The danger of inappropriate use of personal protective equipment

The coronavirus pandemic is a global health emergency which has had widespread unforeseen mental health consequences. Those with borderline personality disorder are predisposed to poor coping strategies to manage such stress and require intense psychological input which was not widely available during the peak of the pandemic. It is likely that the coronavirus outbreak has had a significant impact on the mental stability of such patients aggravating deliberate self-harm behaviours. A 20-year old psychiatric in-patient with borderline personality disorder, held under Section III of the mental health act, presented to the adult plastic surgery team in Bristol with localised infection of her right forearm. Foreign bodies were easily palpable and imaging revealed linear metal objects. The patient reported that she had removed metal strips from her collection of face masks and inserted them into her forearm as an act of deliberate self-harm. The patient was taken to operating theatre for removal of these foreign bodies under general anaesthetic. After twenty-four hours of antibiotics she was discharged safely back to the psychiatric ward. Despite the epilogue of the COVID-19 pandemic facemasks are still mandatory within the hospital setting. Clinicians need to be aware of these unusual circumstances where a form of protective equipment was deconstructed to cause actual bodily harm. The purpose of this report is to promote awareness of this type of injury especially in those suffering from mental illness. The authors would suggest an alternative mask without any form of metal.

Management of Laryngotracheal Trauma During the COVID 19 Pandemic: Our Experience.

Objective To study the outcomes in terms of airway, voice and swallowing as well as the economic impact of the trauma on patients' finances and the constrained health infrastructure due to the pandemic. Materials and methods Study design Retrospective study. Setting : Tertiary care teaching hospital. Subjects and methods: A retrospective study was done of the 19 subjects who sustained acute laryngotracheal trauma during the SARS CoV-2 pandemic and was managed at our institution from January 2020 to September 2021. Results Change in voice was the most common presenting symptom and thyroid cartilage fractures were the commonest cartilage injury noted. It was found that 93% (decannulated) of the patients had good functional outcome and 90% of them required financial support to meet the medical expenses. Conclusion During the COVID 19 pandemic, it was not only, early presentation, timely detection and intervention by the treating team, but also the multidisciplinary teamwork and the support system that facilitated the recuperation and restoration of these traumatized individuals back into society with good laryngeal function.

Locked in and locked out: sequelae of a pandemic for distressed and vulnerable teenagers in Ireland : Post-COVID rise in psychiatry assessments of teenagers presenting to the emergency department out-of-hours at an adult Irish tertiary hospital.

OBJECTIVE: The aim of this study is to investigate the impact of the coronavirus pandemic on teenage psychiatry referrals following crisis presentation to the adult emergency department (ED) of an Irish tertiary hospital. In doing so, this study will specifically examine the effect of COVID-19 on self-injurious behaviour, suicidality and substance use among older adolescents (age 16/17 years). METHODS: This is a retrospective descriptive analysis of acute adolescent psychiatry referrals assessed out-of-hours via the adult ED psychiatry service across three consecutive time points (during the months of March, April and May) from pre-pandemic, 2019 (T1); initial pandemic, 2020 (T2); and peak pandemic, 2021 (T3). Data were obtained via the hospital's ED-specific electronic database, review of original assessment notes and cross-referenced by manually extracting data logged in the on-call register. RESULTS: Crisis psychiatry assessments of teenagers during on-call hours trebled during the period of this study (p < 0.001). Although ED/crisis referrals initially decreased overall at the start of the pandemic, the rate of teenage referrals remained constant, before increasing as restrictions tightened in lockdown. The negative impact of COVID-19 on teenagers' ability to cope was found to be statistically significant (p = 0.001). Changes in rates of self-harming and/or suicidal behaviours were not statistically significant between 2019, 2020 and 2021 (p = 0.082). Alcohol misuse occurred in up to one-third of cases across each timeframe and remained virtually constant throughout the pandemic. Drug misuse decreased from onset of COVID-19 (p = 0.01). CONCLUSIONS: To our knowledge, this is the first study to specifically examine the impact of COVID-19 on suicidality, self-harming behaviours, substance misuse and on-call ED presentations of teenagers in Ireland. This study demonstrates that coronavirus-related stress is associated with negative mental health sequelae for vulnerable at-risk older adolescents, as evidenced by a rise in ED presentations and on-call referrals since the onset of the pandemic. Presentation of increased numbers of under-18's for psychiatry assessment at the adult ED/general hospital indicates a deepening chasm between available and aspirational emergency (adolescent-specific) psychiatric care in the community. Mobilising resilience factors and maximising coping skills for at-risk youth will inform tailored intervention and support strategies along with adequate resourcing of services for vulnerable adolescents in the community.

