Hospital For Self-harm Research Articles

Substance use and self-harm emergency department presentations during COVID19: evidence from a National Clinical Programme for Self-Harm.

Given the evidence that drinking patterns and self-harm hospital presentations have changed during COVID-19, this study aimed to examine any change in self-harm and suicide-related ideation presentations, together with any possible contribution made by alcohol or substance misuse, to Irish Emergency Departments in 2020, compared with 2018 and 2019. A population-based cohort with self-harm and suicide-related ideation presenting to Irish hospitals derived from the National Clinical Programme for Self-Harm was analysed. Descriptive analyses were conducted based on sociodemographic variables and types of presentation for the period January to August 2020 and compared with the same period in 2018 and 2019. Binomial regression analyses were performed to investigate the independent effect of demographic characteristics and pre/during COVID-19 periods on the use of substances as contributory factors in the self-harm and suicide-related ideation presentations. 12,075 presentations due to self-harm and suicide-related ideation were recorded for the periods January-August 2018-2020 across nine emergency departments. The COVID-19 year was significantly associated with substances contributing to self-harm and suicide-related ideation ED presentations (OR = 1.183; 95% CI, 1.075-1.301, p < 0.001). No changes in the demographic characteristics were found for those with self-harm or suicide-related ideation across the years. Suicide-related ideation seemed to be increased after May 2020 compared with previous years. In terms of self-harm episodes with comorbid drug and alcohol overdose and poisoning, these were significantly increased in January-August 2020, compared with previous timepoints (χ2 = 42.424, df = 6, p < 0.001). An increase in suicide-related ideation and substance-related self-harm presentations may indicate longer term effects of the pandemic and its relevant restrictions. Future studies might explore whether those presenting with ideation will develop a risk of suicide in post-pandemic periods.

The Association of Physical and Mental Illness and Self-Harm Resulting in Hospitalization: A Population-Based Study of Older Adults in South Korea.

Self-harm injury among older adults is a pressing problem that demands social attention in South Korea. This study sought to identify the association between physical and mental illness and hospitalization following self-harm injuries, compared to non-self-harm injuries, among older adults living in Korea. We analyzed individuals aged 65 and older who were admitted to hospitals either for self-harm or non-self-harm from a population-based survey of the Korea National Hospital Discharge In-depth Injury Survey (KNHDIS). A logistic regression analysis was performed. Compared with non-self-harm-related hospitalization, self-harm hospitalization was associated with higher odds of depression, other disorders of the nervous system, malignancies, alcohol misuse and dependence, and drug-related dependence. Dementia, anxiety disorder, diabetes, arthritis, cerebral palsy, and other paralytic syndromes had a lower likelihood of leading to self-harm than non-self-harm hospitalization. The findings of this study can inform medical professionals to identify older adults with a heightened risk of self-harming behavior leading to hospitalization.

