Self-harm Events Research Articles

Association of Overcrowding and Turnover with Self-Harm in a Swiss Pre-Trial Prison.

Self-harm is a common issue in detention and includes both suicidal and non-suicidal behaviours. Beyond well-known individual risk factors, institutional factors such as overcrowding (i.e., when the prison population exceeds its capacity) and turnover (i.e., the rate at which the prison population is renewed), may also increase the risk of self-harm. However, these factors are understudied or previous studies reported inconsistent findings. This study investigated the association of self-harm with overcrowding and turnover in the largest pre-trial Swiss prison in Geneva. Data were collected yearly between 2011 and 2017. Measures included self-harm (all kinds of self-injuring acts requiring medical attention, including self-strangulations and self-hangings). We performed meta-regressions to analyse the relationships between self-harm and institutional factors. Self-harm events were frequent, with a prevalence estimate of 26.4%. Overcrowding and turnover were high (average occupation rate of 177% and average turnover of 73%, respectively). Overcrowding and turnover were significantly associated with self-harm (respectively b = 0.068, p < 0.001 and (b = 1.257, p < 0.001). In both cases, self-harm was higher when overcrowding and turnover increased. Overcrowding and turnover raise important human rights concerns and have damaging effects on the health of people living in detention. Identification of and care for this vulnerable population at risk of self-harm are needed and institutional factors should be addressed.

Method of self-harm in adolescents and young adults and risk of subsequent suicide.

Self-harm is common in youth and an important risk factor for suicide. Certain self-harm methods might indicate a higher risk of suicide. The main aim of this study was to determine whether some methods of self-harm in adolescents (10-17years) and young adults (18-24years) are associated with a particularly high risk of suicide. A secondary aim was to ascertain how different self-harm methods might affect the probability of psychiatric follow-up. Five Swedish registers were linked in a national population-based cohort study. All nonfatal self-harm events recorded in specialist health care, excluding psychiatry and primary care services, among 10-24year olds between 2000 and 2009 were included. Methods were classified as poisoning, cutting/piercing, violent method (gassing, hanging, strangulation/suffocation, drowning, jumping and firearms), other and multiple methods. Hazard Ratios (HR) for suicide were calculated in Cox regression models for each method with poisoning as the reference. Odds Ratios (OR) for psychiatric inpatient care were determined in logistic regression models. Analyses were adjusted for important covariates and stratified by age group and treatment setting (inpatient/outpatient). Among adolescents with initial medical hospitalisation, use of a violent method was associated with a near eightfold increase in HR for suicide compared to self-poisoning in the adjusted analysis [HR 7.8; 95% confidence interval (CI) 3.2-19.0]. Among hospitalised young adult women, adjusted HRs were elevated fourfold for both cutting [4.0 (1.9-8.8)] and violent methods [3.9 (1.5-10.6)]. Method of self-harm did not affect suicide risk in young adult men. Adolescents using violent methods had an increased probability of psychiatric inpatient care following initial treatment for self-harm. Violent self-harm requiring medical hospitalisation may signal particularly high risk of future suicide in adolescents (both sexes) and in young adult women. For the latter group this is the case for cutting requiring hospitalisation as well.

Effectiveness of systemic family therapy versus treatment as usual for young people after self-harm: a pragmatic, phase 3, multicentre, randomised controlled trial

SummaryBackgroundSelf-harm in adolescents is common and repetition occurs in a high proportion of these cases. Scarce evidence exists for effectiveness of interventions to reduce self-harm.MethodsThis pragmatic, multicentre, randomised, controlled trial of family therapy versus treatment as usual was done at 40 UK Child and Adolescent Mental Health Services (CAMHS) centres. We recruited young people aged 11–17 years who had self-harmed at least twice and presented to CAMHS after self-harm. Participants were randomly assigned (1:1) to receive manualised family therapy delivered by trained and supervised family therapists or treatment as usual by local CAMHS. Participants and therapists were aware of treatment allocation; researchers were masked. The primary outcome was hospital attendance for repetition of self-harm in the 18 months after group assignment. Primary and safety analyses were done in the intention-to-treat population. The trial is registered at the ISRCTN registry, number ISRCTN59793150.FindingsBetween Nov 23, 2009, and Dec 31, 2013, 3554 young people were screened and 832 eligible young people consented to participation and were randomly assigned to receive family therapy (n=415) or treatment as usual (n=417). Primary outcome data were available for 795 (96%) participants. Numbers of hospital attendances for repeat self-harm events were not significantly different between the groups (118 [28%] in the family therapy group vs 103 [25%] in the treatment as usual group; hazard ratio 1·14 [95% CI 0·87–1·49] p=0·33). Similar numbers of adverse events occurred in both groups (787 in the family therapy group vs 847 in the treatment as usual group).InterpretationFor adolescents referred to CAMHS after self-harm, having self-harmed at least once before, our family therapy intervention conferred no benefits over treatment as usual in reducing subsequent hospital attendance for self-harm. Clinicians are therefore still unable to recommend a clear, evidence-based intervention to reduce repeated self-harm in adolescents.FundingNational Institute for Health Research Health Technology Assessment programme.

