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

An ecological study of temporal trends in ‘deaths of despair’ in England and Wales

PURPOSE: There is growing interest in the concept of ‘deaths of despair’ (DoD)—defined as deaths from three causes: suicide, drug poisoning, and alcohol-related conditions—as a more comprehensive indicator of the impact of psychological distress on mortality. The purpose of this study is to investigate the degree of commonality in trends and geographic patterning of deaths from these causes in England and Wales. METHODS: WHO mortality data were used to calculate age-standardised, sex-specific temporal trends in DoD mortality and in mortality from suicide, drug poisonings, and alcohol-related conditions in England and Wales, 2001–2016. Three-year average crude rates were calculated for English local authorities for 2016–2018 and associations between rates were assessed using Spearman’s rank correlation. RESULTS: Between 2001 and 2016, the DoD mortality rate increased by 21·6% (males) and 16·9% (females). The increase was largely due to a rise in drug poisoning deaths, with limited tracking between trends in mortality by each cause. DoD mortality risk was highest in middle-aged people; there were rises in all age groups except 15–24 year old males and 65 + females. There were strong positive correlations (r = 0.66(males) and 0.60(females)) between local authority-area drug poisoning and alcohol-specific mortality rates in 2016–2018. Correlations of these outcomes with suicide were weaker (r = 0.29–0.54). CONCLUSIONS: DoD mortality is increasing in England and Wales but there is limited evidence of commonality in the epidemiology of cause-specific mortality from the component causes of DoD (suicide, drug poisoning and alcohol-related conditions), indicating the need for tailored prevention for each outcome

Child suicide rates during the COVID-19 pandemic in England

BACKGROUND: There is concern about the impact of COVID-19, and the control measures to prevent the spread, on children's mental health. The aim of this work was to identify if there had been a rise of childhood suicide during the COVID pandemic. METHOD: Using data from England's National Child Mortality Database (NCMD) the characteristics and rates of children dying of suicide between April to December 2020 were compared with those in 2019. In a subset (1(st) January to 17(th) May 2020) further characteristics and possible contributing factors were obtained. RESULTS: A total of 193 likely childhood deaths by suicide were reported. There was no evidence overall suicide deaths were higher in 2020 than 2019 (RR 1.09 (0.80-1.48), p=0.584) but weak evidence that the rate in the first lockdown period (April to May 2020) was higher than the corresponding period in 2019 (RR 1.56 (0.86-2.81), p=0.144). Characteristics of individuals were similar between periods. Social restrictions (e.g. to education), disruption to care and support services, tensions at home and isolation appeared to be contributing factors. LIMITATIONS: As child suicides are fortunately rare, the analysis is based on small numbers of deaths with limited statistical power to detect anything but major increases in incidence. CONCLUSION: We found no consistent evidence that child suicide deaths increased during the COVID-19 pandemic although there was a possibility that they may have increased during the first UK lockdown. A similar peak was not seen during the following months, or the second lockdown

Is Google Trends a useful tool for tracking mental and social distress during a public health emergency? A time–series analysis

Background: Google Trends data are increasingly used by researchers as an indicator of population mental health, but few studies have investigated the validity of this approach during a public health emergency.Methods: Relative search volumes (RSV) for the topics depression, anxiety, self-harm, suicide, suicidal ideation, loneliness, and abuse were obtained from Google Trends. We used graphical and time-series approaches to compare daily trends in searches for these topics against population measures of these outcomes recorded using validated self-report scales (PHQ-9; GAD-7; UCLA-3) in a weekly survey (n=~70,000) of the impact COVID-19 on psychological and social experiences in the UK population (12/03/2020 to 21/08/ 2020).Results: Self-reported levels of depression, anxiety, self-harm/suicidal ideation, self-harm, loneliness and abuse decreased during the period studied. There was no evidence of an association between self-reported anxiety, self-harm, abuse and RSV on Google Trends. Trends in Google topic RSV for depression and suicidal ideation were inversely associated with self-reports of these outcomes (p=0.03 and p=0.04 respectively). However, there was statistical and graphical evidence that self-report and Google searches for loneliness (p<0.001) tracked one another. Limitations: No age/sex breakdown of Google Trends data are available. Survey respondents were not representative of the UK population and no pre-pandemic data were available. Conclusion: Google Trends data do not appear to be a useful indicator of changing levels of population mental health during a public health emergency, but may have some value as an indicator of loneliness. Keywords: Mental Health, Pandemic, Suicide, Depression, Loneliness, Anxiety, Domestic violenc

Which are the most useful scales for predicting repeat self-harm?:A systematic review evaluating risk scales using measures of diagnostic accuracy

The aims of this review were to calculate the diagnostic accuracy statistics of risk scales following self-harm and consider which might be the most useful scales in clinical practice.Systematic review.We based our search terms on those used in the systematic reviews carried out for the National Institute for Health and Care Excellence self-harm guidelines (2012) and evidence update (2013), and updated the searches through to February 2015 (CINAHL, EMBASE, MEDLINE, and PsychINFO). Methodological quality was assessed and three reviewers extracted data independently. We limited our analysis to cohort studies in adults using the outcome of repeat self-harm or attempted suicide. We calculated diagnostic accuracy statistics including measures of global accuracy. Statistical pooling was not possible due to heterogeneity.The eight papers included in the final analysis varied widely according to methodological quality and the content of scales employed. Overall, sensitivity of scales ranged from 6% (95% CI 5% to 6%) to 97% (CI 95% 94% to 98%). The positive predictive value (PPV) ranged from 5% (95% CI 3% to 9%) to 84% (95% CI 80% to 87%). The diagnostic OR ranged from 1.01 (95% CI 0.434 to 2.5) to 16.3 (95%CI 12.5 to 21.4). Scales with high sensitivity tended to have low PPVs.It is difficult to be certain which, if any, are the most useful scales for self-harm risk assessment. No scales perform sufficiently well so as to be recommended for routine clinical use. Further robust prospective studies are warranted to evaluate risk scales following an episode of self-harm. Diagnostic accuracy statistics should be considered in relation to the specific service needs, and scales should only be used as an adjunct to assessment

Analysis of trends in adolescent suicides and accidental deaths in England and Wales, 1972–2011

Background Previous analyses of adolescent suicides in England and Wales have focused on short time periods. Aims To investigate trends in suicide and accidental deaths in adolescents between 1972 and 2011. Method Time trend analysis of rates of suicides and deaths from accidental poisoning and hanging in 10- to 19-year-olds by age, gender and deprivation. Rate ratios were estimated for 1982–1991, 1992–2001 and 2002–2011 with 1972–1981 as comparator. Results Suicide rates have remained stable in 10- to 14-year-olds, with strong evidence for a reduction in accidental deaths. In males aged 15–19, suicide rates peaked in 2001 before declining. Suicide by hanging is the most common method of suicide. Rates were higher in males and in 15- to 19-year-olds living in more deprived areas. Conclusions Suicide rates in adolescents are at their lowest since the early 1970s with no clear evidence that changes in coroners' practices underlie this trend