The incidence and repetition of hospital-treated deliberate self harm: findings from the world's first national registry

Background

Suicide is a significant public health issue with almost one million people dying by suicide each year worldwide. Deliberate self harm (DSH) is the single most important risk factor for suicide yet few countries have reliable data on DSH. We developed a national DSH registry in the Republic of Ireland to establish the incidence of hospital-treated DSH at national level and the spectrum and pattern of presentations with DSH and repetition.

Methods and Findings

Between 2003 and 2009, the Irish National Registry of Deliberate Self Harm collected data on DSH presentations to all 40 hospital emergency departments in the country. Data were collected by trained data registration officers using standard methods of case ascertainment and definition. The Registry recorded 75,119 DSH presentations involving 48,206 individuals. The total incidence rate fell from 209 (95% CI: 205–213) per 100,000 in 2003 to 184 (95% CI: 180–189) per 100,000 in 2006 and increased again to 209 (95% CI: 204–213) per 100,000 in 2009. The most notable annual changes were successive 10% increases in the male rate in 2008 and 2009. There was significant variation by age with peak rates in women in the 15–19 year age group (620 (95% CI: 605–636) per 100,000), and in men in the 20–24 age group (427 (95% CI: 416–439) per 100,000). Repetition rates varied significantly by age, method of self harm and number of previous episodes.

Conclusions

Population-based data on hospital-treated DSH represent an important index of the burden of mental illness and suicide risk in the community. The increased DSH rate in Irish men in 2008 and 2009 coincided with the advent of the economic recession in Ireland. The findings underline the need for developing effective interventions to reduce DSH repetition rates as a key priority for health systems.     

Suicide rates in young men in England and Wales in the 21st century: time trend study

Objectives To explore trends in suicide in young people to investigate the recent observation that after year on year rises in the 1970s, 1980s, and early 1990s, rates in young men are now declining.Design Time trend analysis.Setting England and Wales, 1968-2005.Population Men and women aged 15-34 years.Results Since the 1990s, rates of suicide in young men have declined steadily and by 2005 they were at their lowest level for almost 30 years. This decline is partly because of a reduction in poisoning with car exhaust gas as an increased number of cars have catalytic converters; but there have been declines in suicides from all common methods, including hanging, suggesting a more pervasive effect. Other risk factors for suicide, such as unemployment and divorce, have also decreased. Possible recent reductions in alcohol use among young men and increases in prescribing of antidepressants do not seem to be temporally related to the decline in suicide.Conclusions Suicide rates in young men have declined markedly in the past 10 years in England and Wales. Reductions in key risk factors for suicide, such as unemployment, might be contributing to lower rates.     

Changing pattern of poisoning in children in Newcastle, 1974-81.

All children aged under 15 years admitted to hospital in Newcastle upon Tyne between 1974 and 1981 with a diagnosis of poisoning were studied. After the introduction in 1976 of child resistant containers for salicylates and paracetamol, salicylate poisonings fell dramatically. The other most important medicines to cause poisoning in young children were tricyclic antidepressants, benzodiazapines, Lomotil (diphenoxylate and atropine), and iron preparations; these should also be packaged in child resistant containers by regulation. Few children had symptoms after poisoning with household products, but bleach, turpentine, and paraffin might also be packaged in child resistant containers. The numbers of adolescent girls admitted after deliberate self poisoning and of teenage boys admitted after ingestion of alcohol increased over the study period.     

High mortality by natural and unnatural causes: a 10 year follow up study of patients admitted to a poisoning treatment centre after suicide attempts.

