Self-harm Events Research Articles

Non-suicidal self-injury: Demographics, self-harm events, characteristics, and reasons

Background: Suicide and suicide attempt rates for children and adolescents have been increasing overtime. Objectives: Our objectives were to study the characteristics of adolescents who practice non-suicidal self-injury (NSSI) with respect to the self-harm events and motives. Materials and Methods: The cases consisted of 25 adolescents referred to the School Health Psychiatric Clinic with NSSI. Diagnoses were made according to the Diagnostic and Statistical Manual of Mental Disorders – 5th edition. A collection sheet was designed to obtain information regarding case demographics, type of injury, injury characters, and reasons for self-harm events. Results: The majority of cases were young female adolescents (84%) whose parents had received a good education; most had used cuts with sharp objects (92%). The cuts were carried out alone (92%) and within 1 h of thought acquisition. All cases were exposed to maltreatment during childhood. Half of the cases had obtained the idea from friends and one-third from social media. The stated reasons were controlling stress in 60%, coping with loneliness in 32%, and experiencing in 32%. Conclusion: NSSI is common among young adolescent girls, and practitioners should routinely inquire about its presence in clinical interviews and during periodic health surveys. The management of negative emotions is an essential step toward prevention.

Self-Harm Risk in Pregnancy: A Recurrent Events Survival Analysis Using UK Primary Care Data

Aim: To determine if the risk of self-harm changes during pregnancy and the first post-partum year compared to other times in a woman’s life. Methods: Utilising the Clinical Practice Research Datalink, a primary care register, we followed women aged 15 to 45 years from the 1st January 1990 to 31st December 2017. Time was split into: pregnancy, 0-3, 3-6 and 6-12 months post-partum, and any other time outside the perinatal period. Additional time-varying covariates were constructed for: common mental illness (depression/anxiety); addiction (alcohol/drug misuse); serious mental illness (affective/non-affective psychosis); other mental illness (eating/personality disorders); age (15-45 in 5-year bands); and calendar year (1990-2017). UK region and index of multiple deprivation were also included. Utilising a gap-time and stratified Cox model to manage multiple self-harm events, we report unadjusted and adjusted HRs of self-harm associated with pregnancy and the post-partum compared to other periods. Pre-planned interactions examined whether or not effect measures were modified by mental illness exposure, age and birth outcome. Results: The analysis included 2,666,088 women, 1,102,040 pregnancies, 57,791, self-harm events and 14,712,319 person-years of follow-up. Compared to any other time, women were at lowest risk of self-harm during pregnancy (adjHR=0·53, 95%CI 0·49-0·58) and highest risk at 6-12 months post-partum (adjHR=1·08, 95%CI 1·02-1·15). Women with mental illness experienced the greatest self-harm risk reduction in pregnancy (adjHR=0·40, 95%CI 0·36-0·44) and at 6-12 months post-partum (adjHR=0·92, 95%CI 0·87-0·98). Post-partum younger women (15-19 adjHR=1·67, 95%CI 1·48-1·90; 20-24 adjHR=1·27, 95%CI 1·12-1·44) and women who experienced a pregnancy loss (adjHR=1.41, 95%CI 1·21-1·65) or termination (adjHR=1·93, 95%CI 1·72-2·17) were particularly at risk. Conclusion: Overall, pregnancy represents a time of reduced self-harm risk for women. This is especially the case for women with a mental illness. Post-partum, young women represent a vulnerable group who may require additional support. Services aimed at planning for motherhood may have additional psychological benefit in self-harm reduction. Funded by the European Research Council (ref: GA682741) and the National Institute for Health Research (ref: 111905).The study sponsor and funder had no role in the study design, nor the collection, analysis or interpretation of data. Declaration of Interest: None to declare Ethical Approval: The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The study was approved by the Independent Scientific Advisory Committee (ISAC) for MHRA Database Research (protocol number: 17_187). All observational research using CPRD patient data with approval from ISAC was granted by a Health Research Authority (HRA) Research Ethics Committee (East Midlands—Derby, REC reference number 05/MRE04/87).

