Self-harm on rise, but many denied mental health assessments

Given that rates of self-harm appear to be on the increase in many countries, the accumulation of accurate data on self-harm is vital to help researchers, clinicians, and purchasers of clinical services understand national trends in self-harm, evaluate changes in the methods used to self-harm over time with reference to changes in availability of lethal means (e.g., following the UK introduction of pack size restrictions for paracetamol/acetaminophen), evaluate the potential effectiveness of these preventive measures, and plan for the provision of appropriate clinical services.

In many countries, however, national data sources on self-harm do not provide the necessary information to inform clinical and service provision (Hiles S, 2015) as they are typically too limited (Gunnell D, 2005) and therefore seriously underestimate the rate of self-harm within the target population (Steenkamp M, 2001).

The use of continuously active (also known as “sentinel”) monitoring systems, such as the Multicentre Study of Self-Harm in England (Hawton K, 2007), can bridge this knowledge gap by prospectively collecting standardised data on all persons presenting to hospital following an episode of self-harm within a known regional referral catchment population.

Monitoring systems are required to inform clinical and service provision for self-harm.

Methods

A cohort study was undertaken of all patients, aged 15 years and older, presenting to emergency department facilities in Oxford, Manchester or Derby in the United Kingdom over a 13 year period (2000-12) following an episode of self-harm. The aim was to understand whether there have been any changes in rates of self-harm by age, gender, and regional centre (i.e., Oxford, Manchester, Derby) as well as changes in methods of self-harm used over this period.

Additionally, the research takes account of the publication of the NICE guidance for the short-term management of self-harm in primary and secondary care, which recommended that:

Everyone who has self-harmed should have a comprehensive assessment of needs and risk.
– NICE, 2004

A further aim of this study was therefore to investigate whether there has been a significant increase in the proportion of patients who receive a psychosocial assessment over this 13 year period.

Using a standard patient record form, basic information on patient demographics (e.g. age, gender), method of self-harm (e.g., including information on the drug/s ingested in the case of self-poisoning), psychiatric history (e.g. diagnoses of major mental disorders and information on any prior episodes of self-harm including the nature of these), and hospital management information (e.g., whether the patient received a psychosocial assessment or not) was collected for each patient. This information was supplemented by the emergency department’s electronic database registry.

The study focused on UK urban populations who are known to have higher rates of self-harm than rural populations.

Results

Over the 13 year study period a total of 47,048 persons (26,738 females, 20,285 males, and 25 whose gender was not recorded), presented to one of the six participating hospitals for treatment following an episode of self-harm on at least one occasion. The 25 persons whose gender was not recorded were excluded from subsequent analyses, however, leaving a total sample of 47,023 persons [26,738 (58.6%) females and 20,285 (41.4%) males].

Rates of self-harm by gender

Overall, the authors found that rates of self-harm declined significantly over the 13 year study period in both males and females:

Males: Incidence rate ratio (IRR) IRR 0.99; 95% confidence interval (CI) 0.97 to 1.00; p=0.021;
Females: IRR 0.98; 95% CI 0.97 to 0.99; p<0.0001.

Rates of self-harm by age

This overall trend, however, varied as a function of age, particularly in males. For males, there was no evidence of a significant decrease in suicide rates between 2000-12 amongst those aged 15-24 or 35-54 years, however, a significant decrease was noted in males aged 25-34 years:

15-24 years: IRR 0.99; 95% CI 0.99 to 1.00; p=0.08;
25-34 years: IRR 0.96; 95% CI 0.95 to 0.98, p<0.0001;
35-54 years: IRR 0.99; 95% CI 0.98 to 1.01; p=0.28.

For females, rates of self-harm decreased significantly for all age brackets aside from amongst those aged 55 years or older in which a significant increase in self-harm rates was observed:

15-24 years: IRR 0.98; 95% CI 0.97 to 0.99; p<0.0001;
25-34 years: IRR 0.96; 95% CI 0.96 to 0.97; p<0.0001;
35-54 years: IRR 0.99; 95% CI 0.98 to 1.00; p=0.004;
55+ years: IRR 1.02; 95% CI 1.01 to 1.04; p=0.003.

Methods of self-harm

Using data on episodes of self-harm (67,653 episodes), rather than individual persons, the authors found that between 2003-2012:

50,484 episodes (74.6%) were due to self-poisoning alone;
14,213 episodes (21.0%) involved self-injury alone, and;
2,956 episodes (4.4%) involved a mixture of both self-poisoning and self-injury.

The most common methods of self-injury over this period were:

Self-cutting/self-stabbing (76.7%);
Hanging/asphyxiation (6.0%), and;
Jumping from a height (2.8%);

Whilst the most common methods of self-poisoning over this period involved the use of:

Paracetamol/acetaminophen or salicylate analgesics (in their pure or compound form) (45.6%);
Antidepressants, including tricyclics, SSRIs, SNRIs (24.7%), and;
Benzodiazepines (13.8%).

The authors found evidence of a significant increase in the number of episodes involving self-injury alone from 2007 onwards [Odds Ratio (OR) 1.08, 95% CI 1.07 to 1.10; p<0.0001], largely driven by a significant increase in the number of episodes involving:

Self-cutting/stabbing: OR=1.05, 95% CI 1.04 to 1.07; p<0.0001;
Hanging/asphyxiation: OR=1.03, 95% CI 1.02 to 1.04; p<0.0001, or;
Jumping from a height OR=1.13, 95% CI 1.09 to 1.17; p<0.0001.

There did not appear to be a similar increase in the number of episodes involving self-poisoning, although these results were not presented.

The researchers note that there is a stronger risk of suicide following self-cutting compared to self-poisoning.