Trends and Prevalence of Hospital Admissions Related to Deliberate Self-Poisoning and Used Substances in Romanian Adolescents between 2016 and 2022.

Rates of self-poisoning are increasing substantially all around the world, with self-poisoning being the most common form of self-harm leading to hospitalization in children and adolescents. This study aims to investigate the trends in the number of deliberate self-poisoning admissions in Romanian adolescents during the period of 2016-2022, as well as the most frequently used substances and the impact of the COVID-19 pandemic on hospital admissions due to self-poisoning and substance use in relation to these episodes. The sample included 178 patients admitted to the Clinic of Pediatric Psychiatry in Cluj-Napoca from 2016 to 2022 due to an episode of self-poisoning. Data were collected on patients' sociodemographic characteristics, psychosocial characteristics, and medical histories. We report a slight overall increase in the self-poisoning admission rate during the studied period. There was a decrease during the initial period of the pandemic, with significantly increasing rates in the second year of the pandemic. The mean prevalence rate of hospital admissions due to self-poisoning episodes during the study period was 3.14% (95% CI 2.72, 3.63). Adolescent girls were identified as the most vulnerable group, with the female-to-male ratio increasing dramatically. In terms of substance use, benzodiazepines; over-the-counter analgesics, including paracetamol; and antidepressants were the most frequently used substances. We emphasize the importance of careful consideration in prescribing psychotropic drugs, as well as the need for regulation of over-the-counter drug dispensation.

Management of suicide and self-harm risk by the National Mental Health Helpline in the State of Qatar.

BACKGROUND: Suicide is a serious public health problem. AIMS: To investigate the sociodemographic and clinical features of callers (patients) classed by the Qatar National Mental Health Helpline (NMHH) as moderate to high priority based on the risk of self-harm or suicide during the COVID-19 pandemic. METHOD: The study design was a retrospective chart review of patients who contacted the helpline in the first 12 months, starting 1 April 2020. Data of those classed as moderate to high priority based on risk to self were collected using a specifically designed form. Absolute and relative frequencies for each of the studied categorical variables were determined. RESULTS: Four hundred and ninety-eight patients were included. More than half were female. The mean age was 32 years (range 8-85 years). Two-thirds of patients were from Arab countries and more than half of all patients had contacted mental health services for the first time. The most common symptoms elicited included suicidal thoughts, depressed mood and disturbed sleep. The most common psychiatric disorders were depression and generalised anxiety disorder. Most patients were seen within 4 h and received psychiatric interventions. Virtually all patients received non-pharmacological interventions; only 38.5% received pharmacological interventions. The majority had follow-up appointments arranged with mental health services. CONCLUSIONS: People from the Indian subcontinent and males proportionally approached services less, which may reflect stigma. The NMHH improved access to care for patients considered at risk to self and prevented hospital admissions. The NMHH offers a valuable additional choice to patients and assists in prevention and management of suicidal behaviour and other mental health difficulties.

Depression and suicidal behavior in adolescents. (Special Issue: Clinical psychiatry.)

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A Rapid Systematic Review of the Prevalence of Suicide and Self-Harm Behaviors in Adolescents During the COVID-19 Pandemic.

