Rohan Borschmann

The natural history of self-harm from adolescence to young adulthood: a population-based cohort study

BACKGROUND Knowledge about the natural history of self-harm is scarce, especially during the transition from adolescence to young adulthood, a period characterised by a sharp rise in self-inflicted deaths. From a repeated measures cohort of a representative sample, we describe the course of self-harm from middle adolescence to young adulthood. METHODS A stratified, random sample of 1943 adolescents was recruited from 44 schools across the state of Victoria, Australia, between August, 1992, and January, 2008. We obtained data pertaining to self-harm from questionnaires and telephone interviews at seven waves of follow-up, commencing at mean age 15·9 years (SD 0·49) and ending at mean age 29·0 years (SD 0·59). Summary adolescent measures (waves three to six) were obtained for cannabis use, cigarette smoking, high-risk alcohol use, depression and anxiety, antisocial behaviour and parental separation or divorce. FINDINGS 1802 participants responded in the adolescent phase, with 149 (8%) reporting self-harm, More girls (95/947 [10%]) than boys (54/855 [6%]) reported self-harm (risk ratio 1·6, 95% CI 1·2-2·2). We recorded a substantial reduction in the frequency of self-harm during late adolescence. 122 of 1652 (7%) participants who reported self-harm during adolescence reported no further self-harm in young adulthood, with a stronger continuity in girls (13/888) than boys (1/764). During adolescence, incident self-harm was independently associated with symptoms of depression and anxiety (HR 3·7, 95% CI 2·4-5·9), antisocial behaviour (1·9, 1·1-3·4), high-risk alcohol use (2·1, 1·2-3·7), cannabis use (2·4, 1·4-4·4), and cigarette smoking (1·8, 1·0-3·1). Adolescent symptoms of depression and anxiety were clearly associated with incident self-harm in young adulthood (5·9, 2·2-16). INTERPRETATION Most self-harming behaviour in adolescents resolves spontaneously. The early detection and treatment of common mental disorders during adolescence might constitute an important and hitherto unrecognised component of suicide prevention in young adults. FUNDING National Health and Medical Research Council, Australia, and operational infrastructure support programme, Government of Victoria, Australia.

Risk of emergency medical treatment following consumption of cannabis or synthetic cannabinoids in a large global sample

Background: Synthetic cannabinoids (SCs) have become increasingly popular in recent years. Diverse in chemical structure, many have been subjected to legislative regulation, but their availability and use persists. Often marketed to reflect their similar effects to cannabis, their use has been associated with a range of negative health effects. We sought to determine the relative risk of seeking emergency medical treatment (EMT) following use of SCs and natural cannabis. Methods: We utilized an anonymous online survey of drug use, obtaining data from 22,289 respondents. We calculated the relative risk of seeking EMT between the two substances using an estimate for days used in the past year. Results: Thirty-seven cannabis users (0.2%) and 21 SC users (1.0%) had sought EMT during the past year following use. The relative risk associated with the use of SCs was 30 (95% CI 17.5–51.2) times higher than that associated with cannabis. Significantly more symptoms (p=0.03) were reported by respondents seeking treatment for SCs than for cannabis. Conclusions: Whilst these findings must be treated with caution, SCs potentially pose a greater risk to users’ health than natural forms of cannabis. Regulation is unlikely to remove SCs from the market, so well-informed user-focused health promotion messages need to be crafted to discourage their use.

‘What difference does it make?’ Finding evidence of the impact of mental health service user researchers on research into the experiences of detained psychiatric patients

Background  Interest in the involvement of members of the public in health services research is increasingly focussed on evaluation of the impact of involvement on the research process and the production of knowledge about health. Service user involvement in mental health research is well‐established, yet empirical studies into the impact of involvement are lacking.

Dimethyltryptamine (DMT): Prevalence, user characteristics and abuse liability in a large global sample

This paper presents original research on prevalence, user characteristics and effect profile of N,N-dimethyltryptamine (DMT), a potent hallucinogenic which acts primarily through the serotonergic system. Data were obtained from the Global Drug Survey (an anonymous online survey of people, many of whom have used drugs) conducted between November and December 2012 with 22,289 responses. Lifetime prevalence of DMT use was 8.9% (n=1980) and past year prevalence use was 5.0% (n=1123). We explored the effect profile of DMT in 472 participants who identified DMT as the last new drug they had tried for the first time and compared it with ratings provided by other respondents on psilocybin (magic mushrooms), LSD and ketamine. DMT was most often smoked and offered a strong, intense, short-lived psychedelic high with relatively few negative effects or “come down”. It had a larger proportion of new users compared with the other substances (24%), suggesting its popularity may increase. Overall, DMT seems to have a very desirable effect profile indicating a high abuse liability that maybe offset by a low urge to use more.