Risk of suicide and non-fatal self-harm after bariatric surgery: results from two matched cohort studies

SUMMARYBACKGROUNDBariatric surgery reduces mortality, but may have adverse effects on mental health. We assessed suicide risk after surgical compared to nonsurgical obesity treatment.METHODSSuicide and nonfatal self-harm events retrieved from nationwide Swedish registers were examined in two cohorts. The nonrandomised prospective Swedish Obese Subjects (SOS) study compares bariatric surgery (n=2010; 1369 vertical-banded gastroplasty, 376 gastric banding, 265 gastric bypass) with usual care (n=2037; recruitment 1987–2001). The second cohort comprises individuals from the Scandinavian Obesity Surgery Registry (SOReg; n=20,256 gastric bypass patients) matched to individuals treated with intensive lifestyle modification (n=16,162; intervention 2006–2013) on baseline BMI, age, sex, education level, diabetes, cardiovascular disease, history of self-harm, substance abuse, antidepressant use, anxiolytics use, and psychiatric healthcare contacts.FINDINGSDuring 68,528 person-years (median 18; interquartile range 14–21) in SOS, there were 87 versus 49 suicides or nonfatal self-harm events in the surgery and control groups (adjusted hazard ratio [aHR] 1.78 [95%CI 1.23–2.57]; P=0.0021), of which 9 and 3 were suicides (3.06 [0.79–11.9]; P=0.107). In analyses by primary procedure type, increased risk of suicide or nonfatal self-harm was observed for gastric bypass (aHR 3.48 *1.65–7.31+; P=0.0010), gastric banding (2.43 *1.23–4.82+; P=0.011) and vertical-banded gastroplasty compared to controls (2.25 *1.37–3.71+; P=0.0015). Out of 9 deaths by suicide in the SOS surgery group, 5 occurred after gastric bypass (2 primary and 3 converted procedures). During 149,582 person-years (median 3.9; interquartile range 2.8–5.2), there were 341 suicides or nonfatal self-harm events in the SOReg gastric bypass group and 84 in the intensive lifestyle group (aHR 3.16 [2.46–4.06]; P<0.0001), of which 33 and 5 were suicides (5.17 [1.86–14.4]; P=0.0017). In SOS, substance abuse was recorded in 48% (39/81) of surgery patients and 28% (13/47) of controls with nonfatal self-harm events (P=0.023). The corresponding percentages for SOReg gastric bypass and intensive lifestyle participants were 51% (162/316) versus 29% (23/80; P=0.0003).INTERPRETATIONBariatric surgery was associated with suicide and nonfatal self-harm. Although the absolute risks were low, the findings indicate a need for post-operative psychiatric surveillance and patient information before surgery regarding self-harm.FUNDINGUS National Institutes of Health and Swedish Research Council

Self-Injuring Behavior and Mental Illness in Opioid-Dependent Patients Treated with Implant Naltrexone, Methadone, and Buprenorphine in Western Australia

This study aims to compare rates of intentional self-harm (ISH) and other mental illness events in opioid-dependent patients treated implant naltrexone, with those treated with methadone or buprenorphine. Patients treated between 2001 and 2010 were linked with hospital, emergency (ED), outpatient mental health, and mortality records. Rates of health events were compared between the three groups using survival analysis and generalized estimating equations. Rates of suicide and ISH in patients treated with naltrexone were comparable to patients treated with methadone or buprenorphine. Rates of mental health and psychiatric hospital admissions, ED attendances, and outpatient mental health events were significantly lower in patients treated with methadone compared with naltrexone. Buprenorphine patients had higher rates of psychiatric admission, but lower rates of ED and outpatient mental health events compared with naltrexone patients. Naltrexone was associated with high rates of mental health events, however further controlled research is required.

