Repetition Of Self-harm Research Articles

The DiaS trial: dialectical behavior therapy versus collaborative assessment and management of suicidality on self-harm in patients with a recent suicide attempt and borderline personality disorder traits - study protocol for a randomized controlled trial

BackgroundIn Denmark 8,000 to 10,000 people will attempt suicide each year. The Centre of Excellence in Suicide Prevention in the Capital Region of Denmark is treating patients with suicidal behavior, and a recent survey has shown that 30% of the patients are suffering from borderline personality disorder. The majority of patients (70% to 75%) with borderline personality disorder have a history of deliberate self-harm and 10% have a lifetime risk to die by suicide. The DiaS trial is comparing dialectical behavior therapy with collaborative assessment and management of suicidality-informed supportive psychotherapy, for the risk of repetition of deliberate self-harm in patients with a recent suicide attempt and personality traits within the spectrum of borderline personality disorder. Both treatments have previously shown effects in this group of patients on suicide ideation and self-harm compared with treatment as usual.Methods/DesignThe trial is designed as a single-center, two-armed, parallel-group observer-blinded randomized clinical superiority trial. We will recruit 160 participants with a recent suicide attempt and at least two traits of the borderline personality disorder from the Centre of Excellence in Suicide Prevention, Capital Region of Denmark. Randomization will be performed though a centralized and computer-generated approach that conceals the randomization sequence. The interventions that are offered are a modified version of a dialectical behavior therapy program lasting 16 weeks versus collaborative assessment and management of suicidality-informed supportive psychotherapy, where the duration treatment will vary in accordance with established methods up to 16 weeks. The primary outcome measure is the ratio of deliberate self-harming acts including suicide attempts measured at week 28. Other exploratory outcomes are included such as severity of symptoms, suicide intention and ideation, depression, hopelessness, self-esteem, impulsivity, anger, and duration of respective treatments.Trial registrationClinical Trial.gov: NCT01512602.

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)

Qualitative Approach to Attempted Suicide by Adolescents and Young Adults: The (Neglected) Role of Revenge

BackgroundSuicide by adolescents and young adults is a major public health concern, and repetition of self-harm is an important risk factor for future suicide attempts.ObjectiveOur purpose is to explore the perspective of adolescents directly involved in suicidal acts.MethodsQualitative study involving 16 purposively selected adolescents (sex ratio1∶1) from 3 different centers. Half had been involved in repeated suicidal acts, and the other half only one. Data were gathered through semistructured interviews and analyzed according to Interpretative Phenomenological Analysis.ResultsWe found five main themes, organized in two superordinate themes. The first theme (individual dimensions of the suicide attempt) describes the issues and explanations that the adolescents saw as related to themselves; it includes the subthemes: (1) negative emotions toward the self and individual impasse, and (2) the need for some control over their lives. The second main theme (relational dimensions of attempted suicide) describes issues that adolescents mentioned that were related to others and includes three subthemes: (3) perceived impasse in interpersonal relationships, (4) communication, and (5) revenge.ConclusionsAdolescents involved in suicidal behavior are stuck in both an individual and a relational impasse from which there is no exit and no apparent way to reach the other. Revenge can bridge this gap and thus transforms personal distress into a relational matter. This powerful emotion has been neglected by both clinicians and researchers.

Non-fatal repetition of self-harm in Taipei City, Taiwan: cohort study

Repeat self-harm is an important risk factor for suicide. Few studies have explored risk factors for non-fatal repeat self-harm in Asia. To investigate the risk of non-fatal repeat self-harm in a large cohort of patients presenting to hospital in Taipei City, Taiwan. Prospective cohort study of 7601 patients with self-harm presenting to emergency departments (January 2004-December 2006). Survival analysis was used to examine the rates, timing and factors associated with repeat self-harm. In total 778 (10.2%) patients presented to hospital with one or more further episodes of self-harm. The cumulative risk of non-fatal repetition within 1 year of a self-harm episode was 9.3% (95% CI 8.7-10.1). The median time to repetition within 1 year was 105 days. Females had a higher incidence of repeat self-harm than males (adjusted hazard ratio 1.25, 95% CI 1.05-1.48) but males had shorter median time to repetition (107 v. 80 days). Other independent risk factors for repeat self-harm within 1 year of an index episode were: young age, self-harm by medicine overdose and increasing number of repeat episodes of self-harm. The risk of non-fatal repeat self-harm in Taipei City is lower than that seen in the West. Risk factors for repeat non-fatal self-harm differ from those for fatal self-harm. The first 3 months after self-harm is a crucial period for intervention.

