Multicentre Study Of Self-harm Research Articles

Self-harm in university students: A comparative analysis of data from the Multicentre Study of Self-harm in England

BackgroundIncreases in poor mental health and suicide have been identified among university students in the UK. However, little is known about self-harm in this group. AimsTo describe and identify care needs of university aged-students who self-harm via comparisons with an age-equivalent non-student group who self-harm. MethodsObservational cohort data from The Multicentre Study of Self-harm in England were used to investigate students aged 18 to 24 years who presented to emergency departments for self-harm, 2003 to 2016. Data were collected via clinician reports and medical records from five hospitals in three English regions. Characteristics, rates, repetition, and mortality outcomes were investigated. ResultsThe student sample included 3491 individuals (983, 28.2 % men; 2507, 71.8 % women; 1 unknown) compared to 7807 (3342, 42.8 % men; 4465, 57.2 % women) non-students. Self-harm increased over time in students (IRR 1.08, 95%CI 1.06–1.10, p < 0.01) but not in non-students (IRR 1.01, 95%CI 1.00–1.02, p = 0.15). There were differences in monthly distribution of self-harm with more presentations by students in October, November, and February. Characteristics were broadly similar, but students reported more problems with studying and mental health. Repetition (HR 0.78, 95%CI 0.71–0.86, p < 0.01) and mortality (HR 0.51, 95%CI 0.33–0.80, p < 0.01) were lower in students than non-students. ConclusionsSelf-harm in students may be directly related the student experience, such as academic pressure, relocation, and the transition to independent living. Wellbeing initiatives targeting these factors, alongside mental health awareness training for academic and non-academic staff may help to support students at risk.

A Public Health, Whole-of-Government Approach to National Suicide Prevention Strategies

