Eve Griffin

Impact of the economic recession and subsequent austerity on suicide and self-harm in Ireland: An interrupted time series analysis

BACKGROUND The recent economic recession has been associated with short-term increases in suicide in many countries. Data are lacking on the longer-term effect on suicide and on the impact on non-fatal suicidal behaviour. METHODS Using interrupted time series analyses, we have assessed the impact of economic recession and austerity in Ireland on national rates of suicide mortality and self-harm presentations to hospital in 2008-12. RESULTS By the end of 2012, the male suicide rate was 57% higher [+8.7 per 100,000, 95% confidence interval (CI), 4.8 to 12.5] than if the pre-recession trend continued, whereas female suicide was almost unchanged (+0.3 per 100,000, 95% CI, -1.1 to 1.8). Male and female self-harm rates were 31% higher (+74.1 per 100,000, 95% CI, -6.3 to 154.6) and 22% higher (+63.2 per 100,000, 95% CI, 4.1 to 122.2), respectively. There were 476 more male (95% CI, 274 to 678) and 85 more female (95% CI, -9 to 180) suicide deaths and 5029 more male (95% CI, 626 to 9432) and 3833 more female (95% CI, 321 to 7345) self-harm presentations to hospital in 2008-12 than if pre-recession trends had continued. Men aged 25-64 years were affected in terms of suicide and self-harm with the greatest impact observed in 25-44 year-olds. The increase in self-harm by women was among 15-24 year-olds. CONCLUSIONS Five years of economic recession and austerity in Ireland have had a significant negative impact on rates of suicide in men and on self-harm in both sexes.

Characteristics of hospital-treated intentional drug overdose in Ireland and Northern Ireland.

Objectives This study compared the profile of intentional drug overdoses (IDOs) presenting to emergency departments in Ireland and in the Western Trust Area of Northern Ireland between 2007 and 2012. Specifically the study aimed to compare characteristics of the patients involved, to explore the factors associated with repeated IDO and to report the prescription rates of common drug types in the population. Methods We utilised data from two comparable registries which monitor the incidence of hospital-treated self-harm, recording data from deliberate self-harm presentations involving an IDO to all hospital emergency departments for the period 1 January 2007 to 31 December 2012. Results Between 2007 and 2012 the registries recorded 56 494 self-harm presentations involving an IDO. The study showed that hospital-treated IDO was almost twice as common in Northern Ireland than in Ireland (278 vs 156/100 000, respectively). Conclusions Despite the overall difference in the rates of IDO, the profile of such presentations was remarkably similar in both countries. Minor tranquillisers were the drugs most commonly involved in IDOs. National campaigns are required to address the availability and misuse of minor tranquillisers, both prescribed and non-prescribed.

Effectiveness of Depression-Suicidal Behaviour Gatekeeper Training among police officers in three European regions: Outcomes of the Optimising Suicide Prevention Programmes and Their Implementation in Europe (OSPI-Europe) study.

Background: Gatekeeper training for community facilitators, to identify and respond to those at risk of suicide, forms an important part of multi-level community-based suicide prevention programmes. Aims: This study examined the effects of gatekeeper training on attitudes, knowledge and confidence of police officers in dealing with persons at risk of suicide. Methods: A total of 828 police officers across three European regions participated in a 4-hour training programme which addressed the epidemiology of depression and suicidal behaviour, symptoms of depression, warning signs and risk factors associated with suicidal behaviour, motivating help-seeking behaviour, dealing with acute suicidal crisis and informing bereaved relatives. Participants completed internationally validated questionnaires assessing stigmatising attitudes, knowledge about depression and confidence in dealing with suicidal persons pre- and post-training. Results: There were significant differences among countries in terms of previous exposure to suicidal persons and extent of previous training. Post-training evaluation demonstrated significant improvements in stigmatising attitudes, knowledge and confidence in all three countries. Conclusion: The consistently positive effects of gatekeeper training of police officers across different regions support inclusion of this type of training as a fundamental part of multi-level community-based suicide prevention programmes and roll-out, nationally and internationally.