48. Hospitalization for Suicide Attempt and Self-Harm Among Youth Diagnosed With Gender Dysphoria

Transgender and gender non-conforming (TGNC) youth experience severe discrimination which has been linked to adverse mental health outcomes, including an increased prevalence of suicidality and self-harm. Few epidemiological studies have examined this relationship; thus, we studied the relationship between hospitalization for suicidality, self-harm and gender dysphoria in a large, nationally representative database. We used the 2016 Kids’ Inpatient Database to identify a subset of TGNC youth < 21 years of age captured by the database (using ICD-10 gender dysphoria-related codes). We identified suicidal ideation or suicide attempt using either explicit “suicidality” codes, or one of 355 distinct self-harm codes. Using descriptive statistics, prevalence of suicidality and self-harm was compared between youth with and without gender dysphoria. A multivariable logistic regression model adjusting for individual, admission and hospital-level variables was constructed looking for association between gender dysphoria and suicidality. The cohort included 3,115,589 subjects, of whom 1,980 (64 per 100,000 admissions) had gender dysphoria. Analysis of demographic variables revealed the gender dysphoria diagnosis group was comprised of a disproportionately lower proportion of non-white, publicly insured, and low median income young adults compared to the entire cohort. Prevalence of suicidal ideation and suicide attempt in the entire cohort was 2%, compared to 35.3% in young people with gender dysphoria. Using the expanded definition of self-harm and attempted suicide, prevalence increased to 44.1%. After adjusting for individual, admission and hospital-level variables, subjects with gender dysphoria had 7.89 increased odds of attempted suicide or suicidal ideation (95%CI: 7.09-8.79). Using a large and representative database, we found significantly higher prevalence of suicide attempt and self-harm in hospitalized youth with a gender dysphoria-related diagnosis. For youth hospitalized after suicide attempt or self-harm, gender-affirming care and inclusive language is essential to reduce psychological stress secondary to physician-mediated interpersonal discrimination. Importantly, this study only captured TGNC youth with a formal gender dysphoria diagnosis, and not all youth who identify as TGNC have a diagnosis or disclose their identity; thus, the results should not be generalized to the entire population of TGNC youth. Furthermore, there were fewer non-white, publicly insured, and low median income youth with a gender dysphoria diagnosis compared to the entire cohort, which suggests inequities in accessing gender-affirming care among racial minority and economically disadvantaged youth. The results of this study highlight the need for structural interventions and policies to reduce discrimination and improve access to gender-affirming care in order to prevent these adverse outcomes.

Ten-year trends in depression care in Taiwan

The number of psychiatrists working in community clinics in Taiwan has increased dramatically in the recent decade. This study aimed to investigate the trend of prevalence and incidence of depressive disorders and assess the quality of depression care between 2007 and 2016 in Taiwan. We used the claims database derived from Taiwan's National Health Insurance (NHI) program, in which approximately 23.0 million individuals were enrolled, translating to a coverage rate of 99%. Patients with depressive disorders were identified based on International Classification of Diseases codes. The process indicators of depression care quality included visit, duration, and dose adequacy. The outcome indicators included the rate of psychiatric hospitalisation, emergency visit, self-harm hospitalisation, and suicide. The prevalence of treated depressive disorders increased from 1.61% in 2007 to 1.92% in 2016, i.e., a 25% increase, whereas the incidence of first-ever or recurrent depressive disorder did not change significantly. The number of patients treated by psychiatrists and in community clinics also increased. The quality of depression care improved, the proportion of patients receiving minimum psychiatric clinic follow-up and adequate medication increased, and the rate of emergency visits, psychiatric hospitalisation, and self-harm hospitalisation declined. The community-based psychiatric services increased and the quality indicators of depression care in Taiwan improved during 2007-2016. The causality warrants further investigations.

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

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

Intentional self-harm in culturally and linguistically diverse communities: A study of hospital admissions in Victoria, Australia.

To examine the rates and profiles of intentional self-harm hospital admissions among people from culturally and linguistically diverse and non-culturally and linguistically diverse backgrounds. A retrospective analysis of 29,213 hospital admissions for self-harm among people aged 15 years or older in Victoria, Australia, was conducted using data from the Victorian Admitted Episodes Dataset between 2014/2015 and 2018/2019. The Victorian Admitted Episodes Dataset records all hospital admissions in public and private hospitals in Victoria (population 6.5 million). Population-based incidence of self-harm, logistic regression and percentages (95% confidence intervals) were calculated to compare between culturally and linguistically diverse groups by birthplaces and the non-culturally and linguistically diverse groups of self-harm admissions. When grouped together culturally and linguistically diverse individuals had lower rates of (hospital-treated) self-harm compared with the non-culturally and linguistically diverse individuals. However, some culturally and linguistically diverse groups such as those originating from Sudan and Iran had higher rates than non-culturally and linguistically diverse groups. Among self-harm hospitalised patients, those in the culturally and linguistically diverse group (vs non-culturally and linguistically diverse group) were more likely to be older, Metropolitan Victorian residents, from the lowest socioeconomic status, and being ever or currently married. Self-harm admissions by persons born in Southern and Eastern Europe were the oldest of all groups; in all other groups number of admissions tended to decrease as age increased whereas in this group the number of admissions increased as age increased. There was considerable heterogeneity in rates of hospital-treated self-harm in culturally and linguistically diverse communities, with some countries of origin (e.g. Sudan, Iran) having significantly higher rates. Some of this variation may be due to factors relating to the mode of entry into Australia (refugee vs planned migration), and future research needs to examine this possibility and others, to better plan for support needs in the culturally and linguistically diverse communities most affected by self-harm. Combining all culturally and linguistically diverse people into one group may obscure important differences in self-harm. Different self-harm prevention strategies are likely to be needed for different culturally and linguistically diverse populations.

