Self harm and Suicide

Dr Asif MirLocum Consultant psychiatrist

Meadowbrook unitAsif.mir@gmw.nhs.uk

Introduction

• A World Health Organisation survey reveals that a fifth of 15-year-olds in England say they self-harmed over the past year

• The Guardian, Wednesday 21 May 2014

Epidemiology

• The last comprehensive study of self-harm in England was published by the British Medical Journal in 2002. It surveyed around 6,000 15- and 16-year-olds in 41 schools and found that 6.9% of them said they had self-harmed over the past year. This compares with the 2013-14 WHO study, which puts the figure at 20% of 15-year-olds

Epidemiology and trends in non-fatal self-harm in three centres in England: 2000–2007

Berger et al

• Rates of self-harm declined significantly over 8 years for males in three centres (Oxford: –14%; Manchester: –25%; Derby: –18%) and females in two centres (Oxford: –2% (not significant); Manchester: – 13%; Derby: –17%), in keeping with national trends in suicide.

• A decreasing proportion and number of episodes involved self-poisoning alone, and an increasing proportion and number involved other self-injury (e.g. hanging, jumping, traffic related).

• Episodes involving self-cutting alone showed a slight decrease in numbers over time.

• Trends in alcohol use at the time of self-harm and repetition within 1 year were stable.

Suicide After Deliberate Self-Harm: A 4-Year Cohort Study Cooper et al 2005

• Sixty suicides occurred in the cohort during the follow-up period. An approximately 30-fold increase in risk of suicide, compared with the general population, was observed for the whole cohort.

• The SMR was substantially higher for female patients than for male patients. Suicide rates were highest within the first 6 months after the index self-harm episode.

• The independent predictors of subsequent suicide were avoiding discovery at the time of self-harm, not living with a close relative, previous psychiatric treatment, self-mutilation, alcohol misuse, and physical health problems.

Scales for predicting risk following self-harm: an observational study in 32 hospitals in England

(Quinlivan et al 2014)

• Unvalidated locally developed proformas were the most commonly used instruments (reported in n=22 (68.8%) mental health services).

• Risk assessment scales were used in one-third of services, with the SAD PERSONS being the single most commonly used scale.

• There were no differences in service quality score between hospitals which did and did not use scales as a component of risk assessment (median service quality score (IQR): 14.5 (12.8, 16.4) vs 14.5 (11.4, 16.0), U=121.0, p=0.90),

• Hospitals which used scales had a lower median rate of repeat self-harm within 6 months (median repeat rate (IQR): 18.5% vs 22.7%, p=0.008, IRR (95% CI) 1.18 (1.00 to 1.37).

• When adjusted for differences in casemix, this association was attenuated (IRR=1.13, 95% CI (0.98 to 1.3)).

Premature death after self-harm: a multicentre cohort study(Bergen et al)

• Physical health and life expectancy are severely compromised in individuals who self-harm compared with the general population. In the management of self-harm, clinicians assessing patients' psychosocial problems should also consider their physical needs.

Premature death after self-harm: a multicentre cohort study(Bergen et al)

• Death was more likely in patients than in the general population (SMR 3•6, 95% CI 3•5—3•8), and occurred more in males (4•1, 3•8—4•3) than females (3•2, 2•9—3•4).

• Deaths due to natural causes were 2—7•5 times more frequent than was expected.

• For individuals who died of any cause, mean YLL was 31•4 years (95% CI 30•5—32•2) for male patients and 30•7 years (29•5—31•9) for female patients.

• Mean YLL for natural-cause deaths was 25•9 years (25•7—26•0) for male patients and 25•5 years (25•2—25•8) for female patients, and for external-cause deaths was 40•2 years (40•0—40•3) and 40•0 years (39•7—40•5), respectively.

• Disease of the circulatory (13•1% in males; 13•0% in females) and digestive (11•7% in males; 17•8% in females) systems were major contributors to YLL from natural causes.

• All-cause mortality increased with each quartile of socioeconomic deprivation in male patients (χ2 trend 39•6; p<0•0001), female patients (13•9; p=0•0002), and both sexes combined (55•4; p<0•0001).

• Socioeconomic deprivation was related to mortality in both sexes combined from natural causes (51•0; p<0•0001) but not from external causes (0•30; p=0•58).

• Alcohol problems were associated with death from digestive-system disease, drug misuse with mental and behavioural disorders, and physical health problems with circulatory-system disease.

Death by homicide, suicide, and other unnatural causes in people with mental illness: a population-based study

(Hiroeh et al 2001)

• People with mental disorders, including severe mental illness, are at increased risk of death by homicide. Strategies to reduce mortality in the mentally ill are correct to emphasise the high risk of suicide, but they should also focus on other unnatural causes of death.

Assessment of suicide risk(suicide and self injury: practitioners portfolio 1999)

• High risk groups- Mental disorder (depression, schizophrenia)- Alcohol dependence - Living alone- Young unemployed men- Physical illness- History of deliberate self harm- Impulsive/aggressive- Labile mood

• The most recent suicide attempt- Degree of premeditation and planning- Method used (how lethal)- Level of violence involved - The intent- Level of success anticipated- Feeling about the failure of the attempt

• Any evidence of following- Previous attempts- Social isolation- Hopelessness/helplessness- Substance misuse- Recent experience of failure/rejection- Ongoing relationship difficulties- Actual or attempted suicide by a parent or close relative- Recent major life stressors- Recent discharge from psychiatric hospital- Absence of key therapist- Anniversary of losses- Rapid reduction of addictive drugs or psychotropic drugs

• Protective factors-good social/professional support network -Personal ability to resist impulses-Able to identify reasons not to die-willingness to turn to help in a crisis

Areas of Assessment of self harm

• Personal history• Assessment of self harm-for how long-How frequent-Types of self harm-how damaging and life threatening• Support network• Motivation to change

Theoretical perspectives

• Biological theories- suicidal behaviour results from the dual presence of biologically-based diathesis(such as dysregulation of the serotonergic system in the ventromedial prefrontal cortex) and an activating psychosocial stressor

(Mann2003; Conte et al 1989; van Pragg 2001)

• Psychodynamic theory- propose that suicide is caused by unconscious drives (Menninger, 1938); intensive affective states(Hendin, 1991); desire to escape from psychological pain (Baumister,1990); essential drives for meaning (Rogers 2001); and disturbed attachment (Bowlby, 1973)

• Cognitive-behavioural theories- posit causal roles for hopelessnessBeck et al 1990; Beck et al 1985); the suicidal cognitive mode (Beck et al 2001); autobiographical memory deficits and perceptions of entrapment (Williams, 2001; Williams et al 2008) and emotional dysregulation (Linehan, 1993)

• Developmental/systems theories posit causal roles for disturbed social forces (Durkein, 1897) and family systems( Richman,1986; Sabbath, 1969)

References • Dexter, P., & Towl, G. J. (1995) 'An investigation into suicidal behaviours in prison'. In

Clark, N.• K. and Stephenson, G. M. (Eds.) Criminal Behaviour: Perceptions, Attributions and

Rationality.• Leicester: DCLP/British Psychological Society.• • Towl, G.J., & Crighton, D.A. (1996) The Handbook of Psychology for Forensic

Practitioners.• London: Routledge. Recommended.• • Towl and Crighton (1996) Checklist for Risk Assessment Interviews with Suicidal

Clients• • Hawton, K,. & Catalan, J., (1982). Attempted Suicide. A Practical Guide to its Nature

and• Management. Oxford Medical Publications.• • Linke, S., (1997). Assessing and Managing Suicide Risk. Core Mini-Guides. British

Psychological• Society.