The paradox of public holidays: Hospital-treated self-harm and associated factors.

BACKGROUND Recent research on the patterns of self-harm around public holidays is lacking. This study used national data to examine the patterns of hospital-treated self-harm during public holidays, and to examine associated factors. METHODS Data on self-harm presentations to all emergency departments were obtained from the National Self-Harm Registry Ireland. The association between self-harm presentations and public holidays was examined using univariate and multivariate Poisson regression analyses. RESULTS A total of 104,371 presentations of self-harm were recorded between 2007 and 2015. The mean number of self-harm presentations was 32 on public holidays. St. Patricks Day had the highest number of presentations compared to all other public holidays, with a daily mean of 44 presentations. Across all years, self-harm presentations during public holidays had a 24% increased risk of involving alcohol consumption compared to all other days and this effect was most pronounced during the Christmas period. The association with alcohol remained significant at a multivariate level. Presentations on public holidays were more likely to attend out of normal working hours. An increase in male presentations involving self-cutting was observed on public holidays and there was an over-representation of males presenting for the first time. LIMITATIONS It is likely that extent of alcohol involvement in self-harm presentations reported here is an underestimate, as it was dependent on the information being recorded by the attending clinician. CONCLUSIONS Public holidays are associated with an elevated number of self-harm presentations to hospital, with presentations to hospital involving alcohol significantly increased on these days. Hospital resources should be targeted to address increases during public holidays, including during out-of-hours. Involvement of alcohol may delay delivery of care to these patients in emergency settings.

Risk of repeated self-harm and associated factors in children, adolescents and young adults

BackgroundRepeated self-harm represents the single strongest risk factor for suicide. To date no study with full national coverage has examined the pattern of hospital repeated presentations due to self-harm among young people.MethodsData on consecutive self-harm presentations were obtained from the National Self-Harm Registry Ireland. Socio-demographic and behavioural characteristics of individuals aged 10–29 years who presented with self-harm to emergency departments in Ireland (2007–2014) were analysed. Risk of long-term repetition was assessed using survival analysis and time differences between the order of presentations using generalised estimating equation analysis.ResultsThe total sample comprised 28,700 individuals involving 42,642 presentations. Intentional drug overdose was the most prevalent method (57.9%). Repetition of self-harm occurred in 19.2% of individuals during the first year following a first presentation, of whom the majority (62.7%) engaged in one repeated act. Overall, the risk of repeated self-harm was similar between males and females. However, in the 20–24-year-old age group males were at higher risk than females. Those who used self-cutting were at higher risk for repetition than those who used intentional drug overdose, particularly among females. Age was associated with repetition only among females, in particular adolescents (15–19 years old) were at higher risk than young emerging adults (20–24 years old). Repeated self-harm risk increased significantly with the number of previous self-harm episodes.Time differences between first self-harm presentations were detected. Time between second and third presentation increased compared to time between first and second presentation among low frequency repeaters (patients with 3 presentations only within 1 year following a first presentation). The same time period decreased among high frequency repeaters (patients with at least 4 to more than 30 presentations).ConclusionYoung people with the highest risk for repeated self-harm were 15–19-year-old females and 20–24-year-old males. Self-cutting was the method associated with the highest risk of self-harm repetition. Time between first self-harm presentations represents an indicator of subsequent repetition. To prevent risk of repeated self-harm in young people, all individuals presenting at emergency departments due to self-harm should be provided with a risk assessment including psychosocial characteristics, history of self-harm and time between first presentations.

The involvement of alcohol in hospital-treated self-harm and associated factors: findings from two national registries.