The Epidemiology of Self-Harm in the Romanian Juvenile Prison System: A Two-Year Cohort Study

Background: There is no extensive literature on social predictors of self-harm in the juvenile justice system, over the time of a prisoner’s sentence. Self-harm behavior displays a higher prevalence in prison, 11 to 14 times greater than in the general population. Our study extended the current research in self-harm by examining dynamic factors of self-harm in adolescents over their sentence in the Romanian juvenile prison system. Method: The present research examined longitudinal predictors of self-harm behaviors in 439 adolescent inmates (Mage = 16.21; 5.2% female, 94.8% male), enrolled in prison during 2011-2012, following them for two years. A series of time-to-event analyses were applied to start from the time of the subject’s internment in the juvenile prison system. Results: Findings from the multivariate survival analyses show that adherence to self-harm conduct in prison was consistently influenced by family factors and prison contexts; although low ability to cope with frustration, sensitivity and emotion dysregulation also mattered. Keeping the other covariates invariant, serving a prison sentence in a closed regime reduces the probability of remaining free of self-harm events, increasing the monthly hazard of self-harm by a factor of 5.26 on average (HR = 5.26, 95% CI = 2.37 - 11.64) compared to the open regime. Conclusion: A greater focus on longitudinal studies may help improve the screening process and also follow the progress of each juvenile to warrant the efficacy of preventive programs in self-harm, according to their emerging needs.

Physical, mental, and social wellbeing and their association with death by suicide and self-harm in older adults: a community-based cohort study.

To assess associations between physical, mental, and social well-being and suicide and self-harm in a community-based sample of older adults. Using a cohort design, questionnaire data from 102,880 individuals aged 65 years or older living in New South Wales, Australia during 2006-2009 were linked to hospital and cause-of-death databases until 2017. Poisson regressions obtained adjusted incidence rate ratios (IRRs). One hundred nine suicides and 191 deliberate self-harm (DSH) events occurred. Compared to those reporting excellent/good overall health, older adults reporting fair overall health had higher suicide rates (IRR = 2.8, 95% confidence interval: 1.8-4.4). Also, suffering from physical limitations was associated with higher rates of suicide. A fair versus excellent/good memory was associated with higher rates of suicide (IRR = 2.0, 1.3-3.3). Male erectile dysfunction was linked to self-harm (IRR = 2.8, 1.0-7.7). Suicide rates were elevated with baseline Kessler-10 scores of 20-50 versus 10-15 (IRR = 5.0, 2.9-8.9); the corresponding IRR for DSH was 2.9 (1.8-4.8). Elevated rates were observed for both self-reported depression and anxiety. Poor versus excellent/good quality of life was associated with suicide (IRR = 4.3, 1.7-10.7) and achieving less than desired to due to emotional problems was linked to self-harm (IRR = 1.8 1.3-2.4). Rates of suicide ande DSH were lower in those with ≥5 people to depend on versus one (suicide: IRR = 0.5, 0.3-0.9; DSH: IRR = 0.5, 0.3-0.7). Older adults experiencing health problems, including those relating to overall health or memory, and those with psychological distress had elevated rates of suicidal behavior. Rates of subsequent self-harm and/or death by suicide were elevated in participants with small social networks.

Prevalence and risk factors for repetition of non-fatal self-harm in Hong Kong, 2002–2016: A population-based cohort study

BackgroundA history of self-harm is strongly associated with future self-harm attempts. Large-scale Asian cohort studies examining risk factors for repeated self-harm are lacking. This paper reports on annual prevalence, cumulative risk, annual risk of non-fatal self-harm repetition, and risk factors among Hong Kong patients with a history of self-harm. MethodsThe Hong Kong Clinical Data Analysis and Reporting System (CDARS) provided all accident & emergency department and inpatient self-harm records between Jan 1, 2002 and Dec 31, 2016. Demographic and clinical characteristics were extracted. Annual prevalence, over-time cumulative and annual risks of non-fatal self-harm repetition were estimated, and the adjusted hazard ratios (HR; plus 95% CIs) of putative risk factors associated with repetition were estimated using Wei-Lin-Weissfeld (WLW) generalization of the Cox model for recurrent event analysis. FindingsThere were 127,801 self-harm episodes by 99,116 individuals. Annual prevalence of repeated self-harm, of all self-harms, ranged from 7•36% to 28•71% during the study period. Risk of self-harm repetition within one year of the index event was 14•25% (95% CI, 14•04%-14•46%). People with four or more previous self-harm episodes carried the highest risk of self-harm repetition (adjusted HR 4•81 [95% CI 4•46–5•18]). Significant risk factors for non-fatal self-harm repetition included male gender (1•08 [1•05–1•11]), older age (65+ years) (1•07 [1•01–1•13]), social welfare for payment (1•30 [1•27–1•34]), psychiatric admission (1•60 [1•50–1•72]), self-injury only (1•19 [1•15–1•23]), self-injury combined with self-poisoning (1•38 [1•24–1•53]), depression and bipolar disorders (1•09 [1•04–1•14]), personality disorders (1•18 [1•06–1•32]), substance misuse (1•31 [1•27–1•36]), and asthma (1•18 [1•02–1•36]). InterpretationHong Kong self-harm patients with non-fatal self-harm events should be supported by effective, timely and ongoing aftercare plans based on their risk profiles, to reduce risk of self-harm reoccurrence. FundingResearch Grants Council, General Research Funding: 17611619.

