Suicide prevention and COVID-19: the role of primary care during the pandemic and beyond

The COVID-19 pandemic has brought with it multiple threats to mental wellbeing — the possibility or reality of serious physical illness; complex COVID-related bereavement; lockdowns that cause isolation and inhibit social contact, or that can increase exposure to abuse in the family; caring for children unable to go to school; and precarious employment and redundancy, failing businesses, and financial insecurity. The pandemic has exacerbated the longstanding pressure on resources and underinvestment in both statutory mental health and wider community services. Against this background we outline the current evidence for impact of COVID-19 on self-harm and suicide rates, and we consider how primary care can contribute to suicide prevention during COVID-19 and after the acute crisis has passed

Risk factors for nonfatal self‐harm and suicide among adolescents: two nested case–control studies conducted in the UK Clinical Practice Research Datalink

BackgroundThe characteristics of adolescents who die by suicide have hitherto been examined in uncontrolled study designs, thereby precluding examination of risk factors. The degree to which antecedents of nonfatal self‐harm and suicide at young age differ remains unknown.MethodWe delineated two nested case–control studies of patients aged 10–19 years using the Clinical Practice Research Datalink with interlinked hospital and national mortality records. Cases were adolescents who between 1st January 2003 and 31st December 2018 had died from suicide (N = 324) – study 1; experienced their first self‐harm episode (N = 56,008) – study 2. In both studies, cases were matched on sex, age and practice‐level deprivation quintile to 25 controls. By fitting conditional logistic regression, we examined how risks varied according to psychiatric diagnoses, prescribed psychotropic medication, patterns of clinical contact and area‐level deprivation.ResultsSuicides occurred more often among boys (66%), but self‐harm was more common in girls (68%). Most individuals who self‐harmed or died from suicide presented to their GP at least once in the preceding year (85% and 75% respectively). Only a third of cases had one of the examined diagnostic categories recorded. Depression was most strongly associated with elevated risks for both outcomes (self‐harm: OR 7.9; 95% CI 7.8–8.2; suicide: OR 7.4; 95% CI 5.5–9.9). Except for autism spectrum disorder, all other diagnostic categories were linked with similar risk elevations for self‐harm as for suicide. Whilst self‐harm risk rose incrementally with increasing levels of area‐level deprivation, suicide risks did not.ConclusionsWe observed few marked differences in risk factor profiles for nonfatal self‐harm versus suicide. As most adolescents who had harmed themselves or died by suicide were known to services in the preceding year, their underlying pathology may not be adequately identified and treated. Our findings highlight the need for a multiagency approach to treatment and prevention

Implementing resources to support the diagnosis and management of Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) in primary care: A qualitative study.

BACKGROUND: Previous research has highlighted that many GPs lack the confidence and knowledge to diagnose and manage people with CFS/ME. Following the development of an online training module for GPs, and an information pack and DVD for patients, this study explored the extent to which these resources can be implemented in routine primary care. METHODS: Semi structured qualitative interviews were completed with patients and GPs across North West England. All interviews were transcribed and analysed using open exploratory thematic coding. Following this thematic analysis, the authors conducted a further theory-driven analysis of the data guided by Normalisation Process Theory. RESULTS: When used in line with advice from the research team, the information resource and training were perceived as beneficial to both patients and GPs in the diagnosis and management of CFS/ME. However, 47 % of patients in this study did not receive the information pack from their GP. When the information pack was used, it was often incomplete, sent in the post, and GPs did not work with patients to discuss the materials. Only13 out of 21 practices completed the training module due to time pressures and the low priority placed on low prevalence, contentious, hard to manage conditions. When the module was completed, many GPs stated that it was not feasible to retain the key messages as they saw so few patients with the condition. Due to the complexity of the condition, GPs also believed that the diagnosis and management of CFS/ME should take place in a specialist care setting. CONCLUSION: While barriers to the implementation of training and resources for CFS/ME remain, there is a need to support CFS/ME patients to access reliable, evidence based information outside primary care. Our findings suggest that future research should develop an online resource for patients to support self-management

The potential of general practice to support young people who self-harm: a narrative review

Background Self-harm in young people is a growing public health concern. Young people commonly present to their GP for help with self-harm, and thus general practice may be a key setting to support young people who have self-harmed. Aim To examine the potential of general practice to support young people aged 10–25 years who have harmed themselves. Design & setting A narrative review of published and grey literature. Method The Scale for the Assessment of Narrative Review Articles (SANRA) was used to guide a narrative review to examine the potential of general practice to support young people who have self-harmed. The evidence is presented textually. Results The included evidence showed that GPs have a key role in supporting young people, and they sometimes relied on gut feeling when handling uncertainty on how to help young people who had self-harmed. Young people described the importance of initial clinician responses after disclosing self-harm, and if they were perceived to be negative, the self-harm could become worse. Conclusion In context of the evidence included, this review found that general practice is a key setting for the identification and management of self-harm in young people; but improvements are needed to enhance general practice care for young people to fulfil its potential

