Clinical management
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.