Risk of Psychiatric Adverse Events Among Montelukast Users

There have been conflicting results from observational studies regarding the risk of psychiatric adverse events (PAEs) with montelukast use. To determine whether there are associations of depressive disorders, self-harm, and suicide with use of montelukast compared with inhaled corticosteroid (ICS) use. Using data from the Sentinel Distributed Database from January 1, 2000, to September 30, 2015, patients (n= 457,377) exposed to montelukast or ICS, aged 6 years and older with a diagnosis of asthma, were matched 1:1 on propensity scores. Hazard ratios (HRs) and 95% CIs were estimated for each study outcome overall and by age, sex, psychiatric history, and pre-/post-2008 labeling updates using Cox proportional hazards regression models. Exposure to montelukast was associated with a lower risk of treated outpatient depressive disorder (HR, 0.91; 95% CI, 0.89-0.93). No increased risks of inpatient depressive disorder (HR, 1.06; 95% CI, 0.90-1.24), self-harm (HR, 0.92; 95% CI, 0.69-1.21), or self-harm using a modified algorithm (HR, 0.81; 95% CI, 0.63-1.05) were observed with montelukast use compared with ICS use. Most PAEs occurred in the roughly one-third of patients having a past psychiatric history. When compared with use of ICS, we did not find associations between montelukast use and hospitalizations for depression or self-harm events. Our findings should be interpreted considering the study's limitations. Psychiatric comorbidity was common, and most PAEs occurred in patients with a past psychiatric history.

Identifying and Predicting Intentional Self-Harm in Electronic Health Record Clinical Notes: Deep Learning Approach.

BackgroundSuicide is an important public health concern in the United States and around the world. There has been significant work examining machine learning approaches to identify and predict intentional self-harm and suicide using existing data sets. With recent advances in computing, deep learning applications in health care are gaining momentum.ObjectiveThis study aimed to leverage the information in clinical notes using deep neural networks (DNNs) to (1) improve the identification of patients treated for intentional self-harm and (2) predict future self-harm events.MethodsWe extracted clinical text notes from electronic health records (EHRs) of 835 patients with International Classification of Diseases (ICD) codes for intentional self-harm and 1670 matched controls who never had any intentional self-harm ICD codes. The data were divided into training and holdout test sets. We tested a number of algorithms on clinical notes associated with the intentional self-harm codes using the training set, including several traditional bag-of-words–based models and 2 DNN models: a convolutional neural network (CNN) and a long short-term memory model. We also evaluated the predictive performance of the DNNs on a subset of patients who had clinical notes 1 to 6 months before the first intentional self-harm event. Finally, we evaluated the impact of a pretrained model using Word2vec (W2V) on performance.ResultsThe area under the receiver operating characteristic curve (AUC) for the CNN on the phenotyping task, that is, the detection of intentional self-harm in clinical notes concurrent with the events was 0.999, with an F1 score of 0.985. In the predictive task, the CNN achieved the highest performance with an AUC of 0.882 and an F1 score of 0.769. Although pretraining with W2V shortened the DNN training time, it did not improve performance.ConclusionsThe strong performance on the first task, namely, phenotyping based on clinical notes, suggests that such models could be used effectively for surveillance of intentional self-harm in clinical text in an EHR. The modest performance on the predictive task notwithstanding, the results using DNN models on clinical text alone are competitive with other reports in the literature using risk factors from structured EHR data.

Exploring behaviours of concern including aggression, self-harm, sexual harm and absconding within an Australian inpatient mental health service.

Patients admitted to mental health services may exhibit behaviours of concern (BOCs) such as aggression, self-harm, absconding and sexual harm. BOCs can lead to restrictive interventions, which have adverse effects on patients, carers and staff. This paper aims to explore the nature and outcome of BOCs within an adult inpatient mental health setting. A retrospective audit was conducted at a metropolitan inpatient service between 1 August 2016 and 31 July 2017. The frequency, nature and outcomes of BOC episodes were described and thematic analysis was used to summarise BOC antecedents. A BOC was documented for 179 (18.2%) patients who also showed high rates of drug abuse, homelessness and longer admission. Most self-harm and sexual harm events occurred outside of normal business hours. Medications and verbal de-escalation were commonly used interventions. Episodes of deliberate self-harm were likely to result in patient and staff injury or mechanical restraint, whereas aggression was associated with seclusion. Mental state, care engagement, physiological stress and situational stressor were identified as BOC antecedents. Multiple forms of BOCs were experienced with mental state, physical and interpersonal contributors identified. Improving multidisciplinary input into early assessment and treatment of BOC causes is needed to improve safety.