Background: COVID-19 has caused psychological, social, and physical isolation in adolescents resulting in varying rates of suicidal behavior and self-harm. Aims: We investigated the pandemic's impact on adolescent suicidal behavior and self-harm by reviewing the existing literature. Methods: We searched PubMed using keywords: adolescent, suicide, suicidal behavior, self-harm, prevalence, and COVID-19 and included studies reporting primary data only. Results: Of the 551 studies identified, we included 39 studies in the final analysis. Two of the six high-quality population-based suicide registry studies reported increased suicide rates during the pandemic. Seven of fifteen emergency department-based studies out of which four were of high quality and three high-quality population-based health registry studies reported increased self-harm. A few school and community-based surveys and national helpline data also reported an increase in suicidal behavior or self-harm. Limitations: Methodological heterogeneity of the included studies. Conclusions: There is wide variation in study methodology, population, settings, and age groups in the included studies. Suicidal behavior and self-harm were increased in specific study settings and adolescent populations during the pandemic. More methodologically rigorous research is needed to evaluate the impact of COVID-19 on adolescent suicidal behavior and self-harm.

Implementing Evidence-Based Suicide Prevention Strategies for Greatest Impact.

Suicide remains a leading cause of death in the United States and globally. In this review, epidemiological trends in mortality and suicide risk are presented, with consideration given to the impact of the COVID-19 pandemic. A public health model of suicide prevention with a community and clinical framework, along with advances in scientific discovery, offer new solutions that await widespread implementation. Actionable interventions with evidence for reducing risk for suicidal behavior are presented, including universal and targeted strategies at community, public policy, and clinical levels. Clinical interventions include screening and risk assessment; brief interventions (e.g., safety planning, education, and lethal means counseling) that can be done in primary care, emergency, and behavioral health settings; psychotherapies (cognitive-behavioral, dialectical behavior, mentalization therapy); pharmacotherapy; and systemwide procedures for health care organizations (training, policies, workflow, surveillance of suicide indicators, use of health records for screening, care steps). Suicide prevention strategies must be prioritized and implemented at scale for greatest impact.

Predictors of self-harm and emergency department attendance for self-harm in deprived communities.

Emergency departments (EDs) are often the first point of contact for individuals following self-harm. The majority of previous research relies on hospital-based data, yet only a minority of individuals who self-harm in the community present to healthcare services. The study design is cross-sectional survey design. Data from the National Institute for Health Research Applied Research Collaboration North West Coast (NIHR ARC NWC) Household Health Survey, a community-based public health survey in North West England, was collected using stratified random sampling. Three thousand four hundred twelve people were recruited in 2018 from relatively disadvantaged areas. The sample included 1490 men and 1922 women aged 18 to 100 years (M = 49.37, SD = 18.91). Logistic regression analysis was employed to examine demographic, health and socioeconomic predictors of self-harm and ED attendance for self-harm. Age (18-24 years), lower financial status, depression, anxiety and physical and mental health co-morbidity was associated with significantly higher levels of self-harm. People aged 18-24 years, with physical and mental health co-morbidity and lower levels of social support had significantly higher levels of attending EDs for self-harm. Improving people's financial situations, social connectivity, mental and physical health may help to reduce individual risk for self-harm and strain on health services.

Global prevalence of self-harm during the COVID-19 pandemic: a systematic review and meta-analysis.

