effects of a brief psychological intervention (brief psychodynamic interpersonal therapy) for patients after deliberate self poisoning, compared with usual treatment and the impact of the intervention and usual treatment on patients' satisfaction with care.

Randomised controlled trial of brief psychological intervention after deliberate self poisoning Commentary: Another kind of talk that works?

Objectives: To determine the effects of a brief psychological intervention (brief psychodynamic interpersonal therapy) for patients after deliberate self poisoning compared with usual treatment. To compare the impact of the...

History of deliberate self harm may predict methods of fatal self harm in the elderly.

In this study we examined the association between methods of Deliberate Self Harm (DSH) by the elderly and their subsequent methods of Fatal Self Harm (FSH). Data was collected from the files of inquests into suicide by the elderly in Birmingham and Cheshire Coroner's Courts. All the subjects were above the age of 60, had history of deliberate self harm before the final act of fatal self harm and attracted either suicide or open verdict returned by the Coroners over a period of four years 1995-1998. We compared the methods of Deliberate Self Harm (DSH) to the methods of Fatal Self Harm (FSH) used by all the included elderly. 18 per cent of elderly victims of FSH had a previous history of DSH and in 35 per cent of the sample, the last known attempt of DSH occurred more than one year prior to the FSH. The majority of the methods that had been used in elderly DSH were used again in their final act of FSH. Nearly two thirds of all the elderly who died of an overdose had attempted suicide earlier by an overdose and one in five of those who died by hanging or drowning used the same method in an unsuccessful attempt of FSH within 12 months. A detailed history of DSH can improve the quality of risk assessment of self harm in the elderly. As more than one in three elderly victims of FSH attempted DSH more than a year prior to the final act, it is important when assessing an elderly DSH attempt that we obtain any previous case notes and question informants about the distant as well as the recent past.

Ethnic density and deliberate self harm; a small area study in south east London

STUDY OBJECTIVERelative risks are frequently used to convey how strongly outcomes like mental illness and suicidal behaviour are associated with personal characteristics like ethnic background. This study examined whether RRs...

Deliberate self poisoning with antidepressant drugs: a comparison of the relative hospital costs of cases of overdose of tricyclics with those of selective-serotonin re-uptake inhibitors

Background: Debate continues over the relative merits of tricyclics and selective serotonin re-uptake inhibitors (SSRIs) as first line antidepressant treatment for depression. SSRIs are safer in overdose but more expensive than tricyclics. This report compared the hospital costs of cases of overdose with both groups of drug. Methods: Records of all persons aged over thirteen years presenting to a general hospital in one year were analysed for demographic information and details of their attendance. Results: There were 1165 episodes of self-poisoning, 151 involving tricyclics as the sole antidepressant and 69 SSRIs as the sole antidepressant. Those taking SSRIs had a shorter (1.96 vs. 2.59 days) and less expensive (£330 vs. £567) stay. A large proportion of this difference in cost was due to a small number of admissions to the Intensive Care Unit. Limitations: This study used only hospital costs, so excluding costs associated with primary care. Conclusions and clinical relevance: If there were similar cost differences countrywide, the difference in hospital costs of self poisoning with SSRIs and tricyclics would represent an additional £3.87 million per year due to self poisoning with tricyclics across the whole of England and Wales. This is a small proportion of the estimated £100 million cost of switching to first-line prescribing of SSRIs for depression.

The management of patients following deliberate self harm - what happens to those discharged from hospital to GP care?

The management of patients following deliberate self harm - what happens to those discharged from hospital to GP care?

Characteristics of children and adolescents presenting to accident and emergency departments with deliberate self harm

Objectives—The aim of this study was to provide a description of the characteristics of children and adolescents presenting to the accident and emergency (A&E) department with deliberate self harm. Method—Descriptive...

Deliberate self harm in medium security

Raising awareness and knowledge surrounding deliberate self harm is an important issue in nursing. Sarah Beasley reports on her study findings

Spinal cord injuries and attempted suicide: a retrospective review.

