Last month, the Department of Health published the ‘Closing the Gap’ report, which highlighted the importance of better integration of physical and mental health care at every level.
The report specifically flagged up the need for frontline services to respond better to people who self-harm, and cited statistics that emphasise the cyclical nature of the illness:
Self-harming can be one of the first outward signs of mental illness. It can be, though is not always, the sign of a mental health crisis – particularly when it is severe enough that the person ends up in an Emergency Department. And it is a habit that, once started, is hard to break: it is estimated that 1 in 6 people who require treatment in Emergency Departments due to self-harm will be back again within a year.
New research published last week in the Journal of the Royal Society of Medicine has brought this issue into sharp focus once again, as it concludes that psychiatric illnesses and chronic physical illnesses both carry an increased risk of self-harm and suicide.
The research team from Oxford, led by Professor Michael Goldacre, conducted a number of retrospective cohort studies using a linked dataset of Hospital Episode Statistics (HES) and mortality data from the Office for National Statistics for 1999-2011, in what they claim is the largest study examining chronic illness and self-harm ever published.
The researchers studied a number of different psychiatric or physical conditions and for each they put together a cohort of people who had been seen as a day case or admitted as an inpatient with a diagnosis of that condition. Reference cohorts were constructed (with other people with a range of other medical conditions and injuries) and both cohorts were then followed over time to see how they compared in terms of subsequent day care, inpatient admissions and death from self-harm.
ICD codes were used to identify the ‘risk factor’ conditions and self-harm itself. Patients were excluded if they had a hospital episode for self-harm before, or at the same time as, the admission for depression.
Self-harm rates were expressed as rate ratios (RR), which were worked out by comparing the rate of self-harm (person-time) in the condition cohort with the reference cohort. All RRs were presented with 95% confidence intervals.
- The mental health conditions all had very high risk of self-harm:
- ￼Depression 14.1 (14.0 to 14.3) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Bipolar disorder 11.6 (11.3 to 11.9)
- ￼￼￼￼￼￼￼￼￼￼￼￼Alcohol abuse 8.0 (7.9 to 8.1)
- ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼Anxiety and neurotic disorders 7.8 (7.7 to 8.0) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Eating disorders 7.5 (7.2 to 7.9) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Schizophrenia 7.2 (7.1 to 7.4) ￼￼￼￼￼￼￼￼
- Some physical conditions had a high risk of self harm:
- ￼Epilepsy 2.9 (2.8 to 2.9) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Asthma 1.8 (1.8 to 1.9) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Migraine 1.8 (1.7 to 1.8) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Psoriasis 1.6 (1.5 to 1.7) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Diabetes mellitus 1.6 (1.5 to 1.6) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Eczema 1.4 (1.3 to 1.5) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Inflammatory polyarthropathies 4318 1.4 (1.3 to 1.4) ￼￼
- ￼Some physical conditions had neither a high nor low high risk of self harm: ￼￼￼￼￼￼￼￼￼
- Cystic fibrosis 1.0 (0.9 to 1.2) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Coeliac disease 1.0 (1.0 to 1.1) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Crohn’s disease 1.0 (1.0 to 1.1)
- ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼Spina bifida 1.1 (0.9 to 1.2) ￼￼￼￼￼￼￼￼￼
- Some physical conditions had a low high risk of self harm:
- ￼￼￼￼￼￼￼￼￼Cancers 1.0 (0.9 to 1.0) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Congenital heart disease 0.9 (0.8 to 0.9) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Ulcerative colitis 0.8 (0.7 to 0.8) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Sickle cell anaemia 0.7 (0.6 to 0.8) ￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼
- Down’s syndrome 0.1 (0.1 to 0.2)
- The total number of observed cases of self-harm for each illness varied quite considerably, from 39,878 for alcohol abuse to just 26 for Down’s syndrome
- The RRs for self-harm were highest for most illnesses in the 45–64 age group, with some exceptions, e.g.
- Eating disorders saw a high risk of self-harm in the 25-44 age group
- Some differences were seen when men and women were analysed separately:
- There were significantly more female admissions with eating disorders
- There were significantly more male admissions with substance abuse
The research team concluded:
Psychiatric illnesses carry a greatly increased risk of self-harm as well as of suicide. Many chronic physical illnesses are also associated with an increased risk of both self-harm and suicide. Identifying those at risk will allow provision of appropriate monitoring and support.
In an interview with the Science Media Centre, coauthor of the study Prof Keith Hawton said:
For psychiatric disorders the increase in risk in relative terms, compared with the general population of the same age, is between five and fifteen times higher (depending on the condition) than that in the general population. In absolute terms, considering the years covered by the study, this means an episode of self-harm, at some time, in around 5-10% of all people with one of the psychiatric disorders studied.
For the physical diseases, like asthma or diabetes, the increase in risk compared with the general population is two-fold or less. In absolute terms this means an episode of self-harm in about 1% of the population of these patients.
- Using population data from English hospitals means that this study will only have found cases of self-harm that resulted in hospital admission or death, and that were identified as intentional self-harm. It is therefore quite likely that cases of suicide and self-harm are under-reported in this study, although this will of course be the same across the reference cohort as well as the condition cohort, so this limitation may not affect the rate ratio comparisons used to report the results.
- The data relating to physical illnesses was based on patients admitted to hospital for that disease, so it excludes outpatients and people who are well managed and require no admission. This means that the findings of this research may only apply to individuals with physical illnesses severe enough to warrant hospitalisation.
- This research did not tackle the more complicated questions of comorbid illnesses, e.g. people with diabetes and depression versus people with diabetes without depression. Clearly this is a further level of detail that warrants further study.
This well conducted and reported research provides vital new information to healthcare professionals caring for people with psychiatric and physical illnesses. At-risk patients can now be identified and monitored for the mental distress associated with self-harm and suicide. Clearly, greater integration of physical and mental health care is a prerequisite for this kind of joined up care.
If you need help
If you need help and support now and you live in the UK or the Republic of Ireland, please call the Samaritans on 116 123.
If you live elsewhere, we recommend finding a local Crisis Centre on the IASP website.
We also highly recommend that you visit the Connecting with People: Staying Safe resource.
Singhal A, Ross J, Seminog O, Hawton K, and Goldacre MJ. Risk of self-harm and suicide in people with specific psychiatric and physical disorders: comparisons between disorders using English national record linkage. J R Soc Med 0141076814522033, first published on February 13, 2014 as doi:10.1177/0141076814522033 [Abstract]
Closing the gap: priorities for essential change in mental health (PDF). Department of Health, January 2014.
Expert reaction to diabetes, epilepsy, asthma and self-harm. Science Media Centre website, last accessed 13 Feb 2014.