Transcript Self harm

Self harm and Suicide
Dr Asif Mir
Locum Consultant psychiatrist
Meadowbrook unit
[email protected]
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 15and 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, selfmutilation, 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 selfharm 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 selfharm 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.