BACKGROUND: COVID-19 and its transmission mitigation measures have caused widespread mental health problems. Previous studies have suggested that psychological, economic, behavioral, and psychosocial problems associated with the COVID-19 pandemic may lead to a rise in self-harm. However, little is known about the prevalence of self-harm worldwide during COVID-19. Therefore, a quantitative synthesis is needed to reach an overall conclusion regarding the prevalence of self-harm during the pandemic. METHODS: By using permutations of COVID-19, self-harm or relevant search terms, we searched the following electronic databases from November 2019 to January 2022: Web of Science, PubMed, MEDLINE, Embase, PsycINFO, Cochrane Database of Systematic Reviews, China National Knowledge Infrastructure (CNKI), Wanfang Database and systematically reviewed the evidence according to MOOSE guidelines. We employed Cochran's chi-squared test (Cochran's Q), I2test and subgroup analysis to assess and address the heterogeneity. Sensitivity analysis was conducted by eliminating each included study individually and then combining the effects. RESULTS: Sixteen studies that met the inclusion and exclusion criteria were identified, with sample sizes ranging from 228 to 49,227. The methodological quality of the included studies was mostly at the medium level. By using a random effect model, the pooled prevalence of self-harm was 15.8% (95% CI 13.3-18.3). Based on subgroup analysis, the following characteristics of the included studies were more likely to have a higher prevalence of self-harm: studies conducted in Asia or prior to July 2020, cross-sectional studies, samples recruited in hospitals or schools, adolescents, females, the purpose of self-harm (NSSI), mental symptoms and restriction experiences. CONCLUSIONS: We provided the first meta-analytic estimated prevalence of self-harm based on a large sample from different countries and populations. The prevalence of self-harm during COVID-19 was not encouraging and requires attention and intervention. Further high-quality and prospective research are needed in order to determine the prevalence of self-harm with greater accuracy because to the clear heterogeneity across the included studies. In addition, this study also provides new directions for future research, including the identification of high-risk groups for self-harm, the formulation and implementation of prevention and intervention programs, and the long-term impact of COVID-19 on self-harm.

Factors Affecting Self-Harm- or Violence-Related Urgent Psychiatric Consultation During the COVID-19 Pandemic in Taiwan.

Purpose: People's health-care-seeking behaviors considerably changed during the COVID-19 pandemic. This study evaluated the changes in self-harm- and violence-related urgent psychiatric consultation (UPC) in the emergency department (ED) during different stages of the pandemic and at different levels of hospitals. Patients and Methods: We recruited patients who received UPC during the baseline (2019), peak (2020), and slack (2021) periods of the same time window (calendar weeks 4-18) during the COVID-19 pandemic. Demographic data such as age, sex, and referral type (by the police/emergency medical system) were also recorded. Results: We found female gender and younger age associated with higher risk of self-harm-related UPCs, whereas patients visiting regional hospitals, male patients, and patients referred by the policy/emergency medical system, had a higher risk of violence-related UPCs. After adjustment, the different pandemic stages were not significantly associated with self-harm- or violence-related UPCs. Conclusion: Patient's demographic data, but not the pandemic itself, may be responsible for the changes in self-harm- and violence-related UPCs during the pandemic.

Suicide attempts among children and adolescents admitted to a Polish Emergency Department: Analysis of epidemiology, circumstances and methods of 154 cases.

BACKGROUND: Suicide attempts among pediatric patients are currently one of the most critical issues in modern psychiatry and emergency medicine, and constitute a serious public health problem that affects people of almost every age group. It is often emphasized that attempted suicide is a cry for help, and according to international studies, the pandemic year of 2020 massively impacted the frequency of suicide attempts among children. However, such studies have yet to appear in Poland. OBJECTIVES: To characterize the frequency, circumstances and methods of suicide attempts among children and adolescents, and investigate their relationship with coronavirus disease 2019 (COVID-19). MATERIAL AND METHODS: The study retrospectively analyzed the medical records of 154 children admitted to the Emergency Department due to suicide attempts between January 2020 and June 2021. RESULTS: No statistical relationship was found between the direct impact of the pandemic and suicide attempts among children and adolescents. However, age and gender influenced the methods used and the frequency of suicide attempts. Females are more likely to attempt suicide than males, and patients as young as 8 tried to take their own lives. CONCLUSIONS: Due to the increasing frequency of suicide attempts in children and adolescents, people at particular risk of such behaviors should be identified and provided with effective care. Unfortunately, although the vast majority of pediatric patients who attempted suicide had psychiatric consultations in the past, it did not prevent them from actively trying to end their lives. Furthermore, even children of a very young age are at risk of suicide events.

Fitting in an Unfit Society With Autism Spectrum Disorder: Case Report.

