Variations in the hospital management of self-harm and patient outcome: a multi-site observational study in England.

INTRODUCTION: Studies have shown wide variations in delivery of self-harm services but it is unclear how these relate to important outcomes such as self-harm repetition. METHODS: Data were collected on self-harm presentations and hospital management from 31 hospitals in England. Key staff were interviewed about service provision for self-harm patients and responses were mapped to a 21-item service quality scale. Our main outcome was repeat hospital-presenting self-harm within six months. RESULTS: 6347 individuals presented with 7599 episodes of self-harm during a three month period in 2010-2011. Re-attendance with self-harm within six months of index episode occurred in 21% (1308/6347) of individuals (range between hospitals 9-27%). We found little association between clinical management at hospital level (i.e. proportion of episodes receiving psychosocial assessment, medical or psychiatric admission, and referral to statutory or non-statutory services) and repetition rate. The median score on service quality scale was 14.5 (range between hospitals 10.5-19). There was no evidence of correlation between total service quality score and repetition of self-harm (Spearman׳s r=-0.06, p=0.73) or between individual service items and repetition. LIMITATIONS: We did not explore certain aspects of service provision e.g. quality of psychosocial assessments and length of admission. Hospital presentation for repeat self-harm may not be the most reliable measure of service quality. CONCLUSION: At aggregate level aspects of management and service structures did not appear to be associated with self-harm repetition rates. Future research should focus on better understanding the processes underlying the delivery of services at hospital level and their relationship to outcome.

Factors influencing coroners' verdicts: an analysis of verdicts given in 12 coroners' districts to researcher-defined suicides in England in 2005.

BACKGROUND: To investigate the variation between coroners in the verdicts given to deaths thought by researchers to be probable suicides and analyse factors associated with the coroners' verdict. METHODS: Data were collected from 12 English coroner districts on all deaths in 2005 given a suicide, open, accidental or narrative verdict where suicide was considered a possibility. The data were reviewed by three experienced suicide researchers. Regression models were used to investigate factors associated with the coroners' verdict. RESULTS: The researchers classified 593 deaths as suicide, of which 385 (65.4%) received a suicide verdict from the coroner. There was marked variation between coroner districts in the verdicts they gave. The suicide method was associated strongly with the coroners' verdict; deaths from poisoning and drowning were the least likely to be given suicide verdicts. The other factors strongly associated with a coroner's verdict of suicide were: whether a note was left, age over 60 years and being married or widowed compared with being single. CONCLUSION: Coroners vary considerably in the verdicts they give to individuals who probably died by suicide. This may compromise the usefulness of suicide statistics for assessing area differences in rates for public health surveillance.

"When you're in the hospital, you're in a sort of bubble." Understanding the high risk of self-harm and suicide following psychiatric discharge: a qualitative study.

BACKGROUND: Individuals are at a greatly increased risk of suicide and self-harm in the months following discharge from psychiatric hospital, yet little is known about the reasons for this. AIMS: To investigate the lived experience of psychiatric discharge and explore service users' experiences following discharge. METHOD: In-depth interviews were undertaken with recently discharged service users (n = 10) in the UK to explore attitudes to discharge and experiences since leaving hospital. RESULTS: Informants had mixed attitudes to discharge, and those who had not felt adequately involved in discharge decisions, or disagreed with them, had experienced urges to self-harm since being discharged. Accounts revealed a number of factors that made the postdischarge period difficult; these included both the reemergence of stressors that existed prior to hospitalization and a number of stressors that were prompted or exacerbated by hospitalization. CONCLUSION: Although inferences that can be drawn from the study are limited by the small sample size, the results draw attention to a number of factors that could be investigated further to help explain the high risk of suicide and self-harm following psychiatric discharge. Findings emphasize the importance of adequate preparation for discharge and the maintenance of ongoing relationships with known service providers where possible.

A contact-based intervention for people recently discharged from inpatient psychiatric care: a pilot study.

