The Epidemiology of Self-Harm in a UK-Wide Primary Care Patient Cohort, 2001–2013

BACKGROUND:

Most of the research conducted on people who harm themselves has been undertaken in secondary healthcare settings. Little is known about the frequency of self-harm in primary care patient populations. This is the first study to describe the epidemiology of self-harm presentations to primary care using broadly representative national data from across the United Kingdom (UK).

METHODS:

Using the Clinical Practice Research Datalink (CPRD), we calculated directly standardised rates of incidence and annual presentation during 2001-2013. Rates were compared by gender and age and across the nations of the UK, and also by degree of socioeconomic deprivation measured ecologically at general practice level.

RESULTS:

We found significantly elevated rates in females vs. males for incidence (rate ratio - RR, 1.45, 95 % confidence interval - CI, 1.42-1.47) and for annual presentation (RR 1.56, CI 1.54-1.58). An increasing trend over time in incidence was apparent for males (P < 0.001) but not females (P = 0.08), and both genders exhibited rising temporal trends in presentation rates (P < 0.001). We observed a decreasing gradient of risk with increasing age and markedly elevated risk for females in the youngest age group (aged 15-24 years vs. all other females: RR 3.75, CI 3.67-3.83). Increasing presentation rates over time were observed for males across all age bands (P < 0.001). We found higher rates when comparing Northern Ireland, Scotland, and Wales with England, and increasing rates of presentation over time for all four nations. We also observed higher rates with increasing levels of deprivation - most vs. least deprived male patients: RR 2.17, CI 2.10-2.25.

CONCLUSIONS:

Incorporating data from primary care yields a more comprehensive quantification of the health burden of self-harm. These novel findings may be useful in informing public health programmes and the targeting of high-risk groups toward the ultimate goal of lowering risk of self-harm repetition and premature death in this population.

Below: Overall incidence and annual presentation rates. a Incidence. b Annual presentation rates

Full article at:  http://goo.gl/xfGSjq

By:  Carr MJ1, Ashcroft DM2,3, Kontopantelis E4,5, Awenat Y6, Cooper J7, Chew-Graham C8,9, Kapur N7, Webb RT7.

• 1Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, M13 9PL, UK. matthew.carr@manchester.ac.uk.
• 2Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, Manchester, UK.
• 3NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester, UK.
• 4Centre for Health Informatics, Institute of Population Health, University of Manchester, UK, Manchester, UK.
• 5NIHR School for Primary Care Research, University of Manchester, Manchester, UK.
• 6School of Psychological Sciences, University of Manchester, Manchester, UK.
• 7Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, Manchester, M13 9PL, UK.
• 8Research Institute of Primary Care and Health Sciences, Keele University, Keele, UK.
• 9Manchester Mental Health and Social Care Trust, Manchester, UK. 
• BMC Psychiatry. 2016 Feb 29;16(1):53. doi: 10.1186/s12888-016-0753-5.

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Young People Who Self-Harm: A Prospective 1-Year Follow-Up Study

Purpose

To explore repetition, service provision and service engagement following presentation of young people to emergency services with self-harm.

Methods

969 patients who presented to accident and emergency services after self-harm were followed up prospectively for a period of 1 year. Data on rates, method, clinical history, initial service provision, engagement and repetition (defined as re-presenting to emergency services with further self-harm) were gathered from comprehensive electronic records.

Results

Young people were less likely to repeat self-harm compared to those aged 25 and above. A psychiatric history and a history of childhood trauma were significant predictors of repetition. Young people were more likely to receive self-help as their initial service provision, and less likely to receive acute psychiatric care or a hospital admission. There were no differences in engagement with services between young people and those aged 25 and above.

Conclusion

Younger individuals may be less vulnerable to repetition, and are less likely to represent to services with repeated self-harm. All young people who present with self-harm should be screened for mental illness and asked about childhood trauma. Whilst young people are less likely to be referred to psychiatric services, they do attend when referred. This may indicate missed opportunity for intervention.