Free AccessA Public Health, Whole-of-Government Approach to National Suicide Prevention StrategiesJane Pirkis, David Gunnell, Keith Hawton, Sarah Hetrick, Thomas Niederkrotenthaler, Mark Sinyor, Paul S. F. Yip, and Jo RobinsonJane PirkisJane Pirkis, Melbourne School of Population and Global Health, The University of Melbourne, VIC, Australia, j.pirkis@unimelb.edu.auhttps://orcid.org/0000-0002-2538-4472Melbourne School of Population and Global Health, University of Melbourne, VIC, AustraliaSearch for more papers by this author, David Gunnellhttps://orcid.org/0000-0002-0829-6470National Institute of Health and Care Research Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, UKSearch for more papers by this author, Keith Hawtonhttps://orcid.org/0000-0003-4985-5715Centre for Suicide Research, Department of Psychiatry, University of Oxford, UKSearch for more papers by this author, Sarah HetrickDepartment of Psychological Medicine, University of Auckland, New ZealandSearch for more papers by this author, Thomas Niederkrotenthalerhttps://orcid.org/0000-0001-9550-628XUnit Suicide Research and Mental Health Promotion, Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna, AustriaSearch for more papers by this author, Mark Sinyorhttps://orcid.org/0000-0002-7756-2584Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, CanadaDepartment of Psychiatry, University of Toronto, ON, CanadaSearch for more papers by this author, Paul S. F. YipHong Kong Jockey Club Centre for Suicide Research and Prevention, Department of Social Work and Social Administration, University of Hong Kong, Hong Kong SAR, PR ChinaSearch for more papers by this author, and Jo RobinsonOrygen, Melbourne, VIC, AustraliaCentre for Youth Mental Health, University of Melbourne, VIC, AustraliaSearch for more papers by this authorPublished Online:March 24, 2023https://doi.org/10.1027/0227-5910/a000902PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreMany countries have national suicide prevention strategies, all of which aim to reduce suicide and many of which also address self-harm more generally (World Health Organization, 2018). In this editorial, we argue that national strategies could be strengthened through an increased focus on the social determinants associated with suicide and self-harm. We present a public health model that articulates how these social determinants might operate and how they might interact with individual-level risk factors. We then describe how these social determinants might be addressed by a whole-of-government approach involving cross-sectoral action and genuine social participation and empowerment of people with lived experience of suicide and self-harm.Identifying the Social Determinants and Individual Risk Factors Associated With Suicide and Self-HarmFigure 1 provides a framework for considering the myriad of social determinants or societal influences that impact on suicide and self-harm, identifying targets for intervention that could be incorporated into national suicide prevention strategies. The model draws on the conceptual framework for action on the social determinants of health that was developed by the World Health Organization (WHO) Commission on Social Determinants of Health (CSDH; Solar & Irwin, 2010) and on other public health models that take a risk factor-based approach to suicide prevention (Moscicki, 1997; Silverman & Felner, 1995; Silverman & Maris, 1995). It describes a range of social determinants that may play a role in suicide and self-harm by interacting with various individual-level risk factors.Figure 1 Social determinants of suicide and self-harm. Adapted from Solar and Irwin (2010).The first panel of the model highlights the kinds of social determinants that are known to have an impact on suicide and self-harm. Many of these are taken directly from the original CSDH framework (Solar & Irwin, 2010). The list is not meant to be exhaustive, but rather to illustrate the range of social determinants. They include macro-economic policies (i.e., policies that are concerned with the given society’s overall economy, such as taxation policies), public policies (i.e., policies that relate to broad societal issues, such as healthcare), social policies (i.e., policies relating to addressing disadvantage, such as social welfare and housing), legislative/regulatory frameworks (i.e., laws and other regulatory mechanisms that govern the way individuals and organizations operate), cultural and societal values (i.e., societally reinforced beliefs and values that influence the way members of the society think and behave), and healthcare coverage and health system capacity and responsiveness (i.e., the ability of the health system to provide acute and ongoing care to members of society), and social cohesion and social capital (i.e., the extent to which members of society support each other and share a common purpose). All of these are underpinned by a society’s governance (i.e., the structures, processes, and principles that shape societal decision-making).The second panel describes the kinds of individual risk factors with which the aforementioned social determinants interact. These include sociodemographic, contextual, clinical, personality-based, genetic/familial, and neurobiological factors (Moscicki, 1997). The arrows between the social determinants and individual risk factors are bidirectional because they represent the interaction between the two.Together, the two panels illustrate the model’s breadth. It incorporates the social determinants and individual-level risk factors that sit at the core of a clinical or medical approach, highlighting the importance of healthcare coverage and health system capacity, and the relevance of clinical factors such as mental illness. It extends beyond this to take into account social determinants and individual-level risk factors that relate to wider aspects of people’s lives, some of which may have an impact from childhood or even inter-generationally.In line with the original CSDH framework, which is concerned with social determinants of health and health inequities (Solar & Irwin, 2010), the current model gives some prominence to sociodemographic risk factors, particularly those that are directly related to socioeconomic position (e.g., education, employment, occupation, and income). It does this because there is strong evidence from multiple studies that low socioeconomic position is associated with suicide and self-harm (Iemmi et al., 2016; Knipe et al., 2015) Social determinants are particularly powerful in terms of exacerbating or mitigating this risk. We know, for example, that economic recession is usually associated with elevated rates of suicide and self-harm, and that certain macroeconomic policies (e.g., taxation policies that widen inequalities) can intensify this, whereas particular social policies (e.g., active labor market policies and policies that guarantee a minimum wage) can offset it (Gertner et al., 2019; Stuckler et al., 2009). The interactions between social determinants and various other sociodemographic risk factors are also prominent in this model, with the relationship between culture and societal values and ethnicity and cultural heritage being a key example. This interaction is critical, with, for example, ill-treatment, discrimination, and prejudice influencing patterns of suicide in refugees and asylum seekers (Awaad et al., 2020).The model also recognizes, however, that social determinants can bypass sociodemographic risk and interact with individual risk factors that are not necessarily related to inequities. In doing so, they can have a broader influence on suicide and self-harm across the population. One example is the way in which legislative/regulatory frameworks that govern firearm availability interact with contextual factors relating to access to means and personality-based factors such as impulsivity. Multiple studies have shown that use of firearms is a relatively common method of suicide in countries where gun control laws are lax and firearms are readily accessible. Conversely, where gun control legislation is stricter, firearm suicides occur far less frequently (Chen et al., 2016; Miller & Azrael, 2016).As noted, the relationship between social determinants and individual risk factors can be bidirectional. For example, in the absence of comprehensive and effective public and social policies, people with no job, insecure housing, and problematic alcohol use may be placed at risk because they lose hope for their future, see no solution, and experience depression; conversely, people with severe mental illness may find it hard to hold down employment or settle in stable housing. If strong public and social policies are in place, however, both groups of individuals may benefit from job training opportunities or rent relief and find it easier to find support for their substance use or mental illness. This is not to diminish the impact of living with substance use or mental illness, nor to deny the fact that timely access to high-quality treatment is critical.The health system may exert a major direct protective effect on suicide and self-harm for some people. Like the other social determinants in the model, it may interact with the sociodemographic and other individual risk factors in the model, sometimes underpinning them and sometimes intensifying or attenuating them. Societies that offer universal healthcare coverage may be able to mitigate risk by addressing some of the individual-level clinical risk factors for suicide and self-harm (e.g., by offering accessible, high-quality care for those with mental illness; Bolton & Robinson, 2010; Too et al., 2019). However, universal healthcare coverage may not be enough if the health system is at capacity, and people are not appropriately referred, have long wait times to get into care, do not receive adequate care, or are unable to access care at all.Some social determinants may benefit or disadvantage both those with sociodemographic risk factors and the population in general. Public policies that limit the consumption of alcohol are a case in point of how benefits can impact both those at risk and the entire population. Alcohol misuse is a key individual-level clinical risk factor for suicide, and although alcohol-related harms occur on a socioeconomic gradient, policies that limit alcohol consumption are likely to confer benefits across all socioeconomic strata (Rajput et al., 2019).In the model, social cohesion and social capital are important social determinants that have a protective effect. The contribution of these constructs to suicide rates has been recognized for over 120 years, well before these specific terms were in use. Durkheim’s text, Le Suicide: Étude de Sociologie (Suicide: A Study in Sociology; Durkheim, 1897/1951) drew attention to the fact that markers of societal integration and connectedness in certain European countries (e.g., typical family structure, dominant religion, level of economic stability) were associated with lower suicide rates. More recent studies have shown that social capital, as measured by indicators of social participation, political participation, and trust, is inversely associated with suicide rates (Kelly et al., 2009).The ultimate outcomes in the model are suicide and self-harm, as represented by the third panel. The interplay between the social determinants and individual-level risk factors in the preceding panels mean that a disproportionate burden of both suicide and self-harm falls on those who are more susceptible to negative effects of the various social determinants. A pernicious feedback loop – represented by the bidirectional arrow – operates here with the effect that some individuals who have self-harmed may find that they are more vulnerable to risk because they are more exposed to harmful social determinants (e.g., facing economic hardship because they are unable to return to the workforce, or bearing the brunt of negative cultural and societal values such as stigma and discrimination). They may also be at more direct increased risk by virtue of having already self-harmed (Geulayov et al., 2019). With suicide, because the outcome is fatal, the effect is unidirectional.A Whole-of-Government Approach to Preventing Suicide and Self-HarmThe public health model recognizes the salience of the kind of social determinants and individual-level risk factors identified above and addresses them through prevention activities classified as universal, selective, or indicated depending on how their target groups are defined. Universal interventions target the whole population, without necessarily identifying individuals who might be at risk of suicide or self-harm. Selective interventions target individuals who are not yet thinking about suicide or engaging in self-harm, but who exhibit risk factors that predispose them to do so in the future. Indicated interventions are designed for individuals who are already suicidal or self-harming and include a range of solutions typically (although not exclusively) offered in clinical settings. All three types of interventions are designed to minimize or ameliorate risk factors (or to bolster protective factors).The ways in which social determinants influence suicide and self-harm will require us to intensify our focus on universal and selective interventions as we develop national suicide prevention strategies. We should not do this at the expense of indicated interventions for those who are already suicidal or self-harming, because these are critical, but we do need to broaden our thinking in relation to the full range of social determinants. Universal and selective interventions have the potential to benefit the whole population.Figure 2 presents a hybrid, whole-of-government approach to preventing suicide and self-harm that overlays the CSDH framework on the traditional public health model. The model centers on context-specific strategies for tackling social determinants and their interactions with individual-level risk factors. These strategies take the form of universal, selective, and indicated interventions that involve cross-sectoral action that is undertaken not only by the health sector but importantly, also by sectors beyond health. The strategies are informed by and designed to promote social participation and empowerment. Like the CSDH framework, this model also emphasizes the importance of monitoring the impacts of policies and other interventions and strengthening the evidence for their effectiveness. This involves collecting data to determine what interventions are being delivered to whom and what outcomes are being achieved as a result. Further detail is provided in the next sections on the cross-sectoral action and social participation and empowerment that are integral to the whole-of-government approach.Figure 2 Suicide and self-harm prevention model. Adapted from Silverman and Felner (1995) and Silverman and Maris (1995).Cross-Sectoral ActionAs indicated earlier, healthcare coverage and health system capacity and responsiveness are important social determinants of suicide and self-harm. They are vital for ensuring that suicidal people can access appropriate services and receive the support they need. However, cross-sectoral action (i.e., interventions that occur outside the health sector but affect health outcomes) must be a key component of any prevention strategy. This cross-sectoral action must involve genuine partnerships from all levels of multiple sectors.Traditionally, national suicide prevention strategies have not gone far enough in fostering cross-sectoral action. Many national suicide prevention strategies draw on the advice of the WHO and recommend a range of universal, selective, and indicated interventions, underpinned by strong, cohesive leadership and, wherever possible, evidence from a range