Scales for predicting risk following self-harm: an observational study in 32 hospitals in England

ObjectiveTo investigate the extent to which risk scales were used for the assessment of self-harm by emergency department clinicians and mental health staff, and to examine the association between the...

Hospital Presenting Self-Harm and Risk of Fatal and Non-Fatal Repetition: Systematic Review and Meta-Analysis

BackgroundNon-fatal self-harm is one of the most frequent reasons for emergency hospital admission and the strongest risk factor for subsequent suicide. Repeat self-harm and suicide are key clinical outcomes of the hospital management of self-harm. We have undertaken a comprehensive review of the international literature on the incidence of fatal and non-fatal repeat self-harm and investigated factors influencing variation in these estimates as well as changes in the incidence of repeat self-harm and suicide over the last 30 years.Methods and FindingsMedline, EMBASE, PsycINFO, Google Scholar, article reference lists and personal paper collections of the authors were searched for studies describing rates of fatal and non-fatal self-harm amongst people who presented to health care services for deliberate self-harm. Heterogeneity in pooled estimates of repeat self-harm incidence was investigated using stratified meta-analysis and meta-regression. The search identified 177 relevant papers. The risk of suicide in the 12 months after an index attempt was 1.6% (CI 1.2–2.4) and 3.9% (CI 3.2–4.8) after 5 years. The estimated 1 year rate of non-fatal repeat self-harm was 16.3% (CI 15.1–17.7). This proportion was considerably lower in Asian countries (10.0%, CI 7.3–13.6%) and varies between studies identifying repeat episodes using hospital admission data (13.7%, CI 12.3–15.3) and studies using patient report (21.9%, CI 14.3–32.2). There was no evidence that the incidence of repeat self-harm was lower in more recent (post 2000) studies compared to those from the 1980s and 1990s.ConclusionsOne in 25 patients presenting to hospital for self-harm will kill themselves in the next 5 years. The incidence of repeat self-harm and suicide in this population has not changed in over 10 years. Different methods of identifying repeat episodes of self-harm produce varying estimates of incidence and this heterogeneity should be considered when evaluating interventions aimed at reducing non-fatal repeat self-harm.

Validation of the Chinese SAD PERSONS Scale to predict repeated self-harm in emergency attendees in Taiwan

BackgroundPast and repeated self-harm are long-term risks to completed suicide. A brief rating scale to assess repetition risk of self-harm is important for high-risk identification and early interventions in suicide prevention. The study aimed to examine the validity of the Chinese SAD PERSONS Scale (CSPS) and to evaluate its feasibility in clinical settings.MethodsOne hundred and forty-seven patients with self-harm were recruited from the Emergency Department and assessed at baseline and the sixth month. The controls, 284 people without self-harm from the Family Medicine Department in the same hospital were recruited and assessed concurrently. The psychometric properties of the CSPS were examined using baseline and follow-up measurements that assessed a variety of suicide risk factors. Clinical feasibility and applicability of the CSPS were further evaluated by a group of general nurses who used case vignette approach in CSPS risk assessment in clinical settings. An open-ended question inquiring their opinions of scale adaptation to hospital inpatient assessment for suicide risks were also analyzed using content analysis.ResultsThe CSPS was significantly correlated with other scales measuring depression, hopelessness and suicide ideation. A cut-off point of the scale was at 4/5 in predicting 6-month self-harm repetition with the sensitivity and specificity being 65.4% and 58.1%, respectively. Based on the areas under the Receiver Operating Characteristic curves, the predictive validity of the scale showed a better performance than the other scales. Fifty-four nurses, evaluating the scale using case vignette found it a useful tool to raise the awareness of suicide risk and a considerable tool to be adopted into nursing care.ConclusionsThe Chinese SAD PERSONS Scale is a brief instrument with acceptable psychometric properties for self-harm prediction. However, cautions should be paid to level of therapeutic relationships during assessment, staff workload and adequate training for wider clinical applications.

