Epidemiology

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.