Multicentre studies
Clements, C., Hawton, K., Geulayov, G., Waters, K., Ness, J., Rehman, M., Townsend, E., Appleby, L., Kapur, N. (2019). Self-harm in midlife: analysis using data from the Multicentre Study of Self-harm in England. BJPsych doi: 10.1192/bjp.2019.90.
In England the highest suicide rates are in men and women aged 40–59 years, with rates in men increasing to a peak of 25 suicides per 100 000 population in 2013. Similar increases in suicide by men in midlife have been found internationally. Given the strong link between self-harm and suicide, a concomitant increase in rates of self-harm in this age group would be expected, however there has been little focus on self-harm in this age group. The aim of this study was to describe self-harm in men and women aged 40–59 years, using data from the Multicentre Study of Self-harm in England. Data from the Multicentre Study of Self-harm in England was used to look at rates over time, demographics, psychiatric history and referrals to aftercare from the emergency department, as well as repetition and mortality during a follow-up period. We found that a quarter of self-harm presentations on the Multicentre database were made by people in midlife (n = 24 599, 26%). Self-harm increased in men in midlife, especially after 2008 and followed the same pattern of increase as found in suicide rates. Self-harm in women in midlife were however relatively stable over time. Alcohol use, unemployment, housing and financial factors were more common in men; whereas indicators of poor mental health were more common in women. In men and women 12-month repetition was 25%, and during follow-up 2.8% of men and 1.2% of women died by suicide.
Conclusions: Self-harm in midlife represents a key target for intervention. Addressing underlying issues, alcohol use and economic factors may help prevent further self-harm and suicide.
Geulayov, G., Casey, D., McDonald, K.C., Foster, P., Pritchard, K., Wells, C., Clements, C., Kapur, N., Ness, J., Waters, K., Hawton, K. (2018). Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): a retrospective study. Lancet Psychiatry, 5:167-174.
Little is known about the relative incidence of fatal and non-fatal self-harm in young people. We estimated the incidence of suicide, non-fatal self-harm which result in presentation to hospital, and community-occurring non-fatal self-harm in adolescents aged 12-17 years in England. We used national mortality statistics, hospital monitoring data for five hospitals from the Multicentre Study of Self-Harm in England, and data from a schools survey. These incidences are described in terms of an iceberg model of self-harm. During three years, 171 adolescents aged 12-17 years died by suicide in England (70% male, 78% aged 15-17 years) and 1320 adolescents presented to the study hospitals following non-fatal self-harm (78% female, 74% aged 15-17 years). Six percent of adolescents surveyed reported self-harm in the past year in the community (78% female, 51% aged 15-17 years). In 12-14 year olds, for every boy who died by suicide, 109 attended hospital following self-harm and 3067 reported self-harm in the community, whereas for every girl who died by suicide, 1255 attended hospital for self-harm and 21 995 reported self-harm in the community. In 15-17 year olds, for every male suicide, 120 males presented to hospital with self-harm and 838 self-harmed in the community; whereas for every female suicide, 919 females presented to hospital for self-harm and 6406 self-harmed in the community. Hanging or asphyxiation was the most common method of suicide (73%), self-poisoning was the main reason for presenting to hospital after self-harm (71%), and self-cutting was the main method of self-harm used in the community (89%). Ratios of fatal to non-fatal rates of self-harm differed between males and females and between adolescents aged 12-14 years and 15-17 years, with a particularly large number of females reporting self-harm in the community.
Conclusions: These findings emphasise the need for well-resourced community and hospital-based mental health services for adolescents, with greater investment in school-based prevention.
Clements, C., Turnbull, P., Hawton, K, Geulayov, G., Waters, K., Ness, J., Townsend, E., Khundakar, K., Kapur, N. (2016). Rates of self-harm presenting to general hospitals: a comparison of data from the Multicentre Study of Self-harm in England and Hospital Episode Statistics. BMJ Open; 6:e009749.
Self-harm is a common causes of hospital admission and estimates of emergency department presentations for self-harm are high. To improve care for people who self-harm it is essential that clinicians, care providers and researchers have access to data that accurately captures hospital service use due to self-harm and changes over time. We compared rates of self-harm based on routinely collected Hospital Episode Statistics (HES) admission and emergency department data to rates based on detailed self-harm data collected by the Multicentre Study of Self-Harm in England. Nationally, HES underestimated overall rates of hospital presentations for self-harm by around 60% in comparison to rates based on data from the Multicentre Study. When we looked at these data in detail, using only HES data from people living within the areas covered by the Multicentre Study, the overall underestimate was confirmed. However, the size of the difference in rates varied between locations. We also found that HES data did not capture important trends in self-harm rates over time, such as the recent increase in self-harm by men.
Conclusions: The results of this study show that routinely collected hospital data, such as Hospital Episode Statistics, does not accurately capture all hospital presentations for self-harm – although this varies by hospital site and over time. It is important that researchers, policymakers, clinicians and the media are aware of this potential underestimate when using or quoting routinely collected hospital data, and may be particularly important in relation to commissioning services for people who self-harm.
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.
Self-harm is a major public health problem in many countries, with potential serious consequences including death by suicide and early death by other causes. It is important to monitor changes in this behaviour nationally. In this study we examined changes in self-harm over time in England during 13 years from 2000 to 2012. We also examined changes in the management of self-harm behaviour in participating hospitals during the same period.The study was conductedthe three centres of the Multicentre Study of Self-harm in England, which includes five general hospitals in Oxford, Manchester and Derby. We included individuals who attended the emergency departments in these hospitals due to self-harm. Only persons whose age was 15 years or over were included. During these 13 years, there were 84,378 presentations forself-harm by 47,048 individuals. Over half (58.6%) were females. In females, self-harm declined between 2000 and 2012 whilein males self-harm declined until 2008 and then increased until 2012. Death by suicide in England and self-harm in this study followed a similar path. Over 75% of self-harm presentations to the emergency departments were due to self-poisoning, mainly with painkillers (46%) and antidepressants (25%). There was a substantial increase in self-injury between 2007 and 2012. This was especially marked for self-cutting/stabbing and hanging/asphyxiation. A little over half of patients presenting to the hospital for self-harm received a psychosocial assessment (assessment of their risks and needs) by mental health staff. The majority of patients who attend the hospital for self-injury did not receive a psychosocial assessment.
Conclusions: Self-harm and suicide may be closely related. Self-injury as a form of self-harm has been increasing but this group of patients is often not assessed by a mental health professional. Clinicians should offer psychosocial assessment to all patients who attend the emergency department for self-harm.
Hawton, K., Bergen, H., Geulayov, G., Waters, K., Ness, J., Cooper, J., & Kapur, N. (2016). Impact of the recent recession on self-harm: longitudinal ecological and patient-level investigation from the Multicentre Study of Self-harm in England. Journal of Affective Disorders, 191, 132-138.