OBJECTIVE--To describe mortality by suicide and other causes of death in a group of patients who attempted suicide, and to identify predictive factors. DESIGN--10 year follow up study based on records of suicide attempters in 1980. SETTING--Poisoning treatment centre at a general hospital. SUBJECTS--974 patients aged 15 and over referred to the poisoning treatment centre after deliberate self poisoning. MAIN OUTCOME MEASURES--Death by different causes registered in the Danish death cause register. RESULTS--In 10 years of follow up 306 patients died: 103 by suicide, 131 from natural causes, and 31 by accident; five were murdered, and in 36 cases the cause of death was uncertain. The standard mortality ratio was 550. Cause specific standardised mortality rates were 2960 for suicide, 236 for natural causes, 1256 for accidents, and 5459 for uncertain causes. In a Cox regression analysis, high risk factors for subsequent suicide were: more than one previous suicide attempt (relative risk 2.25), living alone (2.28), and age (1.03 per year). Predictors of death by natural causes were receiving a pension (1.69), drug misuse (2.72), more than one previous suicide attempt (2.25), age (1.06 per year), and male sex (2.49). The group of patients fulfilling at least one high risk criterion for later suicide differed significantly from the rest of the patient group in incidence of suicide, but both sensitivity and specificity were low. CONCLUSIONS--Most patients who attempted suicide were at high risk of succeeding because the risk factors, though significant, are not very specific. A strategy to prevent suicide must be directed toward the majority of those who attempt suicide.     

Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study

ObjectivesTo determine whether a serious paracetamol overdose in the medical television drama Casualty altered the incidence and nature of general hospital presentations for deliberate self poisoning.DesignInterrupted time series analysis of presentations for self poisoning at accident and emergency departments during three week periods before and after the broadcast. Questionnaire responses collected from self poisoning patients during the same periods.Setting49 accident and emergency departments and psychiatric services in United Kingdom collected incidence data; 25 services collected questionnaire data.Subjects4403 self poisoning patients; questionnaires completed for 1047.ResultsPresentations for self poisoning increased by 17% (95% confidence interval 7% to 28%) in the week after the broadcast and by 9% (0 to 19%) in the second week. Increases in paracetamol overdoses were more marked than increases in non-paracetamol overdoses. Thirty two patients who presented in the week after the broadcast and were interviewed had seen the episode—20% said that it had influenced their decision to take an overdose, and 17% said it had influenced their choice of drug. The use of paracetamol for overdose doubled among viewers of Casualty after the episode (rise of 106%; 28% to 232%).ConclusionsBroadcast of popular television dramas depicting self poisoning may have a short term influence in terms of increases in hospital presentation for overdose and changes in the choice of drug taken. This raises serious questions about the advisability of the media portraying suicidal behaviour.

Key messages

• This study found that portrayal of self poisoning in a popular television drama was associated with a short lived increase in presentation of self poisoning patients to general hospitals
• Choice of substance taken in overdose was also influenced by the broadcast
• Extreme caution should be exercised about portraying suicidal behaviour on television, and especially about giving details of the method used
• The potential role of television in preventing suicidal behaviour requires investigation

     

Comparative study of cases of poisoning by organophosphorous insecticides in various regions of Costa Rica

336 cases of organophosphorous poisoning from case records of hospitals in Costa Rica between 1972 and 1978 were classified in four categories according to signs and symptoms: 8% latent; 25.9% mild; 43.8% moderate and 22.3% severe. Eighteen of the total patients died during hospitalization. Suicidal ingestion was the principal cause of severe and latent poisoning, especially in urban areas, followed by occupational poisoning in agricultural workers in mild and moderate cases. Occupational poisoning was common in men; in women it was attempted suicide and in children accidental poisoning. Under 40 years of age, the main cause was suicidal ingestion among both men and women, and occupational poisoning after 40 years of age. After discharge from the hospital, 19.6% of the total poisoned patients were referred to psychiatric treatment; 22.7% and 18.2% had had mental and alcoholic problems, respectively, prior to poisoning. Attempted suicide was the principal cause of poisoning in 86.4% of these patients, indicating emotional instability. In this study, the incidence in psychiatric consultation after discharge from the hospital is not indicative of a relationship between mental disorders and acute insecticide poisoning. In 42.6% and in 22% of the deceased patients pralidoxime (PAM) and atropine respectively, were not administered as antidotes in the emergency room. Aminophylline and skeletal muscle relaxants among other contraindicated drugs were administered as part of the treatment in these deceased patients. The consequences of this misguided treatment are questioned.     