of sources. Platt et al. (2019) summarized the typical interventions and described these and their underpinnings as the components of national strategies. These components are like the tree in Figure 3. The root system represents the underpinnings: oversight and coordination, which are crucial elements of strong leadership and appropriate investment; and surveillance, monitoring, and evaluation, which contribute to the evidence base. The branches represent the different interventions that are commonly delivered through national strategies.Figure 3 Typical components of national suicide prevention strategies. Adapted from Platt et al. (2019).Few would dispute the value of most of the components of national strategies, and some are helpful in addressing the key social determinants of suicide and self-harm. However, national suicide prevention strategies are limited because they are usually signed off by health ministers and the responsibility for their oversight rests with health bureaucrats. A search of relevant national strategies conducted in November 2020 identified 28 current strategies (Schlichthorst et al., 2022), 21 (75%) of which were published by health ministries (M. Schlichthorst, personal communication, December 1, 2020). Although these health-led strategies often make mention of the role of social determinants, they are light on genuine cross-sectoral collaboration, failing to attach appropriate import to the broader impact that policy decisions in other sectors can have on suicide and self-harm. They acknowledge the inequities created by these decisions but do not address them in a meaningful way. For example, they do not recognize the major influence on suicide and self-harm of far-reaching policies relating to economic austerity measures. Nor do they recognize the impact of weak regulation of the alcohol and gambling industries, where market decisions are made for commercial gain. These policies can have a major impact on the risk of suicide and self-harm for some of the most vulnerable members of society. Worse, there is an implication that if governments recommend health sector-centric interventions prescribed by typical national suicide prevention strategies then they have “done their bit.”This skewed emphasis flows from policy to practice. This is evident in the list of interventions that comprise the typical components of national strategies in Figure 3. The majority of these are delivered by clinically oriented health and related services and focus on individuals rather than populations (e.g., access to health and social care services, psychotherapeutic interventions designed to reduce repeated suicidal and self-harming behaviors, enhanced care/follow-up for people who have attempted suicide, crisis intervention). These are a critical part of any dedicated effort to reduce suicide and self-harm and, if done well, have the potential to make a real difference for suicidal individuals who make contact with the health system. By themselves, however, indicated interventions are not able to prevent people reaching the point of crisis; on-the-ground action from outside the health system is necessary here.Even interventions that are not solely the responsibility of health services tend to be implemented through a healthcare lens. For example, training and education targeting gatekeepers or first responders is often developed and delivered by health professionals, as are programs designed to address the stigma and discrimination surrounding suicide. Health services and individual health professionals have a clear role to play in preventing suicide and self-harm but achieving population-wide prevention requires a more holistic approach and a workforce with broad-ranging expertise. It is absolutely appropriate that when someone is in crisis or has self-harmed that clinicians in health services should provide care. However, frontline healthcare staff are often not optimally equipped to help with nonclinical issues (e.g., financial hardship, job losses, and relationship break-ups), and therefore clear referral pathways are required to ensure that clinical and nonclinical issues can be addressed at the same time.There may also be benefits in complementing some of the more clinical interventions with other approaches. There is evidence, for example, that peer workers with lived experience of suicide and self-harm may be well-placed to support those in a suicidal crisis in supportive and/or open environments (Oostermeijer et al., 2022).National suicide prevention strategies need to involve a whole-of-government partnership that recognizes how policies in a range of sectors can increase or decrease people’s risk of suicide and self-harm. This would lead to better, more robust and concerted prevention efforts and signal a greater prioritization of suicide and self-harm as major targets of societal intervention. As one example, the communications portfolio and online safety regulator might look closely at how their policies and regulations could be modified to improve online safety. This could include approaches that maximize the chances of online conversations about suicide being helpful and unlikely to have adverse impacts. It could also include working with the social media industry to address the ways in which their algorithms operate, in order to maximize the helpful content and minimize the harmful content that people – particularly young people – are exposed to.There are precedents for this. The “Health in All Policies” approach holds politicians and policy-makers from all sectors accountable for considering the consequences of their decisions on health and wellbeing, with a view to improving population health and reducing health inequities (WHO, 2014). Ideally, national suicide prevention strategies should promote a “Suicide and Self-harm Prevention in All Policies” approach that is led by chief ministers, or by specially appointed ministers with a cross-sectoral remit. This strong leadership is critical and relates to the notion of governance underpinning the kinds of social determinants of suicide and self-harm that are outlined in Figure 1.The actions that flow from more cross-sectoral suicide prevention strategies need to reflect the urgency of dealing with the social determinants of suicide and self-harm. They should draw on the best available evidence wherever possible, but should not be stalled while we wait for the evidence to accrue. Judicious decisions should be made about investing in innovative solutions that are likely to have a significant impact. Of course, these promising actions should be carefully evaluated to determine whether they do in fact achieve their goals.In order to significantly reduce rates of suicide and self-harm, we need to move beyond the single health sector tree in Figure 3. We need a forest of trees, like those in Figure 4, that form a multisector ecosystem that recognizes that preventing suicide and self-harm is “everybody’s business.” Each tree represents a different sector; health is a key sector but not the only one. The trees are underpinned by a root ball that represents the most powerful leadership, and their branches are intertwined in a way that promotes optimal cross-sectoral policy and practice. Some trees are grafted from others, representing ideal cross-sectoral collaboration. Within sectors, the trees’ trunks bring the branches together to ensure that they are not competing for resources. The biodiversity of the forest floor is critical too, representing the many stakeholders who are involved at a grass-roots level and drive bottom–up initiatives that are key to innovation in suicide and self-harm prevention. These stakeholders include but are by no means limited to businesses and community and social organizations. With nutrients and sunlight representing sustainable funding support, the trees form a canopy that provides optimal protection against suicide and self-harm.Figure 4 A new approach to national suicide prevention strategies.Social Participation and EmpowermentSocial participation is critical for suicide and self-harm prevention. Social participation is based on the notion that all groups in society are empowered to have a significant influence on policy decisions that affect their wellbeing and quality of life. In this case, people with lived experience of suicide should be empowered to influence decisions that affect their risk of suicide and self-harm. Family members, friends, and others who care about these people should also have a major say in these decisions, as should those who have lost someone to suicide.A response to suicide and self-harm that fosters social participation and empowerment is vital for two reasons. The first of these is based on a simple human rights argument. Everyone has the right to participate in shaping public and social policies that affect their wellbeing or, in this case, influence their risk of suicide and self-harm. The second reason is that policies that influence suicide and self-harm are likely to be more effective and more sustainable if relevant groups of stakeholders have genuine ownership of them. Solutions are more likely to come from those who are affected by the social determinants of suicide and self-harm, living with them as part of their reality every day.We have a long way to go in terms of participation and empowerment in suicide and self-harm prevention, although some progress has been made. Increasingly, people with lived experience of suicide and self-harm are being offered a seat at the decision-making table, although not all groups are well-represented (e.g., young people often miss out). Despite this generally positive direction, the decisions that people with lived experience are invited to have input into tend to be quite specific, often relating to the way in which elements of the mental health system might be better reconfigured to support them, or to how specific suicide prevention programs might be designed and delivered. Even when they are involved in higher-level policy committees, these committees tend to have the health-centric policy focus described above.We need to ensure that people who are at heightened risk of suicide and self-harm have a genuine, meaningful influence over policy decisions in the “big-ticket” non-health areas that perpetuate their disproportionate level of risk. Their experiences need to be fully incorporated into agenda-setting across the full gamut of relevant policies. They should be involved in the highest-level committees, sit on working groups that draft these policies, and be employed in relevant government departments. They should be recognized as experts; many people with lived experience of suicide and self-harm are also professionals, and viewing their input as separate to or different from that of other stakeholders creates a false dichotomy.ConclusionWe have provided a framework for national suicide prevention strategies that is based on addressing the social determinants of suicide and self-harm by emphasizing interventions that use policy, legislative/regulatory, and systems levers from beyond the health sector. The suggested approach is not designed to replace existing international efforts, but rather to build on them through broader-ranging, longer-term, more visionary solutions that have people with lived experience at their core. There are already many great efforts happening in communities around the world, and national strategies should build on and leverage from these.Author BiographiesJane Pirkis, PhD, is Director of the Centre for Mental Health at the University of Melbourne. She is also the Editor-in-Chief of Crisis and a past vice president of the International Association for Suicide Prevention (IASP). She is well-known for her work on suicide prevention policy and has received various awards, including IASP’s 2019 Erwin Stengel Research Award.David Gunnell, MB, ChB, DSc, is Emeritus Professor of Epidemiology at the University of Bristol, UK. He is a public health physician and epidemiologist with a longstanding research interest in the etiology and prevention of suicide and in improving population mental health.Keith Hawton is Professor of Psychiatry and Director of the Centre for Suicide Research, University of Oxford as well as a consultant psychiatrist at the Oxford Health NHS Foundation Trust, UK. His research group is involved in investigating the causes, treatment, prevention, and outcome of suicidal behavior. This has included a long-standing interest in public health approaches to prevention.Sarah Hetrick is Associate Professor of Youth Mental Health, University of Auckland, and Principal Clinical Advisor in the Suicide Prevention Office, Ministry of Health, New Zealand. She is a coordinating editor for the Cochrane Common Mental Disorders Group and a clinical psychologist.Thomas Niederkrotenthaler is Associate Professor and Head of the research unit Suicide Research and Mental Health Promotion, Center for Public Health, Medical University of Vienna, Austria. He is an internationally recognized expert in the area of suicide and the media.Mark Sinyor is a psychiatrist at Sunnybrook Health Sciences Centre, an associate professor at the University of Toronto, and the America’s lead for the International Association for Suicide Prevention’s Partnerships for Life initiative. He was lead author of the 2018 Canadian Psychiatric Association recommendations for media reporting on suicide.Paul S. F. Yip is Director of the Hong Kong Jockey Club Centre for Suicide Research and Prevention at the University of Hong Kong, PR China. He is a recipient of the International Association for Suicide Prevention’s Erwin Stengel Research Award (2011). His interests lie in adopting a public health approach for suicide prevention.Jo Robinson is a professor at Orygen in Melbourne, Australia, where she leads the suicide prevention research unit. Her work focuses on developing and testing novel interventions that specifically target at risk youth across settings and on the translation of research evidence into practice and policy. She is also Vice President of the International Association for Suicide Prevention (IASP).We would like to thank our Lived Experience Advisory Group for helping us shape this editorial. As individuals and as a group they generously shared perspectives and offered insights that made the document stronger, sharper, and much more relevant than it would otherwise have been. Members of the group were: Glenn Cotter, Alan Earls, Maddox Gifford, Kerry Gleeson, David Kelly, Karyn Moyle, Grace Sholl, Atria Rezwan, Lucia Volker Smith, and Natalie Willis.ReferencesAwaad, R., Dailami, M., & Noureddine, N. (2020). US policy of public charge inadmissibility and refugee suicides. Lancet Psychiatry, 7(3), Article e12. 10.1016/s2215-0366(20)30037-7 First citation in articleCrossref Medline, Google ScholarBolton, J., & Robinson, J. (2010). Population-attributable fractions of Axis I and Axis II mental disorders for suicide attempts: Findings from a representative sample of the adult, noninstitutionalized US population. American Journal of Public Health, 100(12), 2473–2480. 10.2105/ajph.2010.192252 First citation in articleCrossref Medline, Google ScholarChen, Y.-Y., Wu, K. 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As individuals and as a group they generously shared perspectives and offered insights that made the document stronger, sharper, and much more relevant than it would otherwise have been. Members of the group were: Glenn Cotter, Alan Earls, Maddox Gifford, Kerry Gleeson, David Kelly, Karyn Moyle, Grace Sholl, Atria Rezwan, Lucia Volker Smith, and Natalie Willis.PDF download Funding: This work was funded by the Australian National Suicide Prevention Office (NSPO), which contributed to model development and to the preparation of this editorial.