Effectiveness of household lockable pesticide storage to reduce pesticide self-poisoning in rural Asia: a community-based, cluster-randomised controlled trial

SummaryBackgroundAgricultural pesticide self-poisoning is a major public health problem in rural Asia. The use of safer household pesticide storage has been promoted to prevent deaths, but there is no evidence of effectiveness. We aimed to test the effectiveness of lockable household containers for prevention of pesticide self-poisoning.MethodsWe did a community-based, cluster-randomised controlled trial in a rural area of North Central Province, Sri Lanka. Clusters of households were randomly assigned (1:1), with a sequence computer-generated by a minimisation process, to intervention or usual practice (control) groups. Intervention households that had farmed or had used or stored pesticide in the preceding agricultural season were given a lockable storage container. Further promotion of use of the containers was restricted to community posters and 6-monthly reminders during routine community meetings. The primary outcome was incidence of pesticide self-poisoning in people aged 14 years or older during 3 years of follow-up. Identification of outcome events was done by staff who were unaware of group allocation. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT1146496.FindingsBetween Dec 31, 2010, and Feb 2, 2013, we randomly assigned 90 rural villages to the intervention group and 90 to the control group. 27 091 households (114 168 individuals) in the intervention group and 26 291 households (109 693 individuals) in the control group consented to participate. 20 457 household pesticide storage containers were distributed. In individuals aged 14 years or older, 611 cases of pesticide self-poisoning had occurred by 3 years in the intervention group compared with 641 cases in the control group; incidence of pesticide self-poisoning did not differ between groups (293·3 per 100 000 person-years of follow-up in the intervention group vs 318·0 per 100 000 in the control group; rate ratio [RR] 0·93, 95% CI 0·80–1·08; p=0·33). We found no evidence of switching from pesticide self-poisoning to other forms of self-harm, with no significant difference in the number of fatal (82 in the intervention group vs 67 in the control group; RR 1·22, 0·88–1·68]) or non-fatal (1135 vs 1153; RR 0·97, 0·86–1·08) self-harm events involving all methods.InterpretationWe found no evidence that means reduction through improved household pesticide storage reduces pesticide self-poisoning. Other approaches, particularly removal of highly hazardous pesticides from agricultural practice, are likely to be more effective for suicide prevention in rural Asia.FundingWellcome Trust, with additional support from the American Foundation for Suicide Prevention, Lister Institute of Preventive Medicine, Chief Scientist Office of Scotland, University of Copenhagen, and NHMRC Australia.

Cardiovascular and neuropsychiatric risks of varenicline and bupropion in smokers with chronic obstructive pulmonary disease

BackgroundVarenicline and bupropion are effective smoking cessation treatments, but there are concerns about their safety in smokers with COPD.ObjectiveTo investigate whether varenicline and bupropion are associated with serious adverse cardiovascular...

A brief psychological intervention to reduce repetition of self-harm in patients admitted to hospital following a suicide attempt: a randomised controlled trial