Validation of Machine Learning-Based Individualized Treatment for Depressive Disorder Using Target Trial Emulation

This study aims to develop and validate the use of machine learning-based prediction models to select individualized pharmacological treatment for patients with depressive disorder. This study used data from Taiwan’s National Health Insurance Research Database. Patients with incident depressive disorders were included in this study. The study outcome was treatment failure, which was defined as psychiatric hospitalization, self-harm hospitalization, emergency visits, or treatment change. Prediction models based on the Super Learner ensemble were trained separately for the initial and the next-step treatments if the previous treatments failed. An individualized treatment strategy was developed for selecting the drug with the lowest probability of treatment failure for each patient as the model-selected regimen. We emulated clinical trials to estimate the effectiveness of individualized treatments. The area under the curve of the prediction model using Super Learner was 0.627 and 0.751 for the initial treatment and the next-step treatment, respectively. Model-selected regimens were associated with reduced treatment failure rates, with a 0.84-fold (95% confidence interval (CI) 0.82–0.86) decrease for the initial treatment and a 0.82-fold (95% CI 0.80–0.83) decrease for the next-step. In emulation of clinical trials, the model-selected regimen was associated with a reduced treatment failure rate.

Self-harm hospitalization following bariatric surgery in adolescents and young adults

While bariatric surgery has demonstrated physical and psychological benefits, a risk of suicide and non-fatal self-harm has also been shown. The aim of this study was to compared the rate of hospitalization for self-harm during a three-year observational follow-up period between adolescents/young adults who underwent bariatric surgery in France in 2013-2014 and two control groups. All individuals aged 12-25 years old who underwent bariatric surgery in France between January 1st, 2013, and December 31st, 2014, were identified with a validated algorithm from the French national hospital database, and compared to a healthy sample of the general population matched for age and gender. Information relative to hospitalizations, including for self-harm (ICD-10 codes X60-84), were extracted i) between 2008 and the surgery, and ii) for a three-year follow-up period. A second unmatched control group with obesity but no bariatric surgery was also identified. Survival analyses with adjustments for confounding variables were used. In 2013-2014, 1984 youths had bariatric surgery in France. During follow-up, 1.5% were hospitalized for self-harm vs. 0.3% for controls (p<0.0001). After adjustment, subsequent hospitalization for self-harm was associated with bariatric surgery (HR 3.64, 95% CI 1.70-7.81), prior psychiatric disorders (HR 7.76, 95% CI 3.76-16.01), and prior self-harm (HR 4.43, 95% CI 1.75-11.24). When compared to non-operated youths with obesity, bariatric surgery was not associated with self-harm while prior mental disorders and self-harm were. Mortality reached 0.3% after surgery. Bariatric surgery is associated with an increased risk of self-harm, mainly in relation to preexisting psychological conditions. Vigilance and appropriate care are thus warranted in vulnerable individuals.

Rapid national increases in the hospitalisation of Australian youth due to intentional self-harm between 2008 and 2019.

