Deborah Casey

Hospital care and repetition following self-harm: multicentre comparison of self-poisoning and self-injury.

BACKGROUND Quantitative research about self-harm largely deals with self-poisoning, despite the high incidence of self-injury. AIMS We compared patterns of hospital care and repetition associated with self-poisoning and self-injury. METHOD Demographic and clinical data were collected in a multicentre, prospective cohort study, involving 10,498 consecutive episodes of self-harm at six English teaching hospitals. RESULTS Compared with those who self-poisoned, people who cut themselves were more likely to have self-harmed previously and to have received support from mental health services, but they were far less likely to be admitted to the general hospital or receive a psychosocial assessment. Although only 17% of people repeated self-harm during the 18 months of study, survival analysis that takes account of all episodes revealed a repetition rate of 33% in the year following an episode: 47% after episodes of self-cutting and 31% after self-poisoning (P<0.001). Of those who repeated, a third switched method of self-harm. CONCLUSIONS Hospital services offer less to people who have cut themselves, although they are far more likely to repeat, than to those who have self-poisoned. Attendance at hospital should result in psychosocial assessment of needs regardless of method of self-harm.

Monitoring Deliberate Self-Harm Presentations to General Hospitals

Monitoring of deliberate self-harm (DSH) presentations to hospitals (and in other settings) is receiving increased attention in many countries. This is due to greater recognition of the size of the problem and awareness of its relevance to suicide prevention policy initiatives, because of the strong association between DSH and suicide. A system for monitoring all DSH presentations has been in place in the general hospital in Oxford for 30 years. Based on our experience, in this paper we describe procedures for monitoring, including case definition and identification, linkage of persons and episodes in order to investigate repetition of DSH and other outcomes (including deaths), and data protection and ethical issues. We also provide details of how to carry out monitoring, including different models of data collection, and what data to collect. Finally we consider the potential uses of the data for both clinical and research purposes, including evaluation of national suicide prevention initiatives.

Deliberate self-harm in Oxford University students, 1993-2005: a descriptive and case-control study.

BackgroundDeliberate self-harm (DSH; intentional self-poisoning or self-injury) is a major problem among young people and has been identified as one of the key mental health problems affecting students.MethodData on DSH presentations to the general hospital in Oxford by Oxford University students were analysed for the 12-year period from 1993 to 2005. The characteristics of the students with DSH were compared with those of age-matched DSH controls in the Oxford City area.ResultsProblems with academic work, relationships with family, partners and friends were most likely to contribute to DSH episodes in students. Many experienced problems with psychiatric disorders and social isolation. The frequency of eating disorders was very high in students, and contributed to DSH significantly more often than in controls. Fewer students than controls self-poisoned in the DSH episode, fewer had personality disorder and fewer had problems with physical health, finance, housing and violence. Alcohol consumption in association with DSH and alcohol-related problems were common in both students and controls. Male students had significantly higher suicide intent than controls. Many students were referred to the university counselling service for follow-up, a resource not available to non-student controls.ConclusionsComparison of university students following DSH with age-matched controls has shown key differences in psychiatric characteristics, problems contributing to DSH and aftercare offered. These findings may help in the design of targeted self-harm prevention and management strategies for students.

Self-harm in people with epilepsy: a retrospective cohort study

Little is known about self‐harm in people with epilepsy, despite suicide being recognized as a leading cause of mortality in this population. This study aimed to investigate the characteristics of self‐harm in people with epilepsy, and associated demographic and psychosocial factors.

Self-harm in UK armed forces personnel: descriptive and case-control study of general hospital presentations

BACKGROUND Little is known about self-harm in the armed forces. AIMS To investigate the characteristics of armed forces personnel presenting to a general hospital following self-harm and compare these with matched controls who had self-harmed. METHOD Investigation of armed forces personnel presenting to hospital between 1989 and 2003 following self-harm and case-control comparison with people in the general population who had self-harmed. RESULTS One hundred and sixty-six armed forces personnel presented with self-harm during the study period, of whom 72.3% (120) were male. Nearly two-thirds (62.7%) were aged under 25 years. Relationship problems (62.0%), employment problems (43.9%) and alcohol misuse (40.5%) were common. Fewer armed forces personnel than controls had evidence of current or past psychiatric disorders or treatment or a prior history of self-harm, and their suicidal intent was lower (males only). Of 64 people in the armed forces who presented during the first 9 years of the study period, 1 had died (from natural causes) by the end of 2000, compared with 9 (5.1%) of the controls, 6 by probable suicide. CONCLUSIONS Self-harm by armed forces personnel may often be a response to interpersonal and employment problems complicated by alcohol misuse, with relatively low suicide intent.

Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): a retrospective study

BACKGROUND Little is known about the relative incidence of fatal and non-fatal self-harm in young people. We estimated the incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England. METHODS We used national mortality statistics (Jan 1, 2011, to Dec 31, 2013), hospital monitoring data for five hospitals derived from the Multicentre Study of Self-Harm in England (Jan 1, 2011, to Dec 31, 2013), and data from a schools survey (2015) to estimate the incidence of fatal and non-fatal self-harm per 100 000 person-years in adolescents aged 12-17 years in England. We described these incidences in terms of an iceberg model of self-harm. FINDINGS During 2011-13, 171 adolescents aged 12-17 years died by suicide in England (119 [70%] male and 133 [78%] aged 15-17 years) and 1320 adolescents presented to the study hospitals following non-fatal self-harm (1028 [78%] female and 977 [74%] aged 15-17 years). In 2015, 322 (6%) of 5506 adolescents surveyed reported self-harm in the past year in the community (250 [78%] female and 164 [51%] aged 15-17 years). In 12-14 year olds, for every boy who died by suicide, 109 attended hospital following self-harm and 3067 reported self-harm in the community, whereas for every girl who died by suicide, 1255 attended hospital for self-harm and 21 995 reported self-harm in the community. In 15-17 year olds, for every male suicide, 120 males presented to hospital with self-harm and 838 self-harmed in the community; whereas for every female suicide, 919 females presented to hospital for self-harm and 6406 self-harmed in the community. Hanging or asphyxiation was the most common method of suicide (125 [73%] of 171), self-poisoning was the main reason for presenting to hospital after self-harm (849 [71%] of 1195), and self-cutting was the main method of self-harm used in the community (286 [89%] of 322). INTERPRETATION Ratios of fatal to non-fatal rates of self-harm differed between males and females and between adolescents aged 12-14 years and 15-17 years, with a particularly large number of females reporting self-harm in the community. Our findings emphasise the need for well resourced community and hospital-based mental health services for adolescents, with greater investment in school-based prevention. FUNDING UK Department of Health.

General hospital costs in England of medical and psychiatric care for patients who self-harm: a retrospective analysis

Summary Background Self-harm is an extremely common reason for hospital presentation. However, few estimates have been made of the hospital costs of assessing and treating self-harm. Such information is essential for planning services and to help strengthen the case for investment in actions to reduce the frequency and effects of self-harm. In this study, we aimed to calculate the costs of hospital medical care associated with a self-harm episode and the costs of psychosocial assessment, together with identification of the key drivers of these costs. Methods In a retrospective analysis, we estimated hospital resource use and care costs for all presentations for self-harm to the John Radcliffe Hospital (Oxford, UK), between April 1, 2013, and March 31, 2014. Episode-related data were provided by the Oxford Monitoring System for Self-harm and we linked these with financial hospital records to quantify costs. We assessed time and resources allocated to psychosocial assessments through discussion with clinical and managerial staff. We then used generalised linear models to investigate the associations between hospital costs and methods of self-harm. Findings Between April 1, 2013, and March 31, 2014, 1647 self-harm presentations by 1153 patients were recorded. Of these, 1623 (99%) presentations by 1140 patients could be linked with hospital finance records. 179 (16%) patients were younger than 18 years. 1150 (70%) presentations were for self-poisoning alone, 367 (22%) for self-injury alone, and 130 (8%) for a combination of methods. Psychosocial assessments were made in 75% (1234) of all episodes. The overall mean hospital cost per episode of self-harm was £809. Costs differed significantly between different types of self-harm: self-injury alone £753 (SD 2061), self-poisoning alone £806 (SD 1568), self-poisoning and self-injury £987 (SD 1823; p<0·0001). Costs were mainly associated with the type of health-care service contact such as inpatient stay, intensive care, and psychosocial assessment. Mean costs of psychosocial assessments were £228 for adults and £392 for individuals younger than 18 years. Interpretation If our findings are extrapolated to England, the estimated overall annual cost of general hospital management of self-harm is £162 million per year. More use of psychosocial assessment and other preventive measures, especially for young people and against self-poisoning, could potentially lower future costs at a time of major cost pressures in the NHS. Funding National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research, Care Oxford at Oxford Health NHS Foundation Trust, and Department of Health.