Method of self-harm and precipitating factors by age group

Variablesa	All ages	16–24 years	25+ years
	n (%)	n (%)	n (%)
Method of SH (969)
Self-poisoning	704 (72.7)	236 (76.4)	468 (70.9)
Self-injury	214 (22.0)	59 (19.1)	155 (23.5)
Both self-injury and self-poisoning	51 (5.3)	14 (4.5)	37 (5.6)
Drugs in overdose
Single drug in overdose (931)	418 (44.9)	144 (48.2)	274 (43.4)
Paracetamol	127 (13.6)	59 (20.3)	68 (11.0)
Opioid analgesic	55 (5.9)	18 (6.2)	37 (6.0)
Antidepressant	51 (5.5)	16 (5.5)	35 (5.6)
Multiple drugs in overdose (931)	297 (31.9)	94 (31.4)	203 (32.1)
Self-injury (969)
Self-cutting	156 (16.1)	48 (15.5)	108 (16.4)
Other self-injury	109 (11.2)	26 (8.4)	83 (12.6)
Alcohol with SH (966)	334 (34.5)	69 (22.3)	265 (40.1)
Precipitating factors to SH
Alcohol misuse (957)	289 (30.2)	50 (16.4)	239 (36.6)
Drug misuse (956)	145 (15.2)	47 (15.5)	98 (15.0)
Child abuse (sexual/physical/emotional) (952)	204 (21.4)	80 (26.4)	124 (19.1)
Adult abuse (sexual/physical/emotional) (943)	109 (11.4)	33 (10.9)	76 (11.7)
Bereavement (955)	145(15.2)	30 (9.9)	115 (17.6)
Financial problems (956)	113 (11.8)	20 (6.6)	93 (14.3)
Housing problems (957)	75 (7.8)	16 (5.2)	59 (9.0)
Legal problems (959)	29 (3.0)	7 (2.3)	22 (3.4)
Relationship problems (958)	445 (46.5)	165 (54.1)	280 (42.9)
Physical health problems (960)	278 (29.0)	55 (18.0)	223 (34.1)
Self-harm in response to symptoms (961)	36 (3.7)	11 (3.6)	25 (3.8)

aNumber of patient cases with available information varied between variables

Below:  Kaplan–Meier curve showing cumulative probability of self-harm repetition by age groups

Full article at:   http://goo.gl/uydTsf

By:  Madiha Majid, Maria Tadros, George Tadros, Swaran Singh, Matthew R. Broome, and Rachel Upthegrove*

College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT UK

Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK

Warwick University, Coventry, UK

Department of Psychiatry, University of Oxford, Oxford, UK

Oxford Health NHS Foundation Trust, Oxford, UK

Rachel Upthegrove, Email: ku.ca.mahb@evorgehtpu.r.

*Corresponding author.

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Mysore Study: A Study of Suicide Notes

BACKGROUND:

Suicide is one of the leading causes of preventable deaths. Recent data suggest South India as one of the regions with highest suicide rates in the world. In 2013, 134,799 people committed suicide in India according to the statistics released by the National Crime Records Bureau. Suicide note is one of the most important sources to understand suicide, which may be beneficial in suicide prevention. Studies on suicidal notes from this part of the world are sparse.

OBJECTIVE:

The aim was to study the themes in suicide notes that might be useful in prevention strategies.

MATERIALS AND METHODS:

A descriptive study of all suicide notes of those individuals who committed suicide between 2010 and 2013 available with Police Department, Mysore district was obtained and analyzed.

RESULTS:

A total of 22 suicide note were available. A majority of suicide note was in age group of 16-40 years (86%) and most were men (59%). All suicide notes were handwritten, the majority (70%) in regional language Kannada. Length of notes varied from just few words to few pages. Contents of suicide notes included apology/shame/guilt (80%), love for those left behind (55%) and instruction regarding practical affairs (23%). Most have blamed none for the act (50%). 23% mentioned that they are committing suicide to prove their innocence. 32% mentioned a last wish.

CONCLUSION:

The majority of suicidal note contained "guilt" which is a strong indicator of possible depression in deceased. Creating awareness about suicide among public and ensuring access to professionals trained in suicide prevention is need of the hour in this part of the world.

Below:  Gender and marital status of those who left suicide note

Below:  Overall content in 22 suicide notes

Full article at:   http://goo.gl/gazM4W

By:  P. Namratha, M. Kishor, T. S. Sathyanarayana Rao, and Rajesh Raman

Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore, Karnataka, India

Address for correspondence: Dr. M. Kishor, Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore - 570 004, Karnataka, India. E-mail: moc.liamg@dmrohsikrd

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Emergency Department Visits Prior to Suicide and Homicide

BACKGROUND:

Emergency departments (EDs) serve a wide range of patients who present at risk of impending suicide and homicide.