Factors associated with suicide after parasuicide in young people.

OBJECTIVE--To determine factors associated with completed suicide in young parasuicide patients. DESIGN--Case-control study. SETTING--Regional poisoning treatment centre in a teaching general hospital. SUBJECTS--Patients who, between 1968 and 1985 when aged 15-24 years, were admitted to the regional poisoning treatment centre because of deliberate self poisoning or self injury. Cases (n = 62) consisted of those who by the end of 1985 had died locally from either suicide (n = 41) or possible suicide (n = 21). Controls (n = 124) were patients who were known not to have died locally during the study period. Two controls were selected for each case, matched by sex, age (within two years), and length of follow up. MAIN OUTCOME MEASURES--Possible predictors of completed suicide. RESULTS--Univariate analysis (conditional logistic regression) showed that risk of death due to suicide and possible suicide was associated with six factors: social class V (odds ratio 2.7, 95% confidence interval 1.1 to 6.7), unemployment (2.8, 1.4 to 5.8), previous inpatient psychiatric treatment (4.9, 2.2 to 10.9), substance misuse (3.3, 1.6 to 6.8), personality disorder (2.1, 1.03 to 4.4), and previous attempted suicide (2.3, 1.2 to 4.4). Multivariate analysis identified two factors as significantly contributing to the model that best discriminated between the cases and controls: substance misuse (alcohol or drugs, or both) (adjusted odds ratio 3.9) and previous inpatient psychiatric treatment (3.7). These factors seemed to be associated with suicide after attempted suicide in both the short term (less than 12 months) and the long term (one year or more) and were also identified when the analysis was restricted to subjects who definitely died by suicide and their controls. CONCLUSIONS--Suicide after parasuicide in young people is associated with substance misuse. This suggests that prevention of suicide in young people who attempt suicide might be improved by close liaison between general hospital services for patients who have attempted suicide and services for young substance misusers and by measures aimed at preventing substance misuse in young people.     

The population impact on incidence of suicide and non-fatal self harm of regulatory action against the use of selective serotonin reuptake inhibitors in under 18s in the United Kingdom: ecological study

Objective To investigate the population impact on the incidence of suicide and non-fatal self harm of regulatory action in 2003 to restrict the use of selective serotonin reuptake inhibitors (SSRIs) in under 18s.Design Ecological time series study.Setting United Kingdom.Populations Young people in the UK aged 12-19 years (prescribing trends), in England and Wales aged 12-17 years (mortality), and in England aged 12-17 years (hospital admissions).Main outcome measures Deaths from suicide and hospital admissions for self harm.Results Antidepressant prescribing doubled between 1999 and 2003 but fell to the 1999 level between 2004 and 2005. These large changes in prescribing did not seem to be associated with temporal trends in suicide or self harm. In the years 1993 to 2005 the annual percentage reduction for suicide among 12-17 year olds was −3.9% (95% confidence interval −6.2% to −1.5%) in males and −3.0% (−6.6% to 0.6%) in females, with no indication of a substantial change in this rate of decrease during that period. Similarly, hospital admission rates for self harm in the years 1999 to 2005 indicated an annual percentage increase for males of 1.1% (−0.5% to 2.7%) and for females of 5.7% (3.6% to 7.8%), again with no statistical evidence of a change in rate after the regulatory action.Conclusions The noticeable reduction in prescribing of antidepressants since regulatory action in 2003 to restrict the use of SSRIs in under 18s does not seem to have been associated with changes in suicidal behaviour in young people. Specifically, these data for England do not indicate that reductions in antidepressant use have led to an increase in suicidal behaviour.     