People recently discharged from inpatient psychiatric care are at high risk of suicide and self-harm, with 6% of all suicides in England occurring in the 3 months after discharge. There is some evidence from a randomized trial carried out in the United States in the 1960s-70s that supportive letters sent by psychiatrists to high-risk patients in the period following hospital discharge resulted in a reduction in suicide. The aim of the current pilot study was to assess the feasibility of conducting a similar trial, but in a broader group of psychiatric discharges, in the context of present day UK clinical practice. The intervention was piloted on 3 psychiatric inpatient wards in southwest England. On 2 wards a series of 8 letters were sent to patients over the 12 months after discharge and 6 letters were sent from the third ward over a 6 month period. A total of 102 patients discharged from the wards received at least 1 letter, but only 45 (44.1%) received the full series of letters. The main reasons for drop-out were patient opt-out (n = 24) or readmission (n = 26). In the context of a policy of intensive follow-up post-discharge, qualitative interviews with service users showed that most already felt adequately supported and the intervention added little to this. Those interviewed felt that it was possible that the intervention might benefit people new to or with little follow-up from mental health services but that fewer letters should be mailed.

Suicide by burning barbecue charcoal in England.

BACKGROUND: Suicide by carbon monoxide poisoning from burning barbecue charcoal has become a common method of suicide in several Asian countries over the last 15 years. The characteristics of people using this method in Western countries have received little attention. METHOD: We reviewed the inquest reports of 12 English Coroners (11% of all Coroners) to identify charcoal-burning suicides. We compared socio-demographic and clinical characteristics of suicide by charcoal burning occurring between 2005 and 2007 with suicides using other methods in 2005. RESULTS: Eleven charcoal-burning suicides were identified; people using this method were younger (mean age 33.4 versus 44.8 years, P = 0.02), and more likely to be unemployed (70.0 versus 30.1%, P = 0.01) and unmarried (100 versus 70%, P = 0.04) than those using other methods. Charcoal-burning suicides had higher levels of contact with psychiatric services (80.0 versus 59.1%) and previous self-harm (63.6 versus 53.0%) compared with suicides using other methods, but these differences did not reach conventional levels of statistical significance. Over one-third of people dying by charcoal burning obtained information on this method from the Internet. CONCLUSIONS: Working with media, including Internet Service Providers, and close monitoring of changes in the incidence of suicide using this method might help prevent an epidemic of charcoal-burning suicides such as that seen in some Asian countries.

Qualitative interviewing with vulnerable populations: individuals' experiences of participating in suicide and self-harm based research.

BACKGROUND: Concern exists that involving vulnerable individuals as participants in research into suicide and self-harm may cause distress and increase suicidal feelings. Actual understanding of participants' experiences is however limited, especially in relation to in-depth qualitative research. METHODS: Data were collected from four separate studies focused on self-harm or suicide. These included people with varying levels of past distress, including some who had made nearly lethal suicide attempts. Each involved semi-structured qualitative interviewing. Participants (n=63) were asked to complete a visual analogue scale measuring current emotional state before and after their interview and then comment on how they had experienced the interview, reflecting on any score change. RESULTS: Most participants experienced a change in well-being. Between 50% and 70% across studies reported improvement, many describing the cathartic value of talking. A much smaller group in each study (18-27%) reported lowering of mood as they were reminded of difficult times or forced to focus on current issues. However, most anticipated that their distress would be transient and it was outweighed by a desire to contribute to research. An increase in distress did not therefore necessarily indicate a negative experience. LIMITATIONS: There was no follow-up so the long-term effects of participation are unknown. Scores and post interview reflections were collected from participants by the researcher who had conducted the interview, which may have inhibited reporting of negative effects. CONCLUSIONS: These findings suggest individuals are more likely to derive benefit from participation than experience harm. Overprotective gate-keeping could prevent some individuals from gaining these benefits.

The use of the Internet by people who die by suicide in England: a cross sectional study.

