Factors explaining variation in recommended care pathways following hospital-presenting self-harm:a multilevel national registry study

BACKGROUND People who present to hospital following self-harm are at high risk of suicide. Despite this, there are considerable variations in the management of this group across hospitals and the factors influencing such variations are not well understood. AIMS The aim of this study was to identify the specific hospital and individual factors associated with care pathways following hospital-presenting self-harm. METHOD Data on presentations to hospitals by those aged 18 years and over were obtained from the National Self-Harm Registry Ireland for 2017 and 2018. Factors associated with four common outcomes following self-harm (self-discharge, medical and psychiatric admission and psychosocial assessment before discharge) were examined using multilevel Poisson regression models. RESULTS Care pathways following self-harm varied across hospitals and were influenced by both hospital and individual factors. Individual factors were primarily associated with self-discharge (including male gender, younger age and alcohol involvement), medical admission (older age, drug overdose as a sole method and ambulance presentations) and psychiatric admission (male gender, methods associated with greater lethality and older age). The hospital admission rate for self-harm was the only factor associated with all outcomes examined. The availability of psychiatric in-patient facilities and specialist mental health staff contributed to variation in psychiatric admissions and psychosocial assessments prior to discharge. Hospital factors explained the majority of observed variation in the provision of psychosocial assessments. CONCLUSIONS Characteristics of the presenting hospital and hospital admission rates influence the recommended care pathways following self-harm. Provision of onsite mental health facilities and specialist mental health staff has a strong impact on psychiatric care of these patients

Psychotropic medication involved in intentional drug overdose: implications for treatment.

Aims: Limited information is available on the source of medications taken in intentional drug overdoses (IDOs). The present study aimed to investigate the proportion of patients who engaged in IDOs with current prescriptions and the proportion of those that used their medicines in overdose acts, as well as the factors associated with patients who do so. Methods: The registration systems of three hospital emergency departments participating in the Irish National Registry of Deliberate Self Harm were screened over a continuous 6-month period and a consecutive series of 299 IDO presentations were identified. Results: Most of the IDO presentations involved female patients (59.9%) and half (50.4%) had a previous history of self-harm. The prescription of psychotropic drugs was associated with the use of these drugs in IDOs, particularly minor tranquilizers. Having a prescription of a minor tranquilizer increased the risk of using prescribed psychotropic drugs in IDOs even when controlling for other factors. Conclusion: These findings highlight the importance of considering the risk of IDO among patients who are prescribed minor tranquilizers

Variation between hospitals in inpatient admission practices for self-harm patients and its impact on repeat presentation

PURPOSE: Self-harm patient management varies markedly between hospitals, with fourfold differences in the proportion of patients who are admitted to a medical or psychiatric inpatient bed. The current study aimed to investigate whether differences in admission practices are associated with patient outcomes (repeat self-harm) while accounting for differences in patient case mix. METHODS: Data came from the National Self-Harm Registry Ireland. A prospective cohort of 43,595 self-harm patients presenting to hospital between 2007 and 2012 were included. As well as conventional regression analysis, instrumental variable (IV) methods utilising between hospital differences in rates of hospital admission were used in an attempt to gain unbiased estimates of the association of admission with risk of repeat self-harm. RESULTS: The proportion of self-harm patients admitted to a medical bed varied from 10 to 74 % between hospitals. Conventional regression and IV analysis suggested medical admission was not associated with risk of repeat self-harm. Psychiatric inpatient admission was associated with an increased risk of repeat self-harm in both conventional and IV analyses. This increased risk persisted in analyses stratified by gender and when restricted to self-poisoning patients only. CONCLUSIONS: No strong evidence was found to suggest medical admission reduces the risk of repeat self-harm. Models of health service provision that encourage prompt mental health assessment in the emergency department and avoid unnecessary medical admission of self-harm patients appear warranted. Psychiatric inpatient admission may be associated with a heightened risk of repeat self-harm in some patients, but these findings could be biased by residual confounding and require replication

Hospital-presenting self-harm and ideation: Comparison of incidence, profile and risk of repetition