Understanding self-harm in older adults: a qualitative study

Background Self-harm is the leading risk factor for suicide, with elevated rates reported amongst older populations. This study explores how older adults experience self-harm, identifying factors leading to self-harm. Methods Semi-structured interviews with older adults (≥ 60 years) engaging in self-harm and support workers from third sector services in England. Older adults were invited to participate in a follow-up interview. Interviews were recorded, transcribed verbatim and data analysed thematically. Ethical approval obtained from Keele University's Ethics Review Panel. A Patient Involvement group contributed to study design, data analysis and interpretation. Outcomes Between September 2017 to September 2018, 24 interviews were conducted involving 16 participants: nine older adults and seven support workers. Eight older adults consented to follow-up interviews. All older adults reported diagnoses of mental illness in addition to physical illness. Participants identified diverse stressors accumulating over the life-course leaving older adults particularly vulnerable to self-harm. Such stressors included adverse events, loss, interpersonal and health problems. A sense of shame and stigma amongst older people using self-harm to manage distress was also reported. Interpretation Self-harm is often concealed due to stigma and shame, being further accentuated amongst older adults, which may result in low levels of medical help-seeking behaviour for self-harm. Self-harm occurred along a spectrum of no-suicidal intent to high-levels of intent, suggesting self-harm holds different functions to older adults. Clinicians should be aware of the existence of self-harm in this age-group, and the heightened risk amongst those with comorbidities so adequate assessment, support and/or referral is provided

The functions of self‐harm in young people and their perspectives about future general practitioner‐led care: A qualitative study

Background Self-harm in young people is a serious concern but a deeper understanding of the functions of self-harm in young people can tailor care and inform new clinical interventions to reduce repeat self-harm and suicide risk. General practitioners (GPs), as frontline healthcare professionals, have an important role in managing self-harm in young people. This study aimed to explore the functions of self-harm in young people and their perspectives on future GP-led care. Methods A qualitative study using interviews with young people aged between 16 and 25 years with a personal history of self-harm was conducted. Interviews were transcribed and analysed using reflexive thematic analysis. Findings Four distinct functions were identified: (1) handling emotional states; (2) self-punishment; (3) coping with mental illness and trauma; and (4) positive thoughts and protection. Young people valued GP-led support and felt future GP interventions should include self-help and be personalised. Conclusions These findings support clinicians, including GPs, to explore the functions of self-harm in young people aged 16–25 in a personalised approach to self-harm care. It should be noted that self-harm may serve more than one function for a young person and thus interventions should recognise this. Patient and Public Contribution A group consisting of young people with lived experience of self-harm, carers, the public, and those who work with young people who harm themselves conceived this study idea, informed recruitment methods and the interview topic guide, and supported the interpretation of findings

Patient and public involvement and engagement in a doctoral research project exploring self-harm in older adults

Background: The contribution of involving patients and public in health research is widely reported, particularly within mental health research. Less is written about such contributions to doctoral research. The research focus of this doctoral research, self-harm in older adults, was put forward by a Patient Public Involvement Engagement (PPIE) group, who contributed to its development. Aims: Critically reflect on the process, potential impact and identify challenges and opportunities in involving robust PPIE in a doctoral study. Methods: Three PPIE members contributed to a systematic review (SR) and a qualitative study through a series of four workshops to meet the aims of the study. PPIE contributed to developing the SR review questions, protocol, data analysis and dissemination of findings. For the qualitative study, they helped develop research questions, protocol, public-facing documentation, recruitment strategies and data analysis. Involvement followed the GRIPP2-SF reporting checklist. Results: PPIE enhanced methodological rigour, data analysis, interpretation and dissemination of findings. Challenges included lack of ethical guidance, time-related pressures and ensuring support for PPIE members. These were successfully managed through ongoing dialogue and regular communication. Conclusions: PPIE can enhance the quality and depth of doctoral research, as lived experiences shared by PPIE members add to research's components. Exposing early-career researchers to PPIE can build research cultures sensitive to PPIE's potential contribution and develop the expertise needed to avoid tokenistic involvement. Capturing lay perspectives is essential in mental health research to ensure research findings are accessible and that findings inform clinical practice. However, clear guidance on the ethical dimensions to PPIE is needed

Pre-eclampsia is associated with a twofold increase in diabetes : a systematic review and meta-analysis

CSK and RH are funded by National Institute for Health Research Academic Clinical Fellowships. This study was supported by a grant from the North Staffs Heart Committee.Peer reviewedPublisher PD

Identification of post-traumatic stress disorder following ICU

'No abstract

Substantially more children receiving antidepressants see a specialist than reported by Jack et al.

We would like to draw attention to evidence of substantial bias in the article published in this journal by Jack et al. (BMC Med 18:1-12, 2020). They provide an analysis of antidepressant prescribing to children and young people (CYP; ages 5 to 17) in primary care in England and reported that only 24.7% of CYP prescribed SSRIs for the first time were seen by a child and adolescent psychiatrist—contrary to national guidelines. We believe that their analysis is based on incomplete data that misses a large proportion of specialist mental health contacts. This is because the dataset Jack et al. used to capture specialist mental health contact—The Hospital Episode Statistics (HES) dataset—has poor coverage, as most CYP mental health services do not submit data. We demonstrate the level of underreporting with an analysis of events in a large primary care dataset where there has been a record of definite contact with CYP mental health services. We report that as many as three quarters of specialist CYP contacts with mental health specialists are missed in the HES dataset, indicating that the figure presented by Jack et al. is substantially wrong