Predictive factors of diagnostic conversion from major depressive disorder to bipolar disorder in young adults ages 19–34: A nationwide population study in South Korea

BackgroundPredicting patients who convert to bipolar disorder is important for deciding appropriate treatment for young adults with major depressive disorder (MDD). We focused on the predictive factors of bipolar conversion in a large population of young adults. MethodsA nationwide, population-based electronic medical records database from the Health Insurance Review & Assessment service of South was used to investigate adjusted hazard ratio (HR) of each potential predictor of the bipolar converter group compared to the non-converter group using Cox regression analysis including age of onset, medication use, clinical features, comorbid disorders, admission, self-harm, and negative life events in childhood. ResultsAmong 291,721 subjects who were initially diagnosed with MDD in young adults, 12,376 subjects experienced diagnostic conversion to bipolar disorder. The cumulative incidence was 6.46% during the average 3.26 years of follow-up. Among the predictive factors during diagnosis of MDD, antipsychotic use (HR 3.12, 95%CI, 2.99–3.26, p < 0.0001) and mood stabilizers (HR 2.45, 95%CI, 2.35–2.55, p < 0.0001) showed the strongest association with diagnostic conversion to bipolar disorder. In addition, female sex, younger age of onset, mood stabilizer use, recurrent depression, psychotic symptoms, and admission to a psychiatric ward during diagnosis of MDD were also associated with diagnostic conversion to bipolar disorder. ConclusionIn young adults with MDD, antipsychotic and mood stabilizer use during diagnosis of MDD were the strongest predictive factors with diagnostic conversion to bipolar disorder during follow-up. If young adults with MDD need antipsychotics or mood stabilizer, patients should be carefully evaluated for possibility of bipolar disorder.

Death due to delirium: a case of a self-cut hemodialysis dialysis catheter - a case report

BackgroundNeuropsychiatric conditions such as depression, delirium and cognitive impairment are common in patients with end-stage kidney disease (ESKD) and individuals suffering from ESKD are more likely to commit suicide than members of the general population. Self-harm gestures are not infrequent for ESKD patients suffering from depression, but not well described in other conditions.Case presentationWe present a case of self-harm in a patient with ESKD suffering from acute delirium. A man in his mid-seventies was admitted with fungal peritoneal dialysis (PD) associated peritonitis. On the first day post operatively, he was found with absent vital signs due to exsanguination from newly inserted central catheter which he which had self-severed. He died a few days later as a result of the self-harm gesture.ConclusionThis case highlights that delirium may lead to self-harm events in ESKD and identifies a few strategies to help reduce the risk of self-harm events.

Imputation and characterization of uncoded self-harm in major mental illness using machine learning.

ObjectiveWe aimed to impute uncoded self-harm in administrative claims data of individuals with major mental illness (MMI), characterize self-harm incidence, and identify factors associated with coding bias.Materials and MethodsThe IBM MarketScan database (2003-2016) was used to analyze visit-level self-harm in 10 120 030 patients with ≥2 MMI codes. Five machine learning (ML) classifiers were tested on a balanced data subset, with XGBoost selected for the full dataset. Classification performance was validated via random data mislabeling and comparison with a clinician-derived “gold standard.” The incidence of coded and imputed self-harm was characterized by year, patient age, sex, U.S. state, and MMI diagnosis.ResultsImputation identified 1 592 703 self-harm events vs 83 113 coded events, with areas under the curve >0.99 for the balanced and full datasets, and 83.5% agreement with the gold standard. The overall coded and imputed self-harm incidence were 0.28% and 5.34%, respectively, varied considerably by age and sex, and was highest in individuals with multiple MMI diagnoses. Self-harm undercoding was higher in male than in female individuals and increased with age. Substance abuse, injuries, poisoning, asphyxiation, brain disorders, harmful thoughts, and psychotherapy were the main features used by ML to classify visits.DiscussionOnly 1 of 19 self-harm events was coded for individuals with MMI. ML demonstrated excellent performance in recovering self-harm visits. Male individuals and seniors with MMI are particularly vulnerable to self-harm undercoding and may be at risk of not getting appropriate psychiatric care.ConclusionsML can effectively recover unrecorded self-harm in claims data and inform psychiatric epidemiological and observational studies.