Economic recessions are associated with increases in suicide rates but there is little information for non-fatal self-harm. We aimed to investigate the impact of the economic recession beginning in 2008 on rates of self-harm in England and on the problems faced by patients who self-harmed. We used data from the Multicentre Study of Self-harm in England for 2001 -2010 and local employment statistics for Oxford, Manchester and Derby. In order to investigate the effect of the recession on rates of self-harm we used a method called “interrupted time series”, through which one can investigate actual trends in rates of self-harm compared with those that would have been expected based on previous trends before a particular time point (i.e. the onset of the recession). Rates of self-harm increased in both genders in Derby and in males in Manchester in 2008 - 2010 compared with the preceding years, but not in either gender in Oxford. These results largely followed changes in general population and employment, with marked increases in Manchester and Derby following the onset of the recession but not in Oxford. More patients who self-harmed were unemployed in 2008 – 2010 compared to before the recession. The proportion of patients who were receiving sickness or disability allowances decreased. More patients of both genders had employment and financial problems in 2008 – 2010 and more females also had housing problems. Interestingly, these changes were largely also found in self-harm patients who were employed at the time of their self-harm.
Conclusions: It appears that the recent economic recession had an impact on rates of self-harm. Increased rates were found in areas where there were greater rises in rates of unemployment. Work, financial and housing problems became more common in people who self-harmed following the onset of the recession. These were apparent even in those who remained in employment. There was some indication that changes in availability of welfare benefits may have contributed to self-harm after the onset of the recession.
Clements, C., Turnbull, P., Hawton, K, Geulayov, G., Waters, K., Ness, J., Townsend, E., Khundakar, K., Kapur, N. (2015). Rates of self-harm presenting to general hospitals: a comparison of data from the Multicentre Study of Self-harm in England and Hospital Episode Statistics. BMJ Open 2016; 6:e009749.
Self-harm is a common causes of hospital admission and estimates of emergency department presentations for self-harm are high. To improve care for people who self-harm it is essential that clinicians, care providers and researchers have access to data that accurately captures hospital service use due to self-harm and changes over time. We compared rates of self-harm based on routinely collected Hospital Episode Statistics (HES) admission and emergency department data to rates based on detailed self-harm data collected by the Multicentre Study of Self-Harm in England. Nationally, HES underestimated overall rates of hospital presentations for self-harm by around 60% in comparison to rates based on data from the Multicentre Study. When we looked at these data in detail, using only HES data from people living within the areas covered by the Multicentre Study, the overall underestimate was confirmed. However, the size of the difference in rates varied between locations. We also found that HES data did not capture important trends in self-harm rates over time, such as the recent increase in self-harm by men.
The results of this study show that routinely collected hospital data, such as Hospital Episode Statistics, does not accurately capture all hospital presentations for self-harm – although this varies by hospital site and over time. It is important that researchers, policymakers, clinicians and the media are aware of this potential underestimate when using or quoting routinely collected hospital data, and may be particularly important in relation to commissioning services for people who self-harm.
Townsend, E., Ness, J., Waters, K., Kapur, N., Turnbull, P., Cooper, J., Bergen, H., Hawton, K. (2016). Self-harm and life problems: findings from the Multicentre Study of Self-harm in England. Social Psychiatry and Psychiatric Epidemiology, 51, 183-192.
It is important to understand the problems faced by those who self-harm in order to design effective clinical services, policies and prevention strategies. We investigated the life problems experienced by patients presenting to general hospital for self-harm. We used data from the Multicentre Study of Self-harm in England for 2000–2010 to investigate life problems associated with self-harm and their relationship to patient and clinical characteristics, including age, gender, repeat self-harm and employment status. Of 24,598 patients (36,431 assessed self-harm episodes), 92.6 % were identified as having at least one contributing life problem. The most frequently reported problems at a first episode of self-harm were relationship difficulties, especially with partners. Mental health issues and problems with alcohol were also very common, especially in patients aged 35–54 years. Those who repeated self-harm were more likely to report problems with alcohol, housing, mental health and dealing with the consequences of abuse.
Conclusions: Self-harm usually occurs in the context of multiple life problems. Clinical services for self-harm patients should be able to access appropriate care provision for relationship difficulties and problems concerning alcohol and mental health issues. Individualised clinical support (e.g. psychological therapy, interventions for alcohol problems and relationship counselling) for self-harm patients facing these life problems may play a crucial role in suicide prevention.
Ness, J., Hawton, K., Bergen, H., Waters, K., Kapur, N., Cooper, J., Steeg, S,. Clarke, M. High volume repeaters of self-harm: Characteristics, patterns of emergency department attendance and subsequent deaths based on findings from the Multicentre Study of Self-harm in England. CRISIS (IN PRESS).
Self-harm is a behaviour which is often repeated and is associated with an increased risk of dying by suicide. In this study, we explored how common repeat attendance to the emergency department (ED) following self-harm was and the patterns of attendance amongst those who attended most frequently. Data collected as part of the Multicentre Study of Self-harm in England. High volume repetition was defined as ≥15 attendances to the ED following self-harm within four years. Every person with high volume repetition had an ED attendance timeline created. These timelines were then subjected to an executive sorting task and a hierarchical cluster analysis to try to identify similar groupings of patterns of presentations. We found that a very small number of people attending ED following self-harm did so frequently. Thus just 0.6% of patients fitted our high volume repeater definition, but they accounted10% of all the self-harm attendances to ED. Three types of attendance patterns were identified: 1. Intermittent attendance with few clusters, 2. Intermittent attendance with multiple clusters, 3. Most frequent attendees. We also found that a greater proportion of those attending ED frequently subsequently died from external causes (e.g. accidental, suicide) compared to those who did not repeat self-harm frequently.
Conclusions: Individuals who frequently attend ED following self-harm represent a very small proportion of self-harm patients but account for a large number of all self-harm attendances. The need for early intervention is highlighted by the large clustered nature of attendances and the higher frequency of death from external causes. The research methods used in this study offer a new way of exploring very frequent repeat self-harm behaviour, which could have both clinical and research benefits.
Ness, J., Hawton, K., Bergen, H., Cooper, J., Steeg, S., Kapur, N. Clarke, M., Waters, K. (2015). Alcohol use and misuse, self-harm and subsequent mortality: an epidemiological and longitudinal study from the multicentre study of self-harm in England. Emergency Medicine Journal Published Online First: [23.01.2015].
Alcohol use, misuse and related harm have been increasing in the UK. Alcohol use and misuse are strongly associated with self-harm and increased risk of future self-harm and suicide. In this study we used data from the Multicentre Study of Self-harm in England to examine how common alcohol use and misuse is within the self-harm patient population presenting to general hospitals and whether use increased between 2000 and 2009. We also looked at the impact of such misuse on the likelihood of repetition of self-harm and death. We found that 58% of patients used alcohol within 6 hours of their self-harm act and 36% were using alcohol excessively or were dependent upon it (alcohol misuse). Alcohol misuse was most common in men, those aged 35–54 years and those from white ethnicities. The frequency of alcohol misuse in self-harm patients increased between 2000 and 2009, especially in women. Patients who misused alcohol were more likely to repeat self-harm within one year and suicide was more common in women misusing alcohol.
