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Complex challenges may arise when patients present to emergency services with an advance decision to refuse life-saving treatment following suicidal behaviour.
To investigate the use of advance decisions to refuse treatment in the context of suicidal behaviour from the perspective of clinicians and people with lived experience of self-harm and/or psychiatric services.
Forty-one participants aged 18 or over from hospital services (emergency departments, liaison psychiatry and ambulance services) and groups of individuals with experience of psychiatric services and/or self-harm were recruited to six focus groups in a multisite study in England. Data were collected in 2016 using a structured topic guide and included a fictional vignette. They were analysed using thematic framework analysis.
Advance decisions to refuse treatment for suicidal behaviour were contentious across groups. Three main themes emerged from the data: (a) they may enhance patient autonomy and aid clarity in acute emergencies, but also create legal and ethical uncertainty over treatment following self-harm; (b) they are anxiety provoking for clinicians; and (c) in practice, there are challenges in validation (for example, validating the patient’s mental capacity at the time of writing), time constraints and significant legal/ethical complexities.
The potential for patients to refuse life-saving treatment following suicidal behaviour in a legal document was challenging and anxiety provoking for participants. Clinicians should act with caution given the potential for recovery and fluctuations in suicidal ideation. Currently, advance decisions to refuse treatment have questionable use in the context of suicidal behaviour given the challenges in validation. Discussion and further patient research are needed in this area.
Declaration of interest
D.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for Depression. K.H. and D.G. are NIHR Senior Investigators. K.H. is also supported by the Oxford Health NHS Foundation Trust and N.K. by the Greater Manchester Mental Health NHS Foundation Trust.
In England suicide rates are highest in midlife (defined as age 40–59). Despite a strong link with suicide there has been little focus on self-harm in this age group.
To describe characteristics and treatment needs of people in midlife who present to hospital following self-harm.
Data from the Multicentre Study of Self-harm in England were used to examine rates over time and characteristics of men and women who self-harm in midlife. Data (2000–2013) were collected via specialist assessments or hospital records. Trends were assessed by negative binomial regression models. Comparative analysis used logistic regression models for binary outcomes. Repetition and suicide mortality were assessed by Cox proportional hazards models.
A quarter of self-harm presentations were made by people in midlife (n = 24 599, 26%). Incidence rates increased over time in men, especially after 2008 (incidence rate ratio [IRR] 1.07, 95% CI 1.02–1.12, P < 0.01), and were positively correlated with national suicide incidence rates (r = 0.52, P = 0.05). Rates in women remained relatively stable (IRR 1.00, 95% CI 1.00–1.02, P = 0.39) and were not correlated with suicide. Alcohol use, unemployment, housing and financial factors were more common in men; whereas indicators of poor mental health were more common in women. In men and women 12-month repetition was 25%, and during follow-up 2.8% of men and 1.2% of women died by suicide.
Self-harm in midlife represents a key target for intervention. Addressing underlying issues, alcohol use and economic factors may help prevent further self-harm and suicide.
Declaration of interest
K.H. and N.K. are members of the Department of Health's National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group which developed the quality standards for self-harm services. N.K. also chairs the NICE guideline committee for the management of depression. All other authors declare no conflict of interest.
Death of patients by suicide can have powerful effects on psychiatrists. We report the findings of a survey completed by 174 psychiatrists on the effects of patient suicide on their emotional well-being and clinical practice, and the support and resources they felt would be helpful.
Results and clinical implications
The death of a patient by suicide usually had a major effect on respondents. Clinical practice was often negatively affected, and over a quarter of respondents considered a change of career path as a result. There were some gender differences in responses, with women reporting more sense of responsibility for the deaths and a greater effect on their clinical confidence. Desired support included a senior suicide lead clinician, support during formal post-suicide processes, opportunity for reflection on practice, information about resources to support families and help communicating with families and friends of the deceased.
Declaration of interest
K.L. is Nurse Consultant for Suicide Prevention at Oxford Health NHS Foundation Trust. K.H. is a member of the National Suicide Prevention Strategy for England Advisory Group. G.W. offers independent workshops on working with suicidal patients.
High body mass index (BMI) has been associated with lower risks of suicidal behaviour and being underweight with increased risks. However, evidence is inconsistent and sparse, particularly for women. We aim to study this relationship in a large cohort of UK women.
In total 1.2 million women, mean age 56 (s.d. 5) years, without prior suicide attempts or other major illness, recruited in 1996–2001 were followed by record linkage to national hospital admission and death databases. Cox regression yielded relative risks (RRs) and 95% confidence intervals (CIs) for attempted suicide and suicide by BMI, adjusted for baseline lifestyle factors and self-reported treatment for depression or anxiety.
After 16 (s.d. 3) years of follow-up, 4930 women attempted suicide and 642 died by suicide. The small proportion (4%) with BMI <20 kg/m2 were at clearly greater risk of attempted suicide (RR = 1.38, 95% CI 1.23–1.56) and suicide (RR = 2.10, 1.59–2.78) than women of BMI 20–24.9 kg/m2; p < 0.0001 for both comparisons. Small body size at 10 and 20 years old was also associated with increased risks. Half the cohort had BMIs >25 kg/m2 and, while risks were somewhat lower than for BMI 20–24.9 kg/m2 (attempted suicide RR = 0.91, 0.86–0.96; p = 0.001; suicide RR = 0.79, 0.67–0.93; p = 0.006), the reductions in risk were not strongly related to level of BMI.