Progression of optic neuritis to multiple sclerosis in the County of Split-Dalmatia, Croatia

The aim of this study was to determine the incidence of monosymptomatic optic neuritis (MON) and progression of MON to multiple sclerosis (MS) from the Mediterranean region of southern Europe in the County of Split-Dalmatia, Croatia during the 11 years period from 1991 to 2001. This study was made retrospectively on the 87 cases (59 female, aged 25.9 +/- 11.3 and 28 male aged 29.9 +/- 9.2) of MON, which were treated at the Department of Ophthalmology and Department of Neurology, Split, University Hospital, from January 1991 to December 2001. In each case the diagnosis was confirmed by a chart review and cases were ascribed to the data of admittance at hospital. The annual incidence of MON was 1.9 per 100,000 (95% CI, 0.4-3.5). The incidence among males was 1.2 (95% CI, 0-2.9) cases / 100,000 per year and 2.5 (95% CI, 0.1-4.9) among females. A significant seasonal variations in the incidence of MON was not found (chi2 = 6.81, p = 0.08). MS developed in 20 of 87 patients (22.9%) and median time was 25 (SE 8) months, (95% CI, 9-41) after the MON onset. After two years 12.6% of patients with MON developed MS, 20.6% after 5 years and 22.9% after 10 years. MS was slightly but not significantly more frequent in women than in men (chi2 = 0.72, p = 0.3). In conclusion, the progression of MON to MS in the County of Split-Dalmatia, Croatia was at a relatively moderate frequency.     

Trends in suicide in Scotland 1974-84: an increasing problem.

A detailed investigation of trends in suicide rates in Scotland from 1974 to 1984 showed a complex pattern. Overall rates for men increased by 40% with the greatest increases in those aged 45-64. In contrast, rates for women showed a small decline, which was most noticeable in those aged 15-24. The well recognised decline in poisoning by domestic gas was seen over this period, and suicide by this method virtually stopped. Both sexes showed a decline in suicide by poisoning with drugs, although the decrease was larger among women. The fall in suicide rates among young women was almost all due to the decrease in this method. The rise in rates for men was largely due to increases in hanging and poisoning with vehicle exhaust gases, although all methods except drugs and domestic gas showed some increase. These findings indicate that suicide is an increasing problem with causes that are far from understood, so that prevention may be difficult.     

Suicides after pregnancy in Finland, 1987-94: register linkage study.

OBJECTIVE: To determine rates of suicide associated with pregnancy by the type of pregnancy. DESIGN: Register linkage study. Information on suicides in women of reproductive age was linked with the Finnish birth, abortion, and hospital discharge registers to find out how many women who committed suicide had had a completed pregnancy during her last year of life. SETTING: Nationwide data from Finland. SUBJECTS: Women who committed suicide in 1987-94. RESULTS: There were 73 suicides associated with pregnancy, representing 5.4% of all suicides in women in this age group. The mean annual suicide rate was 11.3 per 100,000. The suicide rate associated with birth was significantly lower (5.9) and the rates associated with miscarriage (18.1) and induced abortion (34.7) were significantly higher than in the population. The risk associated with birth was higher among teenagers and that associated with abortion was increased in all age groups. Women who had committed a suicide tended to come from lower social classes and were more likely to be unmarried than other women who had had a completed pregnancy. CONCLUSIONS: The increased risk of suicide after an induced abortion indicates either common risk factors for both or harmful effects of induced abortion on mental health.     

The incidence of optic neuritis in Split-Dalmatia county, Croatia

The aim of the study was to determine the incidence of monosymptomatic optic neuritis (MON) in residents of Split-Dalmatia County, Croatia. The 127 cases (83 female, aged 26.2+/-9.9 and 44 male aged 26.9+/-11.2) with MON presented between January 1985 and December 2001 were analyzed from hospital data. The annual incidence was 1.6 per 100,000 (95% CI, 0-3). The incidence among females was 2.2 (95% CI, 0-4.6) cases / 100,000 per year and 1.1 (95% CI, 0-3) among males. The difference in incidence rates for women vs. men was not significant (chi2=0.41; p=0.52), although it is more likely that a true difference exists. The peak incidence in both sexes observed in the group 20-29 years of age was 4.2 (95% CI, 0-10). The highest incidence of MON was found in spring (46 cases). In summary, the incidence of MON in Split-Dalmatia County during the 17 years period is relatively low.     