SummaryBackgroundWe investigated whether a volitional helpsheet (VHS), a brief psychological intervention, could reduce repeat self-harm in the 6 months following a suicide attempt.MethodsWe did a prospective, single-site, randomised controlled trial. Patients admitted to a hospital in Edinburgh, UK, after a suicide attempt were deemed eligible for the study if they were over the age of 16 years, had a self-reported history of self-harm, were fluent in English, were medically fit to interview, and were not participating in other research studies within the hospital. Eligible patients were randomly assigned (1:1), via web-based randomisation, to receive either VHS plus usual treatment (intervention group) or only treatment as usual (control group). Randomisation was stratified by sex and self-reported past self-harm history. The Information Services Division of the National Health Service (NHS-ISD) staff and those extracting data from medical notes were masked to the study group the participant was allocated to. Clinical staff working within the hospital were also masked to participants' randomisation status. There were three primary outcomes: the proportion of paticipants who re-presented to hospital with self-harm during the 6-month follow-up period; the number of times a participant re-presented to hospital with self-harm during the 6-month follow-up period; and cost-effectiveness of the VHS as measured by estimated incremental cost per self-harm event averted. Primary outcomes were analysed in all randomised patients. Follow-up data collection was extracted from the Information Services Division of the NHS and from patient medical records. The trial is registered with International Standard Randomised Controlled Trial Number Registry, number ISRCTN99488269.FindingsBetween May 9, 2012, and Feb 24, 2014, we assessed 1308 people for eligibility. Of these, 259 patients were randomly assigned to the intervention group and 259 to the control group. We obtained complete follow-up data on 512 (99%) of 518 patients (five participants were lost to follow-up in the intervention group and one in the control group). 11 patients assigned to the intervention group did not complete the VHS in hospital. Overall, the intervention did not affect the number of people who re-presented with self-harm (67 [26%] of 254 patients in the intervention group vs 71 [28%] of 258 patients in the control group, odds ratio [OR] 0·90, 95% CI 0·58–1·39, p=0·63). The intervention had no effect on the number of re-presentations per patient (mean 0·67 [SD 2·55] re-presentations for the intervention group vs 0·85 [2·79] for the control group, incident rate ratio [IRR] 1·65, 95% CI 0·74–3·67, p=0·21). Mean total costs per person for NHS hospital services in the VHS intervention group over the 6 months were £513 versus £561 in the control group but this difference was not significant (95% CI–£353 to £257, p=0·76). Three patients died by suicide in the 6 months following their index suicide attempt (one in the intervention group and two in the control group). There were no reported unintended effects or adverse events in either group.InterpretationFor the primary outcomes, there were no significant differences between groups. Although the VHS had no overall effect, post-hoc analyses suggest VHS might be effective in reducing the number of self-harm repetitions following a suicide attempt in people who complete the helpsheet and who have been previously admitted to hospital with self-harm. This is the first study to investigate the usefulness of the VHS to reduce self-harm among those who have attempted suicide. These subgroup findings require replication. The potential use of the VHS in those who self-harm for different motives requires further exploration.FundingChief Scientist Office (CZH/4/704).

Suicide Following Deliberate Self-Harm.

The authors sought to identify risk factors for repeat self-harm and completed suicide over the following year among adults with deliberate self-harm. A national cohort of Medicaid-financed adults clinically diagnosed with deliberate self-harm (N=61,297) was followed for up to 1 year. Repeat self-harm per 1,000 person-years and suicide rates per 100,000 person-years (based on cause of death information from the National Death Index) were determined. Hazard ratios of repeat self-harm and suicide were estimated by Cox proportional hazard models. During the 12 months after nonfatal self-harm, the rate of repeat self-harm was 263.2 per 1,000 person-years and the rate of completed suicide was 439.1 per 100,000 person-years, or 37.2 times higher than in a matched general population cohort. The hazard of suicide was higher after initial self-harm events involving violent as compared with nonviolent methods (hazard ratio=7.5, 95% CI=5.5-10.1), especially firearms (hazard ratio=15.86, 95% CI=10.7-23.4; computed with poisoning as reference), and to a lesser extent after events of patients who had recently received outpatient mental health care (hazard ratio=1.6, 95% CI=1.2-2.0). Compared with self-harm patients using nonviolent methods, those who used violent methods were at significantly increased risk of suicide during the first 30 days after the initial event (hazard ratio=17.5, 95% CI=11.2-27.3), but not during the following 335 days. Adults treated for deliberate self-harm frequently repeat self-harm in the following year. Patients who use a violent method for their initial self-harm, especially firearms, have an exceptionally high risk of suicide, particularly right after the initial event, which highlights the importance of careful assessment and close follow-up of this group.

A comparative study of patient sitters with video monitoring versus in-room sitters

Background/Objective : Use of in-room sitters to prevent patient’s fall or injury is widespread in hospitals. This practice, however, is expensive, seldom reimbursed, controversial in the literature, and not supported by a strong body of evidence. The objective of this study was to determine the prevalence of patient falls and self-harm using in-room sitters and video monitoring and associated costs. Methods : In-room sitters and video monitoring was studied in two adult, medical surgical units, using an evaluative research design, with quasi-experimental approach. Descriptive statistics and independent samples t tests were performed for analysis. Results : The study identified no statistically significant difference in the prevalence of falls or self-harm events when video monitoring was used to provide constant observation. There was statistically significant lower cost per patient day with video monitoring. Conclusions : Video monitoring is less expensive than sitters and does not impose a patient safety risk for falls or self-harm.

