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    ABSTRACT: To describe the characteristics and management of individuals attending hospital with self-harm and assess changes in management and service quality since an earlier study in 2001, a period in which national guidance has been available. Observational study. A stratified random sample of 32 hospitals in England, UK. 6442 individuals presenting with 7689 episodes of self-harm during a 3-month audit period between 2010 and 2011. Self-harm episodes, key aspects of individual management relating to psychosocial assessment and follow-up, and a 21-item measure of service quality. Overall, 56% (3583/6442) of individuals were women and 51% (3274/6442) were aged under 35 years. Hospitals varied markedly in their management. The proportion of episodes that received a psychosocial assessment by a mental health professional ranged from 22% to 88% (median 58%, IQR 48-70%); the proportion of episodes resulting in admission to general hospitals varied from 22% to 85% (median 54%, IQR 41-63%); a referral for specialist mental health follow-up was made in 11-64% of episodes (median 28%, IQR 22-38%); a referral to non-statutory services was made in 4-62% of episodes (median 15%, IQR 8-23%); 0-21% of episodes resulted in psychiatric admission (median 7%, QR 4-12%). The specialist assessment rate varied by method of harm; the median rate for self-cutting was 45% (IQR 28-63%) vs 58% (IQR 48-73%) for self-poisoning. Compared with the 2001 study, there was little difference in the proportion of episodes receiving specialist assessment; there was a significant increase in general hospital admission but a decrease in referrals for specialist mental health follow-up. However, scores on the service quality scale had increased from a median of 11.5-14.5 (a 26% increase). Services for the hospital management of self-harm remain variable despite national guidelines and policy initiatives. We found no evidence for increasing levels of assessment over time but markers of service quality may have improved. This paper forms part of the study 'Variations in self-harm service delivery: an observational study examining outcomes and temporal trends'. The National Institute for Health Research Clinical Research Network (NIHR CRN) Portfolio database registration number: HOMASH 2 (7333). The NIHR Coordinated System for gaining NHS Permission (CSP) registration number: 23226.
    BMJ Open 11/2013; 3(11):e003444. DOI:10.1136/bmjopen-2013-003444
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    ABSTRACT: To investigate the impact of narrative verdicts on suicide statistics among 10-19-year-olds; to identify the number and rate of suicide and accidental deaths, particularly in 10-14-year-olds. National cohort study. England and Wales. Mid-year population estimates from the Office for National Statistics (ONS) were used to calculate rates per 100 000 population for suicide (undetermined and suicide verdicts) and accidental deaths (poisoning, hanging) for those aged 10-14 and 15-19. Trends in rates over time (2001-2010) were investigated using Poisson regression. Interaction tests were carried out to determine differences in trends between the two time periods (2001-2005 and 2006-2010). There were 1523 suicides (2.25/100 000). Suicide rates were highest in those aged 15-19 years (4.04/100 000) and in males (3.14/100 000). Between 2001 and 2010, rates significantly decreased among those aged 15-19 years (incidence rate-ratio (IRR): 0.95; 95% CI 0.93 to 0.97), with no change in rates of accidental deaths (IRR: 1.01, 95% CI 0.95 to 1.07). However, there was a significant interaction between the two time periods for accidental poisonings (2001-2005: IRR: 0.79 (95% CI 0.69 to 0.91); 2006-2010: IRR: 1.01 (95% CI 0.89 to 1.15), interaction p=0.012) and accidental hangings (2001-2005: IRR: 0.93 (95% CI 0.76 to 1.14); 2006-2010: IRR: 1.25 (95% CI 1.04 to 1.49), interaction=0.01) Undetermined deaths significantly decreased among females aged 15-19 yeras (IRR: 0.93; 95% CI 0.88 to 0.98). There were no significant trends among 10-14-year-olds. Rates of suicide are higher among older adolescents and males. There was a significant fall in suicide rates in males aged 15-19 years that was not accounted for by changes in rates of accidental death. The absence of a significant trend in suicide or accidental deaths in those aged 10-14 years may have been the result of small numbers. However, monitoring should continue to identify longitudinal trends in all young people.
    Archives of Disease in Childhood 09/2013; 98(12). DOI:10.1136/archdischild-2012-302539
  • Annals of internal medicine 08/2013; 159(4):JC8. DOI:10.7326/0003-4819-159-4-201308200-02008
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    ABSTRACT: Evidence to guide clinical management of self-harm is sparse, trials have recruited selected samples, and psychological treatments that are suggested in guidelines may not be available in routine practice. To examine how the management that patients receive in hospital relates to subsequent outcome. We identified episodes of self-harm presenting to three UK centres (Derby, Manchester, Oxford) over a 10 year period (2000 to 2009). We used established data collection systems to investigate the relationship between four aspects of management (psychosocial assessment, medical admission, psychiatric admission, referral for specialist mental health follow up) and repetition of self-harm within 12 months, adjusted for differences in baseline demographic and clinical characteristics. 35,938 individuals presented with self-harm during the study period. In two of the three centres, receiving a psychosocial assessment was associated with a 40% lower risk of repetition, Hazard Ratios (95% CIs): Centre A 0.99 (0.90-1.09); Centre B 0.59 (0.48-0.74); Centre C 0.59 (0.52-0.68). There was little indication that the apparent protective effects were mediated through referral and follow up arrangements. The association between psychosocial assessment and a reduced risk of repetition appeared to be least evident in those from the most deprived areas. These findings add to the growing body of evidence that thorough assessment is central to the management of self-harm, but further work is needed to elucidate the possible mechanisms and explore the effects in different clinical subgroups.