Socio-economic disparities in patients who present to hospital for self-harm: patients' characteristics and problems in the Multicentre Study of Self-harm in England

BackgroundWe examined disparities in sociodemographic and clinical characteristics and in problems preceding self-harm across levels of socio-economic deprivation (SED) in persons who presented to hospital for self-harm. Method108,092 presentations to hospitals (by 57,306 individuals) following self-harm in the Multicentre Study of Self-harm in England (1/1/2000–31/12/2016). Information on area-level SED was based on the English Index of Multiple Deprivation. Information about patients' characteristics and problems was obtained from self-harm monitoring systems in the hospitals. We assessed the association of SED with the characteristics of interest using descriptive statistics. ResultsOverall, 45 % of the presentations were by individuals from areas ranked nationally as most deprived, while 13 % of episodes were by individuals from the least deprived areas. Males and non-white ethnic groups were over-represented in the most deprived SED stratum. Previous self-harm was more prevalent in the two most deprived groups. Relationships difficulties with partners and other family members were reported more commonly by individuals from less socio-economically deprived areas, as were problems pertaining to finances and employment or studies. Problems in relationships with friends were more prevalent in the most deprived group relative to other groups. LimitationsInformation about problems which preceded self-harm was available only for patients who received psychosocial assessment. ConclusionsPatients vary considerably across area-level SED strata in terms of gender, ethnicity, and the problems which preceded their self-harm. These findings emphasise the need to use an individualised approach to patients in understanding the unique circumstances which contribute to their self-harm and their specific care needs.