Evidence for an environmental effect in the aetiology of insulin dependent diabetes in a transmigratory population.

OBJECTIVE--To examine whether children of families moving from an area of low incidence of childhood diabetes to one which is higher show a corresponding rise in disease incidence. DESIGN--Disease incidence study over 12 years. SETTING--Bradford District Metropolitan Council area. SUBJECTS--All subjects aged 0-16 years resident within the study area. MAIN OUTCOME MEASURES--The incidences of childhood diabetes in Asian and non-Asian families. RESULTS--The incidence of diabetes in Asian children increased from 3.1/100,000 per year in 1978-81 to 11.7/100,000 per year in 1988-90 (chi 2 for trend = 4.95, df = 1, p = 0.026) whereas that for other children remained constant at 10.5/100,000 per year. Over the entire study period rates were lower in Asian females (4.9/100,000 per year) than in Asian males (8.8/100,000 per year) whereas the reverse was true for other children (males 9.2/100,000 per year; females 12.0/100,000 per year) (test for common odds ratio: chi 2 = 3.81, df = 1, p = 0.052). CONCLUSIONS--Offspring of this transmigratory population had a rising incidence of childhood diabetes which was approaching that of the indigenous population. The data provide strong evidence for an environmental effect in the aetiology of insulin dependent diabetes.     

Age-Period-Cohort Projections of Ischaemic Heart Disease Mortality by Socio-Economic Position in a Rapidly Transitioning Chinese Population

Background

With economic development and population aging, ischaemic heart disease (IHD) is becoming a leading cause of mortality with widening inequalities in China. To forewarn the trends in China we projected IHD trends in the most economically developed part of China, i.e., Hong Kong.

Methods

Based on sex-specific IHD mortality rates from 1976 to 2005, we projected mortality rates by neighborhood-level socio-economic position (i.e., low- or high-income groups) to 2020 in Hong Kong using Poisson age-period-cohort models with autoregressive priors.

Results

In the low-income group, age-standardized IHD mortality rates among women declined from 33.3 deaths in 1976–1980 to 19.7 per 100,000 in 2016–2020 (from 55.5 deaths to 34.2 per 100,000 among men). The rates in the high-income group were initially higher in both sexes, particularly among men, but this had reversed by the end of the study periods. The rates declined faster for the high-income group than for the low-income group in both sexes. The rates were projected to decline faster in the high-income group, such that by the end of the projection period the high-income group would have lower IHD mortality rates, particularly for women. Birth cohort effects varied with sex, with a marked upturn in IHD mortality around 1945, i.e., for the first generation of men to grow up in a more economically developed environment. There was no such upturn in women. Birth cohort effects were the main drivers of change in IHD mortality rates.

Conclusion

IHD mortality rates are declining in Hong Kong and are projected to continue to do so, even taking into account greater vulnerability for the first generation of men born into a more developed environment. At the same time social disparities in IHD have reversed and are widening, partly as a result of a cohort effect, with corresponding implications for prevention.     

Circadian Rhythm Variation in Attempted Suicide by Deliberate Self-Poisoning, and in Completed Suicide, in Central Nepal

Daily rhythms are described in almost every variable that can be measured, including suicide rate. The present study aims to find if circadian rhythm exist in suicidal poisoning and completed suicide due to poisoning in central Nepal. The study included all the attempted suicide cases admitted in Patan Hospital and all the completed suicide cases by poisoning reported to Kathmandu District Police during March 2002 to April 2003. The time was grouped into 24 increments of 1 hour. The data were analysed by Kolmogorov-Smirnov test and cosinor analysis. The circadian rhythm of attempted suicide by deliberate self poisoning exhibits a peak at 18:00 h, whereas no circadian rhythm is seen in completed suicides by poisoning although it is bimodal in distribution (6:00-12:00 and 15:00-20:00) with peaks at 7:00 and 18:00 h.     

Consultants' workload in outpatient clinics.