Background Alcohol is often involved in hospital-treated self-harm. Therefore it is important to establish the role of alcohol in self-harm as well as to identify associated factors, in order to best inform service provision. Methods Data on self-harm presentations to hospital emergency departments in Ireland and Northern Ireland from April 2012 to December 2013 were analysed. We calculated the prevalence of alcohol consumption in self-harm. Using Poisson regression models, we identified the factors associated with having consumed alcohol at the time of a self-harm act. Results Alcohol was present in 43% of all self-harm acts, and more common in Northern Ireland (50 versus 37%). The factors associated with alcohol being involved were being male, aged between 25 and 64 years, and having engaged in a drug overdose or attempted drowning. Presentations made out-of-hours were more likely to have alcohol present and this was more pronounced for females. Patients with alcohol on board were also more likely to leave without having been seen by a clinician. Conclusions This study has highlighted the prevalence of alcohol in self-harm presentations, and has identified factors associated with presentations involving alcohol. Appropriate out-of-hours services in emergency departments for self-harm presentations could reduce the proportion of presentations leaving without being seen by a clinician and facilitate improved outcomes for patients.

Recommended next care following hospital-treated self-harm: patterns and trends over time

Objective The specific objectives of this study were to examine variation in the care of self-harm patients in hospital settings and to identify the factors that predict recommended next care following self-harm. Methods Data on consecutive presentations to Irish emergency departments (EDs) involving self-harm from the National Self-Harm Registry Ireland from 2004 to 2012 were utilised. Univariate and multivariate regression analyses were performed to assess the associations between patients’ clinical and demographic characteristics, and recommended next care received. Results Across the study period a total 101,904 self-harm presentations were made to hospital EDs, involving 63,457 individuals. Over the course of the study there was a declining number of presentations resulting in patient admission following attendance with self-harm. Recommended next care varied according to hospital location, with general admission rates ranging from 11% to 61% across administrative health regions. Multinomial logistic regression identified that the factor which most strongly affected next care was the presenting hospital. Being male, older age, method, repeat self-harm, time of attendance and residence of the patient were all identified as influencing care received. Psychiatric admission was most common when highly lethal methods of self-harm were used (OR = 4.00, 95% CI, 3.63–4.41). A relatively large proportion of patients left the ED without being seen (15%) and the risk of doing so was highest for self-harm repeaters (1.64, 1.55–1.74 for those with 5+ presentations). Conclusions The extensive hospital variation in recommended next care indicates that management of self-harm patients may be determined more by where they present than by the needs of the patient. The study outcomes underline the need to standardise the clinical management of self-harm patients in general hospital settings.

Frequently used drug types and alcohol involvement in intentional drug overdoses in Ireland: a national registry study

Background Intentional drug overdose (IDO) is the most common form of hospital-treated self-harm, yet no national study has systematically classified the range of drugs involved using a validated system. We aimed to determine the profile of patients engaging in overdose, to identify drugs frequently used and to quantify the contributions of multiple drug use and alcohol involvement. Methods Between 2012 and 2014, the National Self-Harm Registry, Ireland recorded 18 329 presentations of non-fatal IDO to Irish emergency departments. Information on demographic and overdose characteristics were obtained. Drugs were categorized using the Anatomical Therapeutic Chemical classification system. Results Analgesics (32.4%), antidepressants (21.9%), anxiolytics (21.2%) and hypnotics and sedatives (21.0%) were the most frequently used drugs types involved in overdose. Presentations involving analgesic and antidepressant medication were more common for females whereas males more often took illegal, anxiolytic and hypnotic and sedative drugs. Overdoses with drugs other than those which affect the nervous system were identified, including musculoskeletal drugs, taken in 12.0% of presentations. Paracetamol was the most frequently used drug, particularly among females (32.0%) and persons under 25 years (36.2%). Alcohol was most often present in overdoses involving anxiolytics and illegal drugs. Multiple drug use was a factor in almost half (47.1%) of presentations. Conclusions People who engage in IDO frequently take prescription only or sales restricted drugs, often involving alcohol and/or multiple drug use. These findings highlight the importance of addressing drug and alcohol misuse, potential inappropriate prescribing and the enforcement of legislation restricting specific drug sales.