Self-harm in people experiencing homelessness: investigation of incidence, characteristics and outcomes using data from the Multicentre Study of Self-Harm in England.

People who experience homelessness are thought to be at high risk of suicide, but little is known about self-harm in this population. To examine characteristics and outcomes in people experiencing homelessness who presented to hospital following self-harm. Data were collected via specialist assessments and/or hospital patient records from emergency departments in Manchester, Oxford and Derby, UK. Data were collected from 1 January 2000 to 31 December 2016, with mortality follow-up via data linkage with NHS Digital to 31 December 2019. Trend tests estimated change in self-harm over time; descriptive statistics described characteristics associated with self-harm. Twelve-month repetition and long-term mortality were analysed using Cox proportional hazards models and controlled for age and gender. There were 4841 self-harm presentations by 3270 people identified as homeless during the study period. Presentations increased after 2010 (IRR = 1.09, 95% CI 1.04-1.14, P < 0.001). People who experienced homelessness were more often men, White, aged under 54 years, with a history of previous self-harm and contact with psychiatric services. Risk of repetition was higher than in domiciled people (HR = 2.05, 95% CI 1.94-2.17, P < 0.001), as were all-cause mortality (HR = 1.45, 95% CI 1.32-1.59. P < 0.001) and mortality due to accidental causes (HR = 2.93, 95% CI 2.41-3.57, P < 0.001). People who self-harm and experience homelessness have more complex needs and worse outcomes than those who are domiciled. Emergency department contact presents an opportunity to engage people experiencing homelessness with mental health, drug and alcohol, medical and housing services, as well as other sources of support.

Life problems in children and adolescents who self-harm: findings from the multicentre study of self-harm in England.

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. 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. 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. 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.

Cost-effectiveness of psychosocial assessment for individuals who present to hospital following self-harm in England: A model-based retrospective analysis.

Guidance in England recommends psychosocial assessment when presenting to hospital following self-harm but adherence is variable. There is some evidence suggesting that psychosocial assessment is associated with lower risk of subsequent presentation to hospital for self-harm, but the potential cost-effectiveness of psychosocial assessment for hospital-presenting self-harm is unknown. A three-state four-cycle Markov model was used to assess cost-effectiveness of psychosocial assessment after self-harm compared with no assessment over 2years. Data on risk of subsequent self-harm and hospital costs of treating self-harm were drawn from the Multicentre Study of Self-Harm in England, while estimates of effectiveness of psychosocial assessment on risk of self-harm, quality of life, and other costs were drawn from literature. Incremental cost-effectiveness ratios (ICERs) for cost per Quality Adjusted Life Year (QALY) gained were estimated. Parameter uncertainty was addressed in univariate and probabilistic sensitivity analyses. Cost per QALY gained from psychosocial assessment was £10,962 (95% uncertainty interval [UI] £15,538-£9,219) from the National Health Service (NHS) perspective and £9,980 (95% UI £14,538-£6,938) from the societal perspective. Results were generally robust to changes in model assumptions. The probability of the ICER being below £20,000 per QALY gained was 78%, rising to 91% with a £30,000 threshold. Psychosocial assessment as implemented in the English NHS is likely to be cost-effective. This evidence could support adherence to NICE guidelines. However, further evidence is needed about the precise impacts of psychosocial assessment on self-harm repetition and costs to individuals and their families beyond immediate hospital stay.

Research round-up

In an observational cohort study with data from the Multicentre Study of Self-harm in England, Bushra Farooq and colleagues have reported on rates of self-harm in youth aged 10–19 years presenting to five emergency departments. Between 2000 and 2016, there were 14 894 young people who presented a total of 22 128 times to the emergency departments with self-harm. Over the study period, presentation rates increased in all groups, although to a lesser extent in White youth (incidence rate ratio 1·02 [95% CI 1·00 to 1·03]) than in south Asian individuals (1·05 [1·01 to 1·09]), Black individuals (1·07 [1·03 to 1·11]), and other non-White individuals (1·11 [1·06 to 1·16]).

Self-harm in children and adolescents by ethnic group: an observational cohort study from the Multicentre Study of Self-Harm in England

Studies report an increasing incidence of self-harm in children and adolescents, but the extent to which this is seen in different ethnic groups is unclear. We aimed to investigate rates of emergency department presentations for self-harm in children and adolescents by ethnicity, as well as to examine their demographic characteristics, clinical characteristics, and outcomes. In this observational cohort study, we used data on hospital emergency department presentations for self-harm in children and adolescents aged 10-19 years between 2000 and 2016 from the Multicentre Study of Self-harm in England. This study collects data from five general hospitals in Manchester, Oxford, and Derby in the UK, and defines self-harm as any act of intentional self-injury or self-poisoning, regardless of intent. All children and adolescents aged 10-19 years for whom ethnicity data were available were included. Mortality follow-up was available through linkage with mortality records from the Office for National Statistics. Rates of self-harm over time, demographic and clinical characteristics, and self-harm methods were investigated by ethnic group. Risk of repeat self-harm and mortality following an initial presentation for self-harm was compared by ethnic group using Kaplan-Meier curves and Cox proportional hazards models. Of 14 894 individuals who presented at hospitals with self-harm, 11 906 had data for ethnicity, of whom 10 211 (85·8%) were White, 344 (2·9%) were Black, 619 (5·2%) were South Asian, and 732 (6·1%) were other non-White. Rates of self-harm were highest in White children and adolescents but increased between 2009 and 2016 in all ethnicities. Mean annual rates of self-harm per 100 000 population were 574 for White, 225 for Black, 260 for South Asian, and 344 for other non-White groups. Increases in rates of self-harm between 2009 and 2016 appeared slightly greater in Black groups (incidence rate ratio 1·07 [95% CI 1·03-1·11]), South Asian groups (1·05 [1·01-1·09]), and other non-White groups (1·11 [1·06-1·16]) than in White groups (1·02 [1·00-1·03]). Children and adolescents from a minority ethnic background were more likely to live in areas of high deprivation and were less likely to receive a specialist psychosocial assessment than were White children and adolescents. Children and adolescents from minority ethnic groups were also less likely to repeat self-harm. However, there were no differences in suicide mortality by ethnic group, although the numbers were small. Minority ethnic children and adolescents accounted for an increased proportion of self-harm presentations to hospital over time compared with White ethnic groups. The minority ethnic groups also tended to be more socioeconomically disadvantaged and were less likely to receive a psychosocial assessment. Socioeconomic disparities need to be addressed, and equitable access to culturally sensitive comprehensive psychosocial assessments must be ensured. UK Department of Health and Social Care.

