Self-harm Events Research Articles

Self‐harm in people with epilepsy: A retrospective cohort study

Little is known about self-harm in people with epilepsy, despite suicide being recognized as a leading cause of mortality in this population. This study aimed to investigate the characteristics of self-harm in people with epilepsy, and associated demographic and psychosocial factors. Patients presenting to hospital following self-harm between 1994 and 2008 were identified from the Oxford Monitoring System for Self-Harm. Epilepsy diagnosis was confirmed through review of medical records. Demographic features, patient, and self-harm characteristics of 132 people with epilepsy and 9,778 self-harm patients without epilepsy were compared using a regression model, adjusting for age, sex, and repetition. Patients presenting between 1998 and 2008 were followed up for all-cause mortality to the end of 2011. The rate of self-harm per individual with epilepsy was 2.04 (95% confidence interval [CI] 1.85-2.25) times that of the comparison group, and time between first and second self-harm events was shorter (hazard ratio 1.86; 1.46-2.38). People with epilepsy were significantly more likely to use antiepileptic medication in overdose, although overall methods of self-harm were similar in the two groups. No significant differences in suicide intent scores or the proportion of patients who died by suicide were found. Previous outpatient psychiatric treatment, longer duration of unemployment, experience of violence, and housing problems were associated with self-harm in people with epilepsy. People with epilepsy who self-harm do so more frequently than other self-harm patients. Clinicians should be aware of this and pay attention to contributory factors as these may enhance risk in this population. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.

MIDSHIPS: multicentre intervention designed for self-harm using interpersonal problem-solving: protocol for a randomised controlled feasibility study.

BackgroundAround 150,000 people each year attend hospitals in England due to self-harm, many of them more than once. Over 5,000 people die by suicide each year in the UK, a quarter of them having attended hospital in the previous year because of self-harm. Self-harm is a major identifiable risk factor for suicide. People receive variable care at hospital; many are not assessed for their psychological needs and little psychological therapy is offered. Despite its frequent occurrence, we have no clear research evidence about how to reduce the repetition of self-harm. Some people who have self-harmed show less active ways of solving problems, and brief problem-solving therapies are considered the most promising psychological treatments.Methods/DesignThis is a pragmatic, individually randomised, controlled, feasibility study comparing interpersonal problem-solving therapy plus treatment-as-usual with treatment-as-usual alone, for adults attending a general hospital following self-harm. A total of 60 participants will be randomised equally between the treatment arms, which will be balanced with respect to the type of most recent self-harm event, number of previous self-harm events, gender and age. Feasibility objectives are as follows: a) To establish and field test procedures for implementing the problem-solving intervention; b) To determine the feasibility and best method of participant recruitment and follow up; c) To assess therapeutic delivery; d) To assess the feasibility of obtaining the definitive trial’s primary and secondary outcomes; e) To assess the perceived burden and acceptability of obtaining the trial’s self-reported outcome data; f) To inform the sample size calculation for the definitive trial.DiscussionThe results of this feasibility study will be used to determine the appropriateness of proceeding to a definitive trial and will allow us to design an achievable trial of interpersonal problem-solving therapy for adults who self-harm.Trial registrationCurrent Controlled Trials (ISRCTN54036115)

Method Choice in Nonfatal Self-Harm as a Predictor of Subsequent Episodes of Self-Harm and Suicide: Implications for Clinical Practice

We examined time-varying and time-invariant characteristics of nonfatal intentional self-harm episodes in relation to subsequent episodes of self-harm and suicide. We conducted a follow-up cohort study through 2007 of 3600 patients discharged from hospitals in New Jersey with a primary diagnosis of intentional self-harm in 2003. We determined repetition of self-harm from hospital records and suicide from state registers. Use of methods other than drug overdose and cutting in self-harm events, greater medical severity of nonfatal episodes, and a history of multiple self-harm episodes increased the risk of suicide. However, most suicides occurred without these risk factors. Most suicides took place without intervening episodes of self-harm, and most persons used a low-lethality method (drug overdose or cutting) in their index episode, but switched to a more lethal method in their fatal episode. Our findings suggest that preventing suicide among persons with a history of self-harm must account for the possibility that they will adopt methods with higher case-fatality ratios than they previously tried.

