Julia Sinclair

Understanding resolution of deliberate self harm: qualitative interview study of patients' experiences

Abstract ObjectiveTo explore the accounts of those with a history of deliberate self harm but who no longer do so, to understand how they perceive this resolution and to identify potential implications for provision of health services. Design Qualitative in-depth interview study. Setting Interviews in a community setting. Participants 20 participants selected from a representative cohort identified in 1997 after an episode of deliberate self poisoning that resulted in hospital treatment. Participants were included if they had no further episodes for at least two years before interview. Results We identified three recurrent themes: the resolution of adolescent distress; the recognition of the role of alcohol as a precipitating and maintaining factor in self harm; and the understanding of deliberate self harm as a symptom of untreated or unrecognised illness. Conclusion Patients with a history of deliberate self harm who no longer harm themselves talk about their experiences in terms of lack of control over their lives, either through alcohol dependence, untreated depression, or, in adolescents, uncertainty within their family relationships. Hospital management of deliberate self harm has a role in the identification and treatment of depression and alcohol misuse, although in adolescents such interventions may be less appropriate.

Healthcare and social services resource use and costs of self-harm patients

BackgroundPatients who have self-harmed have increased morbidity across a wide range of health outcomes, but there is no evidence on their pattern of health and social service use, and its relationship with repetition of self-harm. Previous studies have shown that resource use and costs in the short-term hospital management of self-harm is associated with certain patient and service characteristics but their impact in the longer term has not been demonstrated. The aim of this study is to test the association between changing levels of costs of health and social care with further episodes of self-harm and to identify the clinical and social factors associated with this.MethodThis was a cost-analysis incidence study of a sample of patients from a cohort of self-harm patients who remained within one region over the course of their follow-up. Resource use was retrospectively observed from their first episode of self-harm (dating back on some occasions to the 1970’s), and costs applied. Panel data analyses were used to identify factors associated with observed costs over time.ResultsPatients with five or more episodes of self-harm had the highest levels of resource costs. Health and social care costs reduced with time from last episode of self-harm. In the year following the first episode of self-harm, psychiatric care accounted for 69% and psychotropic drug prescriptions 1% of the mean resource costs.ConclusionsThe management of self-harm occurs within a complex system of health and social care. Major self-harm repeaters place the greatest cost burden on the system. Better understanding of the impact of risk assessment models and consequent service provision on clinical outcome may help in the design of effective services for this patient group.

Six year follow-up of a clinical sample of self-harm patients

BACKGROUND Mortality from suicide and other causes is significantly increased in patients who engage in self-harm, but their long-term morbidity and quality of life are poorly defined. As the majority of self-harm patients are under the age of 35 years, understanding their longer term health outcomes is important if we are to adequately manage their care. The aim of this study was to investigate the long-term mortality, morbidity and quality of life of such patients. METHOD A representative cohort of patients who had presented to hospital following an episode of self-harm was traced after 6 years. Mortality and repetition of self-harm were primary outcome measures. Psychiatric morbidity and indices of quality of life, and social functioning were also obtained. RESULTS 143/150 (95.3%) patients were traced after a mean of 6.2 years. Eight (5.6%) had died during follow-up, significantly more than general population estimates (p < or = 0.001), four of these (2.8%) by probable suicide. Further self-harm occurred in 58/101 (57.4%) participants; 70/97 (72.2%) fulfilled criteria for at least one psychiatric disorder, and 51.3% screened positive for harmful use of alcohol. Measures of health status (EQ-5D and SF36-II) were significantly lower (p<0.001) than in the general population. LIMITATIONS Due to the nature of this population group the attrition rate at 6 years is high; although this is the most complete such study to date. CONCLUSION Despite positive outcomes in some patients, overall levels of mortality, morbidity, and harmful use of alcohol are high, whilst quality of life is reported as low. This has significant implications for the long-term management of this group.

Acceptability of offering financial incentives to achieve medication adherence in patients with severe mental illness: a focus group study

Background Offering financial incentives to achieve medication adherence in patients with severe mental illness is controversial. Aims To explore the views of different stakeholders on the ethical acceptability of the practice. Method Focus group study consisting of 25 groups with different stakeholders. Results Eleven themes dominated the discussions and fell into four categories: (1) ‘wider concerns’, including the value of medication, source of funding, how patients would use the money, and a presumed government agenda behind the idea; (2) ‘problems requiring clear policies’, comprising of practicalities and assurance that incentives are only one part of a tool kit; (3) ‘challenges for research and experience’, including effectiveness, the possibility of perverse incentives, and impact on the therapeutic relationship; (4) ‘inherent dilemmas’ around fairness and potential coercion. Conclusions The use of financial incentives is likely to raise similar concerns in most stakeholders, only some of which can be addressed by empirical research and clear policies.

Patient, psychiatrist and family carer experiences of community treatment orders: qualitative study

PurposeCurrent literature on personal experiences of community treatment orders (CTO) is limited. This paper examines participants’ experiences of the mechanisms via which the CTO was designed to work: the conditions that form part of the order and the power of recall. We also report an emergent dimension, legal clout and participants’ impressions of CTO effectiveness. This paper will contribute to a fuller picture of how the law is implemented and how CTOs operate in practice.MethodsIn-depth qualitative interviews were conducted with a purposive sample of 26 patients, 25 psychiatrists and 24 family carers about their experiences and views of CTOs. Data were analysed using the constant comparative method.ResultsAll three sample groups perceived the chief purpose of CTOs to be medication enforcement and that its legal clout was central to achieving medication adherence. Understanding of how the inbuilt mechanisms of the CTO work varied considerably: participants expressed uncertainty regarding the enforceability of discretionary conditions and the criteria for recall. We found mixed evidence regarding whether recall simplified responses to relapse or risk. The range of experiences and views identified within each group suggests that there is no single definitive experience or view of CTOs.ConclusionsThe (perceived) focus of the CTO on medication adherence combined with the variations in understanding within and across groups might not only have consequences for how CTOs are viewed and subsequently experienced, but also for broader goals in patient care and patient and carer involvement.