Objective: The aim of this study was to describe presentations to hospital as a result of self-harm or suicidal ideation and to examine patterns of repetition. Method: Presentations made to hospital emergency departments in Northern Ireland following self-harm and ideation between April 2012 and March 2017 were recorded by the Northern Ireland Registry of Self-harm. Person-based rates per 100,000 were calculated using national population estimates. Risk of repeat attendance to hospital was examined using Kaplan-Meier analyses. Results: A total of 62,213 presentations to emergency departments following self-harm or with ideation were recorded. The rate of self-harm was more than twice the rate of hospital-presenting ideation. Rates of ideation were higher among men, and both self-harm and ideation rates peaked for girls aged 15–19 and men aged 20–24 years. The cumulative probability of repeat attendance to hospital was higher following ideation (52% after 12 months), primarily because 12% of ideation presentations were followed by a subsequent self-harm presentation, whereas 4% of self-harm presentations were followed by ideation. Conclusions: Our findings indicate that hospital presenters with ideation are at high risk of future self-harm. The transition from ideation to suicidal behaviour is important to consider and research could inform effective and early intervention measures

Method of self-harm and risk of self-harm repetition: findings from a national self-harm registry

Background: Risk of self-harm repetition has consistently been shown to be higher following self-cutting compared to intentional drug overdose (IDO) and other self-harm methods. The utility of previous evidence is limited due to the large heterogeneous method categories studied. This study examined risk of hospital presented self-harm repetition according to specific characteristics of self-harm methods. Methods: Data on consecutive self-harm presentations to hospital emergency departments (2010-2016) were obtained from the National Self-Harm Registry Ireland. Associations between self-harm method and repetition were analysed using survival analyses. Results: Overall, 65,690 self-harm presentations were made involving 46,661 individuals. Self-harm methods associated with increased repetition risk included minor self-cutting, severe self-cutting, multiple drug IDOs involving psychotropic drugs and self-harm by blunt object. Minor self-cutting was the method associated with highest repetition risk (adjusted hazard ratio (AHR) 1.38, 95% CI 1.31-1.45). Risk of repetition was comparable following IDOs of four or more drugs involving psychotropic drugs (AHR=1.29, 95 % CI 1.20-1.39), severe self-cutting (AHR 1.25, 95% CI 1.16-1.34) and blunt object (AHR=1.23, 95% CI 1.07-1.42). Limitations: Information was not available on suicide or other causes of mortality. Conclusions: Self-harm method and the associated risk of repetition should form a core part of biopsychosocial assessments and should inform follow-up care for self-harm patients. The observed differences in repetition associated with specific characteristics of IDO underline the importance of safety planning and monitoring prescribing for people who have engaged in IDO

Effectiveness of Depression–Suicidal Behaviour Gatekeeper Training among police officers in three European regions: Outcomes of the Optimising Suicide Prevention Programmes and Their Implementation in Europe (OSPI-Europe) study

Background: Gatekeeper training for community facilitators, to identify and respond to those at risk of suicide, forms an important part of multi-level community-based suicide prevention programmes.    Aims:  This study examined the effects of gatekeeper training on attitudes, knowledge and confidence of police officers in dealing with persons at risk of suicide.    Methods:  A total of 828 police officers across three European regions participated in a 4-hour training programme which addressed the epidemiology of depression and suicidal behaviour, symptoms of depression, warning signs and risk factors associated with suicidal behaviour, motivating help-seeking behaviour, dealing with acute suicidal crisis and informing bereaved relatives. Participants completed internationally validated questionnaires assessing stigmatising attitudes, knowledge about depression and confidence in dealing with suicidal persons pre- and posttraining. Results: There were significant differences among countries in terms of previous exposure to suicidal persons and extent of previous training. Post-training evaluation demonstrated significant improvements in stigmatising attitudes, knowledge and confidence in all three countries. Conclusion: The consistently positive effects of gatekeeper training of police officers across different regions support inclusion of this type of training as a fundamental part of multi-level community-based suicide prevention programmes and roll-out, nationally and internationally

National Self-Harm Registry Ireland annual report 2017.