Adjunctive Sleep Medications and Depression Outcome in the Treatment of Serotonin-Selective Reuptake Inhibitor Resistant Depression in Adolescents Study

In the Treatment of Resistant Depression in Adolescents, study participants who received medication for sleep had a lower response rate. This report sought to clarify this finding. Depressed adolescents who had not responded to a previous adequate serotonin-selective reuptake inhibitor (SSRI) trial were randomly assigned to another SSRI, venlafaxine, another SSRI+cognitive behavior therapy (CBT), or venlafaxine+CBT. Augmentation with sleep medication was permitted as clinically indicated. Youth who received trazodone were six times less likely to respond than those with no sleep medication (adjusted odds ratio [OR]=0.16, 95% confidence interval [CI]: 0.05-0.50, p=0.001) and were three times more likely to experience self-harm (OR=3.0, 95% CI: 1.1-7.9, p=0.03), even after adjusting for baseline differences associated with trazodone use. None (0/13) of those cotreated with trazodone and either paroxetine or fluoxetine responded. In contrast, those treated with other sleep medications had similar rates of response (60.0% vs. 50.4%, χ(2)=0.85, p=0.36) and of self-harm events (OR=0.5, 95% CI: 0.1-2.6, p=0.53) as those who received no sleep medication. These findings should be interpreted cautiously because these sleep agents were not assigned randomly, but at clinician discretion. Nevertheless, they suggest that the use of trazodone for the management of sleep difficulties in adolescent depression should be re-evaluated and that future research on the management of sleep disturbance in adolescent depression is needed. The very low response rate of participants cotreated with trazodone and either fluoxetine or paroxetine could be due to inhibition of CYP 2D6 by these antidepressants.

The New Zealand serious non-fatal self-harm indicators: how valid are they for monitoring trends?

BackgroundTo monitor accurately injury incidence trends, indicators should measure incidence independently of extraneous factors. Frequencies and rates of New Zealand's serious non-fatal self-harm indicators may be prone to fluctuations in...

Psychiatric Adverse Events Associated with Varenicline

Psychiatric adverse events, including depression, suicidal ideation and psychotic reactions have been reported in patients taking the smoking cessation medicine varenicline. However, data regarding the frequency of psychiatric adverse reactions in 'real-life' postmarketing use are limited to date. The aim of the study was to calculate the occurrence rates of psychiatric adverse reactions in a nationwide general population prescribed varenicline in New Zealand. Observational prospective cohort study using Prescription Event Monitoring methods. All New Zealand patients dispensed a prescription for varenicline from 1 April 2007 to 31 March 2008 were included in this study. Patients were followed up by multiple methods, including linkage to national morbidity and mortality datasets, questionnaires to patients' doctors and assessment of spontaneous reports sent to the Intensive Medicines Monitoring Programme. Main outcome measures were occurrence rates of psychiatric adverse events in the total patient cohort and in the subgroup for whom a follow-up questionnaire was returned (the 'responder population'). The cohort for this study included 3415 patients prescribed varenicline during the first year of monitoring in New Zealand. Follow-up by record linkage was performed for 3353 (98%) patients, and questionnaires were returned for 1394 (42%) of these patients. Of 1394 questionnaires returned, 1310 were valid and defined as the 'responder' population. Sleep disorders, including insomnia, sleep disturbance, dreams and nightmares, were the most frequently reported psychiatric events and were experienced by 56 (4.3%) patients in the responder population. Symptoms of depression were reported by 39 (2.98%) patients in the responder population (24 new-onset depression, 14 worsening of pre-existing depression and 1 report of impaired motivation). Withdrawal reactions after stopping varenicline were reported by 6 (0.46%) patients in the responder population. Serious psychiatric reactions including suicide (one case), suicidal ideation (two cases) and psychotic reactions (three cases) were also identified. Six self-harm events (one fatal, five non-fatal) were identified in the total cohort, giving an occurrence rate of 0.18% (95% CI 0.06, 0.38) in this population. This intensive postmarketing study of 3415 New Zealand patients demonstrates that psychiatric adverse events are commonly reported in patients taking varenicline. Approximately 3% of patients experienced symptoms of depression and the majority of these cases appeared to have a causal association with varenicline. Serious psychiatric reactions including suicide, suicidal ideation and psychotic reactions were also identified, but these were less frequently reported.

A systematic review of psychosocial interventions for suicidal adolescents

Suicide is a leading cause of death for young people and rates of serious suicidal thoughts are even higher. Due to these high rates and potential harm to youth, effective interventions are necessary. The purpose of this systematic review was to determine the impact of interventions designed for suicidal adolescents. Both quasi-experimental and experimental designs in the published and unpublished literature were included, and a total of 17 studies were located. According to meta-analysis, intervention group participants were slightly less likely to have suicidal and self-harm events than control group participants. However, when studies assessed outcome at a later period than immediately after intervention, experimental group participants were slightly more likely to have suicidal and self-harm events than control group participants. For studies that measured suicidal ideation at posttest, intervention group participants were slightly less likely to report suicidal ideation than control group participants, both at posttest and at follow-up. These contradictory findings are explored and discussed.