Relative toxicity of benzodiazepines and hypnotics commonly used for self-poisoning: An epidemiological study of fatal toxicity and case fatality

The relative toxicity of anxiolytic and hypnotic drugs commonly used for self-poisoning was assessed using data on suicides, prescriptions and non-fatal self-poisonings in England, 2005–2012. Data on suicide by self-poisoning were obtained from the Office for National Statistics, information on intentional non-fatal self-poisoning was derived from the Multicentre Study of Self-harm in England and data on prescriptions in general practice from the Clinical Practice Research Datalink. We used two indices of relative toxicity: fatal toxicity (the number of fatal self-poisonings relative to the number of individuals prescribed each drug) and case fatality (the number of fatal relative to non-fatal self-poisonings). Diazepam was the reference drug in all analyses. Temazepam was 10 times (95% confidence interval 5.48–18.99) and zopiclone/zolpidem nine times (95% confidence interval 5.01–16.65) more toxic in overdose than diazepam (fatal-toxicity index). Temazepam and zopiclone/zolpidem were 13 (95% confidence interval 6.97–24.41) and 12 (95% confidence interval 6.62–22.17) times more toxic than diazepam, respectively (case-fatality index). Differences in alcohol involvement between the drugs were unlikely to account for the findings. Overdoses of temazepam and zopiclone/zolpidem are considerably more likely to result in death than overdoses of diazepam. Practitioners need to exercise caution when prescribing these drugs, especially for individuals who may be at risk of self-harm, and also consider non-pharmacological options.

The effect of using NHS number as the unique identifier for patients who self-harm: a multi-centre descriptive study

BackgroundProcessing personal data for research purposes and the requirement of anonymity has been the subject of recent debate. We aimed to determine the proportion of individuals who present to emergency departments with non-fatal suicidal behavior where an NHS number has been successfully traced and to investigate the characteristics of patients associated with non-capture.MethodThis was a descriptive study of people attending after self-harm using allocation of NHS numbers as main outcome measurement. Data from the Multicentre Monitoring of Self-Harm Project from 3 centres in England were used to identify consecutive patients (N = 3000) who were treated in six emergency departments in Oxford, Manchester and Leeds in 2004 and 2005 following self-harm.ResultsNHS number was available between 55–73% of individuals across centres. Characteristics associated with non-recording of NHS number in more than one centre included those from ethnic minority groups (Oxford: chi-squared statistic = 13.6, df = 3, p = 0.004; Manchester: chi-squared statistic = 13.6, df = 3, p ≤0.001) and the homeless or living in a hostel or other institution (Oxford: chi-squared statistic = 40.9, df = 7, p = <0.001; Manchester: chi-squared statistic = 23.5, df = 7, p = 0.001). Individual centre characteristics included being of male gender (Leeds: chi-squared statistic = 4.1, df = 1, p = 0.4), those under 25 years (Oxford: chi-squared statistic = 10.6, df = 2, p = 0.005), not being admitted to general hospital (Leeds: chi-squared statistic = 223.6, df = 1, p ≤0.001) and using self-injury as a method of harm (Leeds: chi-squared statistic = 41.5, df = 2, p ≤0.001).ConclusionBasing research studies on NHS number as the unique identifier, as suggested by the Data Protection Act 1998 and the Patient Information Advisory Group, would exclude some of the most vulnerable groups for further self-harm or suicide. This bias may also affect other research registers.