Conclusions: Alcohol and alcohol misuse are very common in self-harm patients. Alcohol misuse is related to subsequent repetition of self-harm and, in this study future suicide in women (other studies have also found this for men). The increase in alcohol misuse within the self-harm population, especially in women, underlines the need for clinicians to routinely investigate alcohol use in self-harm patients and for close integration of self-harm services with alcohol misuse services.
Cooper, J., Steeg, S., Webb, R., Stewart, S.L.K., Applegate, E. Hawton, K., Bergen, H., Waters, K., Kapur, N. (2012) Risk factors associated with repetition of self-harm in Black and Minority Ethnic (BME) groups: a multi-centre cohort study. Journal of Affective Disorders, 148(2-3), 435-439. eScholarID:184243 | PMID:23228569.
In our earlier study based on the Multicentre Study of Self-harm in England we found that rates of self-harm were highest in young Black females (pooled rate ratio for Black females aged 16–34 years compared with White females 1.70, 95% CI 1.5–2.0) (Cooper et al., 2010). BME groups experience socioeconomic inequalities which have been linked to subsequent inequalities in health, and racial/ethnic discrimination has a strong association with common mental disorders. Yet little information is available to clinicians to inform their assessments on risk of self-harm repetition in ethnic minority groups. We aimed to determine how the risk factors for repetition differed in South Asian and Black groups compared to White people. In a prospective cohort study, using data collected from six hospitals in England for self-harm presentations occurring between 2000 and 2007, we investigated the risk factors for repeat self-harm in South Asian and Black people in comparison to White people. During the study period, 751 South Asian, 468 Black and 15,705 White people presented with self-harm in the study centres. Repeat self harm occurred in 4379 individuals during the study period, which included 229 suicides (with eight of these fatalities being in the ethnic minority groups). The risk of repetition was significantly lower in the ethnic minority groups compared to the White group. Risk factors for repetition were broadly similar across all three groups, although excess risk versus Whites was seen in Black people presenting with mental health symptoms, and in South Asian people reporting alcohol use and not having a partner. Additional modelling taking repeat self-harm episodes into account showed that alcohol misuse was especially strongly linked with multiple repetitions in both BME groups. There were some limitations to this study that need to be considered. Ethnicity was not recorded in around a third of cases which may introduce a selection bias. Undetected differences may exist due to cultural diversity within the broad ethnic groups studied.
Conclusions: Our findings have important clinical implications. Clinical assessment in these ethnic minority groups should ensure adequate recognition of mental illness and alcohol misuse. Interventions should be ethnic group-specific and require stronger collaboration between sectors sympathetic to cultural differences in beliefs around mental health problems.
Murphy, E., Kapur, N., Webb, R., Purandare, N., Hawton, K., Bergen, H., Waters, K. & Cooper, J. (2012) Risk factors for repetition and suicide following self-harm in older adults: Multicentre cohort study. British Journal of Psychiatry, 200:399-404.
Older adults are known to have high suicide rates. One of the most important risk factors for suicide is having a history of self-harm. However, up-to-date and reliable estimates of the risk of suicide following self-harm were not available for older adults. The Multicentre Study of Self-harm in England allowed us to study 1,177 older adults aged 60 years and over who had presented to hospital with self-harm. We found that within one-year of their self-harm presentation, 1.5% of older adults had subsequently died by suicide. Their risk of suicide was 67 times greater than older adults in the general population. Men aged 75 years and over had the highest suicide rate. We also examined older adults who re-presented to hospital with another non-fatal self-harm episode: 12.8% repeated self-harm within one-year. Risk factors for non-fatal repetition included previous self-harm, previous psychiatric treatment and age 60–74 years.
Conclusions: Older adults presenting to hospital with self-harm are an extremely high-risk group for subsequent suicide, especially men aged 75 years and over. These findings emphasise the requirement for all older adults to receive a detailed psychosocial assessment following self-harm, in accordance with the recommendation from the National Institute for Clinical Excellence.
Hawton, K., Bergen, H., Kapur, N., Cooper, J., Steeg, S., Ness, J., Waters, K. (2011) Repetition of self-harm and suicide following self-harm in children and adolescents. Journal of Child Psychology and Psychiatry.
Self-harm in children and adolescents is often repeated and is associated with increased risk of future suicide. We have investigated factors associated with these outcomes. We used data collected in the Multicentre Study of Self-harm in England on all self-harm hospital presentations by individuals aged 10-18 years between 2000 and 2007, and national death information on these individuals to the end of 2010. Cox hazard proportional models were used to identify independent and multivariable predictors of repetition of self-harm and of suicide. Repetition of self-harm occurred in 27.3% of individuals (N=3920) who presented between 2000 and 2005 and were followed up until 2007. Multivariate analysis showed that repetition was associated with age, self-cutting, and previous self-harm and history of psychiatric treatment (presumably a measure of severity of psychiatric disorder). Of 51 deaths in individuals who presented between 2000 and 2007 and were followed up to 2010 (N=5133) half (49.0%) were suicides (with hanging being a particularly common method of suicide). The method used for suicide was usually different to that used for preceding non-fatal self-harm. Some deaths recorded as accidents may also have been suicides. Multivariate analysis showed that suicide was associated with male gender (Hazard ratio (HR) = 2.4, 95% CI 1.2-4.8), self-cutting (HR = 2.1, 95% CI 1.1-3.7) and prior psychiatric treatment at initial presentation (HR = 4.2, 95% CI 1.7-10.5). It was also associated with self-cutting and history of psychiatric treatment at the last episode before death, and history of previous self harm.
Conclusions: Self-cutting as a method of self-harm in children and adolescents conveys greater risk of future suicide (and repetition of self-harm) than self-poisoning. However, different methods are usually used for suicide than for self-harm. The findings underline the need for psychosocial assessment in all cases, especially since clinicians often regard self-cutting as having less serious consequences than self-poisoning.
Hawton, K., Bergen, H., Waters, K., Ness, J., Cooper, J., Steeg, S., Kapur, N. (2011) Epidemiology and nature of self-harm in children and adolescents: findings from the Multicentre Study of Self-harm in England. European Child and Adolescent Psychiatry.