Distinguishing Suicidal from Non-Suicidal Deliberate Self-Harm Events in Women with Borderline Personality Disorder

Deliberate self-harm (DSH) is common in Borderline Personality Disorder, may be due to a variety of reasons, and is associated with different degrees of suicidal intent. Understanding the reasons for episodes of DSH in this population may be helpful in developing interventions to reduce the rate of DSH or to assist in the clinical judgement of suicidal intention after DSH has occurred. The Parasuicide History Interview, version 2 (PHI-2) was used to determine the reasons for DSH events in 70 Australian women diagnosed with Borderline Personality Disorder. Factor analysis of the responses identified four empirically derived component factors. Multivariate models were developed to identify the independent predictors of suicidal deliberate self-harm (S-DSH) versus non-suicidal deliberate self-harm (NS-DSH) events. Participants and raters showed strong agreement in classifying S-DSH and NS-DSH events. Methods used that involved self-poisoning, jumping or stabbing showed increased risk for S-DSH, adjusted odds ratio 12.07 (95% CI 2.17, 67.29), compared to the referent group, external damage to skin with no rescue contact being sought. Although no grouping of reasons were independently significant, the lower the effectiveness of the DSH event to resolve the reasons for the event, the higher the risk of it having been a S-DSH event. In clinical situations, any Borderline Personality Disorder patient seeking help or medical attention, using any method other than superficial external injury to skin, or reporting a failure to effectively resolve the reasons for the DSH event, should be considered as likely to have had a S-DSH event (greater suicidal intention). However, specific reasons for the DSH event, or individual subject characteristics, did not meaningfully distinguish S-DSH from NS-DSH events.

The effectiveness of joint crisis plans for people with borderline personality disorder: protocol for an exploratory randomised controlled trial

BackgroundBorderline Personality Disorder (BPD) is a common mental disorder associated with raised mortality, morbidity and substantial economic costs. Although complex psychological interventions have been shown to be useful in the treatment of BPD, such treatments are expensive to deliver and therefore have limited availability and questionable cost-effectiveness. Less complex interventions are required for the management of BPD. A Joint Crisis Plan (JCP) is a record containing a service user's treatment preferences for the management of future crises and is created by the service user with the help of their treating mental health team. These plans have been shown to to be an effective way of reducing compulsory treatment in people with psychosis. However, to date they have not been used with individuals with BPD. This exploratory trial will examine whether use of a JCP is an effective and cost-effective intervention for people with BPD for reducing self-harm.Methods/DesignIn this single blind exploratory randomized controlled trial, a total of 120 participants (age >18 years with a primary diagnosis of DSM-IV borderline personality disorder) will be recruited from community mental health teams and, after completing a baseline assessment, will be assigned to one of two conditions: (1) a Joint Crisis Plan, or (2) treatment as usual. Those allocated to the JCP condition will take part in a facilitated meeting, the purpose of which will be to agree the contents of the plan. Following the meeting, a typed version of the JCP will be sent to the patient and to any other individuals specified by the participant. All participants will be followed-up at 6 months. The primary outcome measures are: any self-harm event, time to first episode of self-harm and number of self-harm events over the follow-up period. Secondary outcome measures are length of time from contemplation to act of self-harm, help-seeking behaviour after self-harm, cost, working alliance, engagement with services and perceived coercion. Other outcome variables are quality of life, social impairment and satisfaction with treatment.DiscussionResults of this trial will help to clarify the potential beneficial effects of JCPs for people with BPD and provide information to design a definitive trial.Trial RegistrationCurrent Controlled Trials ISRCTN12440268

Factors associated with deliberate self-harm among Irish adolescents

Deliberate self-harm (DSH) is a major public health problem, with young people most at risk. Lifetime prevalence of DSH in Irish adolescents is between 8% and 12%, and it is three times more prevalent among girls than boys. The aim of the study was to identify the psychological, life-style and life event factors associated with self-harm in Irish adolescents. A cross-sectional study was conducted, with 3881 adolescents in 39 schools completing an anonymous questionnaire as part of the Child and Adolescent Self-harm in Europe (CASE) study. There was an equal gender balance and 53.1% of students were 16 years old. Information was obtained on history of self-harm life events, and demographic, psychological and life-style factors. Based on multivariate analyses, important factors associated with DSH among both genders were drug use and knowing a friend who had engaged in self-harm. Among girls, poor self-esteem, forced sexual activity, self-harm of a family member, fights with parents and problems with friendships also remained in the final model. For boys, experiencing bullying, problems with schoolwork, impulsivity and anxiety remained. Distinct profiles of boys and girls who engage in self-harm were identified. Associations between DSH and some life-style and life event factors suggest that mental health factors are not the sole indicators of risk of self-harm. The importance of school-related risk factors underlines the need to develop gender-specific initiatives in schools to reduce the prevalence of self-harm.

