A new study has shown just how high the risks of suicide and all-cause death can be for patients who have self-harmed. Here Sarah Steeg and Pauline Turnbull, joint authors of the study, explain that it is not all bad news.
Using real-world data on people who go to hospital emergency departments following self-harm, we found that more than one in 50 people died in the year after coming to hospital, and suicide was a common cause of death. While these figures appear stark, there were also some more positive findings. The study found that the people most at risk of suicide and all-cause death were indeed receiving the most intensive care, such as psychiatric inpatient admission and referral to outpatient care. Rather than suggesting that these treatments are harmful, it seems that clinicians are preferentially providing treatment for the people who are at most immediate risk. Encouragingly, in some groups of patients, this care could potentially reduce deaths; psychiatric admission might be associated with reductions in suicide and all-cause mortality in men, people aged 65 and over and those who had self-harmed in the past. This is the first time these associations have been examined on a large, multicentre scale. The possibility that particular routine hospital care for people who have self-harmed could help reduce deaths is important progress in on-going suicide prevention efforts.
Appropriate and consistent provision of routine care in hospital emergency departments is a key focus of the National Suicide Prevention Strategy, as people with a history of self-harm are identified as a group at high risk of suicide. This current study and other research from the Multicentre Study of Self-Harm have also reported that people who attend hospital following self-harm have a higher risk of death from all causes. It’s encouraging to see results suggesting that particularly vulnerable and high-risk individuals are being directed to the most intensive forms of clinical management.
Research from the Manchester Self-Harm Project and the Multicentre Study of Self-Harm has contributed to national policy, including the National Suicide Prevention Strategy and guidelines on the hospital management of self-harm.
In 2004, two clinical guidelines were published, both of which stated that all patients attending hospital following self-harm should receive a comprehensive psychosocial assessment. We previously found that this routine clinical care can reduce the risk of further self-harm by as much as 40%, and patients have reported that talking about their situation in the context of an assessment can help to alleviate distress and loneliness. Evaluating the uptake of this guidance can be difficult; one of the ways we have previously investigated this is to compare the hospital management of self-harm in 31 hospitals between 2001/2 and 2010/11. In this study we found that 42% of patients did not receive a specialist mental health assessment, despite the introduction of the guidelines. There was also wide variation between hospitals, ranging from 22% of people being assessed to 88% elsewhere in the country. The quality of hospital services for self-harm patients seemed to have improved since 2001/2. However, there was evidence that measures of good clinical practice were still not being adopted; guidance suggests that information regarding the assessment should always be sent to the patient’s GP, but we found that this was only happening in 36% of instances. Disappointingly, there was no evidence that management of self-harm patients had improved at all over the ten year study period.
We hope to improve the standards of care for people who go to hospital following self-harm. In 2013, a quality standard for self-harm was published by the National Institute of Health and Clinical Excellence, outlining eight key statements that all hospitals should aim to implement in order to provide the best possible clinical care for people who attend hospital following self-poisoning or self-injury. At the Manchester Self-Harm project, we’re currently working with local hospitals to develop training for A&E staff based on evidence from the literature and guidelines. With our colleagues from the Multicentre Study of Self-Harm, we’re also working with the Department of Health to ensure that nationally collected self-harm data are complete and robust.
These results from our most recent study are reassuring, suggesting as they do that people who are most at risk of suicide and other early death following self-harm are being appropriately identified and managed by clinical staff. There is more for us to understand about the differences between people who receive certain care and those who don’t, and how subsequent contact with health services may influence risks of mortality, but our initial results are promising. Appropriately allocating aspects of routine care could improve services for patients, and may ultimately reduce the number of deaths.