Self-harm has become increasingly common during teenage years. Reliable information on epidemiology is required. We examined epidemiology and characteristics of self-harm in adolescents and impact of national guidance on management over an eight year period. Data were collected in six hospitals in three centres between 2000 and 2007 in the Multicentre Study of Self-harm in England. Of 5205 individuals who self-harmed (7150 episodes of self-harm), three-quarters were female. The female:male ratio in 10-14 year-olds was 5.0, and 2.7 in 15-18 year-olds. Rates of self-harm varied somewhat between the centres, with highrer rates in Manchester, espeically in 15-18 year-olds of both genders. In females, rates averaged 302 per 100,000 (95% CI 269-335) in 10-14 year-olds and 1423 (95% CI 1346-1501) in 15-18 year-olds, and were 67 (95% CI 52-82) and 466 (95% CI 422-510) respectively in males. Self-poisoning was the most common method of self-harm, involving paracetamol in 58.2% of episodes. Presentations, especially those involving alcohol, peaked at night. Repetition of self-harm was frequent in that 53.3% of the adolescents had a history of prior self-harm at this first presentation in the study period and 17.7% repeated within a year. Relationship problems were the predominant difficulties associated with self-harm, with problems with partners being more common in 15-18 year-olds and problems with families and friends being more common in 10-14 year-olds. Problems with families and friends were more frequent in females than males, and problems with alcohol, drugs, housing and legal issues more frequent in males. In spite of NICE guidance that all self-harm patients should receive a psychosocial assessment, this occurred in only 57% of episodes. Admission to a general hospital bed occurred in most (81%) under 16 year-olds.
Conclusions: Self-harm in children and adolescents in England is common, especially in older adolescents. Paracetamol overdose is the predominant method in those presenting to hospital. The fact that presentations are most common at night has implications for clinical services. The problems facing children and adolescents who self-harm include a range of difficulties, which vary by age and gender.Self-harm is requently repeated. National guidance on provision of psychosocial assessment in all cases of self-harm requires further implementation.
See also: Evid Based Mental Health
Cooper, J., Murphy, E., Webb, R., Hawton, K., Bergen, H., Waters, K. & Kapur, N. (2010). Ethnic differences in self-harm, rates, characteristics and service provision: Three-city cohort study. British Journal of Psychiatry 197, 212-218.
Most of our information about risk factors for self-harm are based on data predominantly from a White population and previous research on ethnic minority groups have tended to be limited by small sample size and data collected from one area. We compared the rates of self-harm in different ethnic groups in different areas in England (Oxford, Manchester and Derby) using data from the Multicentre Study of Self-harm in England for 2001 – 2006, and compared the characteristics of patients and what services were provided, to better inform suicide prevention strategies in ethnic minority groups. We found that rates of self-harm were highest in young Black women in all three centres, whereas risk of self-harm varied in young South Asian people between areas. Both minority ethnic groups in the older age range had a lower risk in all cities. Characteristics of individuals from ethnic minority groups differed from those in White groups. For example, they were less likely to use alcohol with the attempt and report a history of self-harm and previous psychiatric treatment. We also found differences in clinical management, with ethnic minority groups being less likely to receive a specialist psychiatric assessment and psychiatric follow-up services than the White population.
Conclusions: Despite the increased risk of self-harm in young Black females, fewer receive psychiatric care. Clinicians assessing ethnic minority patients should be aware of the differences in their characteristics. A lack of recognition of mental health problems may result in a subsequent failure to offer further services. Culturally sensitive training that informs skills and attitudes of clinicians is recommended. Service providers need to consider barriers to uptake of care in ethnic minority groups.
Bergen, H., Hawton, K., Waters, K., Cooper, J. & Kapur, N. (2010). Epidemiology and trends in non-fatal self-harm in three centres in England, 2000 to 2007. British Journal of Psychiatry 197, 493-498.
In this study we found that the occurrence of self-harm declined significantly from 2000 to 2007 for males in the three centres in the Multicentre Study of Self-harm in England (Oxford -14%, Manchester -25%, Derby -18%) and females in two centres (Oxford -2% (not significant), Manchester -13%, Derby -17%). This trend is in keeping with national trends in suicide following the introduction of the National Suicide Prevention Strategy for England in 2002. A decreasing number of episodes involved self-poisoning and self-cutting alone, however an increasing number involved other self-injury (e.g. hanging, jumping, traffic-related). Trends in alcohol use at the time of self-harm and repetition within one year were stable.
Conclusions: The introduction of the suicide prevention strategy in England, as well as favourable economic conditions, appear to have had a positive effect on suicide and non-fatal self-harm over the years 2000 to 2007.
Cooper, J., Murphy, E., Bergen, H., Casey, D., Hawton, K., Owens, D., Lilley, R., Noble, R. & Kapur, N. (2007). The effect of using NHS number as the unique identifier for patients who self-harm: a multi-centre descriptive study. Clinical Practice and Epidemiology in Mental Health 3, 16.
Patient identifiable information is required in order to be able to follow up individuals for medical research purposes. A possible way of avoiding keeping unnecessary data on individuals would be to collect their NHS number. We sought to determine the allocation of NHS numbers in three well established self-harm registers in England to identify those people likely to be excluded. We found that individuals from ethnic minority groups, the homeless or living in a hostel were the least likely groups to have an NHS number.
Conclusions: Basing research studies on NHS number as the unique identifier, would exclude some of the most vulnerable groups for further self-harm or suicide. We therefore felt we could not recommend replacing information that enables individuals’ to be identified, with NHS numbers as the sole identifier. This bias may also affect other research registers.
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.
Self-harm is a major healthcare problem in the United Kingdom, but monitoring of hospital presentations has largely been done separately in single centres. The Multicentre Study of Self-harm in England has been established as a result of the National Suicide Prevention Strategy for England. Data on self-harm presentations to general hospitals in Oxford (1 hospital), Manchester (3 hospitals) and Leeds (2 hospitals), collected through monitoring systems in each centre, were analysed for the 18-month period March 2000 to August 2001. The findings were based on 7344 persons who presented following 10498 episodes of self-harm. Gender and age patterns were similar in the three centres, 57% of patients being female and two-thirds under 35 years of age. The largest numbers by age groups were 15-19 year-old females and 20-24 year-old males. The female to male ratio decreased with age. Rates of self-harm were higher in Manchester than Oxford or Leeds, in keeping with local suicide rates. The proportion of patients receiving a specialist psychosocial assessment varied between centres and was strongly associated with admission to the general hospital. Approximately 80% of self-harm episodes involved self-poisoning. Overdoses of paracetamol, the most frequent method, were more common in younger age groups, antidepressants in middle age groups, and benzodiazepines and sedatives in older age groups. Alcohol was involved in more than half of assessed episodes. The most common time of presentation to hospital was between 10pm and 2am.
Conclusions: This multicentre study of self-harm in England has demonstrated similar overall patterns of hospital-presenting self-harm in Oxford, Manchester and Leeds, but with some differences reflecting local suicide rates. Four out of five episodes involve self-poisoning, with substances used in overdoses varying by age groups. Daily variation in time of presentation to hospital and the need for assessment of non-admitted patients have implications for service provision.