BACKGROUND: There is widespread concern regarding the possible influence of the Internet on suicidal behaviour. The aim of this study was to estimate the prevalence and characteristics of Internet-related suicide in England. METHODS: Cross sectional study based on detailed review of the inquest reports of suicides occurring in the areas served by 12 Coroners in England. Evidence of Internet use in relation to the suicide was sought for each death. RESULTS: Altogether inquest reports for 593 suicides (all methods) in 2005 and 166 suicides using specific methods in 2006-7 were assessed. There was evidence of a direct Internet contribution in nine (1.5% 95%CI 0.7 to 2.9%) of the 593 suicides in 2005. In seven (77.8%) of the cases the individuals had used the Internet to research the methods of suicide they used. Five (55.6%) individuals had used 'unusual' high-lethality methods, whereas such methods were only used in 1.7% of all suicides (p<0.001). There was evidence of Internet involvement in 2.4% (0.7% to 6.1%) of the suicides in 2006-2007. None of the Internet-related suicides appeared to occur as part of a suicide pact. LIMITATIONS: The contribution of the Internet to suicide rates may be under-estimated in this analysis as Coroners are unlikely to comprehensively pursue the possibility of Internet involvement in all the deaths they investigate. CONCLUSIONS: Easy access to information about suicide methods and pro-suicide web sites on the Internet appears to contribute to a small but significant proportion of suicides. A key impact of the Internet appears to be in relation to information concerning suicide methods.

A comparison of participant information elicited by service user and non-service user researchers.

OBJECTIVE: The study examined whether data collected by researchers who were service users differed from data collected by non-service user researchers in a study that measured perceived coercion. METHODS: Over two years, 548 inpatients in England were interviewed during their first week of compulsory admission to a psychiatric bed at three regional mental health provider settings. Each site had one service user researcher and one nonuser researcher. The dependent variables were two measures of perceived coercion. Service users disclosed their status, including past hospitalization, to 93 of the 242 (38%) patients they interviewed. RESULTS: No differences were found on either variable between the three researcher categories (nondisclosed user, disclosed user, and nonuser researcher). An interaction with site was noted, and possible interpretations of this finding are discussed. CONCLUSIONS: Further research is needed to determine the conditions under which service user researchers obtain information that differs from that obtained by nonuser researchers.

Suicidal behaviour and suicide from the Clifton Suspension Bridge, Bristol and surrounding area in the UK: 1994-2003.

BACKGROUND: Little is known about the characteristics of people who die by jumping from different locations (e.g. bridges, buildings) and the factors that might influence the effectiveness of suicide prevention measures at such sites. METHODS: We collected data on suicides by jumping (n = 134) between 1994 and 2003 in Bristol, UK, an area that includes the Clifton Suspension Bridge, a site renowned for suicide. We also carried out interviews with Bridge staff and obtained records of fatal and non-fatal incidents on the bridge (1996-2005) before and after preventive barriers were installed in 1998. RESULTS: The main sites from which people jumped were bridges (n = 71); car parks (n = 12); cliffs (n = 20) and places of residence (n = 20). People jumping from the latter tended to be older than those jumping from other sites; people jumping from different sites did not differ in their levels of past self-harm or current psychiatric care. As previously reported, suicides from the bridge halved after the barriers were erected; people jumping from the Clifton Suspension Bridge following their construction were more likely to have previously self-harmed and to have received specialist psychiatric care. The number of incidents on the bridge did not decrease after barriers were installed but Bridge staff reported that the barriers 'bought time', making intervention possible. CONCLUSION: There is little difference in the characteristics of people jumping from different locations. Barriers may prevent suicides among people at lower risk of repeat self-harm. Staff at suicide hotspots can make an important contribution to the effectiveness of installations to prevent suicide by jumping.

Postcards, green cards and telephone calls: therapeutic contact with individuals following self-harm.

Self-harm is a major public health problem and universal interventions such as contacting individuals by post or telephone following a self-harm episode have received much attention recently. They may also appeal to service providers because of their low cost. However, a widespread introduction of these interventions cannot be justified without a better understanding of whether they work, and if so how.

Ethnicity and coercion among involuntarily detained psychiatric in-patients.

