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To examine trends in rates of self-harm among emergency department (ED) presenting older adults in Ireland over a 13-year period.
Population-based study using data from the National Self-Harm Registry Ireland.
National hospital EDs.
Older adults aged 60 years and over presenting with self-harm to hospital EDs in Ireland between January 1, 2007 and December 31, 2019.
ED self-harm presentations.
Between 2007 and 2019, there were 6931 presentations of self-harm in older adults. The average annual self-harm rate was 57.8 per 100,000 among older adults aged 60 years and over. Female rates were 1.1 times higher compared to their male counterparts (61.4 vs 53.9 per 100,000). Throughout the study time frame, females aged 60–69 years had the highest rates (88.1 per 100,000), while females aged 80 years and over had the lowest rates (18.7 per 100,000). Intentional drug overdose was the most commonly used method (75.5%), and alcohol was involved in 30.3% of presentations. Between the austerity and recession years (2007–2012), self-harm presentations were 7% higher compared to 2013–2019 (incidence rate ratio (IRR): 1.07 95% CI 1.02–1.13, p = 0.01).
Findings indicate that self-harm in older adults remains a concern with approximately 533 presentations per year in Ireland. While in younger age groups, females report higher rates of self-harm, this gender difference was reversed in the oldest age group (80 years and over), with higher rates of self-harm among males. Austerity/recession years (2007–2012) had significantly higher rates of self-harm compared to subsequent years.
Evidence on the impact of the pandemic on healthcare presentations for self-harm has accumulated rapidly. However, existing reviews do not include studies published beyond 2020.
To systematically review evidence on presentations to health services following self-harm during the COVID-19 pandemic.
A comprehensive search of databases (WHO COVID-19 database; Medline; medRxiv; Scopus; PsyRxiv; SocArXiv; bioRxiv; COVID-19 Open Research Dataset, PubMed) was conducted. Studies published from 1 January 2020 to 7 September 2021 were included. Study quality was assessed with a critical appraisal tool.
Fifty-one studies were included: 57% (29/51) were rated as ‘low’ quality, 31% (16/51) as ‘moderate’ and 12% (6/51) as ‘high-moderate’. Most evidence (84%, 43/51) was from high-income countries. A total of 47% (24/51) of studies reported reductions in presentation frequency, including all six rated as high-moderate quality, which reported reductions of 17–56%. Settings treating higher lethality self-harm were overrepresented among studies reporting increased demand. Two of the three higher-quality studies including study observation months from 2021 reported reductions in self-harm presentations. Evidence from 2021 suggests increased numbers of presentations among adolescents, particularly girls.
Sustained reductions in numbers of self-harm presentations were seen into the first half of 2021, although this evidence is based on a relatively small number of higher-quality studies. Evidence from low- and middle-income countries is lacking. Increased numbers of presentations among adolescents, particularly girls, into 2021 is concerning. Findings may reflect changes in thresholds for help-seeking, use of alternative sources of support and variable effects of the pandemic across groups.
Research into the association between childhood sexual abuse (CSA) and self-harm repetition is limited.
We aimed to examine the association between self-harm repetition, mental health conditions, suicidal intent and CSA experiences among people who frequently self-harm.
A mixed-methods study was conducted including consecutive patients aged ≥18 years, with five or more self-harm presentations, in three Irish hospitals. Information was extracted from psychiatric records and patients were invited to participate in a semi-structured interview. Data was collected and analysed with a mixed-methods, convergent parallel design. In tandem, the association between CSA and self-harm repetition, suicidal intent and mental health conditions was examined with logistic regression models and independent sample t-test, with psychiatric records data. Thematic analysis was conducted with interview data, to explore CSA experiences and self-harm repetition.
Between March 2016 and July 2019, information was obtained on 188 consecutive participants, with 36 participants completing an interview. CSA was recorded in 42% of the total sample and 72.2% of those interviewed. CSA was positively associated with self-harm repetition (odds ratio 6.26, 95% CI 3.94−9.94, P = 0.00). Three themes emerged when exploring participants’ CSA experiences: CSA as a precipitating factor for self-harm, secrecy of CSA accentuating shame, and loss experiences linked to CSA and self-harm.