Domestic and sexual violence against patients with severe mental illness.

Background Domestic and sexual violence are significant public health problems but little is known about the extent to which men and women with severe mental illness (SMI) are at risk compared with the general population. We aimed to compare the prevalence and impact of violence against SMI patients and the general population. Method Three hundred and three randomly recruited psychiatric patients, in contact with community services for ⩾1 year, were interviewed using the British Crime Survey domestic/sexual violence questionnaire. Prevalence and correlates of violence in this sample were compared with those from 22 606 general population controls participating in the contemporaneous 2011/12 national crime survey. Results Past-year domestic violence was reported by 27% v. 9% of SMI and control women, respectively [odds ratio (OR) adjusted for socio-demographics, aOR 2.7, 95% confidence interval (CI) 1.7–4.0], and by 13% v. 5% of SMI and control men, respectively (aOR 1.6, 95% CI 1.0–2.8). Past-year sexual violence was reported by 10% v. 2.0% of SMI and control women respectively (aOR 2.9, 95% CI 1.4–5.8). Family (non-partner) violence comprised a greater proportion of overall domestic violence among SMI than control victims (63% v. 35%, p < 0.01). Adulthood serious sexual assault led to attempted suicide more often among SMI than control female victims (53% v. 3.4%, p < 0.001). Conclusions Compared to the general population, patients with SMI are at substantially increased risk of domestic and sexual violence, with a relative excess of family violence and adverse health impact following victimization. Psychiatric services, and public health and criminal justice policies, need to address domestic and sexual violence in this at-risk group.

Violent and non-violent crime against adults with severe mental illness

BACKGROUND Little is known about the relative extent of crime against people with severe mental illness (SMI). AIMS To assess the prevalence and impact of crime among people with SMI compared with the general population. METHOD A total of 361 psychiatric patients were interviewed using the national crime survey questionnaire, and findings compared with those from 3138 general population controls participating in the contemporaneous national crime survey. RESULTS Past-year crime was experienced by 40% of patients v. 14% of controls (adjusted odds ratio (OR) = 2.8, 95% CI 2.0-3.8); and violent assaults by 19% of patients v. 3% of controls (adjusted OR = 5.3, 95% CI 3.1-8.8). Women with SMI had four-, ten- and four-fold increases in the odds of experiencing domestic, community and sexual violence, respectively. Victims with SMI were more likely to report psychosocial morbidity following violence than victims from the general population. CONCLUSIONS People with SMI are at greatly increased risk of crime and associated morbidity. Violence prevention policies should be particularly focused on people with SMI.

Polysubstance use, mental health and high-risk behaviours: Results from the 2012 Global Drug Survey

INTRODUCTION AND AIMS Polysubstance use is associated with adverse health and social outcomes, but few studies have investigated whether these associations differ between individuals engaged in different patterns of illicit drug and non-prescription medication use. DESIGN AND METHODS Latent class analysis (LCA) was used to identify patterns of drug use in the Global Drug Survey, a purposive sample collected in late 2012 and surveyed using an online questionnaire including past-year drug use, sociodemographics, mental illness, involvement in violence and sexual behaviour. The sample analysed (n = 14, 869; median age 27 years; 68.5% male) included those residing in the UK (n = 5869), Australia (n = 6313) and the USA (n = 2687). RESULTS LCA of cannabis, ecstasy, cocaine, stimulants, nitrous, ketamine, benzodiazepines and opioid painkiller use identified six classes: no polysubstance use (Class 1, 49.1%); cannabis and ecstasy (Class 2, 23.6%); all illicit drugs (Class 3, 9.4%); ecstasy and cocaine (Class 4, 8.3%); cannabis and medication (Class 5, 5.9%); and all drugs (Class 6, 3.8%). Participants diagnosed with anxiety were most likely to belong to Class 5 [odds ratio (OR) 2.66, 95% confidence interval (CI) 2.10-3.38]. Violent behaviour was most strongly associated with Class 6 membership (OR 1.9, 95% CI 1.36-2.64). Sexual risk-taking also predicted membership of this class (OR 5.79, 95% CI 4.66-7.18) and Class 4 (OR 4.41, 95% CI 3.57-5.43). DISCUSSION AND CONCLUSIONS Five heterogeneous groups of polysubstance users were identified in this international sample covering the UK, Australia and USA. Anxiety disorders were associated with medication and cannabis use, while high-risk behaviours predicted use of cocaine and ecstasy, or wide-ranging polysubstance use including ketamine and medications.