Facets of clinical stigma after attempted suicide in Mumbai, India

Community stigma studies may neglect clinically relevant experience and views of stigma that are important features of mental health problems. After attempting suicide, patients in a hospital emergency ward in Mumbai, India, were assessed for stigma referring to underlying prior problems motivating their deliberate self-harm (DSH) event, the DSH event itself and serious mental illness generally based on both anticipated community views and distinctive personal views. In this cultural epidemiological study of 196 patients, assessment items and four corresponding indexes were analysed and compared on a four-point scale, 0 to 3, for prominence of indicated stigma. Narratives from patients with high, low and discordant levels of stigma for prior problems and DSH events were analysed and compared. Disclosure, critical opinions of others and problems to marry were greater concerns for DSH events than prior problems. Problem drinking, unemployment, and sexual or financial victimization were common features of prior problems. Impulsivity of the DSH event and externalizing blame were features of lower levels of stigma. Ideas about most people’s views of serious mental illness were regarded as more stigmatizing than patients’ prior problems and DSH event; patients’ personal views of serious mental illness were least stigmatizing. Findings suggest linking suicidality and stigmatized mental illness may discourage help seeking. Suicide prevention strategies should therefore emphasize available help needed for severe stress instead of equating suicidality and mental illness. Findings also indicate the relevance of assessing clinical stigma in a cultural formulation and the value of integrated qualitative and quantitative stigma research methods.

Association of Restless Legs Syndrome With Risk of Suicide and Self-harm

Restless legs syndrome (RLS) is a common neurologic disorder that has been previously found to be associated with higher odds of suicidal ideation. In the context of the increasing suicide rate in the United States, the evidence regarding the association between RLS and the risk of suicide and self-harm is limited. To investigate the association between RLS and risk of suicide and self-harm. This cohort study was performed using Truven Health MarketScan national claims data from 2006 to 2014; the baseline data were from 2006 to 2008, and the follow-up data covered 6 years (January 1, 2009, to December 31, 2014). Included were 24 179 nonpregnant participants with RLS and 145 194 age- and sex-matched participants without RLS at baseline (2006-2008), who were free of suicide, self-harm, cardiovascular disease, or cancer at study baseline. Data analysis was performed from February 1, 2018, to January 1, 2019. Diagnosis of RLS, as identified by the International Classification of Diseases, Ninth Revision code. Incident suicide and self-harm event, identified by the International Classification of Diseases, Ninth Revision diagnosis code. Among 169 373 participants in the current analysis, the mean (SD) age was 49.4 (9.1) years; 53 426 (31.5%) participants were men. During a mean (SD) follow-up duration of 5.2 (2.2) years, 119 incident suicide and self-harm cases were identified. Individuals with RLS had a higher risk of suicide or self-harm compared with those without RLS (adjusted hazard ratio, 2.66; 95% CI, 1.70-4.15), after adjusting for lifestyle factors (eg, alcohol and obesity), presence of chronic diseases (eg, depression, insomnia, diabetes, chronic kidney disease, peripheral neuropathy, iron-deficiency anemia, and Parkinson disease), and use of medications. Excluding those with depression, insomnia, obstructive sleep apnea, and other common chronic conditions, the significant association between RLS and suicide or self-harm persisted (adjusted hazard ratio, 4.14; 95% CI, 2.17-7.92). Restless legs syndrome was associated with a high risk of suicide and self-harm, and the risk was independent of most identified diseases and conditions.

Suicide Immediately After Discharge From Psychiatric Inpatient Care: A Cohort Study of Nearly 2.9 Million Discharges.

The risk of suicide is elevated after discharge from a psychiatric hospital. This study aimed to investigate how recent suicidal behavior affects the risk of suicide in patients with different psychiatric diagnoses immediately after discharge. Registers with national coverage were linked to create a study cohort including all individuals discharged from psychiatric hospitals in Sweden from 1973 through 2009. Hazard ratios for discharge diagnoses were calculated. The risk of suicide within 30 days after discharge in each diagnostic category when suicidal behavior had been registered within 30 days before admission was estimated. A total of 3,695 suicides occurred after 2,883,088 discharges. If recent suicidal behavior was registered, the risk of completed suicide increased prominently in all diagnostic categories, but particularly for schizophrenia (hazard ratio [HR] = 8.9; 95% CI, 6.4-12.4) and other nonorganic psychosis (HR = 6.8; 95% CI, 5.1-9.0). Patients suffering from depression had the highest overall risk of suicide postdischarge (HR = 3.0; 95% CI, 2.7-3.3). This finding applied especially to male patients with depression (HR = 4.5; 95% CI, 4.0-5.0) or with reaction to crisis (HR = 3.6; 95% CI 3.0-4.4). A distinct elevation of the risk of suicide was seen in all diagnostic groups if a recent self-harm event had occurred, particularly among patients with psychotic disorders. Overall, the immediate risk of suicide after discharge was high regardless of recent suicidal behavior. The findings in this study have relevance for clinical decisions about immediate after-care and treatment in connection with discharge from psychiatric inpatient care.