Non-fatal repetition of self-harm: population-based prospective cohort study in Taiwan

Repeated self-harm is relatively common and is linked with an elevated risk of eventual suicide. There has been no study of this involving a large sample from the Far East. To estimate the risk over the medium term of non-fatal repetition of self-harm and identify predictive factors in those carrying out self-harm. A total of 970 individuals who had self-harmed were recruited from a community-based suicide behaviour register system in Nantou, Taiwan from July 2000 to February 2003. Information regarding demography and suicide methods was collected. Individuals were followed-up until December 2005 to examine the risk of repeated self-harm and independent predictive factors. Ninety cohort members had repeated self-harm during the follow-up period (accounting for 131 repeated self-harm episodes in all). The cumulative risks were 5.7% for the first year, 7.8% for the second year and 9.5% for the fourth year. The risk was highest within the first year after the self-harm event. Independent risk factors included female gender and self-cutting as well as self-poisoning with drugs. Effect of younger age was mediated through the choice of methods. Individuals with self-harm have a high risk of repetition, especially within the first year. Suicide prevention strategies need to focus on intervening with this population to reduce their repetition.

Teenaged, Depressed, and Treatment Resistant: What Predicts Self-Harm?

Self-harm affects thousands of depressed teenagers each year. A careful meta-analysis of pediatric antidepressant trials by the Food and Drug Administration (FDA) showed a higher rate of spontaneously reported suicidal behaviors in adolescents randomly assigned to antidepressants versus placebo. The publicity about this relationship and the subsequent FDA black box warning was followed by a decrease in antidepressant use (1) and a possible increase in adolescent suicides. Whether the increase is real and sustained is still unclear (2-4). Data that can identify who is at risk for an increase in reported self-harm with medication are difficult to find. Standardized systematic assessment of suicidal events in adolescent trials have only recently been developed (5), and adolescents with a history of self-harm behaviors, the ones with greatest risk, have usually been excluded from clinical trials.

Predictors of Spontaneous and Systematically Assessed Suicidal Adverse Events in the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) Study

The authors sought to identify predictors of self-harm adverse events in treatment-resistant, depressed adolescents during the first 12 weeks of treatment. Depressed adolescents (N=334) who had not responded to a previous trial with an SSRI antidepressant were randomized to a switch to either another SSRI or venlafaxine, with or without cognitive behavior therapy. Self-harm events, i.e., suicidal and non-suicidal self-injury adverse events were assessed by spontaneous report for the first 181 participants, and by systematic weekly assessment for the last 153 participants. Higher rates of suicidal (20.8% vs. 8.8%) and nonsuicidal self-injury (17.6% vs. 2.2%), but not serious adverse events (8.4% vs. 7.3%) were detected with systematic monitoring. Median time to a suicidal event was 3 weeks, predicted by high baseline suicidal ideation, family conflict, and drug and alcohol use. Median time to nonsuicidal self-injury was 2 weeks, predicted by previous history of nonsuicidal self-injury. While there were no main effects of treatment, venlafaxine treatment was associated with a higher rate of self-harm adverse events in those with higher suicidal ideation. Adjunctive use of benzodiazepines, while in a small number of participants (N=10) was associated with higher rate of both suicidal and nonsuicidal self-injury adverse events. Since predictors of suicidal adverse events also predict poor response to treatment, and many of these events occurred early in treatment, improving the speed of response to depression, by targeting of family conflict, suicidal ideation, and drug use may help to reduce their incidence. The relationship of venlafaxine and of benzodiazepines to self-harm events requires further study and clinical caution.

Do Geographic Regions with Higher Suicide Rates also have Higher Rates of Nonfatal Intentional Self‐Harm?