Risk of suicide in patients who present to hospital after self-cutting according to site of injury: findings from the Multicentre Study of Self-harm in England.

We compared the risk of death by suicide following hospital presentation for self-harm according to site of self-cut/stab. We included 54 999 self-harm presentations (involving 31 419 individuals) to hospitals in the Multicentre Study of Self-harm in England (1/1/2004-31/12/2014), with mortality follow-up to 31/12/2019. Information on method of self-harm was obtained through monitoring in hospitals. Information about mortality was obtained through linkage with NHS Digital. We assessed the association of site of self-cut with death by suicide using mixed effect models. In total, 10 790 (19.6%) hospital presentations involved self-cutting/stabbing, 7489 of which (69.4%) were due to laceration to the arm/wrist alone, 1846 episodes (17.1%) involved cutting elsewhere on the body, and 1455 (13.5%) were due to laceration to unknown site. Controlling for confounders, presentation to a hospital following self-cut/stab to bodily parts other than wrist/arm was associated with greater chance of subsequent suicide relative to presentation after self-poisoning alone [adjusted odds ratio (aOR) 1.75, 95% confidence interval (CI) 1.03-2.96, p = 0.038]. The likelihood of suicide after presentation for cutting/stabbing the wrist/arm alone was comparable to that of patients who had self-poisoned alone. Presentations after laceration involving the neck were associated with a four-fold greater chance of subsequent suicide relative to self-poisoning (aOR 4.09, 95% CI 1.80-9.30, p = 0.001). Patients who attend hospital after self-cutting/stabbing are a heterogeneous group in terms of characteristics, methods of cutting/stabbing and risk of subsequent suicide. Risk of suicide is greater in individuals who self-cut/stab to parts of the body other than the wrist or arm, especially the neck.

Self-harm in children 12\xa0years and younger: characteristics and outcomes based on the Multicentre Study of Self-harm in England

BackgroundVery little is known about self-harm in children. We describe the characteristics and outcomes of children under 13 years who presented following self-harm to five hospitals in England.MethodsWe included children under 13 years who presented after self-harm to hospitals in the Multicentre Study of Self-harm in England. Information on patients’ characteristics and method of self-harm was available through monitoring of self-harm in the hospitals. Area level of socioeconomic deprivation was based on the English Index of Multiple Deprivation (IMD).Results387 children aged 5–12 years presented to the study hospitals in 2000–2016, 39% of whom were 5–11 years. Boys outnumbered girls 2:1 at 5–10 years. The numbers of boys and girls were similar at age 11, while at 12 years there were 3.8 girls to every boy. The proportion of study children living in neighbourhoods ranked most deprived (43.4%) was twice the national average. 61.5% of children self-poisoned, 50.6% of them by ingesting analgesics. Of children who self-injured, 45.0% self-cut/stabbed, while 28.9% used hanging/asphyxiation. 32% of the children had a repeat hospital presentation for self-harm, 13.5% re-presented within a year.ConclusionsGender patterns of self-harm until age 11 years are different to those of adolescents, with a male preponderance, especially in 5–10 years, and hanging/suffocation being more common. The frequent use of self-poisoning in this age group highlights the need for public health messages to encourage safer household storage of medicines. Self-harm in children is strongly associated with socioeconomic deprivation; understanding the mechanisms involved could be important in effective prevention.

Research round-up

With data from the US National Social Life, Health, and Aging Project, Ziggi Santini and colleagues carried out a longitudinal mediation analysis to investigate the associations between social disconnectedness and isolation and depression and anxiety. Their analysis included data from 3005 adults aged 57–85 years at baseline, who were followed up over 10 years. During follow-up, social disconnectedness was positively associated with perceived social isolation (β=0·09; p<0·0001), and perceived social isolation was positively associated with symptoms of depression (β=0·12; p<0·0001) and anxiety (β=0·12; p<0·0001). There was evidence for a bidirectional relationship—for example, symptoms of depression were predictive of social disconnectedness (β=0·06) and perceived social isolation (β=0·13); symptoms of anxiety were predictive of perceived social isolation (β=0·09); and perceived isolation was predictive of subsequent social disconnectedness (β=0·07; all p<0·0001). Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): a longitudinal mediation analysisSocial network structure and function are strongly intertwined with anxiety and depression symptoms in the general population of older adults. Public health initiatives could reduce perceived isolation by facilitating social network integration and participation in community activities, thereby protecting against the development of affective disorders. Full-Text PDF Open AccessGuided self-help to reduce psychological distress in South Sudanese female refugees in Uganda: a cluster randomised trialSelf-Help Plus is an innovative, facilitator-guided, group-based self-help intervention that can be rapidly deployed to large numbers of participants, and resulted in meaningful reductions in psychological distress at 3 months among South Sudanese female refugees. Full-Text PDF Open AccessDepression and post-traumatic stress during major social unrest in Hong Kong: a 10-year prospective cohort studyWe have identified a major mental health burden during the social unrest in Hong Kong, which will require substantial increases in service surge capacity. Health-care and social care professionals should be vigilant in recognising possible mental health sequelae. In a world of increasing unrest, our findings might have implications for service planning to better protect population mental health globally. Full-Text PDF Mortality in children and adolescents following presentation to hospital after non-fatal self-harm in the Multicentre Study of Self-harm: a prospective observational cohort studyChildren and adolescents who self-harm have a considerable risk of future suicide, especially males, older adolescents, and those who repeated self-harm. Risk might persist over several years. Switching of method from self-harm to suicide was common, usually from self-poisoning to self-injury (especially hanging or asphyxiation). Self-harm is also associated with risk of death from accidental poisoning, particularly involving drugs of abuse, especially in young males. Full-Text PDF

Mortality in children and adolescents following presentation to hospital after non-fatal self-harm in the Multicentre Study of Self-harm: a prospective observational cohort study