CSA was frequently reported among people who frequently self-harm, and associated with self-harm repetition. Identification of patients at risk of repetition is key for suicide prevention. This is an at-risk group with particular characteristics that must be considered; comprehensive patient histories can help inform and tailor treatment pathways.
The aim of the study is to improve patient safety by identifying factors influencing gatekeeping decisions by crisis resolution and home treatment teams. A theoretical sampling method was used to recruit clinicians. Semi-structured interviews to elicit various aspects of clinical decision-making were carried out. The transcripts were thematically analysed using a grounded theory approach.
Patient needs (safety and treatment) was the primary driver behind decisions. The research also revealed that information gathered was processed using heuristics. We identified five key themes (anxiety, weighting, agenda, resource and experience), which were constructed into an acronym ‘AWARE’.
AWARE provides a framework to make explicit drivers for decision-making that are often implicit. Incorporating these drivers into reflective practice will help staff be more mindful of undue influences and result in improved clinical decisions.
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.
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.
Rates of self-harm are high and have recently increased. This trend and the repetitive nature of self-harm pose a significant challenge to mental health services.
To determine the efficacy of a structured group problem-solving skills training (PST) programme as an intervention approach for self-harm in addition to treatment as usual (TAU) as offered by mental health services.
A total of 433 participants (aged 18–64 years) were randomly assigned to TAU plus PST or TAU alone. Assessments were carried out at baseline and at 6-week and 6-month follow-up and repeated hospital-treated self-harm was ascertained at 12-month follow-up.
The treatment groups did not differ in rates of repeated self-harm at 6-week, 6-month and 12-month follow-up. Both treatment groups showed significant improvements in psychological and social functioning at follow-up. Only one measure (needing and receiving practical help from those closest to them) showed a positive treatment effect at 6-week (P = 0.004) and 6-month (P = 0.01) follow-up. Repetition was not associated with waiting time in the PST group.
This brief intervention for self-harm is no more effective than treatment as usual. Further work is required to establish whether a modified, more intensive programme delivered sooner after the index episode would be effective.
Background: Hospital-treated deliberate self harm and suicide among older adults have rarely been examined at a national level.
Methods: The Irish Central Statistics Office provided suicide and undetermined death data for 1980–2006. The National Registry of Deliberate Self Harm collected data relating to deliberate self harm presentations made in 2006–2008 to all 40 Irish hospital emergency departments.
Results: Rates of female suicide among older adults (over 55 years) were relatively stable in Ireland during 1980–2006 whereas male rates increased in the 1980s and decreased in more recent decades. Respectively, the annual male and female suicide and undetermined death rate was 22.1 and 7.6 per 100,000 in 1997–2006. Male and female deliberate self harm was 3.0 and 11.0 times higher at 67.4 and 83.4 per 100,000, respectively. Deliberate self harm and suicide decreased in incidence with increasing age. Deliberate self harm generally involved drug overdose (male: 72%; female 85%) or self-cutting (male: 15%; female 9%). The most common methods of suicide were hanging (41%) and drowning (29%) for men and drowning (39%) and drug overdose (24%) for women. City and urban district populations had the highest rates of hospital-treated self harm. The highest suicide rates were in urban districts.
Conclusions: Older Irish adults have high rates of hospital-treated deliberate self harm but below average rates of suicide. Drowning was relatively common as a method of suicide. Restricting availability of specific medications may reduce both forms of suicidal behavior.
Sandra Dietrich, research fellow at the Department of Psychiatry, Leipzig University, Germany,
Lisa Wittenburg, project manager for the European Alliance Against Depression at the Department of Psychiatry, University of Leipzig, Germany,
Ella Arensman, Director of Research at the National Suicide Research Foundation, and Honorary Senior Lecturer,
Airi Värnik, Professor of Mental Health at Tallinn University, Estonia,
Ulrich Hegerl, Head and Medical Director of the Clinic of Psychiatry at Leipzig University, Germany
There has been much discussion about the most suitable terminology for suicidal acts and researchers have tried to find a common terminology and classification as well as operational definitions for the range of suicidal behaviours (O'Carroll et al, 1996; Maris, 2002; De Leo et al, 2004). In this chapter, we use the outcome-based term ‘fatal suicidal acts’ for suicidal behaviour that results in death and ‘non-fatal suicidal acts’ for suicidal actions that do not result in death.