A retrospective review examining the cases of 137 individuals with spinal cord injury (SCI) as a result of a suicide attempt between 1951 - 1992. To ascertain demographic details of this participant sample, explore and identify the type of psychiatric condition evident around the time of injury, and to review outcome information of this sample with specific focus on mortality, especially further evidence of deliberate self harm. Research examining suicide rates in SCI populations has found such numbers to be significantly higher than in the general population. However, these studies have typically relied on small samples of individuals and have often failed to distinguish between those individuals who sustained SCI as a result of attempted suicide, and those who first attempted suicide following SCI. An established database comprising details of 137 people with SCI as a result of attempted suicide was reviewed and updated using patient admission records. The subsequent database comprised: cause, level and completeness of injury; height fallen; psychiatric history; psychiatric diagnosis; date of last contact; further suicide attempts; religious affiliation; previous and present employment; date and cause of death; date and place of discharge; and any other relevant details. From this database the three primary objectives of the study were ascertained: demographic detail; psychiatric condition; and outcome information. The ratio of males to females was 1 : 1 with a mean age of 32. Almost half (48.9%) were single, around a third (32.8%) had children and 42. 3% were employed. Schizophrenia and depression were evident in 32.8% and 27% of cases respectively. Previous suicide attempts had been made by 23% (n=32). The cause of injury in 85% of cases was 'falls'. Thirty-three people are known to have died, of whom eight (24%) committed suicide. During the period between the first and last spinal cord injury examined within this study (1951 - 1992) 1.6% (n=137) of the total sample of patients treated at the rehabilitation centre (n=8347) sustained a spinal cord injury as a result of a suicide attempt. Significant findings include; a high proportion of patients with schizophrenia; similar findings concerning age profile and level of injuries with previous research, but different sex ratio; and information on longer-term outcomes. Recommendations for further research include an adaptation of the psychological autopsy approach which would provide information beyond that normally available in actual suicides.

Psychosocial versus pharmacological treatments for deliberate self harm.

To identify and synthesise the findings from all randomised controlled trials that have examined the effectiveness of treatments of patients who have deliberately harmed themselves. Electronic databases screened: MEDLINE (from 1966-February 1999); PsycLit (from 1974-March 1999); Embase (from 1980-January 1999); The Cochrane Controlled Trials Register (CCTR) No.1 1999. Ten journals in the field of psychiatry and psychology were hand searched for the first version of this review. We have updated the hand search of three specialist journals in the field of suicidal research until the end of 1998. Reference lists of papers were checked and trialists contacted. All RCTs of psychosocial and/or psychopharmacological treatment versus standard or less intensive types of aftercare for patients who shortly before entering a study engaged in any type of deliberately initiated self-poisoning or self-injury, both of which are generally subsumed under the term deliberate self-harm. Data were extracted from the original reports independently by two reviewers. Studies were categorized according to type of treatment. The outcome measure used to assess the efficacy of treatment interventions for deliberate self-harm was the rate of repeated suicidal behaviour. We have been unable to examine other outcome measures as originally planned (e.g. compliance with treatment, depression, hopelessness, suicidal ideation/thoughts, change in problems/problem resolution). A total of 23 trials were identified in which repetition of deliberate self-harm was reported as an outcome variable. The trials were classified into 11 categories. The summary odds ratio indicated a trend towards reduced repetition of deliberate self-harm for problem-solving therapy compared with standard aftercare (0.70; 0.45 to 1.11) and for provision of an emergency contact card in addition to standard care compared with standard aftercare alone (0.45; 0.19 to 1.07). The summary odds ratio for trials of intensive aftercare plus outreach compared with standard aftercare was 0.83 (0.61 to 1.14), and for antidepressant treatment compared with placebo was 0.83 (0. 47 to 1.48). The remainder of the comparisons were in single small trials. Significantly reduced rates of further self-harm were observed for depot flupenthixol vs. placebo in multiple repeaters (0. 09; 0.02 to 0.50), and for dialectical behaviour therapy vs. standard aftercare (0.24; 0.06 to 0.93). There still remains considerable uncertainty about which forms of psychosocial and physical treatments of self-harm patients are most effective, inclusion of insufficient numbers of patients in trials being the main limiting factor. There is a need for larger trials of treatments associated with trends towards reduced rates of repetition of deliberate self-harm. The results of small single trials which have been associated with statistically significant reductions in repetition must be interpreted with caution and it is desirable that such trials are also replicated.

