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Family involvement has been identified as a key aspect of clinical practice that may help to prevent suicide.
To investigate how families can be effectively involved in supporting a patient accessing crisis mental health services.
A multi-site ethnographic investigation was undertaken with two crisis resolution home treatment teams in England. Data included 27 observations of clinical practice and interviews with 6 patients, 4 family members, and 13 healthcare professionals. Data were analysed using framework analysis.
Three overarching themes described how families and carers are involved in mental healthcare. Families played a key role in keeping patients safe by reducing access to means of self-harm. They also provided useful contextual information to healthcare professionals delivering the service. However, delivering a home-based service can be challenging in the absence of a supportive family environment or because of practical problems such as the lack of suitable private spaces within the home. At an organisational level, service design and delivery can be adjusted to promote family involvement.
Findings from this study indicate that better communication and dissemination of safety and care plans, shared learning, signposting to carer groups and support for carers may facilitate better family involvement. Organisationally, offering flexible appointment times and alternative spaces for appointments may help improve services for patients.
People who experience homelessness are thought to be at high risk of suicide, but little is known about self-harm in this population.
To examine characteristics and outcomes in people experiencing homelessness who presented to hospital following self-harm.
Data were collected via specialist assessments and/or hospital patient records from emergency departments in Manchester, Oxford and Derby, UK. Data were collected from 1 January 2000 to 31 December 2016, with mortality follow-up via data linkage with NHS Digital to 31 December 2019. Trend tests estimated change in self-harm over time; descriptive statistics described characteristics associated with self-harm. Twelve-month repetition and long-term mortality were analysed using Cox proportional hazards models and controlled for age and gender.
There were 4841 self-harm presentations by 3270 people identified as homeless during the study period. Presentations increased after 2010 (IRR = 1.09, 95% CI 1.04–1.14, P < 0.001). People who experienced homelessness were more often men, White, aged under 54 years, with a history of previous self-harm and contact with psychiatric services. Risk of repetition was higher than in domiciled people (HR = 2.05, 95% CI 1.94–2.17, P < 0.001), as were all-cause mortality (HR = 1.45, 95% CI 1.32–1.59. P < 0.001) and mortality due to accidental causes (HR = 2.93, 95% CI 2.41–3.57, P < 0.001).
People who self-harm and experience homelessness have more complex needs and worse outcomes than those who are domiciled. Emergency department contact presents an opportunity to engage people experiencing homelessness with mental health, drug and alcohol, medical and housing services, as well as other sources of support.
The accident and emergency (A&E) department is one of the most accessible elements of health services. Individuals can walk in and request help. It is normally the first port of call for ambulances. Towns and cities have road signs giving directions to the local A&E. Despite the recent drive in the UK to develop alternatives to A&E such as polyclinics and urgent care centres, A&E remains, for many people, the epitome of urgent healthcare. People attend in large numbers and a significant proportion of these will have mental health problems. The first experience of mental health services for many people is the assessment they receive while attending A&E. The importance of first impressions cannot be overstated, particularly as significant numbers of such patients will require ongoing care from mental health services.
The A&E environment can pose challenges to the clinician when conducting a thorough assessment. There may be pressures to conduct an assessment in conditions of disturbance or lack of privacy, or for the assessment to be rushed. It is incumbent on the clinician to ensure that a thorough assessment is conducted in as appropriate an environment as possible.
As A&E allows direct access to the public, the full range of psychiatric conditions can present in this setting. Those which merit special attention, as they are more frequently seen, are discussed in this chapter.
Self-harm imposes a major burden on health services and is a common reason for presentation to A&E (accounting for as many as 200 000 hospital attendances per year in the UK; Hawton et al, 2007). Assessment of individuals who have self-harmed may make up a significant proportion of the workload of liaison psychiatry departments. Patients who self-harm are at increased risk of subsequent suicide, and up to half of those who die by suicide have a history of self-harm. Effective management of self-harm may contribute to suicide prevention.