Kapur, N., Steeg, S., Webb, R., Haigh, M., Bergen, H., Hawton, K. Ness, J. Waters, K. Cooper, J. (2013) Does Clinical Management Improve Outcomes following Self-Harm? Results from the Multicentre Study of Self-Harm in England. PLoS ONE 8(8): e70434. Link to the paper.
It is unclear from research to date what works and does not work in the management of self-harm and the treatments that are suggested in guidelines may not be available in routine practice. We used ten years of data from the Multicentre Study of Self-Harm in England to examine how the management that patients receive in hospital relates to their risk of repeat self-harm. We investigated the relationship between four aspects of management (psychosocial assessment, medical admission, psychiatric admission, referral for specialist mental health follow up) and repetition of self-harm within 12 months, adjusting results to account for differences in patients’ demographic and clinical characteristics. The study included 35,938 individuals presenting with self-harm between 2000 and 2009. Psychosocial assessment was associated with a 40% lower risk of repetition in two of the three centres, and this was the case even after taking into account other medical care and mental health follow-up arrangements. The protective effects of psychosocial assessment may have been weakest in people who lived in the most deprived areas.
These findings add to the evidence that thorough assessment is central to the management of self-harm. Further work is needed so that we can understand more about why assessment is linked to better outcomes for some patients but not for others and the possible mechanisms by which assessment is effective.
Steeg, S., Kapur, N., Webb,R., Applegate, E., Stewart, S.L.K., Hawton,K., Bergen, H., Waters, K., Cooper, J. (2012) The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule. Psychological Medicine, 7:1-12. Link to the paper.
Clinical decision tools have been used to inform clinical management in various areas of medicine. In this study we aimed to develop a clinical tool to help identify patients at higher risk following a self-harm presentation to the Emergency Department. We developed the tool using data from Manchester and Derby and tested it separately on data from Oxford. We found four factors that classified the self-harm presentation as higher risk of repeat self-harm, or suicide, within 6 months: recent self-harm (in the past year), living alone or homelessness, cutting as a method of harm and treatment for a current psychiatric disorder. These factors comprise the ReACT Self-Harm Rule. In Manchester and Derby, the tool performed with 95% (CI 94 to 95%) sensitivity (the proportion of repeat SH attendances or suicides correctly identified as higher risk) and 21% (21 to 22%) specificity (the proportion of non-repetitions that were correctly classified as low risk). There were 92 subsequent suicides in the three centres, of which 83 were classed as higher risk by the tool.
The ReACT Self-Harm Rule might be used as a screening tool to inform the process of assessing SH presentations to ED. The four risk factors could also be used as an adjunct to in-depth psychosocial assessment to help guide risk formulation. The tool should not replace detailed psychosocial assessment of risk and needs. Decisions on follow-up care offered to patients presenting to ED with SH should not be based solely on the result of screening tools. The use of multicentre data helped to maximise the generalisability of the tool, but we need to further verify its external validity in other areas of the UK and in other countries.
Bergen, H., Hawton, K., Waters, K., Cooper, J. & Kapur, N. (2010). Psychosocial assessment and repetition of self-harm: The significance of single and multiple repeat episode analyses. Journal of Affective Disorders 127, 257-265. Link to the paper.
Self-harm is a common reason for presentation to the Emergency Department. An important question is whether psychosocial assessment following self-harm affects further repetition of self-harm. In this study we found that psychosocial assessment reduced the risk of a single repeat episode by 51% in individuals without a history of psychiatric treatment, and by 26% in individuals with a history of psychiatric treatment. For recurrent repetition of up to 5 episodes, psychosocial assessment decreased risk of a further episode by 13%. Appropriate statistical models which take account of multiple episodes by the same person are needed to accurately assess risk in recurrent repetition.
Conclusions: Psychosocial assessment is beneficial in reducing repeated self-harm in people both with and without a history of psychiatric care. Our finding supports the recommendation from the National Institute for Clinical Excellence that all individuals presenting to the emergency department with self-harm should receive a psychosocial assessment.
Lilley, R., Owens, D., Horrocks, J., House, A., Noble, R., Bergen, H., Hawton, K., Casey, D., Simkin, S., Murphy, E., Cooper, J. & Kapur, N. (2008). Hospital care and repetition following self-harm: a multicentre comparison of self-poisoning and self-injury. British Journal of Psychiatry 192, 440-445. Link to the paper.
Quantitative research about self-harm largely deals with self-poisoning, despite the high incidence of self-injury. We compared patterns of hospital care and repetition associated with self-poisoning and self-injury. Demographic and clinical data were collected in a multicentre, prospective cohort study, involving 10,498 consecutive episodes of self-harm at six English teaching hospitals. Compared with those who self-poisoned, people who cut themselves were more likely to have self-harmed previously and to have received support from mental health services, but they were far less likely to be admitted to the general hospital or receive a psychosocial assessment. Although only 17% of people repeated self-harm during the 18-month study, survival analysis that takes account of all episodes revealed a repetition rate of 33% in the year following an episode. There was a significantly greater rate of repetition after episodes of self-cutting (47%) and than after self-poisoning (31%). Of those who repeated, a third switched method of self-harm.
Conclusions: Hospital services offer less to people who have cut themselves, although they are far more likely to repeat, than to those who have self-poisoned. Attendance at hospital should result in psychosocial assessment of needs regardless of method of self-harm.
Kapur, N., Murphy, E., Cooper, J., Bergen, H., Hawton, K., Simkin, S., Casey, D., Horrocks, J., Lilley, R., Noble, R. & Owens, D. (2008). Psychosocial assessment following self-harm: results from the Multi-Centre Monitoring of Self-Harm Project. Journal of Affective Disorders 106, 285-293. Link to the paper.
A good quality assessment is central to the management of self-harm, but not all people are assessed following presentation to hospital. It is unclear whether being assessed affects the risk of repeating self-harm. In this study we used 18 months of data from the Multicentre Study of Self-harm in England (covering Oxford, Leeds and Manchester). We found that 60% of episodes resulted in a specialist psychosocial assessment. Factors which made an assessment more likely included age over 55 years, current psychiatric treatment, admission to a medical ward, and taking an overdose of antidepressants. Factors which made an assessment less likely included unemployment, self-cutting, attending outside normal working hours, and self-discharge. Overall we found no link between assessment and self-harm repetition, but there were differences between hospitals - assessments were protective in one hospital but associated with an increased risk of repetition in another.
Conclusions: Many people who harm themselves, including potentially vulnerable individuals, do not receive an adequate assessment while at hospital. Staff should be aware of this. Identifying which components of psychosocial assessment are particularly helpful will help to shape the way we manage self-harm in the future.
Ness, J., Hawton, K., Bergen, H., Waters, K., Kapur, N., Cooper, J., Steeg, S., Clarke, M. (2016). High volume repeaters of self-harm: Characteristics, patterns of emergency department attendance and subsequent deaths based on findings from the Multicentre Study of Self-harm in England. CRISIS, Oct 12:1-11. Link to the paper.