The challenge of evaluating the effectiveness of treatments for deliberate self-harm

Deliberate self-harm (DSH) is the most important factor associated with risk of suicide. It also poses a considerable burden on health and social services. Repetition of DSH after hospital presentation is common, with most studies reporting between 12 and 25% of patients repeating within a year and again presenting to hospital (Owens et al . 2002) and many more being involved in repeat episodes which do not bring them to clinical attention (Guthrie et al . 2001). Repetition itself increases the risk of a fatal outcome (Sakinofsky, 2000). The results of both psychosocial and pharmacological interventions to prevent repetition have been fairly disappointing (Hawton et al. 1998, 2000), although the findings of treatment trials have not all been negative. Dialectical behaviour therapy had a substantial initial impact on repetition of self-harm, although this did not persist in a treatment study of female patients with borderline personality disorders (Linehan et al. 1991) and depot flupenthixol reduced repetition in frequent self-harmers (Montgomery, 1987). A recent trial of brief psychotherapy was more effective than treatment as usual (Guthrie et al . 2001) and a meta-analysis of trials of problem-solving therapy suggested beneficial effects for depression, hopelessness and specific problems (Townsend et al . 2001).

Systematic review of resource utilization in the hospital management of deliberate self-harm

BACKGROUND Deliberate self-harm (DSH) is a significant public health problem, representing a major burden in terms of morbidity to the individual and health-service utilization. While clinical guidelines suggest good practice for the short-term hospital management of DSH, there remains considerable variability in the way that services are provided. METHOD A systematic review of the literature was undertaken to examine the current evidence on hospital resource use and costs involved in the short-term hospital management of adults following DSH and to elucidate the factors that influence these differences, in terms of clinical characteristics and service provision. RESULTS Twenty-one papers reporting on 17 studies met the inclusion criteria for review. Clinical characteristics associated with an increase in resource use included overdose with tricyclic antidepressants (TCAs) compared with selective serotonin re-uptake inhibitors (SSRIs) (weighted ratio 2.6:1) and co-ingestion of alcohol with SSRIs. Variations in service provision, including medical admissions policy and provision of a specialist liaison service, affected resource utilization independently of the clinical needs of patients. CONCLUSIONS Overdoses of TCAs incur substantially greater hospital costs than overdoses of SSRIs. Variations in the medical seriousness of DSH, and in the structure of service provision, affect the resources used in its short-term hospital management, with little evidence about the impact these differences have on clinical outcome. Research is needed to evaluate the impact of different styles of service provision on outcome, and to incorporate these factors into the trial design of future cost-effectiveness studies of interventions following DSH.

Safety and Tolerability of Pharmacological Treatment of Alcohol Dependence: Comprehensive Review of Evidence

Alcohol use disorders (AUD) cause significant morbidity and mortality worldwide, but pharmacological treatments for them are underused, despite evidence of efficacy. Acamprosate, naltrexone, nalmefene and disulfiram are all approved in one or more region for the treatment of AUD. Baclofen currently has a temporary indication in France. Safety considerations for using psychopharmacological treatments in this patient group include the impact of concurrent alcohol consumption at high levels; multiple physical comorbidities that may interfere with pharmacological effects, distribution and metabolism; and concomitant medication for the treatment of comorbid physical and psychiatric conditions. The five drugs, including an extended-release injectable suspension of naltrexone, have different safety profiles that need to be balanced with the treatment objective (initiation or continuation of abstinence, or reduction of drinking), individual patient preferences and comorbid conditions. Appropriate treatment will be based on the unique risk–benefit profile in each case.

Treatments for dangerous severe personality disorder (DSPD)

Four units established in England for individuals with dangerous severe personality disorder differ significantly in their treatment regimes. Their distribution and relationship to risk are unknown. In this study, a modified Delphi process identified the treatments and allocated them to 11 mutually exclusive categories. Attendance at treatments was obtained from records, and these were compared to annual assessments of risk. Of 150 proposed treatments, 50 were allocated to the 11 categories. Only two treatment categories were provided in all units. Specified psychological treatment programmes occupied an average of less than 2 h a week, and 10% of patients had no treatment in each year. Reduction in risk was significantly associated with total hours of treatment received. A rigorous rationalisation of the treatments is needed to permit a robust evaluation of their effectiveness. Further research is needed to determine whether reductions in risk reflect reoffending rates.

Threats and offers in community mental healthcare

Making threats and offers to patients is a strategy used in community mental healthcare to increase treatment adherence. In this paper, an ethical analysis of these types of proposal is presented. It is argued (1) that the primary ethical consideration is to identify the professional duties of care held by those working in community mental health because the nature of these duties will enable a threat to be differentiated from an offer, (2) that threatening to act in a way that would equate with a failure to uphold the requirements of these duties is wrong, irrespective of the benefit accrued through treatment adherence and (3) that making offers to patients raises a number of secondary ethical considerations that need to be judged on their own merit in the context of individual patient care. The paper concludes by considering the implications of these arguments, setting out a pathway designed to assist community mental healthcare practitioners to determine whether making a specific proposal to a patient is right or wrong.