Receipt of a psychosocial assessment

Given that the risk of repetition of self-harm is higher amongst those who do not receive a psychosocial assessment (Hickey L, 2001), in 2004 NICE recommended that all persons presenting to clinical services for self-harm should be offered an assessment of their social, psychological, and motivational needs, as well as an appraisal of their future risk of suicide (NICE, 2004).

The authors found that between 2003-12, a total of 35,960 psychosocial assessments were conducted in each of the three participating regions. Overall, the proportion of self-harm patients who received a psychosocial assessment increased between 2003-12 (OR=1.35, 95% CI 1.26 to 1.44; p<0.0001), although there was considerable variation between the three participating centres (results not shown). Around one-half of patients did not receive a psychosocial assessment, however (46.8%).

However, patients presenting to hospital with self-injury alone were significantly less likely to receive a psychosocial assessment relative to those presenting following an episode of self-poisoning (OR=0.47, 95% CI 0.46 to 0.49; p<0.0001), or following an episode of combined self-poisoning and self-injury (OR=0.32, 95% CI 0.30 to 0.35; p<0.0001).

Hospital self-harm cases have steadily risen among men in England since 2008.

Conclusions

The authors conclude that although self-harm rates declined in both males and females over the whole 13 year observation period, there was evidence of a steady increase in the rates of self-harm in England since 2008, particularly in males. The authors note this increase likely coincided with the onset of the Global Financial Crisis in the UK which has previously been found to be associated with increases in suicide rates worldwide (Chang S, 2013).

However, little under half (46.8%) of all individuals who presented to hospital following self-harm did not receive a psychosocial needs and risk assessment in this study, despite guidance from the National Institute of Health and Care Excellence suggesting that all self-harm patients should receive such an assessment (NICE, 2004). Those admitted to hospital for self-injury alone (relative to self-poisoning alone or self-injury in combination with self-poisoning) were particularly unlikely to receive a psychosocial assessment.

The researchers suggest that the increase in rates of self-harm since 2008 may be associated with the economic downturn.

Summary

The fact that only around one-half (53.2%) of patients admitted following an episode of self-harm received a psychosocial assessment in this study is of concern.
It is also worrying that only one-third (34.4%) of those patients who presented to hospital for self-injury specifically received a psychosocial assessment, particularly given that previous work suggests the risk of suicide after self-harm is greatest amongst those who engage in self-injury, and particularly amongst those who use hanging/asphyxiation (which was the second most prevalent form of self-injury in this study), relative to self-poisoning (Runeson B, 2016).

The fact that only one-third of people who presented to hospital for self-injury alone received a psychosocial assessment is of great concern.

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.

Conflict of interest

The blogger (Katrina Witt) has previously collaborated on work with three of the authors of this study (KH, ET and NK). However, she was not involved in the research reported in this study.

Links

Primary paper

Geulayov G, Kapur N, Turnbull P, Clements C, Waters K, Ness J, Townsend E, Hawton K. (2016). Epidemiology and trends in non-fatal self-harm in three centres in England, 2000-2012: Findings from the Multicentre Study of Self-Harm in England. BMJ Open, 6: e010538. DOI: 10.1136/bmjopen-2015-010538.

Other references

Chang SS, Stuckler D, Yip P, Gunnell D. (2013). Impact of 2008 global economic crisis on suicide: Time trend study in 54 countries. British Medical Journal, 347: f5239. DOI: 10.1136/bmj.f5239.

Gunnell D, Bennewith O, Peters TJ, House A, Hawton K. (2005). The epidemiology and management of self-harm amongst adults in England. Journal of Public Health, 27: 67-73. DOI: 10.1093/pubmed/fdh192.

Hawton K, Bergen H, Casey D, Simkin S, Palmer B, Cooper J, Kapur N, Horrocks J, House A, Lilley R, Noble R, Owens D. (2007). Self-harm in England: A tale of three cities. Multicentre study of self-harm. Social Psychiatry and Psychiatric Epidemiology, 42: 513-521. DOI: 10.1007/s00127-007-0199-7.

Hawton K, Harriss L, Hall S, Simkin S, Bale E, Bond A. (2003). Deliberate self-harm in Oxford, 1990-2000: A time of change in patient characteristics. Psychological Medicine, 33: 987-995. DOI: 10.1017/S0033291703007943.

Hickey L, Hawton K, Fagg J, Weitzel H. (2001). Deliberate self-harm patients who leave the accident and emergency department without a psychiatric assessment: A neglected population at risk of suicide. Journal of Psychosomatic Research, 50: 87-93. DOI: 10.1016/S0022-3999(00)00225-7.

Hiles S, Bergen H, Hawton K, Lewin T, Whyte I, Carter G. (2015). General hospital-treated self-poisoning in England and Australia: Comparison of presentation rates, clinical characteristics and aftercare based on sentinel unit data. Journal of Psychosomatic Research, 78: 356–362. DOI: 10.1016/j.jpsychores.2016.01.006.

National Institute for Health and Care Excellence (NICE). (2004). Self-Harm: The Short-Term Physical and Psychological Management and Secondary Prevention of Self-Harm in Primary and Secondary Care [Clinical Guideline 16]. London, UK: National Institute for Clinical Excellence.

Runeson B, Haglund A, Lichtenstein P, Tidemalm D. (2016). Suicide risk after nonfatal self-harm: A national cohort study, 2000–2008. Journal of Clinical Psychology, 77: 240-246. DOI: 10.4088/JCP.14m09453.

Steenkamp M, Harrison J. (2001). Suicide and hospitalised self-harm in Australia. Canberra, ACT: Australian Institute of Health and Welfare.