Self-harm is a behaviour which is often repeated and is associated with an increased risk of dying by suicide. In this study, we explored how common repeat attendance to the emergency department (ED) following self-harm was and the patterns of attendance amongst those who attended most frequently. Data collected as part of the Multicentre Study of Self-harm in England. High volume repetition was defined as ≥15 attendances to the ED following self-harm within four years. Every person with high volume repetition had an ED attendance timeline created. These timelines were then subjected to an executive sorting task and a hierarchical cluster analysis to try to identify similar groupings of patterns of presentations. We found that a very small number of people attending ED following self-harm did so frequently. Thus just 0.6% of patients fitted our high volume repeater definition, but they accounted10% of all the self-harm attendances to ED. Three types of attendance patterns were identified: 1. intermittent attendance with few clusters, 2. intermittent attendance with multiple clusters, 3. most frequent attendees. We also found that a greater proportion of those attending ED frequently subsequently died from external causes (e.g. accidental, suicide) compared to those who did not repeat self-harm frequently.
Conclusions: Individuals who frequently attend ED following self-harm represent a very small proportion of self-harm patients but account for a large number of all self-harm attendances. The need for early intervention is highlighted by the large clustered nature of attendances and the higher frequency of death from external causes. The research methods used in this study offer a new way of exploring very frequent repeat self-harm behaviour, which could have both clinical and research benefits.
Turnbull, P., Webb, R., Kapur, N., Clements, C., Bergen, H., Hawton, K., Ness, J., Waters, K., Townsend, E., Cooper, J. (2015). Variation by ethnic group in premature mortality risk following self-harm: a multicentre cohort study in England. BMC Psychiatry. Link to the paper.
People who self-harm are known to be at increased risk of dying early. There are differences in rates of self-harm and risk factors associated with self-harm for different ethnic groups, yet little is known about the influence of ethnicity on death after self-harm. We used data from the Multicentre Study of Self-harm in England, linked to a national mortality dataset, to investigate early death in South Asian and Black people, and compared them to early deaths in White people following a hospital presentation for self-harm. After adjusting for age, gender and area-level socioeconomic deprivation, we found that the risk of death by any cause was lower in South Asian and Black people after self-harm, than it was in White people after self-harm. Risk of dying by suicide after self-harm was much lower in Black people than in White people. We also found that many risk factors usually associated with dying early after self-harm, such as psychiatric treatment or concurrent alcohol misuse, were seen less often in South Asian and Black people than in White people.
Conclusions: The risk of dying after a hospital presentation for self-harm is lower in South Asian and Black people than White people in the UK. South Asian and Black people also have fewer risk factors for premature death. This may truly reflect a lower risk of dying early after a hospital presentation for self-harm, but may also be a result of different help-seeking strategies employed by South Asian and Black people, who may be less likely that White people to attend hospital following self-harm.
Kapur, N., Steeg S, Turnbull, P., Webb, R., Bergen, H., Hawton, K., Geulayov, G., Townsend, E., Ness, J., Waters, K., Cooper, J. (2015). Hospital management of suicidal behavious and subsequent mortality: a prospective cohort study. Lancet Psychiatry. Link to the paper.
Self-poisoning and self-injury are associated with a high risk of suicide or death from any cause but the effect of routine aspects of hospital management on mortality risk is unknown. We followed up 38,145 people admitted to hospital following self-harm between 2000 and 2010 to investigate the association between the treatments patients receive in hospital (psychosocial assessment, medical admission, psychiatric admission, referral for mental health follow-up) and their subsequent risk of death. We found that most aspects of management were associated with increased mortality risk, and psychiatric admission or mental health follow-up were associated with the highest risk of death. This finding suggests that hospitals might be reserving the most intensive treatments for the patients at greatest need. There were significant interactions by subgroup, suggesting that the association between management and outcome was not the same for all people. In particular, admission to an inpatient psychiatric ward might reduce 12 month all-cause mortality in some high risk groups (men, adults older than 65 years, and those with a history of self-harm).
Conclusions:The findings of this study show how high the risk of suicide and other premature death can be for patients who attend A&E after self-harm. The risk is elevated further for people requiring the most intensive forms of clinical management, such as referral to outpatient mental health services and psychiatric hospital admission. Reassuringly, these findings indicate clinicians are appropriately allocating treatment. When we take into account some of the differences between patients, admission to inpatient psychiatry appears to have benefits in terms of reducing suicide and other early death in some subgroups.
Hawton, K., Bergen, H., Cooper, J., Turnbull, P., Waters, K., Ness, J. & Kapur, N. (2015) Suicide following self-harm: findings from the Multicentre Study of self-harm in England, 2000-2012. Journal of Affective Disorders 175, 147-51. Link to the paper.
Self-harm is a key risk factor for suicide and it is important to have up-to-date information on the extent of this risk. We followed up 40,346 self-harm patients identified in the three centres of the Multicentre Study of Self-harm in England between 2000 and 2010. By the end of 2012, 2704 individuals had died. Nearly one in five of the deaths were by suicide (including open verdicts), which occurred in 1.6% of patients (2.6% of males and 0.9% of females). Overall, 0.5% of individuals died by suicide in the first year (including 0.82% of males and 0.27% of females), during which time the risk was 49 times greater than the risk of suicide in the general population. Risk of suicide increased with age. While self-poisoning had been the most frequent method of self-harm, hanging was the most common method of subsequent suicide, particularly in males. The number of suicides was probably a considerable underestimate as there were also a large number of deaths recorded as accidents, the majority of which were poisonings (these often involving psychotropic drugs).
Conclusions: The findings underline the importance of suicide prevention initiatives focused on the self-harm population, especially during the initial months following an episode of self-harm. Estimates of using suicide and open verdicts may underestimate the true risk of suicide following self-harm and inclusion of accidental poisonings may be warranted in future risk estimates.
Owens, D, Kelley, R., Munyombwe, T., Bergen, H., Hawton, K., Cooper, J., Ness, J., Waters, K., West, R. & Kapur N. (2015). Switching methods of self-harm at repeat episodes: Findings from a multicentre cohort study. Journal of Affective Disorders 180, 44-51. Link to the paper.
It is recognised that people who self-harm more than once may switch from one method of self-harm to another. In this study we aimed to find out the frequency, pattern, determinants and characteristics of changes in methods of self-harm in individuals presenting to general hospitals. We used information on over 33,000 consecutive self-harm episodes identified in six general hospitals in Manchester, Derby and Oxford between 2003 and 2007. Over an average of 30 months of follow-up, 23% of people repeated self-harm and one-third of them switched method, often with a very short time interval between episodes, and especially where the person was male, younger, or had self-harmed previously. Self-poisoning was far less likely than other methods to be followed by switching of method.