Various terms have been used to describe non-fatal suicidal behaviour (e.g. parasuicide, attempted suicide, overdose, self-injurious behaviour) and none is entirely satisfactory. ‘Deliberate self-harm’ can be defined as an act of intentional self-poisoning or injury irrespective of the apparent purpose of the act (NHS Centre for Reviews and Dissemination, 1998).
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.
Older adults have elevated suicide rates. Self-harm is the most important
risk factor for suicide. There are few population-based studies of
self-harm in older adults.
To calculate self-harm rates, risk factors for repetition and rates of
suicide following self-harm in adults aged 60 years and over.
We studied a prospective, population-based self-harm cohort presenting to
six general hospitals in three cities in England during 2000 to 2007.
In total 1177 older adults presented with self-harm and 12.8% repeated
self-harm within 12 months. Independent risk factors for repetition were
previous self-harm, previous psychiatric treatment and age 60–74 years.
Following self-harm, 1.5% died by suicide within 12 months. The risk of
suicide was 67 times that of older adults in the general population. Men
aged 75 years and above had the highest suicide rates.
Older adults presenting to hospital with self-harm are a high-risk group
for subsequent suicide, particularly older men.
Helen Linnington, Consultant in Psychiatry for Older Adults, Rotherham, Doncaster and South Humber NHS Foundation Trust, Rotherham, UK,
Allan Johnston, Consultant in General Psychiatry, Hartington Wing, Chesterfield Royal Infirmary, Chesterfield, UK,
Paul Gill, Consultant, Department of Liaison Psychiatry, The Longley Centre, Sheffield, UK,
Navneet Kapur, Professor, Centre for Suicide Prevention, University of Manchester, UK Renuka Lazarus, Consultant
The accident and emergency (A'E) department is one of the most accessible elements of health services. Individuals can walk in and request help. It is normally the first port of call for ambulances. Towns and cities have road signs giving directions to the local A'E. Despite the recent drive in the UK to develop alternatives to A'E such as polyclinics and urgent care centres, A'E remains, for many people, the epitome of urgent healthcare. People attend in large numbers and a significant proportion of these will have mental health problems. The first experience of mental health services for many people is the assessment they receive while attending A'E. The importance of first impressions cannot be overstated, particularly as significant numbers of such patients will require ongoing care from mental health services.
The A'E environment can pose challenges to the clinician when conducting a thorough assessment. There may be pressures to conduct an assessment in conditions of disturbance or lack of privacy, or for the assessment to be rushed. It is incumbent on the clinician to ensure that a thorough assessment is conducted in as appropriate an environment as possible.
As A'E allows direct access to the public, the full range of psychiatric conditions can present in this setting. Those which merit special attention, as they are more frequently seen, are discussed in this chapter.
Self-harm imposes a major burden on health services and is a common reason for presentation to A'E (accounting for as many as 200 000 hospital attendances per year in the UK; Hawton et al, 2007). Assessment of individuals who have self-harmed may make up a significant proportion of the workload of liaison psychiatry departments. Patients who self-harm are at increased risk of subsequent suicide, and up to half of those who die by suicide have a history of self-harm. Effective management of self-harm may contribute to suicide prevention.
Suicide rates in Scotland have increased markedly relative to those in England in recent decades.
To compare changing patterns of suicide risk in Scotland with those in England & Wales, 1960–2008.
For Scotland and for England & Wales separately, we obtained national data on suicide counts and population estimates. Gender-specific, directly age-standardised rates were calculated.
We identified three distinct temporal phases: 1960–1967, when suicide rates in England & Wales were initially higher than in Scotland, but then converged; 1968–1991, when male suicide rates in Scotland rose slightly faster than in England & Wales; and 1992–2008, when there was a marked divergence in national trends. Much of the recent divergence in rates is attributable to the rise in suicide among young men and deaths by hanging in Scotland. Introduction of the ‘undetermined intent’ category in 1968 had a significant impact on suicide statistics across Great Britain, but especially so in Scotland.
Differences in temporal patterns in suicide risk between the countries are complex. Reversal of the divergent trends may require a change in the perception of hanging as a ‘painless' method of suicide.