AIMS:

Two statewide surveillance systems were probabilistically linked to understand who utilizes EDs and then dies violently within 6 weeks.

METHOD:

Each identified case was matched with four randomly selected controls on sex, race, date of birth, resident zip code, and date of ED visit vs. date of death. Matched-pair odds ratios were estimated by conditional logistic regression to assess differences between cases and controls on reported diagnoses and expected payment sources.

RESULTS:

Of 1,599 suicides and 569 homicides in the 3-year study period, 10.7% of decedents who died by suicide (x = 13.6 days) and 8.3% who died by homicide (x = 16.3 days) were seen in a state ED within 6 weeks prior to death. ED attendees who died by suicide were more likely to have a diagnosis of injury/ poisoning diagnosis or mental disorder and more likely to have Medicare. Those who died by homicide were more likely to have a diagnosis of injury/poisoning and less likely to have commercial insurance.

CONCLUSION:

It is essential for research to further explore risk factors for imminent suicide and homicide in ED patients who present for psychiatric conditions and general injuries.

Purchase full article at:   http://goo.gl/jwE2KZ

By:  Cerel J1, Singleton MD2, Brown MM3, Brown SV3, Bush HM4, Brancado CJ5.

• 1 University of Kentucky, College of Social Work (https://socialwork.uky.edu/), Lexington, KY, USA.
• 2 University of Kentucky, Department of Biostatistics and the Kentucky Injury Prevention and Research Center, Lexington, KY, USA.
• 3 University of Kentucky, Department of Epidemiology and Kentucky Injury Prevention and Research Center, College of Public Health, Lexington, KY, USA.
• 4 University of Kentucky, Department of Biostatistics, Lexington, KY, USA.
• 5 University of Kentucky , Department of Statistics/DATAQUeST, Lexington, KY, USA.
• Crisis. 2015 Dec 1:1-8. 

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Alcohol Use and Firearm Violence

Although the misuse of firearms is necessary to the occurrence of firearm violence, there are other contributing factors beyond simply firearms themselves that might also be modified to prevent firearm violence. Alcohol is one such key modifiable factor. 

To explore this, we undertook a 40-year (1975-2014) systematic literature review with meta-analysis. One large group of studies showed that over one third of firearm violence decedents had acutely consumed alcohol and over one fourth had heavily consumed alcohol prior to their deaths. 

Another large group of studies showed that alcohol was significantly associated with firearm use as a suicide means. Two controlled studies showed that gun injury after drinking, especially heavy drinking, was statistically significant among self-inflicted firearm injury victims. 

A small group of studies investigated the intersection of alcohol and firearms laws and alcohol outlets and firearm violence. One of these controlled studies found that off-premise outlets selling takeout alcohol were significantly associated with firearm assault. 

Additional controlled, population-level risk factor and intervention studies, including randomized trials of which only 1 was identified, are needed. 

Policies that rezone off-premise alcohol outlets, proscribe blood alcohol levels and enhance penalties for carrying or using firearms while intoxicated, and consider prior drunk driving convictions as a more precise criterion for disqualifying persons from the purchase or possession of firearms deserve further study.

Purchase full article at:   http://goo.gl/ZIxMts

By:  Branas CC, Han S, Wiebe DJ.

Correspondence to Dr. Charles C. Branas, Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104 (e-mail: cbranas@upenn.edu).

Epidemiol Rev. 2016 Jan 24. pii: mxv010. 

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Two Decades of Adolescent Suicides Assessed at Milan University's Medicolegal Unit

Highlights

• Seventy-eight autopsy cases of adolescents suicide in 20 years were analyzed.
• Epidemiology, forensic pathology and psychopathological data were discussed.
• Adolescents were involved in 2.23% of all suicides committed in the Milan area.
• In the majority of cases there were no premonitory signs or particular motives.

Aim

to analyze the cases of suicide committed by adolescents in and around the city of Milan over a 20-year period (1993–2012).

Materials and methods

cases of suicide involving individuals between 10 and 19 years of age were drawn from 20,757 autopsies performed by the Medico-legal Unit at Milan University. Seventy-eight cases were considered (20 females and 58 males, with the ratio of 1:2.9), and their clinical and circumstantial histories, epidemiology, forensic pathology and psychopathological issues were analyzed.

