Epidemiology and trends in self-harm in the study centres

  • 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. DOI:10.1136/bmjopen-2015-009749

    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. DOI:10.1136/bmjopen-2015- 010538

     

    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. DOI:10.1016/j.jad.2015.11.001

     

    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. DOI:10.1136/bmjopen-2015-009749

    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. DOI: 10.1007/s00127-015-1136-9

     

    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]. DOI:10.1136/emermed-2013-202753

    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. DOI:10.1016/j.jad.2012.11.018

    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. DOI:10.1192/bjp.bp.111.094177

    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. DOI:10.1111/j.1469-7610.2012.02559.x
  • 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. DOI:10.1007/s00787-012-0269-6
  • 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 doi:10.1136/eb-2012-101031

  • 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. DOI:10.1192/bjp.bp.109.072637

    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.DOI:10.1192/bjp.bp.110.077651

    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. DOI:10.1186/1745-0179-3-16

    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. DOI:10.1007/s00127-007-0199-7

    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.