This is the sixteenth annual report from the National Self-Harm Registry Ireland. It is based on data collected on persons presenting to hospital emergency departments following self-harm in 2017 in the Republic of Ireland. The Registry had near complete coverage of the country’s hospitals for the period 2002-2005 and, since 2006, all general hospital and paediatric hospital emergency departments in the Republic of Ireland have contributed data to the Registry. Role of alcohol in self-harm: Alcohol was involved in 31% of all cases. Alcohol was significantly more often involved in male episodes of self-harm than female episodes (33% and 29%, respectively). In line with previous years, misuse or abuse of alcohol is one of the factors associated with the higher rate of self-harm presentations on Sundays, Mondays and public holidays, around the hours of midnight. Recent publications from the Registry data have highlighted the role of alcohol in selfharm. Such complex presentations indicate the need for active consultation and collaboration between the mental health services and addiction treatment services for patients who present with dual diagnoses. In addition, alcohol involvement has been shown to be strongly associated with self-harm presentations out-of-hours, at weekends and on public holidays. The Registry findings related to alcohol provide further support for the full implementation of the Public Health (Alcohol) Bill, which would introduce evidence-based policies to reduce the burden of alcohol harm on our society by improving health, safety and wellbeing. Restricting access to means: …In line with previous years, drug overdose was the most common method of self-harm recorded. Over the years, the Registry has identified the drug types most frequently involved in intentional overdoses. New research has classified the range of drugs recorded by the Registry according to the World Health Organisation’s (WHO) Anatomical Therapeutic Chemical (ATC) classification system. This work has systematically classified the wide range of drugs involved in intentional overdoses, and will be instrumental in facilitating comparative work in this area. This system has allowed for examination of trends in specific drug types, with a recent publication highlighting the increasing involvement of gabapentinoids (prescription-only neuropathic pain medication). Despite a decrease in their involvement in intentional overdose in 2017, minor tranquillisers have been the most frequently used type of drug involved in intentional overdoses. Reducing access to frequently used drugs should be an ongoing priority

Recommendations for Emerging Good Practice and Future Research in Relation to Family and Caregiver Health Spillovers in Health Economic Evaluations:A Report of the SHEER Task Force

BackgroundOmission of family and caregiver health spillovers from the economic evaluation of healthcare interventions remains common practice. When reported, a high degree of methodological inconsistency in incorporating spillovers has been observed.AimTo promote emerging good practice, this paper from the Spillovers in Health Economic Evaluation and Research (SHEER) task force aims to provide guidance on the incorporation of family and caregiver health spillovers in cost-effectiveness and cost-utility analysis. SHEER also seeks to inform the basis for a spillover research agenda and future practice.MethodsA modified nominal group technique was used to reach consensus on a set of recommendations, representative of the views of participating subject-matter experts. Through the structured discussions of the group, as well as on the basis of evidence identified during a review process, recommendations were proposed and voted upon, with voting being held over two rounds.ResultsThis report describes 11 consensus recommendations for emerging good practice. SHEER advocates for the incorporation of health spillovers into analyses conducted from a healthcare/health payer perspective, and more generally inclusive perspectives such as a societal perspective. Where possible, spillovers related to displaced/foregone activities should be considered, as should the distributional consequences of inclusion. Time horizons ought to be sufficient to capture all relevant impacts. Currently, the collection of primary spillover data is preferred and clear justification should be provided when using secondary data. Transparency and consistency when reporting on the incorporation of health spillovers are crucial. In addition, given that the evidence base relating to health spillovers remains limited and requires much development, 12 avenues for future research are proposed.ConclusionsConsideration of health spillovers in economic evaluations has been called for by researchers and policymakers alike. Accordingly, it is hoped that the consensus recommendations of SHEER will motivate more widespread incorporation of health spillovers into analyses. The developing nature of spillover research necessitates that this guidance be viewed as an initial roadmap, rather than a strict checklist. Moreover, there is a need for balance between consistency in approach, where valuable in a decision making context, and variation in application, to reflect differing decision maker perspectives and to support innovation

Hospital-presenting self-harm among older adults living in Ireland: a 13-year trend analysis from the National Self-Harm Registry Ireland.

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, = 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