Australian youth mental health services have received significant funding over the past 15 years. We analysed data on hospitalisation due to intentional self-harm to determine whether increased youth services were associated with reduction in a key indicator of youth population mental health. Trends in national self-harm hospitalisation data from 2008 to 2019 for youth (<25 years) and adults (>25 years) were analysed using joinpoint regression. Rates of hospitalisation due to intentional self-harm increased significantly in both male (1.1% per annum, 95% CI [0.2%, 1.9%]) and female (3.0% per annum, 95% CI [0.9%, 5.1%]) youth aged <25 years between 2008 and 2019. Female youth had higher rates of hospitalisation than males, and there were average annual increases of 9.1% (95% CI [2.4%, 16.3%]) and 4.0% (95% CI [0.1%, 7.9%]), and absolute increases of 120% and 47.9%, in the rate of hospitalisation of females aged 0-14 and 15-19, respectively. In contrast, there was no overall change in adults (>25 years). Rates of hospitalisation due to intentional self-harm in Australian youth have increased despite significant investment in youth mental health services. This result could be attributable to several sociocultural factors and suggests a critical need for more hospital-based emergency youth mental health services.

Using the integrated motivational-volitional (IMV) model of suicidal behaviour to differentiate those with and without suicidal intent in hospital treated self-harm

Self-harm is a major public health concern. In order to respond to self-harm effectively, it is important to understand the factors associated with self-harm with and without suicidal intent. To this end, we investigated psychological factors selected from the Integrated Motivational-Volitional (IMV) model of suicidal behaviour in individuals who had recently been admitted to hospital for self-harm, with the aim of examining the characteristics of those who expressed intent to die versus those without suicidal intent. Individuals (n = 500, 60.6% female) admitted to two hospitals in central Scotland following self-harm with (suicide attempt [SA] group, n = 336) or without (non-suicidal self-harm [NSSH] group, n = 164) suicidal intent completed a range of psychological measures. Over half of the participants reported previous episodes of self-harm (SA, n = 239, 71.1%; NSSH, n = 91, 55.5%). Univariate analyses revealed that the SA and NSSH groups differed on some of the psychological measures with higher depressive symptoms, defeat, entrapment, acquired capability and impulsivity in the SA compared to the NSSH group. In the multivariate model, suicidal ideation, defeat, internal entrapment and perceived burdensomeness independently differentiated between the groups. These findings highlight the complex profiles of individuals presenting at hospital with self-harm and emphasise the need to investigate differences between subtypes of self-harm in order to support individuals optimally. Applying frameworks such as the IMV model to further understanding of self-harm might assist in the development of targeted psychological interventions to reduce risk of repeat self-harm or suicide.

A cohort study of initial self-harm events: method-specific case fatality of index events, predictors of fatal and nonfatal repetition, and frequency of method-switching

Most studies evaluating self-harm repetition risk factors are from Asia and Europe, use cohorts of people who self-injure without differentiating incident and prevalent self-harm episodes, and do not stratify by suicide method. The current study uses an incident user design to (a) examine case fatality at index self-harm events and at each repeat event, by method, (b) describe method-switching, and (c) identify factors associated with repetition of self-harm among those who survive their index hospitalization. Specifically, this study reports psychiatric history and method-specific case fatality for the initial self-harm event among Utah residents with an index event in 2014 or 2015 and who have no history of prior self-harm in hospital records. For survivors of the index self-harm episode, we use Accelerated Failure Time models to identify risk factors for nonfatal repetition and separately for suicide. Key findings: 10,521 Utah residents with no 3-year self-harm hospital history experienced a 2014 or 2015 index event. Of the 9.5% with index deaths, 53.6% used firearms. Of the 90.5% who survived, 63.1% used drugs. Among the index nonfatal cases, over an average 1-year follow-up, 11.7% experienced a nonfatal repetition and 0.8% died by suicide. Most subsequent nonfatal repetitions (59.7%) and suicides (56.8%) had presented with an index drug poisoning; over half (56.8%) of those who died switched methods. For those who subsequently fatally self-harmed, most used poisoning by drugs (33.8%), hanging/strangulation (28.4%), or firearms (24.3%) in the terminal episode. Nonfatal repetition was associated with younger age, index cutting/piercing instruments, and past-year psychiatric and drug abuse diagnoses. Subsequent suicide was associated with male gender, older age, and index gas poisoning and hanging/suffocation. Of the 56 people who survived an index firearm event, none subsequently died by suicide during the study period.