P74 The impact of reconfiguring acute hospital services on hospital-treated self-harm: a before-and-after study

Background Health services in Ireland and the United Kingdom have developed strategies to reduce the number of acute hospitals. This has involved the centralisation of services to centres of excellence along with the reconfiguration of smaller hospitals to urgent care centres – with reduced emergency department (ED) hours. However, the evidence base for improved patient outcomes is limited. We aimed to assess the impact of the reconfiguration of a hospital group in Ireland in terms of the burden of hospital-treated self-harm on each hospital and the clinical management of individual self-harm patients. Methods The study was conducted in three Mid-Western regional hospitals in Ireland. The reconfiguration in April 2009 involved two hospitals (B and C) reducing the operation of their EDs while services at a third hospital (A) remained unchanged. As part of the National Self-Harm Registry Ireland, data were recorded relating to all self-harm presentations during the period January 2004 to April 2014. We used Poisson regression analysis to assess changes in the hospital burden and clinical management of self-harm. Results During the study period there were 9223 self-harm presentations to the EDs of the three hospitals. Hospital A received the majority (75%), with Hospitals B and C receiving 14% and 11% of presentations, respectively. The reconfiguration was associated with a marked increase in the rate of self-harm presentations at Hospital A, from a rate of 46.0 to 65.2 per month [+19.2 (95% CI 16.2, 22.4)]. This increase was approximately equivalent to the decreases at Hospitals B [−7.7 (-8.4,–6.8)] and C [−9.4 (-9.9,–8.4)]. Despite this large increase in presentations, there was only a small increase in admissions into Hospital A [+3.4 per month (1.4, 5.5)]. Conclusion The cumulative decrease in self-harm presentations at the hospitals reconfigured to have reduced ED services was of similar magnitude to the increase at the other hospital’s ED. This suggests that such reconfiguration does not reduce self-harm presentations to hospital EDs but shifts the burden of cases to other hospitals. The disproportionately small impact on hospital admissions suggests that the management of self-harm patients may change in response to increased numbers presenting. This is the first known study to quantify the impact of acute hospital reconfiguration on patterns of self-harm attendances, highlighting changes in the management of self-harm specifically. Patient outcomes following hospital reconfiguration should be an ongoing research priority.

Self-harm among the homeless population in Ireland: A national registry-based study of incidence and associated factors.

BACKGROUND Self-harm is a strong predictor of future suicide, but little is known about self-harm among the homeless population. The study aim was to estimate the incidence of self-harm among the homeless population and to assess factors associated with self-harm. METHODS Data on self-harm presentations to 34 hospital emergency departments in Ireland were collected by the National Self-Harm Registry Ireland (NSHRI). Index presentations between 2010 and 2014 were included for the homeless and fixed residence populations. Incidence rates of self-harm were calculated using NSHRI data and census estimates. Factors associated with self-harm and repeated self-harm were analysed by multivariable-adjusted logistic regression. RESULTS The age-standardised incidence rate of self-harm was 30 times higher among the homeless (5572 presentations per 100,000) compared with those with a fixed residence (187 presentations per 100,000). Homeless people had significantly higher odds of being male (OR 1.86, 95%CI 1.56-2.23), presenting with self-cutting (vs. overdose, OR 2.15, 95%CI 1.74-2.66) and having psychiatric admission (vs. general admission, OR 2.43, 95%CI 1.66-3.57). Homeless people had higher odds of self-harm repetition within 12 months (vs. fixed residence, OR 1.46, 95%CI 1.21-1.77). The odds of repetition were significantly increased among homeless who engaged in self-cutting (vs. overdose, OR 1.76, 95%CI 1.17-2.65) and did not receive psychiatric review at index presentation (vs. reviewed, OR 1.54, 95%CI 1.05-2.26). LIMITATIONS The study only reflects self-harm presenting to hospital, and assumes no change in homelessness status after index presentation. Residual confounding may affect the results. CONCLUSION There is a disproportionate burden of self-harm among the homeless. Targeted preventive actions are warranted.