Being underweight is associated with a definite increase in the risk of suicidal behaviour, particularly death by suicide. Residual confounding cannot be excluded for the small and inconsistent decreased risk of suicidal behaviour associated with being overweight or obese.
A range of factors can contribute to suicide, which means that a multifactorial approach to suicide prevention is necessary. Whereas randomised controlled trials may be suitable for evaluation of some interventions, others require different approaches for assessment of their impact. Also, suicide itself will not always be the most feasible outcome measure.
Scales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.
To evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.
A multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.
In total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0–5) for the SAD PERSONS scale, to 97% (95% CI 93–99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2–47) for the Modified SAD PERSONS Scale to 47% (95% CI 41–53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50–0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69–0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P < 0.001).
Risk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.
Self-harm (SH; intentional self-poisoning or self-injury) is common in children and adolescents, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for SH published in 1998 and updated in 1999. We have now divided the review into three separate reviews; this review is focused on psychosocial and pharmacological interventions for SH in children and adolescents.
Considering the ample evidence of involvement of the glutamate system in the pathophysiology of depression, pre-clinical and clinical studies have been conducted to assess the antidepressant efficacy of glutamate inhibition, and glutamate receptor modulators in particular. This review focuses on the use of glutamate receptor modulators in unipolar depression.
There is emerging evidence that glutamatergic system dysfunction might play an important role in the pathophysiology of bipolar depression. This review focuses on the use of glutamate receptor modulators for depression in bipolar disorder.
Self-harm (intentional self-poisoning or self-injury) is common, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for self-harm, first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews. This review is focused on pharmacological interventions in adults who self-harm.
People with physical illness often have psychiatric disorder and this comorbidity may have a specific influence on their risk of suicide.
To examine how physical illness and psychiatric comorbidity interact to influence risk of suicide, with particular focus on relative timing of onset of the two types of illness.
Based on the national population of Denmark, individual-level data were retrieved from five national registers on 27 262 suicide cases and 468 007 gender- and birth-date matched living controls. Data were analysed using conditional logistic regression.
Both suicides and controls with physical illness more often had comorbid psychiatric disorder than their physically healthy counterparts. Although both physical and psychiatric illnesses constituted significant risk factors for suicide, their relative timing of onset in individuals with comorbidity significantly differentiated the associated risk of suicide. While suicide risk was highly elevated when onsets of both physical and psychiatric illness occurred close in time to each other, regardless which came first, psychiatric comorbidity developed some time after onset of physical illness exacerbated the risk of suicide substantially.
Suicide risk in physically ill people varies substantially by presence of psychiatric comorbidity, particularly the relative timing of onset of the two types of illness. Closer collaboration between general and mental health services should be an essential component of suicide prevention strategies.
People bereaved by suicide are often reported to be distressed by media reporting. Current media guidelines for reporting suicide focus especially on prevention of copycat behaviour.
To explore bereaved individuals' experiences of media reporting after suicide and to examine their priorities in relation to media guidelines.
In-depth interviews with 40 people bereaved by suicide, with qualitative analysis. Review of four guidelines.
There is a difference of emphasis between guidance for the press that aims to prevent copycat suicides (especially avoidance of details such as method used) and the perspectives of bereaved people (who prioritise sympathetic and accurate reporting, sometimes including details of the death and images of the person who died). We found that bereaved relatives were sometimes keen to talk to the press. Those who were upset by the press focused on careless reporting, misquoting and speculation that gave an inaccurate impression of the death.
The Leveson Inquiry has drawn attention to the damage that can be caused by irresponsible journalism. Guidelines written to prevent ‘copycat’ suicides are important, but so are the needs of bereaved relatives. Because accuracy matters greatly to the bereaved, families should be able to work with an intermediary such as a police press officer to prepare a statement for the press to minimise the risk of misrepresentation.
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%).
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.
Risk of self-harm and suicide is greatly increased in the period after
discharge from psychiatric in-patient care.
To investigate the impact on suicide of a series of policy initiatives to
enhance care in the immediate post-discharge period.
A time series analysis was based on 1997–2007 data from the National
Confidential Inquiry into Suicide and from Hospital Episode Statistics
There was no evidence of a reduced risk of suicide in the first 12 weeks
following discharge in 2003–2007 compared with 1997–2002. In contrast,
the relative risk of non-fatal self-harm in the 12 weeks after discharge
declined. The risk ratio for self-harm (2003–2007 v.
1997–2002) at 0–1 week post-discharge was 0.86 (95% CI 0.80–0.92) and at
2–4 weeks it was 0.89 (95% CI 0.85–0.94).
These findings provide some support for the impact of recent policy
changes on the risk of non-fatal self-harm in the immediate period after
discharge from psychiatric in-patient care.