Variation in rates of self-harm hospital admission and re-admission by ethnicity in London: a population cohort study

PurposeTo compare sex-specific rates of hospital admission and repeat admission following self-harm between ethnic groups in London and test whether differences persist after adjustment for socio-economic deprivation.MethodsA population-based cohort of all individuals aged over 11 admitted to a general hospital for physical health treatment following self-harm between 2008 and 2018, using administrative Hospital Episode Statistics for all people living in Greater London.ResultsThere were 59,510 individuals admitted to the hospital following self-harm in the 10 year study period, ethnicity data were available for 94% of individuals. The highest rates of self-harm admission and readmission were found in the White Irish group. Rates of admission and readmission were lower in Black and Asian people compared to White people for both sexes at all ages and in all more specific Black and Asian ethnic groups compared to White British. These differences increased with adjustment for socio-economic deprivation. People of Mixed ethnicity had higher rates of readmission. Rates were highest in the 25–49 age group for Black and Mixed ethnicity men, but in under-25 s for all other groups. There were substantial differences in rates within the broader ethnic categories, especially for the Black and White groups.ConclusionIn contrast to earlier UK studies, self-harm rates were not higher in Black or South Asian women, with lower self-harm admission rates seen in almost all ethnic minority groups. Differences in rates by ethnicity were not explained by socio-economic deprivation. Aggregating ethnicity into broad categories masks important differences in self-harm rates between groups.

Reducing youth suicide: systems modelling and simulation to guide targeted investments across the determinants

BackgroundReducing suicidal behaviour (SB) is a critical public health issue globally. The complex interplay of social determinants, service system factors, population demographics, and behavioural dynamics makes it extraordinarily difficult for decision makers to determine the nature and balance of investments required to have the greatest impacts on SB. Real-world experimentation to establish the optimal targeting, timing, scale, frequency, and intensity of investments required across the determinants is unfeasible. Therefore, this study harnesses systems modelling and simulation to guide population-level decision making that represent best strategic allocation of limited resources.MethodsUsing a participatory approach, and informed by a range of national, state, and local datasets, a system dynamics model was developed, tested, and validated for a regional population catchment. The model incorporated defined pathways from social determinants of mental health to psychological distress, mental health care, and SB. Intervention scenarios were investigated to forecast their impact on SB over a 20-year period.ResultsA combination of social connectedness programs, technology-enabled coordinated care, post-attempt assertive aftercare, reductions in childhood adversity, and increasing youth employment projected the greatest impacts on SB, particularly in a youth population, reducing self-harm hospitalisations (suicide attempts) by 28.5% (95% interval 26.3–30.8%) and suicide deaths by 29.3% (95% interval 27.1–31.5%). Introducing additional interventions beyond the best performing suite of interventions produced only marginal improvement in population level impacts, highlighting that ‘more is not necessarily better.’ConclusionResults indicate that targeted investments in addressing the social determinants and in mental health services provides the best opportunity to reduce SB and suicide. Systems modelling and simulation offers a robust approach to leveraging best available research, data, and expert knowledge in a way that helps decision makers respond to the unique characteristics and drivers of SB in their catchments and more effectively focus limited health resources.

Co-occurrence of psychosocial sequelae in bereaved offspring

Background: Previous studies have found that people who have lost a parent to external causes of death during childhood and adolescence have increased risks of psychosocial sequelae. However, we lack information on the potential co-occurrence of these problems. This study aims to investigate the co-occurrence of psychiatric disorders, deliberate self-harm (DSH) hospitalization, and high school non-completion in people who have lost a parent to external causes of death during childhood and adolescence compared to people who have not experienced such loss. Methods: The study cohort comprised 655 477 individuals born 1970-2012 with a link to both parents. Data on psychiatric disorders, DSH hospitalization, high school completion and parental death were retrieved from four longitudinal Norwegian registers. Chi-square tests of independence investigated potential differences in co-occurrence between bereaved and non-bereaved people. Results: Altogether, 4756 people had experienced the death of a parent due to external causes of death before their 18th birthday. These bereaved offspring had a significantly higher likelihood of having one, two and three adverse outcomes compared to people who had not experienced such loss. Specifically, bereaved offspring had a significantly higher co-occurrence of psychiatric disorders and high school non-completion, but not significantly higher co-occurrences of DSH hospitalization and high school non-completion or DSH hospitalization and psychiatric disorders. Limitations: Information concerning DSH hospitalization and psychiatric disorders was only available from 2008 onwards Conclusions: The significantly higher co-occurrence in bereaved offspring suggests that the relatively small group of people suffering from extensive sequelae should be particularly targeted for postvention measures.