Correction: Risk Factors for Repetition of Self-Harm: A Systematic Review of Prospective Hospital-Based Studies

Correction: Risk Factors for Repetition of Self-Harm: A Systematic Review of Prospective Hospital-Based Studies

Risk Factors for Repetition of Self-Harm: A Systematic Review of Prospective Hospital-Based Studies

BackgroundSelf-harm entails high costs to individuals and society in terms of suicide risk, morbidity and healthcare expenditure. Repetition of self-harm confers yet higher risk of suicide and risk assessment of self-harm patients forms a key component of the health care management of self-harm patients. To date, there has been no systematic review published which synthesises the extensive evidence on risk factors for repetition.ObjectiveThis review is intended to identify risk factors for prospective repetition of self-harm after an index self-harm presentation, irrespective of suicidal intent.Data sourcesPubMed, PsychInfo and Scirus were used to search for relevant publications. We included cohort studies which examining factors associated with prospective repetition among those presenting with self-harm to emergency departments. Journal articles, abstracts, letters and theses in any language published up to June 2012 were considered. Studies were quality-assessed and synthesised in narrative form.ResultsA total of 129 studies, including 329,001 participants, met our inclusion criteria. Some factors were studied extensively and were found to have a consistent association with repetition. These included previous self-harm, personality disorder, hopelessness, history of psychiatric treatment, schizophrenia, alcohol abuse/dependence, drug abuse/dependence, and living alone. However, the sensitivity values of these measures varied greatly across studies. Psychological risk factors and protective factors have been relatively under-researched but show emerging associations with repetition. Composite risk scales tended to have high sensitivity but poor specificity.ConclusionsMany risk factors for repetition of self-harm match risk factors for initiation of self-harm, but the most consistent evidence for increased risk of repetition comes from long-standing psychosocial vulnerabilities, rather than characteristics of an index episode. The current review will enhance prediction of self-harm and assist in the efficient allocation of intervention resources.

Self-harm in prisons in England and Wales: an epidemiological study of prevalence, risk factors, clustering, and subsequent suicide

SummaryBackgroundSelf-harm and suicide are common in prisoners, yet robust information on the full extent and characteristics of people at risk of self-harm is scant. Furthermore, understanding how frequently self-harm is followed by suicide, and in which prisoners this progression is most likely to happen, is important. We did a case-control study of all prisoners in England and Wales to ascertain the prevalence of self-harm in this population, associated risk factors, clustering effects, and risk of subsequent suicide after self-harm.MethodsRecords of self-harm incidents in all prisons in England and Wales were gathered routinely between January, 2004, and December, 2009. We did a case-control comparison of prisoners who self-harmed and those who did not between January, 2006, and December, 2009. We also used a Bayesian approach to look at clustering of people who self-harmed. Prisoners who self-harmed and subsequently died by suicide in prison were compared with other inmates who self-harmed.Findings139 195 self-harm incidents were recorded in 26 510 individual prisoners between 2004 and 2009; 5–6% of male prisoners and 20–24% of female inmates self-harmed every year. Self-harm rates were more than ten times higher in female prisoners than in male inmates. Repetition of self-harm was common, particularly in women and teenage girls, in whom a subgroup of 102 prisoners accounted for 17 307 episodes. In both sexes, self-harm was associated with younger age, white ethnic origin, prison type, and a life sentence or being unsentenced; in female inmates, committing a violent offence against an individual was also a factor. Substantial evidence was noted of clustering in time and location of prisoners who self-harmed (adjusted intra-class correlation 0·15, 95% CI 0·11–0·18). 109 subsequent suicides in prison were reported in individuals who self-harmed; the risk was higher in those who self-harmed than in the general prison population, and more than half the deaths occurred within a month of self-harm. Risk factors for suicide after self-harm in male prisoners were older age and a previous self-harm incident of high or moderate lethality; in female inmates, a history of more than five self-harm incidents within a year was associated with subsequent suicide.InterpretationThe burden of self-harm in prisoners is substantial, particularly in women. Self-harm in prison is associated with subsequent suicide in this setting. Prevention and treatment of self-harm in prisoners is an essential component of suicide prevention in prisons.FundingWellcome Trust, National Institute for Health Research, National Offender Management Service, and Department of Health.

Severity of hospital-treated self-cutting and risk of future self-harm: a national registry study

Background: Risk assessment forms a key component in self-harm management. Among self-harm presentations generally, lethality of an index act is a poor predictor of future non-fatal repetition. However, no study has examined whether severity of an index self-cutting episode is associated with prospective repetition.Aims: To examine factors associated with severity of self-cutting and in particular the association between severity of self-cutting and prospective repetition of self-harm.Methods: All index self-cutting presentations to emergency departments in Ireland over 5 years were grouped by treatment received and compared on the basis of demographic and clinical characteristics.Results: Receiving more extensive medical treatment was associated with male gender, being aged more than 15 years, and not combining self-harm methods. Receiving less extensive treatment conferred a higher risk of prospective 12-month repetition, even after controlling for demographic and clinical characteristics. Repeat self-harm presentations by those with more severe self-cutting in an index act were less prevalent but were more likely to involve high-lethality methods of self-harm.Discussion: The results indicate that the already-elevated repetition risk among self-cutting patients is further increased for those receiving less extensive wound closure treatment. Severity of self-cutting might also affect suicide risk but such an association has yet to be examined.