We assessed whether adult Black and minority ethnic (BME) patients detained for involuntary psychiatric treatment experienced more coercion than similar White patients. We found no evidence of this from patient interviews or from hospital records. The area (mental health trust) where people were treated was strongly associated with both the experience of coercion and the recording of a coercive measure in their records. Regarding charges of institutional racism in psychiatry, this study highlights the importance of investigating the role of area characteristics when assessing the relationship between ethnicity and patient management.

Effect of barriers on the Clifton suspension bridge, England, on local patterns of suicide: implications for prevention.

We assessed the effect of the installation of barriers on the Clifton suspension bridge, Bristol, England, in 1998 on local suicides by jumping. Deaths from this bridge halved from 8.2 per year (1994-1998) to 4.0 per year (1999-2003; P=0.008). Although 90% of the suicides from the bridge were by males, there was no evidence of an increase in male suicide by jumping from other sites in the Bristol area after the erection of the barriers. This study provides evidence for the effectiveness of barriers on bridges in preventing site-specific suicides and suicides by jumping overall in the surrounding area.

Factors associated with the non-assessment of self-harm patients attending an Accident and Emergency Department: results of a national study.

BACKGROUND: Psychosocial assessment of self-harm patients by mental health service staff is an important aspect of their care. Nevertheless, in England around half of those attending a general hospital following a self-harm episode do not receive such an assessment. We have investigated the reasons for this and the characteristics of patients associated with self-discharge or planned discharge without a psychosocial assessment. METHOD: 8-week audits of self-harm attendances were carried out in 32 Accident and Emergency Departments in England. Where a specialist psychosocial assessment by mental health services was not carried out, information on the reason for this was requested. Due to incomplete data 10 of the 32 hospitals were excluded from analysis. RESULTS: There were 2780 self-harm attendances at the 22 hospitals. Psychosocial assessments were carried out on 59% of episodes. Among those not assessed, 57% discharged themselves and the remainder were discharged by hospital staff. In multivariable models, being male, taking illegal drugs/alcohol, attendance out of office hours and not being admitted to a hospital bed were associated with an increased risk of self-discharge. Younger subjects were more likely to self-discharge, but this association was explained by age-related admission patterns. Young age (<45 years), no previous self-harm and not being admitted were associated with an increased likelihood of discharge by hospital staff without a psychosocial assessment. The apparent increased risk of discharge without an assessment for those who self-lacerated was attenuated after allowing for their lower admissions rates. LIMITATIONS: Missing data from 10 hospitals led to their exclusion from analysis. Only the primary reason for discharge was reported on the audit forms. CONCLUSIONS: Those at elevated risk of suicide--older patients and those with a history of self-harm--were the least likely to be discharged by hospital staff without a psychosocial assessment. However, males (at increased risk of suicide compared with females), those who had taken illegal drugs or/and alcohol and those attending 'out of hours' were more likely to self-discharge. Services need to be modified and evaluated, based on further information about why such individuals are not currently engaging in services.

Gunshot suicides in England--a multicentre study based on coroners' records.

BACKGROUND: Gunshot suicides account for 2.5% of suicides in England and Wales. This amounts to more than 100 deaths per year. Information about such deaths may assist in the development of suicide prevention strategies. METHOD: We have examined coroners' inquest records for all gunshot suicides between 1st January 2000 and 31st December 2001 in 24 coroners' jurisdictions in England. RESULTS: Fifty-eight gunshot suicides were identified, including one homicide-suicide. Ninety-three per cent of cases were male. Sport or occupational usage was the main reason for owning the gun. Ten per cent were farmers or farm-workers. In 20% of cases the gun did not belong to the individual who used it for suicide. This was more likely in younger suicides. Seven (12.1%) individuals used illegally owned handguns. Large amounts of alcohol had been consumed before the act in nine cases. Nearly three-quarters (72.9%) of individuals with diagnostic information had a probable diagnosis of depression. However, only 22.4% had ever had contact with psychiatric services. Two shotgun certificate holders were under the care of psychiatric services at the time of their death and two others had a history of previous self-harm. CONCLUSIONS: Strategies to reduce the number of gunshot suicides need to focus on limiting access to guns. These include restricting access to guns by non-certificate holders and those who may be at increased risk of suicide, and holding regular gun amnesties.