The rise in homicides by those with serious mental illness is of concern,
although this increase may not be continuing.
To examine rates of mental illness among homicide perpetrators.
A national consecutive case series of homicide perpetrators in England
and Wales from 1997 to 2006. Rates of mental disorder were based on data
from psychiatric reports, contact with psychiatric services, diminished
responsibility verdict and hospital disposal.
Of the 5884 homicides notified to the National Confidential Inquiry into
Suicide and Homicide by People with Mental Illness between 1997 and 2006,
the number of homicide perpetrators with schizophrenia increased at a
rate of 4% per year, those with psychotic symptoms at the time of the
offence increased by 6% per year. The number of verdicts of diminished
responsibility decreased but no change was found in the number of
perpetrators receiving a hospital order disposal. The likeliest
explanation for the rise in homicide by people with psychosis is the
misuse of drugs and/or alcohol, which our data show increased at a
similar magnitude to homicides by those with psychotic symptoms. However,
we are unable to demonstrate a causal association. Although the Poisson
regression provides evidence of an upward trend in homicide by people
with serious mental illness between 1997 and 2006, the number of
homicides fell in the final 2 years of data collection, so these findings
should be treated with caution.
There appears to be a concomitant increase in drug misuse over the
period, which may account for this rise in homicide. However, an increase
in the number of people in contact with mental health services may
suggest that access to mental health services is improving. Previous
studies have used court verdicts such as diminished responsibility as a
proxy measure of mental disorder. Our data indicate that this does not
reflect accurately the prevalence of mental disorder in this
Self-harm is a common reason for presentation to a general hospital, with a strong association with suicide. Trends in self-harm are an important indicator of community psychopathology, with resource implications for health services and relevance to suicide prevention policy. Previous reports in the UK have come largely from single centres.
To investigate trends in non-fatal self-harm in six general hospitals in three centres from the Multicentre Study of Self-harm in England, and to relate these to trends in suicide.
Data on self-harm presentations to general hospital emergency departments in Oxford (one), Manchester (three) and Derby (two) were analysed over the 8-year period 1 January 2000 to 31 December 2007.
Rates of self-harm declined significantly over 8 years for males in three centres (Oxford: −14%; Manchester: −25%; Derby: −18%) and females in two centres (Oxford: −2% (not significant); Manchester: −13%; Derby: −17%), in keeping with national trends in suicide. A decreasing proportion and number of episodes involved self-poisoning alone, and an increasing proportion and number involved other self-injury (e.g. hanging, jumping, traffic related). Episodes involving self-cutting alone showed a slight decrease in numbers over time. Trends in alcohol use at the time of self-harm and repetition within 1 year were stable.
There were decreasing rates of non-fatal self-harm over the study period that paralleled trends in suicide in England. This was reflected mainly in a decline in emergency department presentations for self-poisoning.
Studies of self-harm in Black and minority ethnic (BME) groups have been restricted to single geographical areas, with few studies of Black people.
To calculate age- and gender-specific rates of self-harm by ethnic group in three cities and compare characteristics and outcomes.
A population-based self-harm cohort presenting to five emergency departments in three English cities during 2001 to 2006.
A total of 20 574 individuals (16–64 years) presented with self-harm; ethnicity data were available for 75%. Rates of self-harm were highest in young Black females (16–34 years) in all three cities. Risk of self-harm in young South Asian people varied between cities. Black and minority ethnic groups were less likely to receive a psychiatric assessment and to re-present with self-harm.
Despite the increased risk of self-harm in young Black females fewer receive psychiatric care. Our findings have implications for assessment and appropriate management for some BME groups 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.
Self-poisoning is a common method of suicide and often involves ingestion of antidepressants. Information on the relative toxicity of antidepressants is therefore extremely important.
To assess the relative toxicity of specific tricyclic antidepressants (TCAs), a serotonin and noradrenaline reuptake inhibitor (SNRI), a noradrenergic and specific serotonergic antidepressant (NaSSA), and selective serotonin reuptake inhibitors (SSRIs).