Emergency Department Recognition of Mental Disorders and Short-Term Outcome of Deliberate Self-Harm

The authors sought to characterize the short-term risks of repeat self-harm and psychiatric hospital admission for deliberate self-harm patients discharged from emergency departments to the community, focusing on recognition of mental disorders in the emergency department. A retrospective longitudinal cohort analysis of national Medicaid claims data was conducted of adults 21-64 years of age with deliberate self-harm who were discharged from emergency departments (N=5,567). Rates and adjusted risk ratios are presented of repeat self-harm visits and inpatient psychiatric admission during the 30 days following the initial emergency visit. Approximately 9.7% of self-harm visits were followed by repeat self-harm visits and 13.6% by inpatient psychiatric admissions within 30 days after the initial emergency visit. The rate of repeat self-harm visits was inversely related to recognition of a mental disorder in the emergency department (adjusted risk ratio [ARR]=0.66, 95% CI=0.55-0.79) and directly related to recent diagnosis of anxiety disorders (ARR=1.56, 95% CI=1.30-1.86) or personality disorders (ARR=1.67, 95% CI=1.19-2.34). Recognition of a mental disorder in the emergency department was inversely related to repeat self-harm among patients with no recent mental disorder diagnosis (ARR=0.57, 95% CI=0.41-0.79); any recent mental disorder diagnosis (ARR=0.70, 95%=0.57-0.87); and depressive (ARR=0.71, 95% CI=0.54-0.94), bipolar (ARR=0.70, 95% CI=0.51-0.94), and substance use (ARR=0.71, 95% CI=0.53-0.96) disorder diagnoses. Recognition of a mental disorder was also inversely related to subsequent inpatient psychiatric admission (ARR=0.81, 95% CI=0.71-0.93). Adults who are discharged to the community after emergency visits for deliberate self-harm are at high short-term risk of repeat deliberate self-harm and hospital admission, although these risks may be attenuated by clinical recognition of a mental disorder in the emergency department.

Comfort from suicidal cognition in recurrently depressed patients

BackgroundPrevious research has suggested that some individuals may obtain comfort from their suicidal cognitions. MethodThis study explored clinical variables associated with comfort from suicidal cognition using a newly developed 5 item measure in 217 patients with a history of recurrent depression and suicidality, of whom 98 were followed up to at least one relapse to depression and reported data on suicidal ideation during the follow-up phase. ResultsResults indicated that a minority of patients, around 15%, reported experiencing comfort from suicidal cognitions and that comfort was associated with several markers of a more severe clinical profile including both worst ever prior suicidal ideation and worst suicidal ideation over a 12 month follow-up period. LimitationsFew patients self-harmed during the follow-up period preventing an examination of associations between comfort and repetition of self-harm. ConclusionsThese results, although preliminary, suggest that future theoretical and clinical research would benefit from further consideration of the concept of comfort from suicidal thinking.

Epidemiology, management and outcome of paracetamol poisoning in an inner city emergency department

BackgroundParacetamol poisoning accounts for just under half of all self-poisoning cases that present to hospitals in England. Treatment with acetylcysteine is routine, yet recommendations regarding its use vary internationally and...

A multicentre programme of clinical and public health research in support of the National Suicide Prevention Strategy for England