Evaluating behavioral mimicking is important in healthcare providers' everyday functioning with an increased presentation of Tourette syndrome-like cases during the COVID-19 pandemic, seen due to the popular video creators on social media (e.g., TikTok) exhibiting these behaviors. Individuals with autism spectrum disorder (ASD) face difficulties with connection and assimilation, and they adapt by camouflaging their behaviors to fit with those of the neurotypical majority. Our team evaluated the behaviors of one individual with ASD to establish whether camouflaging was playing a role in her psychiatric stabilization in our inpatient psychiatric unit. We present a case of a 30-year-old female with ASD, admitted to our long-term inpatient psychiatric facility for significant mood dysregulation that persisted despite numerous treatment approaches (mediations, groups, etc.). While her initial behaviors included head banging and self-induced falls, her behaviors seemed to change based on those of her peers, in an apparent attempt to camouflage into the social environment within the unit. She also appeared to learn new self-harm behaviors, such as skin picking, from peers around her. The team was able to establish a temporal link between some instances of peers exhibiting specific behaviors and our patient engaging in similar behavior. Although inpatient units effectively manage long-term stabilization in other psychiatric disorders, these environments are not designed for individuals with ASD. Treatment teams should recognize the malleability of behaviors in patients with ASD and must identify and manage behavioral mimicking early during inpatient psychiatric treatment; otherwise, it may lead to significant harm.

Impact of loneliness on suicidal ideation during the COVID-19 pandemic: findings from a cross-sectional online survey in Japan.

OBJECTIVES: We aim to reveal how loneliness relates to suicidal ideation following the onset of the COVID-19 pandemic. DESIGN: Cross-sectional online survey. SETTING: Community cohort study in Japan. PARTICIPANTS: The second wave of a large web-based survey, Japan COVID-19 and Society Internet Survey, was conducted in February 2021, and we analysed the data of 6436 men and 5380 women who were aged 20-59 years. MAIN OUTCOME MEASURES: The prevalence ratios (PRs) of suicidal ideation due to loneliness, depression, social isolation and decline in income during the pandemic and other sociodemographic and economic information were adjusted in the analysis. STATISTICAL METHODS: Estimations were conducted by separating a male and female sample. The survey weight (inverse probability weighting) was applied for analyses, and a Poisson regression model was used with all the potential confounders adjected. RESULTS: Overall, 15.1% of male and 16.3% of female participants were found to have had suicidal ideation during the COVID-19 pandemic. Among them, 23% of male and 20% of female participants experienced suicidal ideation for the first time. The results of the Poisson regression suggested that those who were feeling lonely had higher PRs for suicidal ideation (4.83 for men (95% CI, 3.87 to 6.16) and 6.19 for women (95% CI, 4.77 to 8.45)). The relationship between loneliness and suicidal ideation remained robust even after adjusting for depression, although there were declines in PRs. Additionally, the results showed that those who were lonely, and continued to feel lonely during the pandemic, had the highest PRs of suicidal ideation. CONCLUSION: Loneliness had both direct and indirect effects on suicidal ideation mediated through depression. Those who felt lonelier during the pandemic had the highest risk of suicidal ideation. It is necessary to adopt national measures focused on providing psychological support to people who feel lonely to prevent them from taking their own lives.

Significant Increase in Deliberate Self-Poisonings Among Adolescents During the Second Year of the COVID-19 Pandemic.