The impact on hospital resources of variability in referral rates among general practitioners was of concern throughout the 1980s. The overall number of patients referred to outpatient clinics, however, has increased only slowly since the NHS began; in contrast, the number of new outpatients seen by each hospital consultant has declined appreciably. Ironically, despite this decline, further increasing the number of consultants in now being presented as a solution to the demand for outreach clinics in general practice.     

Secular trends in self reported sexual activity and satisfaction in Swedish 70 year olds: cross sectional survey of four populations, 1971-2001

Objective To study secular trends in self reported sexual behaviour among 70 year olds.Design Cross sectional survey.Settings Four samples representative of the general population in Gothenburg, Sweden.Participants 1506 adults (946 women, 560 men) examined in 1971-2, 1976-7, 1992-3, and 2000-1.Main outcome measures Sexual intercourse, attitudes to sexuality in later life, sexual dysfunctions, and marital satisfaction.Results From 1971 to 2000 the proportion of 70 year olds reporting sexual intercourse increased among all groups: married men from 52% to 68% (P=0.002), married women from 38% to 56% (P=0.001), unmarried men from 30% to 54% (P=0.016), and unmarried women from 0.8% to 12% (P<0.001). Men and women from later birth cohorts reported higher satisfaction with sexuality, fewer sexual dysfunctions, and more positive attitudes to sexuality in later life than those from earlier birth cohorts. A larger proportion of men (57% v 40%, P<0.001) and women (52% v 35%, P<0.001) reported very happy relationships in 2000-1 compared with those in 1971-2. Sexual debut before age 20 increased in both sexes: in men from 52% to 77% (P<0.001) and in women from 19% to 64% (P<0.001).Conclusion Self reported quantity and quality of sexual experiences among Swedish 70 year olds has improved over a 30 year period.     

Trends in suicide and unemployment in Scotland, 1976-86.

To establish whether a correlation exists between unemployment and suicide the trends in the rates of both among men in Scotland during 1976-86 were studied. Both rates showed rapid increases in the late 1970s and then much slower increases after 1982. In contrast, among women, although the rate of unemployment followed a similar pattern, there was a gradual fall in the rate of suicide. The trends in regional unemployment for men during 1971-81 were compared with the suicide rates for the period before the increase (1974-7) and the period after the rapid increase (1983-6). No association was observed between trends in suicide and unemployment when analysed by health board areas or aggregates of local government districts. These data do not support the hypothesis that the rise in unemployment is a direct cause of the rise in suicide rates among men.     

Suicide among Arab-Americans

Background

Arab-American (AA) populations in the US are exposed to discrimination and acculturative stress—two factors that have been associated with higher suicide risk. However, prior work suggests that socially oriented norms and behaviors, which characterize recent immigrant ethnic groups, may be protective against suicide risk. Here we explored suicide rates and their determinants among AAs in Michigan, the state with the largest proportion of AAs in the US.

Methodology/Principal Findings

ICD-9/10 underlying cause of death codes were used to identify suicide deaths from among all deaths in Michigan between 1990 and 2007. Data from the 2000 U.S. Census were collected for population denominators. Age-adjusted suicide rates among AAs and non-ethnic whites were calculated by gender using the direct method of standardization. We also stratified by residence inside or outside of Wayne County (WC), the county with the largest AA population in the state. Suicide rates were 25.10 per 100,000 per year among men and 6.40 per 100,000 per year among women in Michigan from 1990 to 2007. AA men had a 51% lower suicide rate and AA women had a 33% lower rate than non-ethnic white men and women, respectively. The suicide rate among AA men in WC was 29% lower than in all other counties, while the rate among AA women in WC was 20% lower than in all other counties. Among non-ethnic whites, the suicide rate in WC was higher compared to all other counties among both men (12%) and women (16%).

Conclusions/Significance

Suicide rates were higher among non-ethnic white men and women compared to AA men and women in both contexts. Arab ethnicity may protect against suicide in both sexes, but more so among men. Additionally, ethnic density may protect against suicide among Arab-Americans.