Conclusions: When self-harm is repeated the method used often changes, but the nature of the change may be relatively unpredictable, except that this less often occurs following self-poisoning. Clinicians should therefore avoid potentially misleading assumptions about risks or needs of patients based simply on the method of harm.
Bergen, H., Hawton, K., Webb, R., Cooper, J., Steeg, S., Haigh, M., Ness, J., Waters, K. & Kapur N. (2014). Alcohol-related mortality following self-harm: a multicentre cohort study. JRSM Open, 5(8), 2054270414533326. Link to the paper.
We assessed alcohol-related premature death in people who self-harm compared to the general population, including differences in risk according to socioeconomic status. We studied 39,014 individuals aged 15 years or more who presented to emergency departments in Oxford, Manchester or Derby following self-harm between 2000 and 2010 and identified deaths up to the end of 2012. After an average (median) of 7.5 years' follow-up, 2695 individuals (6.9%) had died, including significantly more males (9.5%) than females (5.0%). Overall, 307 (11.4%) individuals had died from alcohol-related causes. Alcohol-related death was far more frequent than expected in both males and females. Taking account of the age when deaths occurred, deaths from alcohol-related causes occurred some 34 years earlier than would have been expected in male patients and some 38 years earlier in female patients. This was unrelated to the level of socioeconomic deprivation in the areas where individuals lived. Alcohol-related death was associated with unemployed/sick/disabled status, alcohol use during self-harm, referral to drug/alcohol services and lack of psychosocial assessment following self-harm.
Conclusions: Alcohol-related deaths contribute substantially to premature deaths in self-harm patients. During the assessment of patients following self-harm there should be a particular focus on possible alcohol misuse to enable early detection and treatment of alcohol problems. This requires easy access to alcohol misuse services. It could contribute to prevention of premature death from alcohol-related causes.
Steeg, S., & Kapur, N. (2011). How do methods used in previous episodes of non-fatal self-harm relate to eventual suicide? Journal of Affective Disorders, 136, 526-533. Link to the paper.
Methods used at an index episode of non-fatal self-harm may predict risk of future suicide. In this study we investigated suicide risk associated with most recent non-fatal method, and whether or not change in method was important. Increased risks of suicide by injury were found for individuals who used self-cutting, hanging/ asphyxiation, carbon monoxide/other gas, traffic-related and other self-injury at the last episode of self-harm (1.8 to 5-fold risks compared to poisoning). One-third who died by suicide used the same method for their last self-harm and for suicide, including 41% who self-poisoned.
Conclusions: Individuals using dangerous methods of self-harm, such as hanging and inhalation of car exhaust or other gas, should receive particularly intensive follow-up after a non-fatal attempt. There appears to be no pattern in change of method in the last two episodes of self-harm which leads to increased risk of suicide. Other factors need to be considered, as well as last method non-fatal self-harm, when suicide risk is assessed in the emergency department.
See also: Evid Based Mental Health
Bergen, H., Hawton, K., Kapur, N., Cooper, J., Steeg, S., Ness, J., & Waters, K. (2011). Shared characteristics of suicides and other unnatural deaths following non-fatal self-harm? A multicentre study of risk factors. Psychological Medicine. Link to the paper.
In this study we compared the risk of death by suicide and by accidental cause in individuals who had previously presented to Emergency Departments with self-harm during 2000 to 2007. Individuals were followed up to the end of 2009 using national death registers to identifydeaths and ascertain the cause. There were many risks common to both types of death, such as being male, of older age and having a history of psychiatric treatment. Individuals who died by suicide were more likely to have previously self-harmed, particularly using violent methods or self-cutting rather than poisoning, and to have mental health problems. Individuals dying by accidental narcotic poisoning (or non-narcotic poisoning) were likely to have had recreational/ illicit drug (or alcohol) problems at their last episode of non-fatal self-harm.
Conclusions: Individuals who died by suicide and by accidents have many things in common, such as unemployment or disability, life problems, alcohol or drug use and mental illness. These difficulties may lead to a variety of self-destructive behaviour. Differences seem to be partly related to the criteria coroners use in reaching verdicts. Drug or alcohol use may make an accidental verdict more likely than a suicide verdict.
See also Evid Based Mental Health 2012;15:101
Bergen, H., Hawton, K., Waters, K., Cooper, J. & Kapur, N. (2010).Psychosocial assessment and repetition of self-harm: The significance of single and multiple repeat episode analyses. Journal of Affective Disorders 123, 95-101. Link to the paper.
Self-harm is a common reason for presentation to the Emergency Department. An important question is whether psychosocial assessment following self-harm affects further repetition of self-harm. In this study we found that psychosocial assessment reduced the risk of a single repeat episode by 51% in individuals without a history of psychiatric treatment, and by 26% in individuals with a history of psychiatric treatment. For recurrent repetition of up to 5 episodes, psychosocial assessment decreased risk of a further episode by 13%. Appropriate statistical models which take account of multiple episodes by the same person are needed to accurately assess risk in recurrent repetition.
Conclusions: Psychosocial assessment is beneficial in reducing repeated self-harm in people both with and without a history of psychiatric care. Our finding supports the recommendation from the National Institute for Clinical Excellence that all individuals presenting to the emergency department with self-harm should receive a psychosocial assessment.
Hawton, K., Ferrey, A., Casey, D., Wells, C., Fuller, A., Bankhead, C., Clements, C., Ness, J., Gunnell, D., Kapur, N., Geulayov, G. (2019). Relative toxicity of analgesics commonly used for intentional self-poisoning: A study of case fatality based on fatal and non-fatal overdoses. Journal of Affective Disorders, 246:814-819.
Ferrey, A.E., Geulayov, G., Casey, D., Wells, C., Fuller, A., Bankhead, C., Ness, J., Clements, C., Gunnell, D., Kapur, N., Hawton, K. (2018). Relative toxicity of mood stabilisers and antipsychotics: case fatality and fatal toxicity associated with self-poisoning. BMC Psychiatry, 18:399.
Geulayov, G., Ferrey, A., Casey, D., Wells, C., Fuller, A., Bankhead, C., Gunnell, D., Clements, C., Kapur, N., Ness, J., Waters, K., Hawton, K. (2018). Relative toxicity of benzodiazepines and hypnotics commonly used for self-poisoning: An epidemiological study of fatal toxicity and case fatality. Journal of Psychopharmacology, 32:654-662.
Hawton, K., Bergen, H., Simkin, S., Arensman, E., Corcoran, P., Cooper, J., Waters, K., Gunnell, D., and Kapur, N. (2011). Impact of different pack sizes of paracetamol in the United Kingdom and Ireland on intentional overdoses: a comparative study. BMC Public Health, 11:460. Link to the paper.