A Descriptive Study of Feelings of Arrested Escape (Entrapment) and Arrested Anger in People Presenting to an Emergency Department Following an Episode of Self-Harm.

To explore the role of elevated feelings of anger and desires to escape (fight/flight), which are experienced as inhibited, blocked, and arrested (i.e., arrested anger and arrested flight/escape leading to feelings of entrapment). This descriptive study developed measures of arrested anger and arrested flight and explored these in the context of a recent self-harm event in people presenting to a Hospital's Emergency Department (ED). Fifty-eight individuals presenting to an ED following an act of self-harm were recruited. Participants completed newly developed measures of arrested flight, arrested anger and anger with self in regard to self-harm, and suicide intent and depression. Ninety-three percent of participants presented after self-poisoning. The majority (95%) reported having experienced high escape motivation that felt blocked (arrested flight) with 69% reporting feeling angry with someone but unable to express it (arrested anger). For many participants (53.7%), strong desires to escape from current situations and/or to express anger did not diminish immediately after the act. As with many studies, a select group of participants agreed to take part and we did not keep records of how many refused. There are no other validated measures of arrested escape and arrested anger and so for this study, our short item-focused measures rely on face validity. Arrested defenses of fight and flight, and self-criticism are common in those who have self-harmed and may continue after acts of self-harm. Many participants revealed that talking about their experiences of escape motivation and blocked anger (using our measures) was helpful to them. Feelings of entrapment and arrested anger are common in people who self-harmClinicians could benefit from increased awareness and measures of arrested flight and arrested angerDiscussing these concepts and experiences appears to be useful to people who have self-harmedFurther research is needed on how best to help people with such experiences.

Incidence and outcomes of emergency self-harm among adolescents: a descriptive epidemiological study in Osaka City, Japan

ObjectivesTo evaluate the incidence and outcomes of self-harm from ambulance records.DesignA retrospective, observational study.SettingOsaka City, Japan.ParticipantsA total of 365 adolescents aged 10–19 years with emergency self-harm such as poisoning by...

Self-harm and overcrowding among prisoners in Geneva, Switzerland.

Prison institutional conditions affect risk for self-harm among detainees. In particular, prison overcrowding may increase the likelihood of self-harm by creating competition for resources, space, and enhancing a "deprivation state." The purpose of this paper is to examine the association between overcrowding and prisoner acts of self-harm. This cross-sectional study took place at Geneva's pre-trial prison (capacity:376) between 2006 and 2014. Outcomes were acts of self-harm that required medical attention, and self-strangulation/hanging events (combined into one group, as these are difficult to differentiate). Dichotomous predictors were overcrowding index- annual mean daily population divided by capacity ( > 200 percent vs < 200 percent), and year group (2006-2009 vs 2011-2014). Self-harm and self-strangulations/hangings increased in 2011-2014 compared to 2006-2010 (p < 0.001). Overcrowding in excess of 200 percent was associated with self-strangulation/hangings (p < 0.001) but not with all self-harm events. In terms of pertinent demographics that would affect self-harm, there was no prison change in gender, area of origin, foreign residency, religion, or psychiatric treatment. The present study is limited by the definition and identification of self-harm. The distinction between self-strangulation and self-hanging, and the precise classification of an intent to die is difficult to make in practice, especially with limited prison data records available. The relevant literature addresses the complexity of the association between non-suicidal and suicidal behavior. Despite this, the combined category self-strangulations/hangings gives some indication of severe self-harm events, especially since the methodology of categorization employed was consistent throughout the entire period of the study. Other limitations include the small sample size and the lack of individual patient data and prison data to help control for confounding factors. Despite these drawbacks, pertinent data (socio-demographics and number of prisoners treated for mental health and drug abuse) remained stable over the years. Thus, there are no apparent changes in the inmate population that could be linked to an increase in self-harm. High-security placements and mean prisoner stay have increased over time, with a decrease in staff to prisoner ratio - and these must be looked into further as contributors. Additionally, qualitative methods such as semi-structured interviews and focus groups could delineate the impact of overcrowding on prisoner well-being and self-harm potential. The authors observed a significant increase in self-harm and self-strangulation/hangings over time, and overcrowding was significantly associated with self-strangulation/hangings (but not with all self-harm events). Overcrowding can impose destructive effects on the psychological and behavioral well being of inmates in prison, influencing a myriad of emotional and livelihood factors that predispose to harmful behavior. This report should alert public health and prison authorities to this issue, and garner resources to address such an alarming rise. The findings from this short report demonstrate the need for a further examination of the mechanisms affecting self-harm among prisoners in this population, particularly the relationship between self-strangulations/hangings and overcrowding.