Association of Aripiprazole With the Risk for Psychiatric Hospitalization, Self-harm, or Suicide

Some reports have raised concerns regarding a potential psychiatric worsening associated with first-time use of aripiprazole in patients already treated with other antipsychotic medications. Whether aripiprazole use, particularly in the long term, increases the risk for serious psychiatric events is unclear. To assess whether switching to or adding aripiprazole is associated with serious psychiatric treatment failure compared with switching to or adding another antipsychotic drug in patients previously exposed to antipsychotic medications. This population-based cohort study was conducted from January 1, 2005, to March 31, 2015. Data were obtained from the United Kingdom Clinical Practice Research Datalink, one of the world's largest computerized databases linked to the Hospital Episodes Statistics repository and the Office for National Statistics (ONS) mortality database. Within a base cohort of new users of antipsychotic drugs, patients switching or adding aripiprazole (n = 1643) were propensity matched 1:1 to patients switching to or adding another antipsychotic medication (n = 1643). All patients were followed up until psychiatric treatment failure, for 365 days (1 year) after cohort entry, until death from any cause other than suicide, until end of registration or linkage with the databases, or end of the study period (March 31, 2016). Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% CIs of serious events of psychiatric treatment failure (psychiatric hospitalizations, self-harm, or suicide) associated with switching to or adding aripiprazole compared with other antipsychotic drugs. In addition to propensity score matching, all models were adjusted for age, number of psychiatric hospitalizations or self-harm events in the 6 months before cohort entry, number of different antipsychotic drugs before cohort entry, and quintiles of the Index of Multiple Deprivation. The study cohort included 1643 patients (949 [57.8%] were women with a mean [SD] age of 42.1 [16.8] years) starting aripiprazole use; they were matched 1:1 to 1643 patients (871 [53.0%] were women with a mean [SD] age of 42.4 [17.1] years) starting use of another antipsychotic drug. During 2692 person-years of follow-up, 391 incident serious psychiatric treatment failures occurred, with a crude incidence rate of 14.52 (95% CI, 13.16-16.04) per 100 person-years. First-time use of aripiprazole was not associated with an increased rate of psychiatric treatment failure (HR, 0.87; 95% CI, 0.71-1.06), psychiatric hospitalizations (HR, 0.85; 95% CI, 0.69-1.06), or self-harm or suicide (HR, 0.96; 95% CI, 0.68-1.36) compared with starting use of another antipsychotic drug. Results were consistent across several sensitivity analyses. Initiating aripiprazole use, compared with another antipsychotic medication, after a previous antipsychotic exposure did not appear to be associated with psychiatric hospitalization, self-harm, or suicide; these findings warrant replication in large observational studies.

Assessing the predictability of self-harm in a high-risk adult prisoner population: a prospective cohort study

BackgroundPrisoners are at increased risk of self-harm and when either intent is expressed, or an act of self-harm carried out, prisoners in the UK are subject to self-harm/suicide monitoring (referred to as “open ACCT” monitoring). However, there is a paucity of validated instruments to identify risk of self-harm in prisoner populations. In response to the need to support prison staff to determine who is at increased risk of self-harm or repeat self-harm, the aim of this study was to determine whether any pre-existing, standardised instruments could usefully identify future self-harm events in prisoners undergoing ACCT monitoring.MethodsA multi-stage prospective cohort study was conducted, where the Prison Screening Questionnaire (PriSnQuest), a modified Borderline Symptom List-23 (BSL-23), Self-Harm Inventory (SHI), Patient Health Questionnaire-9 (PHQ-9) and Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM) instruments were administered to prisoners aged 18 and above, who were judged to be at an increased risk of self-harm (on open ACCT monitoring) during the recruitment phase. A 6-month follow-up determined self-harm occurrence since baseline, and Area-Under-the-Curve (AUC) analysis examined the ability of the instruments to predict future self-harm.ResultsPrison records established that 29.1% self-harmed during the follow up period, involving a total of 423 self-harm events reported from 126 individuals, followed up for 66,789 prisoner days (median 167 days; IQR 71–207.5 days). This translated to an ‘event incidence’ of 6.33 per 1000 prisoner days of those who had been placed upon an ACCT, or ‘prisoner incidence’ of 1.89 per 1000 days, with considerable variation for both gender and participating prisons. None of the summary scores derived from the selected instruments showed a meaningful ability to predict self-harm, however, exploratory logistic regression analysis of individual background and instrument items revealed gender-specific item sets which were statistically significant in predicting future self-harm.ConclusionsProspective self-harm was not predicted by any of the pre-existing instruments that were under consideration. Exploratory logistic regression analysis did reveal gender-specific item sets, producing predictive algorithms which were statistically significant in predicting future self-harm; however, the operational functionality of these item sets may be limited.