Result

Adolescents were involved in 2.23% of all suicides committed in Milan during the period examined. The “mean” victim is a male without psychiatric disease, aged between 16 and 19, that commits suicide outdoors.

Conclusions

In the majority of cases, there were no premonitory signs, nor any particular contingent or remote reason that might explain these violent deaths, which therefore remain “impulsive”.

Below:  Graphical representation of the annual distribution of the suicides

Below:  Graphical representation of the monthly distribution of the suicides

Below:  Distribution of the sample of adolescents by method chosen to commit suicide

Full article at:  http://goo.gl/F6rnkQ 

By:  Clerici CA1, Gentile G2, Marchesi M3, Muccino E2, Veneroni L1, Zoja R4.

• 1Sezione di Psicologia, Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Via Fratelli Cervi 93, 20090 Segrate MI, Italy.
• 2Sezione di Medicina Legale e delle Assicurazioni, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Luigi Mangiagalli 37, 20133 Milano, Italy.
• 3Azienda Ospedaliera Papa Giovanni XXIII, Piazza OMS 1, 24127 Bergamo, Italy.
• 4Sezione di Medicina Legale e delle Assicurazioni, Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Via Luigi Mangiagalli 37, 20133 Milano, Italy. Electronic address: riccardo.zoia@unimi.it.
• J Forensic Leg Med. 2016 Jan;37:15-21. doi: 10.1016/j.jflm.2015.09.016. Epub 2015 Oct 3. 

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The Hazard of Sharp Force Injuries: Factors Influencing Outcome

Highlights

• This study is original since sharp force injury is rather uncommon in Norway.
• The overall mortality rate of sharp force injury in this study was 29%.
• Penetrating chest injury was more deadly than penetrating abdominal injury.
• Isolated heart injury had a lethal outcome in 80% of the cases.
• Still the outcome of sharp force injury is often random and unpredictable.

Abstract

The risk of dying from sharp force injury is difficult to ascertain. To the best of our knowledge, no study has been performed in Norway regarding mortality due to sharp force injury or factors that impact survival. Thus, the objective of the present study was to investigate and assess mortality in subjects with sharp force injury. 

This retrospective study comprises data on 136 subjects (34 female, 102 male) with suspected severe sharp force injury (self-inflicted or inflicted by others) admitted to Haukeland University Hospital between 2001 and 2010. The majority of subjects were intoxicated, and the injury was most often inflicted by a knife. The incidence of sharp force injury in Western Norway is similar to the incidence in other European countries. Almost half of the subjects with self-inflicted injury died. In cases with injury inflicted by another individual, one in five died. Mortality rates were higher in those with penetrating chest injuries than those with penetrating abdominal injuries and higher in cases with cardiac injury compared to pleural or lung injury. Sharp force injury can be fatal, but the overall mortality rate in this study was 29%. 

Factors influencing mortality rate were the number of injuries, the topographic regions of the body injured, the anatomical organs/structures inflicted, and emergency measures performed.

Below:  Ethanol and/or drugs in subjects with sharp force injury

Below:  Number of sharp force injuries, related to outcome

Below:  Distribution of sharp force injury in surviving and deceased subjects, related to anatomical regions (both penetrating and non-penetrating injuries)

Below:  Number of surviving and deceased subjects with penetrating sharp force injury

Full article at:   http://goo.gl/q2OIUT

By:  Kristoffersen S1, Normann SA2, Morild I3, Lilleng PK3, Heltne JK4.

• 1Department of Pathology, The Gade Institute, Haukeland University Hospital, 5021 Bergen, Norway; Department of Clinical Medicine, Gade Laboratory of Pathology, University of Bergen and Haukeland University Hospital, 5021 Bergen, Norway. Electronic address: stine.kristoffersen@helse-bergen.no.
• 2Cand.Med.-Degree Programme, Faculty of Medicine and Dentistry, University of Bergen, Norway.
• 3Department of Pathology, The Gade Institute, Haukeland University Hospital, 5021 Bergen, Norway; Department of Clinical Medicine, Gade Laboratory of Pathology, University of Bergen and Haukeland University Hospital, 5021 Bergen, Norway.
• 4Department of Anaesthesia and Intensive Care, Haukeland University Hospital, 5021 Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway. 

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