Self-harm and suicide in children and adolescents are growing problems, and self-harm is associated with a significant risk of subsequent death, particularly suicide. Long-term follow-up studies are necessary to examine the extent and nature of this association. For this prospective observational cohort study, we used data from the Multicentre Study of Self-harm in England for all individuals aged 10-18 years who presented to the emergency department of five study hospitals in Oxford, Manchester, and Derby after non-fatal self-harm between Jan 1, 2000, and Dec 31, 2013. Deaths were identified through the Office for National Statistics via linkage with data from NHS Digital up until Dec 31, 2015. The key outcomes were mortality after presentation to hospital for self-harm, categorised into suicide, accidental deaths, and death by other causes. We calculated incidence of suicide since first hospital presentation for self-harm and used Cox proportional hazard models to estimate the associations between risk factors (sex, age, previous self-harm) and suicide. Between Jan 1, 2000, and Dec 31, 2013, 9303 individuals aged 10-18 years presented to the study hospitals. 130 individuals were excluded because they could not be traced on the national mortality register or had missing data on sex or age, thus the resulting study sample consisted of 9173 individuals who had 13 175 presentations for self-harm. By the end of the follow-up on Dec 31, 2015, 124 (1%) of 9173 individuals had died. 55 (44%) of 124 deaths were suicides, 27 (22%) accidental, and 42 (34%) due to other causes. Of the 9173 individuals who presented for self-harm, 55 (0·6%) died by suicide. Most suicide deaths involved self-injury (45 [82%] of 55 deaths). Switching of method between self-harm and suicide was common, especially from self-poisoning to hanging or asphyxiation. The 12-month incidence of suicide in this cohort was more than 30 times higher than the expected rate in the general population of individuals aged 10-18 years in England (standardised mortality ratio 31·0, 95% CI 15·5-61·9). 42 (76%) of 55 suicides occurred after age 18 years and the annual incidence remained similar during more than 10 years of follow-up. Increased suicide risk was associated with male sex (adjusted hazard ratio 2·50, 95% CI 1·46-4·26), being an older adolescent at presentation to hospital for self-harm (1·82, 0·93-3·54), use of self-injury for self-harm (2·11, 1·17-3·81; especially hanging or asphyxiation [4·90, 1·47-16·39]), and repeated self-harm (1·87, 1·10-3·20). Accidental poisoning deaths were especially frequent among males compared with females (odds ratio 6·81, 95% CI 2·09-22·15). Children and adolescents who self-harm have a considerable risk of future suicide, especially males, older adolescents, and those who repeated self-harm. Risk might persist over several years. Switching of method from self-harm to suicide was common, usually from self-poisoning to self-injury (especially hanging or asphyxiation). Self-harm is also associated with risk of death from accidental poisoning, particularly involving drugs of abuse, especially in young males. UK Department of Health and Social Care.

Incidence and general hospital costs of self-harm across England: estimates based on the multicentre study of self-harm.

The aim of this study was to estimate incidence of self-harm presentations to hospitals and their associated hospital costs across England. We used individual patient data from the Multicentre Study of Self-harm in England of all self-harm presentations to the emergency departments of five general hospitals in Oxford, Manchester and Derby in 2013. We also obtained cost data for each self-harm presentation from the hospitals in Oxford and Derby, as well as population and geographical estimates from the Office for National Statistics. First, we estimated the rate of self-harm presentations by age and gender in the Multicentre Study and multiplied this with the respective populations to estimate the number of self-harm presentations by age and gender for each local Clinical Commissioning Group (CCG) area in England. Second, we performed a regression analysis on the cost data from Oxford and Derby to predict the hospital costs of self-harm in Manchester by age, gender, receipt of psychosocial assessment, hospital admission and type of self-harm. Third, the mean hospital cost per age year and gender were combined with the respective number of self-harm presentations to estimate the total hospital costs for each CCG in England. Sensitivity analysis was performed to address uncertainty in the results due to the extrapolation of self-harm incidence and cost from the Multicentre Study to England. There were 228 075 estimated self-harm presentations (61% were female) by 159 857 patients in 2013 in England. The largest proportions of self-harm presentations were in the age group 40-49 years (30%) for men and 19-29 years (28%) for women. Associated hospital costs were approximately £128.6 (95% CI 117.8-140.9) million in 2013. The estimated incidence of self-harm and associated hospital costs were lower in the majority of English coastal areas compared to inland regions but the highest costs were in Greater London. Costs were also higher in more socio-economically deprived areas of the country compared with areas that are more affluent. The sensitivity analyses provided similar results. The results of this study highlight the extent, hospital costs and distribution of self-harm presentations to hospitals in England and identify potential sub-populations that might benefit from targeted actions to help prevent self-harm and assist those who have self-harmed. They can support national as well as local health stakeholders in allocating funds and prioritising interventions in areas with the greatest need for preventing and managing self-harm.

Self-harm in midlife: analysis using data from the Multicentre Study of Self-harm in England - ADDENDUM.

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Self-harm in midlife: analysis using data from the Multicentre Study of Self-harm in England.

In England suicide rates are highest in midlife (defined as age 40-59). Despite a strong link with suicide there has been little focus on self-harm in this age group.AimTo describe characteristics and treatment needs of people in midlife who present to hospital following self-harm. Data from the Multicentre Study of Self-harm in England were used to examine rates over time and characteristics of men and women who self-harm in midlife. Data (2000-2013) were collected via specialist assessments or hospital records. Trends were assessed by negative binomial regression models. Comparative analysis used logistic regression models for binary outcomes. Repetition and suicide mortality were assessed by Cox proportional hazards models. A quarter of self-harm presentations were made by people in midlife (n = 24 599, 26%). Incidence rates increased over time in men, especially after 2008 (incidence rate ratio [IRR] 1.07, 95% CI 1.02-1.12, P &lt; 0.01), and were positively correlated with national suicide incidence rates (r = 0.52, P = 0.05). Rates in women remained relatively stable (IRR 1.00, 95% CI 1.00-1.02, P = 0.39) and were not correlated with suicide. Alcohol use, unemployment, housing and financial factors were more common in men; whereas indicators of poor mental health were more common in women. In men and women 12-month repetition was 25%, and during follow-up 2.8% of men and 1.2% of women died by suicide. Self-harm in midlife represents a key target for intervention. Addressing underlying issues, alcohol use and economic factors may help prevent further self-harm and suicide.Declaration of interestK.H. and N.K. are members of the Department of Health's National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group which developed the quality standards for self-harm services. N.K. also chairs the NICE guideline committee for the management of depression. All other authors declare no conflict of interest.

Relative toxicity of analgesics commonly used for intentional self-poisoning: A study of case fatality based on fatal and non-fatal overdoses.