Fatal and nonfatal intentional self-harm events in eight U.S. states were compared using emergency department, hospital, and vital statistics data. Nonfatal event rates increased by an estimated 24.20% over 6 years. Case fatality ratios varied widely, but two northeastern states' total event rates (fatal plus nonfatal) were very high (New Hampshire 206.5/100,000 person years; Massachusetts 166.7/100,000). Geographic context did not uniformly impact the likelihood of self-harm across event types. The state-level public health burden posed by such acts cannot, therefore, be accurately estimated from either mortality or morbidity data alone.

NZ Government's trend analysis of hospitalised self‐harm is misleading

The aim of this paper is to demonstrate that the trends published in the New Zealand (NZ) Government's 2006 Suicide Trends document for hospitalised self-harm are misleading. Analysis of incident self-harm events resulting in hospitalisation and reference to published material on injury outcome indicators for the NZ Injury Prevention Strategy (NZIPS). The significant increase in rates of self-harm hospitalisation presented in Suicide Trends from 1989 to a large extent reflect changes in recording practice rather than any change in self-harm in the community. Indicators with significantly fewer threats to validity suggest there has been little, if any, increase in the incidence of self-harm. The authors of Suicide Trends did not adequately specify how they defined a case and, moreover, their methods were not consistent with those used for the NZIPS indicators. The methodological challenges to producing valid indicators for the purposes of measuring trends in important non-fatal injury are substantial. Unless we accept that the usual methods of measuring trends in non-fatal injury are misleading and commit to taking up the challenge to produce and use better indicators, we will continue to run the risk of misleading ourselves and the public.

A study of self-harm in older people: Mental disorder, social factors and motives

Data was collected on seventy-six older people who presented to a specialist self-harm team. Data included: diagnosis, suicide intent, motives for self-harm, social contacts and life events and difficulties. The majority of elderly who harmed themselves had high suicide intent and 69% were depressed. Patients were frequently living alone with an isolated life-style and poor physical health. Depressed self-harm subjects had higher suicide intent scores than non-depressed and to gain relief from an unbearable state of mind was a frequently recorded motive for these patients. Other motives for self-harm appear to be similar between depressed and non-depressed self-harmers. It is important that older people who self-harm receive an appropriate assessment of both risk and need by an experienced mental-health professional skilled at recognising depression in later life. The need for adequate recognition and management of depression in older people in primary care is also highlighted.

Suicidal behaviour in youths with depression treated with new-generation antidepressants

Concern exists that antidepressants can cause suicidality in youths with depression. To determine the pooled risk of self-harm and suicidal behaviour from randomised trials of newer antidepressants. A meta-analysis was carried out to calculate odds ratios for the combined data. Self-harm or suicide-related events occurred in 71 of 1487 (4.8%) of depressed youths treated with antidepressants v. 38 of 1254 (3.0%) of those given placebo (fixed effects odds ratio 1.70, 95% CI 1.13-2.54, P=0.01). There was a trend for individual suicidal thoughts, attempts and self-harm to occur more often in youths taking antidepressants than in those given placebo, but none of these differences was statistically significant. Antidepressants may cause a small short-term risk of self-harm or suicidal events in children and adolescents with major depressive disorder.

Suicide and self-harm following prescription of SSRIs and other antidepressants: confounding by indication.

To identify the incidence and risk of suicide and self harm, among patients prescribed antidepressant drugs. A retrospective cohort study, with nested case control, of patients identified from a nonrandom sample of general practices in New Zealand from 1996 to 2001. A total of 57 361 patients who received a prescription for a single antidepressant were identified from the RNZCGP Research Unit Database. Suicides within 120 days of a prescription were identified from the New Zealand National Mortality Database and self-harm events within 120 days of a prescription were identified from the New Zealand Hospital discharge database. 26 suicides and 330 episodes of self-harm were identified within 120 days of an antidepressant prescription. On univariate analysis the association, expressed as OR (95% CI), between selective serotonin reuptake inhibitors (SSRIs) and self harm and suicide were 2.26 (1.27-4.76) and 1.92 (0.77-4.83), respectively. When corrected for the confounding effects of age, gender and depression/suicidal ideation there was an association between SSRIs and self harm, OR 1.66 (95% CI 1.23-2.23), but not for suicide, 1.28 (0.38-4.35). Paroxetine was a significant risk factor for suicide on univariate analysis, 4.23 (1.19-14.95), but not when corrected for age, gender and depression/suicidal ideation, 2.76 (0.30-24.87). Age, gender and pre-existing depression/suicidal ideation are important confounders in observational studies of the association between antidepressants and suicide or self harm.

Patient Rep Reverses Position On SSRI Black-Box Warning

Patient Rep Reverses Position On SSRI Black-Box Warning