A Population-Based Study of the Prevalence and Correlates of Self-Harm in Juvenile Detention.

BackgroundSuicide is the number one cause of death among incarcerated youth. We examined the demographic and forensic risk factors for self-harm in youth in juvenile detention using a Canadian provincial correctional database.MethodWe analyzed data from de-identified youth aged 12 to 18 at the time of their offense who were in custody in a Manitoba youth correctional facility between January 1, 2005 and December 30, 2010 (N = 5,102). Univariate and multivariate logistic regression analyses determined the association between staff-identified self-harm events in custody and demographic and custodial variables. Time to the event was examined based on the admission date and date of event.ResultsDemographic variables associated with self-harm included female sex, lower educational achievement, older age, and child welfare involvement. Custodial variables associated with self-harm included higher criminal severity profiles, younger age at first incarceration, longer sentence length, disruptive institutional behavior, and a history of attempting escape. Youth identified at entry as being at risk for suicide were more likely to self-harm. Events tended to occur earlier in the custodial admission.InterpretationSelf-harm events tended to occur within the first 3 months of an admission stay. Youth with more serious offenses and disruptive behaviors were more likely to self-harm. Individuals with problematic custodial profiles were more likely to self-harm. Suicide screening identified youth at risk for self-harm. Strategies to identify and help youth at risk are needed.

Rethinking pathways to completed suicide by female prisoners

Purpose – The purpose of this paper is to explore the role of trauma experience in pathways to self-harm or attempted suicide in female prisoners who died through self-inflicted death in England and Wales. Design/methodology/approach – Quantitative study using the Prison and Probation Ombudsmen’s independent reports on deaths in custody. In total, 32 cases of female self-inflicted death in custody were coded on the presence of direct or interpersonal trauma, presence of superficial self-harm (SSH), near-lethal self-harm (NLSH), suicide attempts and recent significant life event. The number of previous suicide attempts (PSAs) and age at time of death was recorded. Findings – Direct trauma is linked with repeated suicide attempts but recued the likelihood of SSH prior to suicide. Neither interpersonal trauma nor age increased likelihood of pre-suicide behaviours. NLSH was not predicted by either traumatic experience. Amongst these completed suicide cases, 56 per cent were not reported as having experienced trauma, 46 per cent had no recorded PSAs and 12 per cent also had no previous self-harm reported. Research limitations/implications – The small sample limited statistical power and specificity of classifications. Provides support for direct trauma in developing capacity for repeated suicidal behaviour as indicated in theoretical models of suicide (Joiner, 2005; O’Connor, 2011). Practical implications – Different pathways to suicide likely to exist for female prisoners and importance of trauma intervention services. Originality/value – Using cases of completed suicide in female prisoners to investigate the pathway to suicide from trauma through previous self-harm and attempted suicide.

Cardiovascular and neuropsychiatric risks of varenicline: a retrospective cohort study