PURPOSE: The COVID-19 pandemic has been associated with a decline in mental health of adolescents. The aim of this study was to analyze the rate of deliberate self-poisonings (DSPs) among adolescents reported to the Dutch Poisons Information Center before and during the COVID-19 pandemic. METHODS: A retrospective study from 2016 until 2021 was performed to characterize DSPs among adolescents, and to analyze trends in the number of DSPs. All DSPs among adolescents with the age of 13 up to and including 17 years were included. DSP characteristics included: age, gender, bodyweight, used substance, dose, and treatment advice. Trends in the number of DSPs were analyzed using time series decomposition and Seasonal Autoregressive Integrated Moving Average models. RESULTS: Six thousand nine hundred fifteen DSPs in adolescents were recorded from January first 2016 until December 31st 2021. Females were involved in 84% of adolescent DSPs. A strong increase in the number of DSPs was observed in 2021 (45% increase compared to 2020), which deviated from the predicted trend based on previous years. This increase was most prominent in 13-, 14-, and 15-year-old female adolescents. Commonly involved drugs were paracetamol, ibuprofen, methylphenidate, fluoxetine, and quetiapine. The contribution of paracetamol rose from 33% in 2019 to 40% in 2021. DISCUSSION: The strong increase in the number of DSPs during the second year of the COVID-19 pandemic suggests that long-term containment measures such as quarantines, lockdowns, and school closures may enhance self-harm behavior among adolescents, especially among younger females (13-15 years of age), with a preference for paracetamol as DSP substance.

Evaluating a Smartphone App for University Students Who Self-Harm

Self-harm and other mental health difficulties are very common amongst university students, but students face numerous barriers in accessing professional support. Support offered via a smartphone app may help to overcome some of the barriers they face, while providing support that is acceptable and helpful. However, there is limited research on supportive apps for students who self-harm. This study aimed to evaluate a self-help app (BlueIce) for helping students manage their self-harm, mental wellbeing and coping ability. This was a pre-post study in which 80 participants completed baseline measures online and were sent a link to download BlueIce. Of these, 27 completed follow-up questionnaires six weeks later assessing anxiety, depression, self-harm, and coping self-efficacy/styles. At follow-up, participants also completed a questionnaire evaluating BlueIce. Self-harm urges and symptoms of anxiety and depression significantly decreased, and coping self-efficacy significantly increased. Around two thirds (64%) said that BlueIce had stopped them from harming themselves an average of 24 times. Feedback showed that BlueIce helped provide a distraction in difficult times and helped them to manage their emotions in a more adaptive way. Following the trial period, participants' wellbeing had significantly improved, suggesting that BlueIce may be helpful for university students in managing their self-harm urges and general mental health.

Police-led real-time surveillance system for suspected suicides in Great Britain.

It has become increasingly apparent that rapidly available information about the occurrence of suicides is needed, particularly to support suicide prevention efforts. Concerns about the potential impact of the COVID-19 pandemic on vulnerability to suicide highlighted the need for such early data internationally. Here, we set out the nature, current status and content of a real-time suicide monitoring system in Great Britain (England, Scotland and Wales), and explore its potential to contribute to timely and targeted suicide prevention initiatives. We also discuss the challenges to successful implementation.

The Risk-Taking and Self-Harm Inventory for Adolescents: Validation of the Italian Version (RTSHIA-I).

The aim of the present paper is to establish the factorial validity and reliability of the Risk-Taking and Self-Harm Inventory for Adolescents (RTSHIA), proposed by Vrouva and colleagues in 2010, in an Italian sample. The RTSHIA measures both Risk-Taking and Self-Harm behavior in adolescents. We administered the scale to a total of 1292 Italian adolescents from 9th to 12th grade; to verify the validity of the scale, we also assessed emotion regulation and psychopathological traits. The exploratory factor analysis (EFA) (N = 638) and the confirmatory factor analysis (CFA) (N = 660) confirmed the original two-factor structure of the RTSHIA (Risk-Taking and Self-Harm). The only differences in the Italian version of the RTSHIA (RTSHIA-I) were that one item was moved from the original Risk-Taking factor to the Italian Self-Harm factor, and another item that was not included in the original RTSHIA is now part of the Risk-Taking factor in the Italian version. The reliability of the RTSHIA-I is also confirmed, and both factors correlate with emotion regulation and externalizing/internalizing traits. Our results suggest that the RTSHIA-I is a useful tool for assessing Risk-Taking and Self-Harm behaviors in Italian adolescents, and the correlational patterns indicate that these behaviors may be related to difficulties in mentalization skills.