Analgesics are used most frequently in fatal and non-fatal medicinal self-poisonings. Knowledge about their relative toxicity in overdose is important for clinicians and regulatory agencies. Using data for 2005-2012 we investigated case fatality (number of suicides relative to number of non-fatal self-poisonings) of paracetamol, aspirin, codeine, dihydrocodeine, tramadol, paracetamol with codeine (co-codamol), paracetamol with dihydrocodeine (co-dydramol), ibuprofen and co-proxamol (paracetamol plus dextropropoxyphene; withdrawn in the UK in 2008 due to high toxicity). Data on suicides obtained from the Office for National Statistics and on non-fatal self-poisonings from the Multicentre Study of Self-harm in England. Case fatality was estimated for each drug, using paracetamol as the reference category. Compared to paracetamol and based on single drug deaths the case fatality index of dihydrocodeine was considerably elevated (odds ratio (OR) 12.81, 95% Confidence Interval (CI) 10.19-16.12). Case fatality indices for tramadol (OR 4.05, 95% CI 3.38-4.85) and codeine (OR 2.21, 95% CI 1.81-2.70) were also significantly higher than for paracetamol. The results when multiple drug deaths were included produced similar results. The relative toxicity of co-proxamol far exceeded that of the other analgesics. Data on fatal self-poisonings were based on national data, whereas those for non-fatal poisonings were based on local data. Dihydrocodeine and tramadol are particularly toxic in overdose and codeine is also relatively toxic. They should be prescribed with caution, particularly to individuals at risk of self-harm.

Relative toxicity of mood stabilisers and antipsychotics: case fatality and fatal toxicity associated with self-poisoning

BackgroundBipolar 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.MethodTwo 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.ResultsThere 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).ConclusionsThere 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.

Suicide and all-cause mortality following routine hospital management of self-harm: Propensity score analysis using multicentre cohort data.

BackgroundObservational studies are suited to examining links between the routine hospital management of self-harm and future suicide and all-cause mortality due to their large scale. However, care must be taken when attempting to infer causal associations in non-experimental settings.MethodsData from the Multicentre Study of Self-Harm in England were used to examine associations between four types of hospital management (specialist psychosocial assessment, general hospital admission, psychiatric outpatient referral and psychiatric admission) following self-harm and risks of suicide and all-cause mortality in the subsequent 12 months. Missing data were handled by multiple imputation and propensity score (PS) methods were used to address observed differences between patients at baseline. Unadjusted, PS stratified and PS matched risk ratios (RRs) were calculated.ResultsThe PSs balanced the majority of baseline differences between treatment groups. Unadjusted RRs showed that all four treatment types were associated with either increased risks or no change in risks of suicide and all-cause mortality within a year. None of the four types of hospital management were associated with lowered risks of suicide or all-cause mortality following propensity score stratification (psychosocial assessment and medical admission) and propensity score matching (psychiatric outpatient referral and psychiatric admission), though there was no longer an increased risk among people admitted to a psychiatric bed. Individuals who self-cut were at an increased risk of death from any cause following psychosocial assessment and medical admission. Medical admission appeared to be associated with reduced risk of suicide in individuals already receiving outpatient or GP treatment for a psychiatric disorder.ConclusionsMore intensive forms of hospital management following self-harm appeared to be appropriately allocated to individuals with highest risks of suicide and all-cause mortality. PS adjustment appeared to attenuate only some of the observed increased risks, suggesting that either differences between treatment groups remained, or that some treatments had little impact on reducing subsequent suicide or all-cause mortality risk. These findings are in contrast to some previous studies that have suggested psychosocial assessment by a mental health specialist reduces risk of repeat self-harm. Future observational self-harm studies should consider increasing the number of potential confounding variables collected.

The association between motives, perceived problems and current thoughts of self-harm following an episode of self-harm. A network analysis

BackgroundA history of self-harm is a major risk factor for suicide. Some patients are more likely than others to repeat suicidal behaviour after an episode of self-harm. Insight in the relation between current thoughts of self-harm, motives for the self-harm episode and perceived problems may improve prevention strategies. Network analysis allows to investigate the co-occurence of these factors and their association with each other. MethodsIsing model based networks are estimated on data collected between 2007–2015 within the Multicentre Study of Self-harm in Flanders. Patients were interviewed within 24 hours after hospitalization by a trained professional on their motives for the episode of self-harm and their perceived problems. Additionally, they were asked whether they had current thoughts of self-harm. Network analyses are used to determine which motives and problems are uniquely related to current thoughts of self-harm, and which are most central in the network. ResultsData were used of 6068 patients (2279 males and 3789 females). Four internal motives (wish to die, lost control, escape from situation, situation was unbearable), one external motive (show somebody how hopeless I was) and four perceived problems (psychiatric, loneliness, trauma, rejection) are directly related to current thoughts of self-harm. Of all motives and problems, the motive a wish to die is most strongly related to current thoughts of self-harm. However, external motives are more central in the network when compared to internal motives and perceived problems. LimitationsData most probably refer to a selected group of self-harm patients as many individuals who self-harm do not come to the attention of hospital services. Patients might be reluctant to tell professionals they had current thoughts of self-harm. ConclusionsMany internal motives and problems are directly related to current thoughts of self-harm, but external motives are more central in the network. The clinically most important motive (wish to die) does not play a central role in the network.

Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): a retrospective study

Little is known about the relative incidence of fatal and non-fatal self-harm in young people. We estimated the incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England. We used national mortality statistics (Jan 1, 2011, to Dec 31, 2013), hospital monitoring data for five hospitals derived from the Multicentre Study of Self-Harm in England (Jan 1, 2011, to Dec 31, 2013), and data from a schools survey (2015) to estimate the incidence of fatal and non-fatal self-harm per 100 000 person-years in adolescents aged 12-17 years in England. We described these incidences in terms of an iceberg model of self-harm. During 2011-13, 171 adolescents aged 12-17 years died by suicide in England (119 [70%] male and 133 [78%] aged 15-17 years) and 1320 adolescents presented to the study hospitals following non-fatal self-harm (1028 [78%] female and 977 [74%] aged 15-17 years). In 2015, 322 (6%) of 5506 adolescents surveyed reported self-harm in the past year in the community (250 [78%] female and 164 [51%] aged 15-17 years). In 12-14 year olds, for every boy who died by suicide, 109 attended hospital following self-harm and 3067 reported self-harm in the community, whereas for every girl who died by suicide, 1255 attended hospital for self-harm and 21 995 reported self-harm in the community. In 15-17 year olds, for every male suicide, 120 males presented to hospital with self-harm and 838 self-harmed in the community; whereas for every female suicide, 919 females presented to hospital for self-harm and 6406 self-harmed in the community. Hanging or asphyxiation was the most common method of suicide (125 [73%] of 171), self-poisoning was the main reason for presenting to hospital after self-harm (849 [71%] of 1195), and self-cutting was the main method of self-harm used in the community (286 [89%] of 322). Ratios of fatal to non-fatal rates of self-harm differed between males and females and between adolescents aged 12-14 years and 15-17 years, with a particularly large number of females reporting self-harm in the community. Our findings emphasise the need for well resourced community and hospital-based mental health services for adolescents, with greater investment in school-based prevention. UK Department of Health.