SummaryBackgroundVarenicline is an effective pharmacotherapy to aid smoking cessation. However, its use is limited by continuing concerns about possible associated risks of serious adverse cardiovascular and neuropsychiatric events. The aim of this study was to investigate whether use of varenicline is associated with such events.MethodsIn this retrospective cohort study, we used data from patients included in the validated QResearch database, which holds data from 753 National Health Service general practices across England. We identified patients aged 18–100 years (registered for longer than 12 months before data extraction) who received a prescription of nicotine replacement treatment (NRT; reference group), bupropion, or varenicline. We excluded patients if they had used one of the drugs during the 12 months before the start date of the study, had received a prescription of a combination of these drugs during the follow-up period, or were temporary residents. We followed patients up for 6 months to compare incident cardiovascular (ischaemic heart disease, cerebral infarction, heart failure, peripheral vascular disease, and cardiac arrhythmia) and neuropsychiatric (depression and self-harm) events using Cox proportional hazards models, adjusted for potential confounders (primary outcomes).FindingsWe identified 164 766 patients who received a prescription (106 759 for nicotine replacement treatment; 6557 for bupropion; 51 450 for varenicline) between Jan 1, 2007, and June 30, 2012. Neither bupropion nor varenicline showed an increased risk of any cardiovascular or neuropsychiatric event compared with NRT (all hazard ratios [HRs] less than 1. Varenicline was associated with a significantly reduced risk of ischaemic heart disease (HR 0·80 [95%CI 0·72–0·87]), cerebral infarction (0·62 [0·52–0·73]), heart failure (0·61 [0·45–0·83]), arrhythmia (0·73 [0·60–0·88]), depression (0·66 [0·63–0·69]), and self-harm (0·56 [0·46–0·68]).InterpretationVarenicline does not seem to be associated with an increased risk of documented cardiovascular events, depression, or self-harm when compared with NRT. Adverse events that do not come to attention of general practitioners cannot be excluded. These findings suggest an opportunity for physicians to prescribe varenicline more broadly, even for patients with comorbidities, thereby helping more smokers to quit successfully than do at present.FundingEgton Medical Information Systems, University of Nottingham, Ministry of Innovation, Science and Research of the German Federal State of North Rhine-Westphalia, Cancer Research UK, Medical Research Council, Commonwealth Fund.

National trends in hospital-treated self-harm events among middle-aged adults.

To assess national trends in hospital-treated self-harm events focusing on adults aged 45-64years. Healthcare Cost and Utilization Project data from 2001 (N=7,452,727) to 2011 (N=7,893,587) were used to assess national trends in hospital stays for suicide and self-inflicted injury among youth (0-24years), young adults (35-44years), middle-aged adults (45-64years) and older adults (≥65years). Among middle-aged adults, hospital-treated self-harm events increased from 5.1 (2001) to 7.1 (2011) per 10,000 population (OR=1.4, 95% CI=1.2, 1.6). This increase was larger than corresponding changes among youth (5.2-4.9) (interaction P=.0003), young adults (10.0-10.6) (interaction P=.006) or older adults (2.2-2.4) (interaction P=.07). Among middle-aged adults, hospital-treated self-harm events per 100 hospital discharges significantly increased (OR=1.4, 95% CI=1.3, 1.6), but there was not a significant increase in self-harm discharges per 100 mental disorder discharges (OR=1.2, 95% CI=1.0, 1.4). Between 2001 and 2011, there was a disproportionate national increase in hospital-treated self-harm events among middle-aged adults that mirrored national trends in suicide. Because the increase was largely accounted for by an overall increase in mental health hospitalizations of middle-aged adults, the rising rate of hospital-treated self-harm events may reflect broader population-based mental health challenges facing US middle-aged adults.

Demographic and clinical correlates of suicidality in adolescents attending a specialist community mental health service: a naturalistic study

Background: Adolescents comprise a unique and often challenging group of patients with diverse presentations to the Mental Health Services; suicidal behavior being one of them.Aims: The main aim of this naturalistic project was to investigate demographic and clinical correlates of adolescent suicidal and self-harm events, which may be of value to decision-making in clinical practice.Method: All adolescents (n = 149) registered and actively managed by a specialist community mental health service in South London were included in the study. Clinical information from their files was used to determine suicidality/self-harm events. The Columbia Classification Algorithm of Suicide Assessment (C-CASA) was utilised for classification purposes. Logistic regression was used to explore the effects of age, sex, diagnosis, medication, substance use (alcohol and/or cannabis) and ethnicity on suicidality/self-harming behaviors.Results: Age, sex and use of psychotropic medication were identified to play a significant role in determining the risk of engaging in self-harming behavior. The risk was higher with increasing age and female sex. Medication seemed to have a protective effect. Reporting a 20% prevalence of non-suicidal self-injury (NSSI) in our population, we highlight the importance of NSSI as a distinct diagnostic category.Conclusions: Our findings have implications for risk assessment and appropriate decision-making in clinical settings. Results are translatable and relevant to other metropolitan areas.

Association between Selective Serotonin Reuptake Inhibitor Therapy and Suicidality: Analysis of U.S. Food and Drug Administration Adverse Event Reporting System Data.