Carbon monoxide: chemistry, role, toxicity and treatment

Carbon Monoxide (CO) is a product of the incomplete combustion of organic materials. It is also produced endogenously in animals by haemoxygenase enzymes. Inducable haemoxygenase is involved in the breakdown of haeme to biliverdin. Constitutive haemoxygenase produces CO at a cellular level, where it acts as a neurotransmitter. It has a role in hyperpolarizing excitable membranes, and appears to be important in the formation and maintenance of memory. CO intoxication is not uncommon, and may result in a thousand deaths per year in Britain. Most cases are due to deliberate self poisoning or to faulty domestic heating appliances. Two iatrogenic sources have been investigated. Intraperitoneal diathermy in a carbon dioxide atmosphere has not been found to cause dangerous intoxication. Excessive dehydration of carbon dioxide absorbing salts in anaesthetic circuits has been shown to be dangerous. CO displaces oxygen from oxyhaemaglobin causing tissue asphyxia. In addition, dissolved CO is delivered to tissues where it acts as a cellular poison by binding to cytochrome a3 and blocking the electron transfer of aerobic respiration. Victims of CO poisoning may show an initial recovery, followed by delayed-onset neurological damage. Controversy continues as to whether CO intoxication should be treated by normobaric or hyperbaric oxygen therapy. A body of evidence is accumulating, which suggests that hyperbaric oxygen therapy is more effective, particularly in preventing delayed neurological deterioration.

The epidemiology of antisocial personality disorder.

This paper reviews the current state of knowledge about the frequency, natural history, risk factors and associations of antisocial personality disorder. Important recent developments are discussed, and where possible, findings have been tabulated Epidemiological surveys have shown that antisocial personality disorder is a common disorder, with a prevalence rate of between 2 and 3% among community samples, rising to 60% among male prisoners. Antisocial personality disorder is a chronic condition, and is associated with a multitude of medical and social problems. These include substance abuse, deliberate self harm and crime. Genetic and environmental factors have been implicated in the aetiology of the disorder. However, despite the large amount of research into antisocial personality disorder, longitudinal data are missing and the validity of the diagnosis, therefore, remains questionable. The paper concludes with recommendations for future research.

Paracetamol overdose in episode of casualty

The possibility that media representation of suicide and deliberate self harm may encourage suicidal behaviour in vulnerable individuals has attracted considerable attention. In a widely reported paper, researchers in Oxford sought to determine whether a paracetamol overdose in the television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning.

Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study

Objectives: To determine whether a serious paracetamol overdose in the medical television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning.Design: Interrupted time series...

Carbon monoxide poisoning treated with hyperbaric oxygen: metabolic acidosis as a predictor of treatment requirements.

A retrospective case note analysis was made of patients who received hyperbaric oxygen for carbon monoxide poisoning and were admitted to the Royal Naval Hospital Haslar between 1991 and 1995....

Deliberate self harm: Results of an integrated team approach in a teaching hospital

The objective of the Self Harm Intervention Project (S.H.I.P.) at Sir Charles Gairdner Hospital is to obtain information and identify significant issues which will assist in the management and contribute towards effective hospital and community care of patients who present with deliberate self-harm. A team of two workers was employed to gather data on all patients who presented to Sir Charles Gairdner Hospital with deliberate self-harm and to monitor their assessment and management until they were linked back to the community. Follow-up agencies were contacted to confirm a patient's attendance and counselling offered to those who did not receive any follow-up. The Self Harm Intervention Project has shown that a team targeting deliberate self-harm patients is useful in terms of gathering data, monitoring the population group and providing direct clinical service. This multi-faceted approach contributes towards ‘best practice’ in the management of deliberate self-harm.

Does initial management affect the rate of repetition of deliberate self harm? Cohort study

In the year following presentation to hospital after deliberate self harm, up to 25% of people repeat the act.1 A range of sociodemographic and psychological factors has been shown to...

Deliberate self harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition

Objective: To identify and synthesise the findings from all randomised controlled trials that have examined the effectiveness of treatments of patients who have deliberately harmed themselves.Design: Systematic review of randomised...