Observational study of prescriptions (UK), poisoning deaths involving single antidepressants receiving coroners' verdicts of suicide or undetermined intent (England and Wales) and non-fatal self-poisoning episodes presenting to six general hospitals (in Oxford, Manchester and Derby) between 2000 and 2006. Calculation of fatal toxicity index based on ratio of rates of deaths to prescriptions, and case fatality based on ratio of rates of deaths to non-fatal self-poisonings.
Fatal toxicity and case fatality indices provided very similar results (rho for relative ranking of indices 0.99). Case fatality rate ratios showed greater toxicity for TCAs (13.8, 95% CI 13.0–14.7) than the SNRI venlafaxine (2.5, 95% CI 2.0–3.1) and the NaSSA mirtazapine (1.9, 95% CI 1.1–2.9), both of which had greater toxicity than the SSRIs (0.5, 95% CI 0.4–0.7). Within the TCAs, compared with amitriptyline both dosulepin (relative toxicity index 2.7) and doxepin (2.6) were more toxic. Within the SSRIs, citalopram had a higher case fatality than the other SSRIs (1.1, 95% CI 0.8–1.4 v. 0.3, 95% CI 0.2–0.4).
There are wide differences in toxicity not only between classes of antidepressants, but also within classes. The findings are relevant to prescribing decisions, especially in individuals at risk, and to regulatory policy.
Self-harm is increasingly common in many countries, is often repeated and may have other negative outcomes.
To systematically review people's attitudes towards clinical services following self-harm in order to inform service design and improvement.
A search of electronic databases was conducted and experts in the field were contacted in order to identify relevant worldwide qualitative or quantitative studies. Data were extracted independently by two reviewers with more weight given to studies of greater quality and relevance.
Thirty-one studies met the inclusion criteria. Despite variations in healthcare systems and setting, participants' experiences were remarkably similar. Poor communication between patients and staff and a perceived lack of staff knowledge with regard to self-harm were common themes. Many participants suggested that psychosocial assessments and access to after-care needed to be improved.
Specific aspects of care that might increase service user satisfaction and treatment adherence include staff knowledge, communication and better after-care arrangements. A standard protocol could aid regular audits of users' experiences of services.
This chapter talks about comorbidity, aetiology, clinical conceptualisations, and assessment and management of four eating disorders: anorexia nervosa, bulimia nervosa, binge-eating disorder, and obesity. The classification systems of eating disorders according to Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV and the 10th revision of the International Classification of Diseases (ICD-10) are also presented in the chapter. Eating disorders expanded from the historical accounts, which were of restricting anorexia nervosa to include a variety of disorders typified by the binge-eating disorders. A systematic review of the epidemiology of eating disorders concluded that the prevalence of bulimic disorders varies according to time and place. Many of the risk factors for bulimia nervosa are shared by people with binge-eating disorder although they may be less intense. The outcome of community ascertained binge eating disorder in terms of abnormal eating behaviour is better than that reported for bulimia nervosa.
Quantitative research about self-harm largely deals with self-poisoning,
despite the high incidence of self-injury.
We compared patterns of hospital care and repetition associated with
self-poisoning and self-injury.
Demographic and clinical data were collected in a multicentre,
prospective cohort study, involving 10 498 consecutive episodes of
self-harm at six English teaching hospitals.
Compared with those who self-poisoned, people who cut themselves were
more likely to have self-harmed previously and to have received support
from mental health services, but they were far less likely to be admitted
to the general hospital or receive a psychosocial assessment. Although
only 17% of people repeated self-harm during the 18 months of study,
survival analysis that takes account of all episodes revealed a
repetition rate of 33% in the year following an episode: 47% after
episodes of self-cutting and 31% after self-poisoning (P<0.001). Of
those who repeated, a third switched method of self-harm.
Hospital services offer less to people who have cut themselves, although
they are far more likely to repeat, than to those who have self-poisoned.
Attendance at hospital should result in psychosocial assessment of needs
regardless of method of self-harm.