Investigating Risk of Self-Harm by Young Aboriginal People with A History of Child Protection System Contact: Identifying Opportunities for Prevention

IntroductionThe Northern Territory (NT) population experiences amongst the highest rates of both child maltreatment and self-harm of any jurisdiction in Australia, especially amongst young Aboriginal people. This is a concern given the evidence linking child maltreatment to self-harm and suicide. However, few longitudinal studies have examined these associations by patterns of child protection system contacts that may represent opportunities for intervention, and none have identified the distinct pathways for Aboriginal children. Objectives and ApproachThis retrospective cohort study investigated the excess risk of self-harm hospital admissions (12-18 years) associated with different levels and timing of child protection contacts (aged &lt;12 years) amongst Aboriginal children. The study used linked, de-identified, individual-level records from multiple agencies for 6,476 Aboriginal children born in the NT between 1999 and 2003. ResultsOver 70% (n=36/50) of the cohort who experienced self-harm had a history of child protection contact. The overall probability of self-harm increased as the level of contact with the child protection system increased. After adjusting for confounding, children with any level of child protection contact in middle childhood (5-11 years) only and across both early (0-4 years) and middle childhood were 3 to 9 times more likely to experience self-harm in adolescence compared to their peers in the general population. Conclusion / ImplicationsThe findings are consistent with evidence of intergenerational trauma impacting Aboriginal families and children and identifies middle childhood as a critical period in which the risk for self-harm emerges. There is a need for culturally appropriate family support and parenting programs to be available at all levels of the child protection system. Furthermore, hospitals should use a trauma-informed approach to assess and care for young Aboriginal people who present following self-harm. Reflections will be offered on the benefits of using data linkage for investigating rare outcomes in difficult-to-reach populations.

Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial)

BackgroundNon-fatal self-harm is one of the commonest reasons for adults’ emergency hospital attendance. Although strongly associated with fatal and non-fatal repetition, there is weak evidence about effective interventions—and no clear NICE guidance or clinical consensus concerning aftercare. We examined the practicability of a definitive trial to evaluate problem-solving therapy (PST) to reduce repetition of self-harm; MIDSHIPS is a single-centre, parallel-group, individually randomised controlled feasibility trial comparing treatment-as-usual (TAU) alone to TAU plus up to six sessions of brief problem-solving therapy (PST) with adults who had recently attended hospital because of self-harm. Objectives were to adapt the intervention for a UK setting, train therapists, recruit and randomise patients, deliver PST under supervision, and establish comparative outcomes, assessed blindly.MethodsWe adapted the problem-solving intervention from an earlier trial and trained a mental-health nurse to deliver it. Adult patients attending the general hospital for self-harm were recruited while undergoing psychosocial assessment by the mental health team, and 62 were randomly allocated (32 TAU, 30 PST). The primary outcome assessed repeat hospital attendance due to further self-harm 6 months post-randomisation. Secondary outcomes included participant-reported outcomes and service use at 3 and 6 months post-randomisation.ResultsThe recruitment period had to be extended and 710 patients screened in order to establish a trial sample of the planned size (N = 62). A quarter of participants allocated to PST did not undertake the therapy offered; those who received PST attended a median of three sessions. Secondary outcomes were established for 49 (79%) participants at 6 months; all participants’ hospital records were retrieved. Repetition of self-harm leading to hospital presentation occurred in 19 of the 62 participants (30.6%, 95% CI 19.2%, 42.1%) within 6 months of randomisation. Promising differential rates of self-harm were observed with an event rate of 23.3% (95% CI 8.2%, 38.5%) in the PST arm; and 37.5% (95% CI 20.7%, 54.3%) in TAU. Economic findings were also encouraging, with a small QALY gain (0.0203) in the PST arm together with less reported use of the NHS in the PST arm (average £2120) than with TAU-only (£2878).ConclusionsThe feasibility trial achieved its objectives despite considerable difficulties with recruitment—adapting the PST, training a therapist, recruiting patients who had recently self-harmed, delivering the therapy, and establishing primary and secondary outcomes. These data provide a robust platform for a definitive multicentre randomised controlled trial of brief problem-solving therapy after hospital attendance due to self-harm.Trial registrationIdentification number and URL: ISRCTN54036115 http://www.isrctn.com/search?q=midships. Registered: 13 January 2012