Selective serotonin reuptake inhibitors (SSRIs) are prescribed for the treatment of depression worldwide. SSRIs are suspected to increase the risk of suicidal ideation and behavior (suicidality) in children, adolescents, and young adults. We examined the association between SSRI therapy and suicidality by applying a logistic regression model to age-stratified data from the Food and Drug Administration (FDA) Adverse Event Reporting System database. We attempted to mitigate the effect of patient-related factors by data subsetting. We selected case reports for SSRIs as referred to in the World Health Organization Anatomical Therapeutic Chemical classification code N06AB. The association between SSRIs and "suicidal events" or "self-harm events" was calculated as a reporting odds ratio (ROR) and adjusted for covariates by logistic regression. For subjects <18 years old (y.o.) the adjusted RORs (95% confidence interval) of SSRI therapy with suicidal events were 9.58 (8.97-10.23) in the whole data analysis and 4.64 (4.15-5.19) in the subset analysis; those with self-harm events were 31.40 (27.71-35.58) and 16.31 (13.12-20.29), respectively. Although the adjusted RORs were lower in the subset analyses than in the whole data analyses, both analyses indicated associations between SSRI treatment and suicidal and self-harm events. In both analyses these associations were stronger in the <18 y.o. group than other age groups. Children and adolescents should be closely monitored for the occurrence of suicidality when they are prescribed SSRIs. In addition, we found that data subsetting might mitigate the effect of an intrinsic risk among patients taking the suspected drug.

Assessing the risk of self-harm in an adult offender population: an incidence cohort study.

Self-harm is common among prisoners, particularly female prisoners. In 2007, concerned about the rising incidence, the prison service introduced a care-planning system called Assessment, Care in Custody, and Teamwork (ACCT). To date, it does not incorporate a standardised diagnostic test to estimate the risk of future self-harm. To identify potential screening instruments, or items from those instruments, to predict the risk of self-harm among prisoners. Prisoners who had been assigned to an ACCT during the recruitment period. A multistage prospective cohort study. Following a pilot study, instruments were administered to prisoners by interview at baseline, and followed up for 6 months (or until point of release if this was sooner) to ascertain self-harm status. Instruments were assessed for unidimensionality, scalability (Mokken) and quantitative structure (Rasch). Area under the curve (AUC) analysis was used to examine the ability of instruments and/or their items to predict future self-harm. Cox proportional hazards regression models were used to examine the multivariate predictive ability of the scales and various sociodemographic and sentencing factors. Three prisons (including one women's prison) in northern England. A set of standardised questionnaires, including the Prison Screening Questionnaire (PriSnQuest), Revised Borderline Symptom List-23 (frequency-based responses) (BSL-23-F), Self-Harm Inventory (SHI), Patient Health Questionnaire (PHQ-9) and the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), together with sociodemographic and sentencing data. In total, 450 prisoners consented to participate in the study, of whom 26% were female. The mean age of participants was 31.2 years. Over half of male prisoners recruited were on remand, compared with just over one-fifth (22.6%) of female prisoners. The average tariff of those sentenced was 41 months, of which 14.7 months, on average, had been served. Just over one-third of ACCTs had been initiated because of a known self-harm event, and over one-quarter (27.8%) of participants self-harmed during the follow-up period. Thus, almost half (46.7%) of those entered into the study were reported to have self-harmed, either from their index ACCT, or subsequently, or both. Cutting was the most frequent behaviour (51%). All screening instruments showed some evidence of unidimensionality, and four out of five showed scaling criteria consistent with ordinal scaling, so verifying the validity of the cut points. However, many showed gender bias and failure to fit the Rasch measurement model. While a resolution was made in most cases, both ordinal raw scores and latent interval scale estimates failed to show predictive value when applied within AUC analysis (0.491-0.566) or adjusted Cox proportional hazards models. However, good predictive values were shown for gender-specific sets of items, thus providing easily applied screening indexes. While four out of five potential screening instruments were found to have acceptable psychometric properties within this setting, their predictive validity of all instruments was poor under AUC analysis. Gender-specific item sets were put together to form two screening indexes with formative indicators which gave reasonable AUC values, particularly so for females. The indexes provide identification of low-medium-high risk of self-harm, and so may help to inform potential care pathways and decisions to sign prisoners off from the ACCT. Future work should concentrate on refining a set of predictive screening items among different offender populations and investigating the time point at which this set of items should be administered. Future work may also look at the different magnitudes of risk as indicators for care pathways. The National Institute for Health Research Health Technology Assessment programme.