    PLoS ONE 08/2013; 8(8):e70434. DOI:10.1371/journal.pone.0070434
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    ABSTRACT: 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%).
    The British journal of psychiatry: the journal of mental science 07/2013; 203(1):73-4. DOI:10.1192/bjp.bp.113.126425
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    ABSTRACT: BACKGROUND: Gaining a greater knowledge of the mechanisms and means by which violent offenders die by suicide can inform tailored preventive strategies. METHODS: Using interlinked national Danish registry data we constructed a nested case-control study dataset of all adult suicides during 1994-2006: N=9708 cases and N=188,134 age and gender matched living controls. Completely ascertained International Classification of Diseases 10th revision cause-specific mortality codes were examined, with all criminal charges since 1980, and covariate information on psychiatric treatment and socio-demographics. Self-poisonings were classified as 'nonviolent' suicide and all other methods as being 'violent' ones. RESULTS: Compared with the general population, risk among male and female violent offenders was strongly and significantly elevated for suicide by either a violent or a nonviolent method, although the relative risk was greater for nonviolent suicide. These patterns were also observed among nonviolent offenders, albeit with smaller effect sizes. Risk was especially raised for self-poisoning with narcotics & hallucinogens. We could only examine the full range of suicide methods in male violent offenders. In these men, hanging was the most frequently used method, although risk was markedly and significantly elevated virtually across the entire range of regularly used suicide methods. LIMITATIONS: We lacked sufficient statistical power for undertaking a detailed profiling of specific suicide methods among female violent offenders. CONCLUSIONS: Our findings indicate that comprehensive and broadly-based preventive approaches are needed for tackling the markedly raised risk of suicide by both violent and nonviolent means in this population. Their high relative risk for self-poisoning by illicit or illegal drugs underlines the importance of access to means and of prevailing subculture.
    Journal of Affective Disorders 05/2013; 150(2). DOI:10.1016/j.jad.2013.04.001
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    ABSTRACT: Non-suicidal self-injury (NSSI) is a term that is becoming popular especially in North America and it has been proposed as a new diagnosis in DSM-5. In this paper we consider what self-harm research can tell us about the concept of NSSI and examine the potential pitfalls of introducing NSSI into clinical practice.
    The British journal of psychiatry: the journal of mental science 05/2013; 202(5):326-8. DOI:10.1192/bjp.bp.112.116111
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    ABSTRACT: Most child victims of homicide are killed by a parent or step-parent. This large population study provides a contemporary and detailed description of filicide perpetrators. We examined the relationship between filicide and mental illness at the time of the offence, and care received from mental health services in the past. All filicide and filicide-suicide cases in England and Wales (1997-2006) were drawn from a national index of homicide perpetrators. Data on people in contact with mental health services were obtained via a questionnaire from mental health teams. Additional clinical information was collected from psychiatric reports. 6144 people were convicted of homicide, 297 were filicides, and 45 cases were filicide-suicides. 195 (66%) perpetrators were fathers. Mothers were more likely than fathers to have a history of mental disorder (66% v 27%) and symptoms at the time of the offence (53% v 23%), most often affective disorder. 17% of mothers had schizophrenia or other delusional disorders. Overall 8% had schizophrenia. 37% were mentally ill at the time of the offence. 20% had previously been in contact with mental health services, 12% within a year of the offence. In the majority of cases, mental illness was not a feature of filicide. However, young mothers and parents with severe mental illness, especially affective and personality disorder who are providing care for children, require careful monitoring by mental health and other support services. Identifying risk factors for filicide requires further research.
    PLoS ONE 04/2013; 8(4):e58981. DOI:10.1371/journal.pone.0058981
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    Social Psychiatry 03/2013; 48(7). DOI:10.1007/s00127-013-0682-2
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    ABSTRACT: BACKGROUND: Bipolar disorder (BD) has been reported to be associated with high risk of suicide. We aimed to investigate the frequency and characteristics of suicide in people with BD in a national sample. Method Suicide in BD in England from 1996 to 2009 was explored using descriptive statistics on data collected by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI). Suicide cases with a primary diagnosis of BD were compared to suicide cases with any other primary diagnosis. RESULTS: During the study period 1489 individuals with BD died by suicide, an average of 116 cases/year. Compared to other primary diagnosis suicides, those with BD were more likely to be female, more than 5 years post-diagnosis, current/recent in-patients, to have more than five in-patient admissions, and to have depressive symptoms. In BD suicides the most common co-morbid diagnoses were personality disorder and alcohol dependence. Approximately 40% were not prescribed mood stabilizers at the time of death. More than 60% of BD suicides were in contact with services the week prior to suicide but were assessed as low risk. CONCLUSIONS: Given the high rate of suicide in BD and the low estimates of risk, it is important that health professionals can accurately identify patients most likely to experience poor outcomes. Factors such as alcohol dependence/misuse, personality disorder, depressive illness and current/recent in-patient admission could characterize a high-risk group. Future studies need to operationalize clinically useful indicators of suicide risk in BD.
    Psychological Medicine 03/2013; 43(12):1-10. DOI:10.1017/S0033291713000329
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