Systems modelling and simulation to inform strategic decision making for suicide prevention in rural New South Wales (Australia).

The need to understand and respond to the unique characteristics and drivers of suicidal behaviour in rural areas has been enabled through the Australian Government's 2015 mental health reforms facilitating a move to an evidence-based, regional approach to suicide prevention. However, a key challenge has been the complex decision-making environment and lack of appropriate tools to facilitate the use of evidence, data and expert knowledge in a way that can inform contextually appropriate strategies that will deliver the greatest impact. This paper reports the co-development of an advanced decision support tool that enables regional decision makers to explore the likely impacts of their decisions before implementing them in the real world. A system dynamics model for the rural and remote population catchment of Western New South Wales was developed. The model was based on defined pathways to mental health care and suicidal behaviour and reproduced historic trends in the incidence of attempted suicide (self-harm hospitalisations) and suicide deaths in the region. A series of intervention scenarios were investigated to forecast their impact on suicidal behaviour over a 10-year period. Post-suicide attempt assertive aftercare was forecast to deliver the greatest impact, reducing the numbers of self-harm hospitalisations and suicide deaths by 5.65% (95% interval, 4.87-6.42%) and 5.45% (4.68-6.22%), respectively. Reductions were also projected for community support programs (self-harm hospitalisations: 2.83%, 95% interval 2.23-3.46%; suicide deaths: 4.38%, 95% interval 3.78-5.00%). Some scenarios produced unintuitive impacts or effect sizes that were significantly lower than what has been anticipated under the traditional evidence-based approach to suicide prevention and provide an opportunity for learning. Systems modelling and simulation offers significant potential for regional decision makers to better understand and respond to the unique characteristics and drivers of suicidal behaviour in their catchments and more effectively allocate limited health resources.

Characteristics associated with later self-harm hospitalization and/or suicide: A follow-up study of the HUNT-2 cohort, Norway

BackgroundTo improve suicide and self-harm prevention in adults, better knowledge on preexisting characteristics and risk factors is of great importance. MethodsThis is a population-based case-control study; baseline measures were collected in the second wave of the North-Trøndelag Health Study (HUNT-2, 1995–1997) in Norway, and outcomes were observed for up to 19 years. Average follow up time was 4.9 years for self-harm and 6.8 years for suicides. Out of 93,898 eligible adult inhabitants aged 20 and above, a total of 65,229 (70%) participated in the study. The data were linked to the National Mortality Registry and hospital patient records in the three hospitals covering the HUNT-2 catchment area. ResultsAmong the participants, 332 patients (68% women) were hospitalized because of self-harm (HSH), and 91 patients (32% women) were died by suicide (SU). A total of 10% of those who died by SU had previously been HSH. People in the HSH and SU groups were younger, reported more depression and anxiety symptoms, sleeping problems, higher use of alcohol and tobacco, poorer social network and more economic problems, compared to the rest of the HUNT-2 population. In addition, the HSH group reported more somatic health problems, higher use of health services, higher sick leave, and lower work participation than the SU group. LimitationsYounger adults (20–40 years) were under-represented in HUNT-2. Younger adults (20–40 years) were constituted 31.7% in HUNT-2, 50% in HSH and 33% in SU. Further, we did not identify less severe self-harm, not requiring hospitalization. Life changes, adverse events, and other possible triggers to self-harming behavior were not recorded. ConclusionPsychological problems were long-term predictors of both HSH and SU. Somatic health problems and lower functional performance were more present in HSH-group compared to the SU-group.