There is no consensus on the definition of fatal suicidal acts, making it difficult, for instance, to collect accurate, comparable total rates of suicide. Numerous definitions are used, the most widely accepted being the definition produced by the World Health Organization (WHO, 2007a): ‘the act of deliberately killing oneself’. Apart from fatal suicidal acts, it is also of great importance to consider non-fatal suicidal acts, because they are one of the strongest predictors of suicide and have significant economic, medical and social costs. Non-fatal suicidal acts are also often called ‘attempted suicide’ (especially in the USA), ‘parasuicide’ and ‘deliberate self-harm’ (especially in Europe), but also ‘non-fatal suicidal behaviour’, ‘non-fatal self-inflicted harm’, ‘self-injury’ and ‘self-directed violence’. The usage of these terms varies considerably between countries.
Approximately one million people died from fatal suicidal acts in the year 2000, reflecting a ‘global’ mortality rate of 16 per 100 000, or one death every 30 seconds. Suicide is now among the three leading causes of death among those aged 15–45 years (both sexes) and in a growing number of countries the first cause of mortality among men aged 15–34. These figures do not include non-fatal suicidal acts, which are up to 20 times more frequent than fatal suicidal acts (WHO, 2007b). According to WHO estimates, approximately 1.53 million people will die from fatal suicidal acts in 2020, and 10–20 times more people will attempt suicide worldwide. This represents on average one death every 20 seconds and one attempt every 1–2 seconds (WHO, 1999).
Self-harm by young people is occurring with increasing frequency. Conventional in-patient and out-patient treatment has yet to be proved efficacious.
To investigate the efficacy of a short cognitive-behavioural therapy intervention with 90 adolescents and adults who had recently engaged in self-harm.
Participants (aged 15–35 years) were randomly assigned to treatment as usual plus the intervention, or treatment as usual only. Assessments were completed at baseline and at 3 months, 6 months and 9 months follow-up.
Patients who received cognitive-behavioural therapy in addition to treatment as usual were found to have significantly greater reductions in self-harm, suicidal cognitions and symptoms of depression and anxiety, and significantly greater improvements in self-esteem and problem-solving ability, compared with the control group.
These findings extend the evidence that a time-limited cognitive-behavioural intervention is effective for patients with recurrent and chronic self-harm.
Background. While recent studies have found problem-solving impairments in individuals who engage in deliberate self-harm (DSH), few studies have examined repeaters and non-repeaters separately. The aim of the present study was to investigate whether specific types of problem-solving are associated with repeated DSH.
Method. As part of the WHO/EURO Multicentre Study on Suicidal Behaviour, 836 medically treated DSH patients (59% repeaters) from 12 European regions were interviewed using the European Parasuicide Study Interview Schedule (EPSIS II) approximately 1 year after their index episode. The Utrecht Coping List (UCL) assessed habitual responses to problems.
Results. Factor analysis identified five dimensions – Active Handling, Passive-Avoidance, Problem Sharing, Palliative Reactions and Negative Expression. Passive-Avoidance – characterized by a pre-occupation with problems, feeling unable to do anything, worrying about the past and taking a gloomy view of the situation, a greater likelihood of giving in so as to avoid difficult situations, the tendency to resign oneself to the situation, and to try to avoid problems – was the problem-solving dimension most strongly associated with repetition, although this association was attenuated by self-esteem.
Conclusions. The outcomes of the study indicate that treatments for DSH patients with repeated episodes should include problem-solving interventions. The observed passivity and avoidance of problems (coupled with low self-esteem) associated with repetition suggests that intensive therapeutic input and follow-up are required for those with repeated DSH.