ObjectivesTo carry out a programme of linked research studies aimed at improving the management of self-harm, reducing the incidence of suicide and providing reliable data to evaluate the impact of theNational Suicide Prevention Strategy for England(2002).MethodsThere were four research streams: (1) we studied inquest records from 12 coroners and Ministry of Justice data to assess the accuracy of official suicide statistics; (2) we used Office for National Statistics mortality statistics, data from the Multicentre Study of Self-harm in England, national liver unit data, prescription data and patient interviews to assess (a) the impact of paracetamol (acetaminophen) pack size restrictions (1998), (b) the impact of withdrawal of co-proxamol in 2007 and (c) the relative toxicity in overdose of commonly used antidepressants; (3) we carried out 3-month audits of self-harm management in 32 hospitals to investigate variations between hospitals and the impact of management on repeat self-harm; and (4) we developed and piloted letter-based contact interventions aimed at reducing self-harm.Key findings(1) Between 1990 and 2005, the proportion of researcher-defined suicides given a verdict of suicide by the 12 coroners studied decreased by almost 7%, largely because of the increased use of misadventure/accident verdicts for deaths thought, on clinical review, to be suicides. Use of narrative verdicts increased markedly. Coroners who gave more narrative verdicts also gave fewer suicide verdicts, and geographical variations in the use of narrative verdicts appeared to distort reliable assessment of small-area differences in suicide rates. 2(a) UK legislation to reduce pack sizes of paracetamol was followed by a 43% reduction in number of deaths and a 61% reduction in registrations for liver transplantation over the next 11 years. Paracetamol overdoses were often impulsive and some were influenced by media (including the internet); sales outlets appeared mostly to be adhering to sales guidance. Smaller pack sizes of paracetamol for sale in Ireland compared with England did not result in a smaller number of tablets being taken in overdose. There was no clear evidence of an effect of the legislation on prescribing of non-steroidal anti-inflammatory drugs, nor on resulting gastrointestinal bleeds. 2(b) Withdrawal of co-proxamol from use in the UK resulted in approximately 600 fewer deaths than predicted between 2005 and 2010 based on previous trends, with no evidence of substitution by poisoning with other analgesics. 2(c) Of the tricyclic antidepressants, dosulepin and doxepin had the greatest toxicity. Citalopram was more toxic than other selective serotonin reuptake inhibitors. (3) There was marked variation between hospitals in the management of self-harm; effects of this variation on patient outcomes were unclear, although psychosocial assessment may have been associated with reduced repetition. Levels of specialist assessment remained static between 2001–2 and 2010–11, but service quality appeared to improve. (4) Findings of two pilot randomised controlled trials suggested that, although it would be feasible to scale up these interventions to full trials, these interventions might have low generalisability and be of limited benefit to patients.ConclusionWithin the context of the strengths and limitations of the individual studies, this research programme has made significant additions to the evidence base related to suicide and self-harm prevention in the UK.Study registrationA pilot study of a contact and information based intervention to reduce repeat self-harm; ISRCTN65171515.FundingThe National Institute for Health Research Programme Grants for Applied Research programme.

A Sad Performance by the SADPERSONS Scale

To evaluate the performance of the SADPERSONS Scale for predicting whether self-harm patients would repeat self-harm, need hospitalization, or need referral for psychiatric care, researchers administered the scale to 126 consecutive self-harm patients presenting to a general hospital emergency department in the U.K. …

The sad truth about the SADPERSONS Scale: an evaluation of its clinical utility in self-harm patients

BackgroundThe SADPERSONS Scale is commonly used as a screening tool for suicide risk in those who have self-harmed. It is also used to determine psychiatric treatment needs in those presenting...

Text Message Intervention to Reduce Repeat Self-harm in Patients Presenting to the Emergency Department-A Study Protocol

Text Message Intervention to Reduce Repeat Self-harm in Patients Presenting to the Emergency Department-A Study Protocol

Messages from Manchester: pilot randomised controlled trial following self-harm

Studies of therapeutic contact following self-harm have had mixed results. We carried out a pilot randomised controlled trial comparing an intervention (information leaflet listing sources of help, two telephone calls soon after presentation and a series of letters over 12 months) to usual treatment alone in 66 adults presenting with self-harm to two hospitals. We found that our methodology was feasible, recruitment was challenging and repeat self-harm was more common in those who received the intervention (12-month repetition rate 34.4% v. 12.5%).

Self-cutting versus intentional overdose: Psychological risk factors

Individuals who present to emergency departments with self-harm are at elevated risk of further self-harm and suicide, and these risks are yet higher among patients who self-cut. Repetitive self-injury has previously been explained using a behaviourist approach focussing on operant conditioning, but we propose that the increased risk of self-harm repetition among those who present with self-cutting is at least partly mediated by pre-existing psychological risk factors. Several studies show that those who present with self-cutting differ from intentional overdose patients on demographic, psychiatric and social factors, but, based on findings from community-based studies, we hypothesise that there may be additional psychological differences that may also be associated with increased repetition risk. We conducted a small-scale cohort study of 29 self-harm patients presenting to A&E and compared theoretically-derived psychological variables between 8 self-cutting and 21 overdose patients. Those presenting with self-cutting scored significantly higher on hopelessness and lower on non-reactivity to inner experience and generally had a more vulnerable profile than those presenting with overdose. These findings support our hypothesis that the association between self-cutting and prospective repetition is at least partly due to pre-existing psychological vulnerabilities that increase both the likelihood of engaging in self-cutting as a method of self-harm and the likelihood of subsequent repetition of self-harm. Existing evidence suggests that self-cutting is a risk factor for repetition of self-harm, and it is possible that reducing and preventing repetition among these patients can be achieved by implementing psychological interventions to reduce hopelessness and increase tolerance of emotional distress.