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

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

Suicide following presentation to hospital for non-fatal self-harm in the Multicentre Study of Self-harm: a long-term follow-up study

Self-harm is the strongest risk factor for subsequent suicide, but risk may vary. We compared the risk of suicide following hospital presentation for self-harm according to patient characteristics, method of self-harm, and variations in area-level socioeconomic deprivation, and estimated the incidence of suicide by time after hospital attendance. In this ongoing Multicentre Study of Self-harm in England, the study population consists of individuals aged at least 15 years who had attended the emergency department of five general hospitals in Oxford, Manchester, and Derby after non-fatal self-harm between Jan 1, 2000, and Dec 31, 2013. Information on method of self-harm was obtained through systematic monitoring in hospitals. Level of socioeconomic deprivation was based on the Index of Multiple Deprivation (IMD) characterising the area where patients lived, grouping them according to IMD quintiles. Mortality follow-up was up to Dec 31, 2015, resulting in up to 16 years of follow-up. We calculated incidence of suicide since first hospital presentation by follow-up period and estimated the association between individual factors (age, gender, method of self-harm, IMD, and number of non-fatal self-harm presentations to hospital) and suicide using mixed-effect models. Between Jan 1, 2000, and Dec 31, 2013, there were 92 177 presentations to the study hospitals by 51 108 individuals. 1325 patients involved in 1563 self-harm episodes were excluded from the study because they had missing information on gender, age, or mortality. The resulting study sample consisted of 90 614 hospital presentations by 49 783 individuals. By the end of follow-up on Dec 31, 2015, 703 patients had died by suicide. The overall incidence of suicide was 163·1 (95% CI 151·5-175·6) per 100 000 person-years, and 260·0 (237·4-284·8) per 100 000 person-years in men and 94·6 (83·3-107·4) per 100 000 person-years in women. The incidence of suicide was highest in the year following discharge from hospital (511·1 [451·7-578·2] per 100 000 person-years), particularly in the first month (1787·1 [1423·0-2244·4] per 100 000 person-years). Based on all presentations to hospital, men were three times more likely than women to die by suicide after self-harm (OR 3·36 [95% CI 2·77-4·08], p<0·0001). Age was positively related to suicide risk in both genders, with a 3% increase in risk for every one-year increase in age at hospital presentation (OR 1·03 [1·03-1·04], p<0·0001). Relative to hospital presentations after self-poisoning alone, presentations involving both self-injury and self-poisoning were associated with higher suicide risk (adjusted OR 2·06 [95% CI 1·42-2·99], p<0·0001], as were presentations after self-injury alone (adjusted OR 1·36 [1·09-1·70], p=0·007). Similarly, relative to self-harm by self-poisoning alone, attempted hanging or asphyxiation (adjusted OR 2·70 [1·53-4·78], p=0·001) and traffic-related acts of self-injury (adjusted OR 2·99 [1·17-7·65], p=0·022) were associated with greater risk of suicide. Self-cutting combined with self-poisoning was also associated with increased suicide risk (adjusted OR 1·36, [1·08-1·71], p=0·01). Compared with those patients living in the most deprived areas, those who lived in the least deprived areas (first national IMD quintile) had a greater risk of dying by suicide (adjusted OR 1·76 [1·32-2·34], p<0·0001) after adjusting for gender, age, previous self-harm, and psychiatric treatment, as did those living in the second least deprived areas (adjusted OR 1·64 [1·20-2·25], p=0·002). Patients attending hospital for self-harm are at high risk of suicide, especially immediately after hospital attendance. Certain patient characteristics and methods of self-harm, together with living in areas of low socioeconomic deprivation, can increase patients' subsequent suicide risk. However, while specific risk factors can be usefully integrated into the assessment process, individual factors have poor utility in predicting suicide, so the needs and risks of all patients should be assessed to develop appropriate aftercare plan, including early follow-up. UK Department of Health and Social Care.