Contact with mental health services after medically verified self-harm: A prospective data linkage study

IntroductionHigh rates of self-harm resulting in acute health service contact have been observed in adults released from prison. Contact with health services due to self-harm is a key intervention opportunity to prevent deleterious health outcomes. Little is known about subsequent mental health service contact after discharge from acute health services.&#x0D; Objectives and ApproachWe aimed to describe mental health service contact after discharge from acute health service contacts following self-harm in a representative sample of adults released from prison. Ambulance, emergency department (ED), hospital inpatient and ambulatory mental health service records were probabilistically linked to pre-release interview data. Self-harm events after release were identified from ICD codes and coded from case notes in ambulance, ED, and hospital records. We calculated the time between discharge from ambulance, ED, or hospital after self-harm and subsequent contact with mental health services. Factors predicting the likelihood of mental health service contact were examined using multivariate logistic regression.&#x0D; ResultsOf 1307 adults released from prison, 108 (8.3%) experienced 218 self-harm events resulting in acute health service use in the community. Of these presentations, 0%, 59%, and 50% of discharges from ambulance attendances, ED and hospital, respectively, had subsequent contact with a specialist mental health service within 7 days of that acute service contact. Mental health service contact within 7 days of acute service contact was positively associated with being female (adjusted odds ratio [AOR]: 3.27; 95%CI: 1.26-8.47) and being identified by prison staff as at risk for self-harm (AOR: 3.34; 95%CI: 1.29-8.62), and was negatively associated with dual diagnosis (AOR: 0.19: 95%CI: 0.06-0.61), substance use disorder only (AOR: 0.13; 95%CI: 0.04-0.48) and physical health functioning (AOR: 0.96; 95\%CI: 0.92-0.99).&#x0D; Conclusion/ImplicationsAlmost half of adults with a recent history of incarceration discharged from acute health service after self-harm did not receive timely specialist mental health care. Improved integration of acute health services and ambulatory mental health services could improve outcomes for adults who present with self-harm.

Second-generation LAI are associated to favorable outcome in a cohort of incident patients diagnosed with schizophrenia

ObjectiveInvestigate the associations of long-acting injectable (LAI) second generation antipsychotic drugs with number of relapses, psychiatric admissions, days hospitalized, intentional self-harm events, and costs linked to hospitalizations in incident patients diagnosed with schizophrenia. MethodA nationwide, population-based, retrospective study utilizing mirror-image models before and after initiation of LAI SGA. Results10,509 patients were included as study population, with analyses being conducted on 2223 patients in a six-month period, 1383 in a 12-month period, 713 in a 24-month period. After initiation of LAI antipsychotics, patients experienced a reduction in number of relapses with an incidence rate ratio (IRR) of 0.60 for the first six months, IRR 0.64 for the first 12 months and IRR 0.64 for the first 24 months following initiation of LAI, all P < 0.001. The number of psychiatric admissions was reduced in a similar manner with respective IRR of 0.59, 0.60 and 0.64, all P < 0.001. Psychiatric bed-days were reduced with 58, 100 and 164 days for the respective periods after LAI initiation, all P < 0.001. In a Cox regression model in patients initiated on LAI, higher age at diagnosis, hazard rate ratio (HR) 0.99, 95%CI(0.98–0.99), P < 0.001, and a later calendar year of diagnosis, HR 0.99, 95%CI(0.98–1.00), P < 0.05, were associated with a lower risk of relapse, whereas mainly psychiatric comorbidity, HR 1.07, 95% CI (1.04–1.11), P < 0.001, and cardiovascular disease, HR 1.12, 95%CI(1.01–1.26), P < 0.05, were associated with relapse. ConclusionEven though the design does not allow inferences regarding causality, these population-based findings support the use of second generation LAI antipsychotics.

