Are hospital services for self-harm getting better? An observational study examining management, service provision and temporal trends in England.

OBJECTIVES: 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. DESIGN: Observational study. SETTING: A stratified random sample of 32 hospitals in England, UK. PARTICIPANTS: 6442 individuals presenting with 7689 episodes of self-harm during a 3-month audit period between 2010 and 2011. OUTCOME: Self-harm episodes, key aspects of individual management relating to psychosocial assessment and follow-up, and a 21-item measure of service quality. RESULTS: 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). CONCLUSIONS: 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.

Time trends in coroners' use of different verdicts for possible suicides and their impact on officially reported incidence of suicide in England: 1990-2005.

BACKGROUND: Official suicide statistics for England are based on deaths given suicide verdicts and most cases given an open verdict following a coroner's inquest. Previous research indicates that some deaths given accidental verdicts are considered to be suicides by clinicians. Changes in coroners' use of different verdicts may bias suicide trend estimates. We investigated whether suicide trends may be over- or underestimated when they are based on deaths given suicide and open verdicts. Method Possible suicides assessed by 12 English coroners in 1990/91, 1998 and 2005 and assigned open, accident/misadventure or narrative verdicts were rated by three experienced suicide researchers according to the likelihood that they were suicides. Details of all suicide verdicts given by these coroners were also recorded. RESULTS: In 1990/91, 72.0% of researcher-defined suicides received a suicide verdict from the coroner, this decreased to 65.4% in 2005 (p trend < 0.01); equivalent figures for combined suicide and open verdicts were 95.4% (1990/91) and 86.7% (2005). Researcher-defined suicides with a verdict of accident/misadventure doubled over that period, from 4.6% to 9.1% (p < 0.01). Narrative verdict cases rose from zero in 1990/91 to 25 in 2005 (4.2% of researcher-defined suicides that year). In 1998 and 2005, 50.0% of the medicine poisoning deaths given accidental/misadventure verdicts were rated as suicide by the researchers. CONCLUSIONS: Between 1990/91 and 2005, the proportion of researcher-defined suicides given a suicide verdict by coroners decreased, largely due to an increased use of accident/misadventure verdicts, particularly for deaths involving poisoning. Consideration should be given to the inclusion of 'accidental' deaths by poisoning with medicines in the statistics available for monitoring suicides rates.

Impact of the growing use of narrative verdicts by coroners on geographic variations in suicide: analysis of coroners' inquest data.

BACKGROUND: Coroners' death certificates form the basis of suicide statistics in England and Wales. Recent increases in coroners' use of narrative verdicts may affect the reliability of local and national suicide rates. METHOD: We used Ministry of Justice data on inquests held between 2008 and 2009 and Local Authority suicide data (2001-02 and 2008-09) to investigate variations between coroners in their use of narrative verdicts and the impact of these on suicide rates, using 'other' verdicts (79% of which are narratives) as a proxy for narrative verdicts. RESULTS: There was wide geographic variation in Coroners' use of 'other' (mainly narrative) verdicts--they comprised between 0 and 50% (median = 9%) of verdicts given by individual coroners in 2008-09. Coroners who gave more 'other' verdicts gave fewer suicide verdicts (r = - 0.41; P < 0.001). In the 10 English Coroners' jurisdictions where the highest proportion of 'other' verdicts were given, the incidence of suicide decreased by 16% between 2001-02 and 2008-09, whereas it did not change in areas served by the 10 coroners who used narratives the least. CONCLUSIONS: Variation in Coroners' use of narrative verdicts influences the validity of reported regional suicide rates. Small-area suicide rates, and changes in these rates over time in the last decade, should be interpreted with caution.

Self-poisoning suicides in England: a multicentre study.

BACKGROUND: Suicide by self-poisoning is an important cause of death worldwide. A substantial proportion of those with a fatal outcome may come into contact with medical services before they die. AIM: To estimate the proportion of self-poisoning suicides who reached hospital alive; to compare those who reached hospital alive with those who did not; to describe in detail the clinical characteristics and medical management of those dying in hospital. DESIGN: Retrospective audit. METHODS: We studied 24 coroners' jurisdictions across England, reviewing coroners' files and identifying all suicides by self-poisoning (drugs and other ingestible poisons) from 1 January 2001 to 31 December 2001. RESULTS: Of the 214 individuals who completed suicide by self-poisoning during the study period, 49 (23%) reached hospital alive. Those reaching hospital were more likely to be female, more likely to have ingested paracetamol and less likely to have ingested co-proxamol. In the hospital sample, the commonest causes of death were respiratory (n = 10), hepatic or hepatorenal (n = 8), cardiac (n = 5), or a result of hypoxic brain injury (n = 5). Only 18% of in-hospital deaths occurred within 24 h of the overdose. DISCUSSION: Extrapolating to England as a whole, we might expect 300 self-poisoning suicides per year to reach hospital alive (6% of all suicides). Improved medical management might produce a small but significant reduction in the rate of suicide. Such interventions should not be restricted to the emergency care domain. Further research will help to clarify the likely contribution of improved medical management to suicide prevention.

Co-proxamol and suicide: preventing the continuing toll of overdose deaths.