In order to reduce fatal self-poisoning legislation was introduced in the UK in 1998 to restrict pack sizes of paracetamol sold in pharmacies (maximum 32 tablets) and non-pharmacy outlets (maximum 16 tablets), and in Ireland in 2001, but with smaller maximum pack sizes (24 and 12 tablets). In order to determine whether this resulted in smaller overdoses of paracetamol in Ireland compared with the UK, we used data on general hospital presentations for non-fatal self-harm for 2002 – 2007 from the Multicentre Study of Self-harm in England (six hospitals) and from the National Registry of Deliberate Self-harm in Ireland to compare sizes of overdoses of paracetamol in the two settings. We found clear peaks in numbers of non-fatal overdoses, associated with the different maximum pack sizes of paracetamol in pharmacy and non-pharmacy outlets in both England and Ireland. Significantly more pack equivalents (based on maximum non-pharmacy pack sizes) were used in (based on maximum non-pharmacy pack sizes) were used in overdoses in Ireland compared with England. However, the overall size of overdoses did not differ significantly between England and Ireland.
Conclusions: The difference in paracetamol pack size legislation between England and Ireland does not appear to have resulted in a major difference in sizes of overdoses. This is because more pack equivalents are taken in overdoses in Ireland, possibly reflecting differing enforcement of sales advice. Differences in access to clinical services may also be relevant.
Hawton, K., Bergen, H., Waters, K., Murphy, E., Cooper, J. & Kapur, N. (2011). Impact of withdrawal of the analgesic co-proxamol in the UK on non-fatal self-poisoning. Crisis 32, 81-87. Link to the paper.
In early 2005 the UK Committee on Safety of Medicines (CSM) announced gradual withdrawal of the analgesic co-proxamol because of its adverse benefit/safety ratio, especially its extensive use for intentional and accidental fatal poisoning. Prescriptions of co-proxamol were reduced in the 3-year withdrawal phase (2005 to 2007) following the CSM announcement. We assessed the impact of the CSM announcement in January 2005 to withdraw co-proxamol on non-fatal self-poisoning with co-proxamol and other analgesics. We used data on general hospital presentations for non-fatal self-poisoning (five hospitals in three centers in England). When the 3-year withdrawal period 2005-2007 was compared with 2000-2004, we found a marked reduction in the number of episodes of non-fatal self-poisoning episodes involving co-proxamol following the CSM announcement (an estimated 62% reduction over the period 2005 to 2007 compared to 2000 to 2004). There was no evidence of an increase in non-fatal self-poisoning episodes involving other analgesics (co-codamol, codeine, co-dydramol, dihydrocodeine, and tramadol) in relation to the CSM announcement over the same period, nor a change in the number of all episodes of self-poisoning.
Conclusions: The withdrawal of co-proxamol in the UK appears to have resulted in reduced non-fatal self-poisoning with co-proxamol, without significant substitution with other analgesics. This finding is in keeping with that found for suicide.
Hawton, K., Bergen, H., Simkin, S., Cooper, J., Waters, K., Gunnell, D. & Kapur, N. (2010). Toxicity of antidepressants: study of rates of suicide relative to prescribing and non-fatal overdose. British Journal of Psychiatry 196, 354-358.
Self-poisoning is a common method of suicide and often involves ingestion of antidepressants. Information on the relative toxicity of antidepressants is therefore extremely important. We assessed the relative toxicity of seven specific antidepressants, by comparing numbers of prescriptions for each antidepressant with poisoning suicide deaths in England and Wales involving each antidepressant (alone), and non-fatal self-poisoning episodes with each antidepressant presenting to six general hospitals (in Oxford, Manchester and Derby), between 2000 and 2006. We calculated fatal toxicity for each antidepressant , based on ratio of rates of deaths to prescriptions, and case fatality, based on ratio of rates of deaths to non-fatal self-poisonings. Fatal toxicity and case fatality indices provided very similar results. Case fatality rate ratios showed far greater toxicity for tricyclic antidepressants than the SNRI antidepressant venlafaxine and the NaSSA antidepressant mirtazapine, both of which had approximately four times greater toxicity than the SSRIs. Within the tricyclic antidepressants, compared with amitriptyline both dosulepin and doxepin were considerably more toxic. Within the SSRIs, citalopram had a higher case fatality than the other SSRIs.
Conclusions: There are wide differences in toxicity not only between classes of antidepressants, but also within classes. The findings are relevant to prescribing decisions, especially in individuals at risk, in whom clinicians should use less toxic antidepressants wherever possible. They are also relevant to regulatory authority policy regarding advice to clinicians. The findings have been communicated to the UK Medicines and Healthcare Products Regulatory Agency.
Bergen, H., Murphy, E., Cooper, J., Kapur, N., Stalker, C., Waters, K. & Hawton, K. (2010). A comparative study of non-fatal self-poisoning with antidepressants relative to prescribing in three centres in England. Journal of Affective Disorders 123, 95-101. Link to the paper.
Antidepressants are used frequently in non-fatal self-poisoning. There are national guidelines for prescribing antidepressants. In this study we compared the use of specific antidepressants (amitriptyline and dosulepin (tricyclics), citalopram, fluoxetine, paroxetine and sertraline (selective serotonin reuptake inhibitors) and venlafaxine (serotonin norepinephrine reuptake inhibitor)) for non-fatal self-poisoning relative to prescribing, in three centres in England, from 2004 to 2006. We found marked variation between centres in the ratio of rates of self-poisoning to prescribing for specific antidepressants. This is likely due to differences in both prescribing practices (despite clear national guidance) and patient characteristics.
Conclusions: Clinicians should consider carefully the toxicity, and the risk of overdose, when prescribing antidepressants for their patients.
Bergen, H., Hawton, K., Murphy, E., Cooper, J., Kapur, N., Stalker, C. & Waters, K. (2009). Trends in prescribing and self-poisoning in relation to UK regulatory authority warnings against use of SSRI antidepressants in under-18 year-olds. British Journal of Clinical Pharmacology 68, 618-629. Link to the paper.
Following the UK Medicines and Healthcare products Regulatory Authority (MHRA) warning in December 2003 not to prescribe selective serotonin reuptake inhibitor (SSRI) antidepressants, except fluoxetine, to under 18 year-olds, the prescribing of antidepressants declined in this group. Other studies had found no related changes in rates of suicide or hospital admissions for self-harm. In this study we found that presentations to general hospitals for non-fatal self-poisoning with SSRI antidepressants (but not fluoxetine) declined in 12-19 year-olds in three centres in England in line with UK prescribing trends. There was some evidence of a possible small substitution effect from use of other SSRIs for non-fatal self-poisoning to use of fluoxetine. Conclusions: The MHRA warning in 2003 not to prescribe SSRI antidepressants to young people was effective, as prescriptions for these drugs decreased after this date. Importantly, the occurrence of non-fatal self-harm in 12-19 year-olds in the three centres in this study was stable before and after 2003, with no major change of method or increase in self-injury. Thus the reduction in prescribing of SSRIs did not appear to result in increased self-harm in young people.