Participation in Early Psychosis Program May Reduce Risk of Death

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessParticipation in Early Psychosis Program May Reduce Risk of DeathNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:18 Apr 2018https://doi.org/10.1176/appi.pn.2018.4a18AbstractThe study of an early psychosis intervention program in Ontario also demonstrated how such programs help to keep patients with psychosis and psychiatrists connected over the long term.Numerous clinical studies have shown that early psychosis programs are effective at helping people who are experiencing psychosis for the first time to manage their symptoms and improve their quality of life. Less is known about how well these programs work for a large population once they are implemented within the broader health care system. A study published March 2 in AJP in Advance has now taken a closer look at health service use and health outcomes among patients who used one such established early psychosis program in the greater London, Ontario, region called the Prevention and Early Intervention Program for Psychoses (PEPP). Analyzing health data from a 17-year period, the investigators found that people who used PEPP services had more frequent contact with psychiatrists and substantially lower rates of mortality during their first two years in the program than people who did not use these services.The findings add to the growing evidence of the value of early psychosis intervention (EPI) services to connect patients with care and improve health outcomes.For the study, Kelly K. Anderson, Ph.D., of the University of Western Ontario and colleagues analyzed health administrative data from the Institute for Clinical Evaluative Sciences, which captures all medical visits covered under the universal Ontario Health Insurance Program. The researchers compared various health outcomes (such as self-harm, suicide, and all-cause mortality) and use of health services (including primary care, outpatient psychiatry, emergency department, and inpatient hospitalizations) in 530 people who were using EPI services between 1997 and 2013 with 922 matched controls who were not using these services. The authors found that in the first two years following admission, EPI service users were six times more likely to have had contact with a psychiatrist and reached out to a psychiatrist more quickly (an average of 13 days after admission compared with 78 days for EPI nonusers). EPI service users were also less likely to visit a primary care physician or the emergency department, but they were more likely to be hospitalized. Anderson told Psychiatric News that when she and her colleagues looked closer at the data, they saw that EPI service users were less likely to be involuntarily admitted to the hospital. She noted that patients who voluntarily arrive at an inpatient setting tend to have shorter stays and a lower risk of rehospitalization. “These findings can therefore be seen as a positive in a real-world system with constrained resources,” Anderson said. “London, like many places, has a shortage of inpatient units.”The increased use of inpatient services may have also contributed to the roughly 75 percent lower rate of all-cause mortality among EPI service users after two years compared with nonusers. There were no differences between the two groups in rates of self-harm or suicide; however, the total number of self-harm events in both groups was small. “[M]any of the observed benefits did not persist in the period from two to five years postadmission, when care is typically stepped down to medical management,” Anderson and colleagues wrote. “These changes in patterns of service use are likely a consequence of both reductions in the intensity of EPI services and improvements in the clinical status of nonusers, due to the natural trajectory of psychosis.”Anderson added, “A major theme of EPI research today is trying to find the optimal duration of intervention. Our findings provide some evidence that a longer duration of intensive care would lead to improved health outcomes.”This study was supported by a New Investigator Fellowship from the Ontario Mental Health Foundation. ■“Effectiveness of Early Psychosis Intervention: Comparison of Service Users and Nonusers in Population-Based Health Administrative Data” can be accessed here. ISSUES NewArchived

Positive predictive value of a register‐based algorithm using the Danish National Registries to identify suicidal events

It is not possible to fully assess intention of self-harm and suicidal events using information from administrative databases. We conducted a validation study of intention of suicide attempts/self-harm contacts identified by a commonly applied Danish register-based algorithm (DK-algorithm) based on hospital discharge diagnosis and emergency room contacts. Of all 101530 people identified with an incident suicide attempt/self-harm contact at Danish hospitals between 1995 and 2012 using the DK-algorithm, we selected a random sample of 475 people. We validated the DK-algorithm against medical records applying the definitions and terminology of the Columbia Classification Algorithm of Suicide Assessment of suicidal events, nonsuicidal events, and indeterminate or potentially suicidal events. We calculated positive predictive values (PPVs) of the DK-algorithm to identify suicidal events overall, by gender, age groups, and calendar time. We retrieved medical records for 357 (75%) people. The PPV of the DK-algorithm to identify suicidal events was 51.5% (95% CI: 46.4-56.7) overall, 42.7% (95% CI: 35.2-50.5) in males, and 58.5% (95% CI: 51.6-65.1) in females. The PPV varied further across age groups and calendar time. After excluding cases identified via the DK-algorithm by unspecific codes of intoxications and injury, the PPV improved slightly (56.8% [95% CI: 50.0-63.4]). The DK-algorithm can reliably identify self-harm with suicidal intention in 52% of the identified cases of suicide attempts/self-harm. The PPVs could be used for quantitative bias analysis and implemented as weights in future studies to estimate the proportion of suicidal events among cases identified via the DK-algorithm.