Restricting means for suicide is a key element in suicide prevention strategies of all countries where these have been introduced. Preventing deaths from analgesic overdoses is highlighted in the National Suicide Prevention Strategy for England. The problem of self-poisoning with the prescription-only drug co-proxamol (dextropropoxyphene plus paracetamol) has received attention in several countries. We have conducted a review of the international literature related to possible strategies to tackle this problem. In England and Wales in 1997-1999, 18% of drug-related suicides involved co-proxamol; these constituted 5% of all suicides. Death usually results from the toxic effects of dextropropoxyphene on respiration or cardiac function. Death from co-proxamol overdose may occur rapidly, the lethal dose can be relatively low, and the effects are potentiated by alcohol and other CNS depressants. The majority of co-proxamol overdose deaths occur before hospital treatment can be received. The risk can extend to others in the household of the person for whom the drug is prescribed. While there is limited evidence that educational strategies have been effective in reducing deaths from co-proxamol poisoning, initiatives in Scandinavia, Australia and the UK to restrict availability of co-proxamol have produced promising results. Given the paucity of evidence for superior therapeutic efficacy of co-proxamol over other less toxic analgesics, there are good reasons to question whether it should continue to be prescribed.

A multicentre study of coproxamol poisoning suicides based on coroners' records in England.

AIMS: To examine in detail a series of coproxamol overdose deaths in order to provide information that will assist in the development of strategies to prevent such fatalities. METHOD: Inquest records in 24 coroners' jurisdictions in England on deaths between January 2000 and December 2001 which received a verdict of either suicide or undetermined cause (with a high or moderate probability of suicide) were examined. RESULTS: One hundred and twenty-three coproxamol poisoning suicides were identified. Alcohol was involved in 58.5% of the overdoses and these individuals generally had lower blood drug levels and consumed fewer tablets. Younger people were more likely to have consumed alcohol and to have lower levels of suicide intent. Nearly half the individuals had a history of self harm, and a third were under psychiatric care. The coproxamol had been prescribed for the individual in 81.5% of cases, although only in 55.0% of those aged 10-34 years. In other cases the source of the coproxamol was nearly always a family member or partner. Some deaths resulted from relatively small overdoses. CONCLUSIONS: Strategies to reduce self poisoning deaths due to coproxamol should take account of the high toxicity of coproxamol in overdose, especially when combined with alcohol, and the fact that risk of death extends beyond the person for whom the drug is prescribed.

Do patients who self-harm consult their general practitioner soon after hospital discharge? A cohort study.

BACKGROUND: Deliberate self-harm (DSH, attempted suicide) is one of the most common reasons for emergency hospital admission in Great Britain. Approximately 20 % of patients repeat self-harm in the 12 months after admission. The GP's role in DSH aftercare and the prevention of repeat episodes is unclear. METHODS: The data were obtained from a 12-month follow-up of a series of 968 consecutive patients from 49 practices who attended an accident and emergency (A&E) department in Bristol or Bath, UK, following an episode of self-harm between 26(th) May 1997 and 1(st) March 1999. RESULTS: Information on consultation patterns were available for 681 (70 %) of the patients. Two hundred and fourteen (31 %) of these consulted their GP in the week following the episode, 360 (53 %) within 4 weeks. Of the subjects, 44 % were discharged directly from A & E; these patients were more likely to consult their GP in the 4 weeks after the episode. Over the 12-month follow-up, 117 (17 %) attended hospital for a repeat episode of DSH; 9 % of these repeats occurred within 1 week and 28 % within 4 weeks of the index event. Although few (2 out of 11 patients--18 %) of those repeating in the first week after the index episode consulted their GP prior to repeating, 50 % (11/22) of those who repeated in the 1-4 weeks after an episode did so. CONCLUSIONS: Consultation patterns indicate that most people who deliberately self-harm consult their GP soon after the episode. This consultation may provide an opportunity for preventing repeat DSH and suicide.

Effects of legislation restricting pack sizes of paracetamol and salicylate on self poisoning in the United Kingdom: before and after study.

OBJECTIVE: To evaluate the effects on suicidal behaviour of legislation limiting the size of packs of paracetamol and salicylates sold over the counter. DESIGN: Before and after study. SETTING: UK population, with detailed monitoring of data from five liver units and seven general hospitals, between September 1996 and September 1999. SUBJECTS: People who died by suicidal or accidental overdose with paracetamol or salicylates or who died of undetermined causes; patients admitted to liver units with hepatic paracetamol poisoning; patients presenting to general hospitals with self poisoning after taking paracetamol or salicylates. MAIN OUTCOME MEASURES: Mortality from paracetamol or salicylate overdose; numbers of patients referred to liver units or listed for liver transplant; numbers of transplantations; numbers of overdoses and tablets taken; blood concentrations of the drugs; prothrombin times; sales to pharmacies and other outlets of paracetamol and salicylates. RESULTS: Numbers of tablets per pack of paracetamol and salicylates decreased markedly in the year after the change in legislation on 16 September 1998. The annual number of deaths from paracetamol poisoning decreased by 21% (95% confidence interval 5% to 34%) and the number from salicylates decreased by 48% (11% to 70%). Liver transplant rates after paracetamol poisoning decreased by 66% (55% to 74%). The rate of non-fatal self poisoning with paracetamol in any form decreased by 11% (5% to 16%), mainly because of a 15% (8% to 21%) reduction in overdoses of paracetamol in non-compound form. The average number of tablets taken in paracetamol overdoses decreased by 7% (0% to 12%), and the proportion involving >32 tablets decreased by 17% (4% to 28%). The average number of tablets taken in salicylate overdoses did not decrease, but 34% fewer (2% to 56%) salicylate overdoses involved >32 tablets. After the legislation mean blood concentrations of salicylates after overdose decreased, as did prothrombin times; mean blood concentrations of paracetamol did not change. CONCLUSION: Legislation restricting pack sizes of paracetamol and salicylates in the United Kingdom has had substantial beneficial effects on mortality and morbidity associated with self poisoning using these drugs.