Polysubstance use, mental health and high-risk behaviours

INTRODUCTION AND AIMS Polysubstance use is associated with adverse health and social outcomes, but few studies have investigated whether these associations differ between individuals engaged in different patterns of illicit drug and non-prescription medication use. DESIGN AND METHODS Latent class analysis (LCA) was used to identify patterns of drug use in the Global Drug Survey, a purposive sample collected in late 2012 and surveyed using an online questionnaire including past-year drug use, sociodemographics, mental illness, involvement in violence and sexual behaviour. The sample analysed (n = 14, 869; median age 27 years; 68.5% male) included those residing in the UK (n = 5869), Australia (n = 6313) and the USA (n = 2687). RESULTS LCA of cannabis, ecstasy, cocaine, stimulants, nitrous, ketamine, benzodiazepines and opioid painkiller use identified six classes: no polysubstance use (Class 1, 49.1%); cannabis and ecstasy (Class 2, 23.6%); all illicit drugs (Class 3, 9.4%); ecstasy and cocaine (Class 4, 8.3%); cannabis and medication (Class 5, 5.9%); and all drugs (Class 6, 3.8%). Participants diagnosed with anxiety were most likely to belong to Class 5 [odds ratio (OR) 2.66, 95% confidence interval (CI) 2.10-3.38]. Violent behaviour was most strongly associated with Class 6 membership (OR 1.9, 95% CI 1.36-2.64). Sexual risk-taking also predicted membership of this class (OR 5.79, 95% CI 4.66-7.18) and Class 4 (OR 4.41, 95% CI 3.57-5.43). DISCUSSION AND CONCLUSIONS Five heterogeneous groups of polysubstance users were identified in this international sample covering the UK, Australia and USA. Anxiety disorders were associated with medication and cannabis use, while high-risk behaviours predicted use of cocaine and ecstasy, or wide-ranging polysubstance use including ketamine and medications.

Measuring self-harm in adults: A systematic review

PURPOSE To identify from the literature, and to critically evaluate, all validated instruments currently available to measure self-harming behaviour in adults. MATERIALS AND METHODS Medline, Embase, PsycInfo, Health and Psychosocial Instruments and Google scholar were searched, grey literature was sought and the reference lists of relevant articles were checked to identify instruments. RESULTS A total of seven validated instruments which met our inclusion criteria were identified and data were extracted regarding each instruments format, administration method, psychometric properties and number of items and domains included. Considerable variation was observed in the overall quality of these instruments. Fourteen other instruments were identified which did not describe their psychometric properties or had not been published and were subsequently excluded from our review. DISCUSSION Although many instruments were identified in our search, only a small number had been validated with published psychometric properties. Of the identified instruments, the Suicide Attempt Self-Injury Interview (SASII) appears to be the most robust and comprehensive instrument currently available. Despite the absence of psychometric data, numerous other instruments have been used in published studies, including clinical trials. CONCLUSION Our results highlight the pressing need for a standardized, empirically validated and versatile measure of intentional self-harming behaviour for use in both clinical and research settings. The optimum characteristics of such an instrument are discussed.

Joint crisis plans for people with borderline personality disorder: feasibility and outcomes in a randomised controlled trial.

BACKGROUND People with borderline personality disorder frequently experience crises. To date, no randomised controlled trials (RCTs) of crisis interventions for this population have been published. AIMS To examine the feasibility of recruiting and retaining adults with borderline personality disorder to a pilot RCT investigating the potential efficacy and cost-effectiveness of using a joint crisis plan. METHOD An RCT of joint crisis plans for community-dwelling adults with borderline personality disorder (trial registration: ISRCTN12440268). The primary outcome measure was the occurrence of self-harming behaviour over the 6-month period following randomisation. Secondary outcomes included depression, anxiety, engagement and satisfaction with services, quality of life, well-being and cost-effectiveness. RESULTS In total, 88 adults out of the 133 referred were eligible and were randomised to receive a joint crisis plan in addition to treatment as usual (TAU; n = 46) or TAU alone (n = 42). This represented approximately 75% of our target sample size and follow-up data were collected on 73 (83.0%) participants. Intention-to-treat analysis revealed no significant differences in the proportion of participants who reported self-harming (odds ratio (OR) = 1.9, 95% CI 0.53-6.5, P = 0.33) or the frequency of self-harming behaviour (rate ratio (RR) = 0.74, 95% CI 0.34-1.63, P = 0.46) between the two groups at follow-up. No significant differences were observed between the two groups on any of the secondary outcome measures or costs. CONCLUSIONS It is feasible to recruit and retain people with borderline personality disorder to a trial of joint crisis plans and the intervention appears to have high face validity with this population. However, we found no evidence of clinical efficacy in this feasibility study.