Suicide by hanging: multicentre study based on coroners' records in England.

We studied 162 cases of hanging by suicide occurring in 24 coroners' jurisdictions in England within a 6-month period in 2001. Prison and psychiatric ward suicides accounted for only 6% of these. The most frequently used ligatures (ropes, belts and cable) and ligature points (beams, girders, lofts and trees) are commonly available in community settings, limiting opportunities for prevention. In only half the cases (52%) were victims fully suspended with both feet off the ground. Four per cent had also taken an overdose.

The epidemiology and prevention of suicide by hanging: a systematic review.

BACKGROUND: Hanging is one of the most commonly used methods for suicide worldwide. In England and a number of other countries, its incidence has increased over the last 30 years. This review summarizes the published literature on suicide by hanging. The focus is on its epidemiology in England and on identifying potential means of prevention. METHODS: We searched Medline (1966-2003), Embase (1980-2003), CINAHL (1982-2003) and PsycINFO (1967-2003). As considerable research on suicides occurring in prisons and psychiatric hospitals in England and Wales has been carried out by the National Confidential Inquiry into Suicide and Homicide (Manchester) and the Prison Service's Safer Custody Group, we obtained additional information from these sources. RESULTS: Only a small proportion (around 10%) of hanging suicides occur in the controlled environments of hospitals, prisons, and police custody; the remainder occur in the community. The most commonly used ligatures (rope, belts, flex) and ligature points (beams, banisters, hooks, door knobs, and trees) are widely available; thus prevention strategies focused around restriction of access to means of hanging are of limited value. Around 50% of hanging suicides are not fully suspended--ligature points below head level are commonly used. Case fatality following attempted suicide by hanging is around 70%; the majority (80-90%) of those who reach hospital alive survive. CONCLUSION: Strategies to reduce suicide by hanging should focus on the prevention of suicide in controlled environments, the emergency management of 'near-hanging' and on the primary prevention of suicide in general. More research is required to better understand the recent rise in popularity of this method.

The epidemiology and management of self-harm amongst adults in England.

BACKGROUND: Previous research into the epidemiology and management of self-harm has been largely based in centres with a special interest in this behaviour or focused on hospital admissions only. There are no national data on the characteristics and management of people presenting to hospital following self-harm. METHODS: Data were collected from 8-week service audits carried out in a stratified random sample of 31 general hospitals in England. RESULTS: 4033 episodes of self-harm resulting in presentation to Accident and Emergency Departments were identified. Overdose alone accounted for 79 per cent of episodes, 80 per cent of presentations were outside normal office hours (9 am - 5 pm, Monday to Friday) and the peak period of attendance was from 8 pm to 2 am. In only 56 per cent of episodes was a specialist psychosocial assessment conducted prior to discharge and less than half (46 per cent) led to admission to a hospital bed. Psychiatric admission occurred in 10 per cent. Episodes involving older subjects (>45 years) and those using methods other than laceration or overdose were the most likely to lead to assessment and admission. CONCLUSIONS: Non-fatal self-harm is one of the strongest predictors of suicide, yet nearly half of all hospital attendances in England following self-harm do not lead to a specialist assessment. Patterns of service provision should take account of the observation that most self-harm attendances occur outside normal working hours and those at greatest risk of repetition are the least likely to receive assessments.

The usefulness of coroners' data on suicides for providing information relevant to prevention.

Coroners' records are an accessible source of information on suicides. To assess their usefulness in relation to the investigation of specific methods of suicide, we examined coroners' records for 492 suicides across 24 jurisdictions in England. Generally data on demographic variables were well recorded. Information on contact with general practitioner and psychiatric services was less commonly available. Where those who had self-poisoned died in hospital, information on treatment and blood levels of drugs taken were not routinely available. For suicides by hanging, information on the source of ligature was frequently missing. Where firearms were used, information about licensing and storage were not routinely recorded. Generally there was wide variation across coroners in information relevant to specific methods. The use of standardized forms by coroners would assist studies of factors associated with suicide and potentially provide a representative source of information relevant to suicide prevention.