An improved understanding of the factors associated with self-harm in young people who die by suicide can inform suicide prevention measures.

To describe sociodemographic and clinical characteristics and service utilisation related to self-harm in a national sample of young people who died by suicide.

We carried out a descriptive study of self-harm in a national consecutive case series (N = 544) of 10- to 19-year-olds who died by suicide over 3 years (2014–2016) in the UK as identified from national mortality data. Information was collected from coroner inquest hearings, child death investigations, criminal justice system and National Health Service serious incident reports.

Almost half (49%) of these young people had harmed themselves at some point in their lives, a quarter (26%) in the 3 months before death. Girls were twice as likely as boys to have recent self-harm (40 v. 20%; P < 0.001). Compared to the no self-harm group, young people with recent self-harm were more likely to have a mental illness diagnosis (63 v. 23%; P < 0.001); misused alcohol (19 v. 9%; P = 0.07); experienced physical, sexual or emotional abuse (17 v. 3%; P < 0.01); and recent life adversity (95 v. 75%; P < 0.001). Furthermore, they were more likely to be in contact with mental health services (60 v. 10%), or emergency departments or general physicians for a mental health condition (52 v. 10%) in the 3 months before death.

Presentation to services in young people who self-harm is an important opportunity to intervene through comprehensive psychosocial assessment and treatment of underlying conditions.

Little is known about when youth may be at greatest risk for attempting suicide, which is critically important information for the parents, caregivers, and professionals who care for youth at risk. This study used adolescent and parent reports, and a case-crossover, within-subject design to identify 24-hour warning signs (WS) for suicide attempts.

Adolescents (N = 1094, ages 13 to 18) with one or more suicide risk factors were enrolled and invited to complete bi-weekly, 8–10 item text message surveys for 18 months. Adolescents who reported a suicide attempt (survey item) were invited to participate in an interview regarding their thoughts, feelings/emotions, and behaviors/events during the 24-hours prior to their attempt (case period) and a prior 24-hour period (control period). Their parents participated in an interview regarding the adolescents’ behaviors/events during these same periods. Adolescent or adolescent and parent interviews were completed for 105 adolescents (81.9% female; 66.7% White, 19.0% Black, 14.3% other).

Both parent and adolescent reports of suicidal communications and withdrawal from social and other activities differentiated case and control periods. Adolescent reports also identified feelings (self-hate, emotional pain, rush of feelings, lower levels of rage toward others), cognitions (suicidal rumination, perceived burdensomeness, anger/hostility), and serious conflict with parents as WS in multi-variable models.

This study identified 24-hour WS in the domains of cognitions, feelings, and behaviors/events, providing an evidence base for the dissemination of information about signs of proximal risk for adolescent suicide attempts.

Psychological therapies following an episode of self-harm should happen quickly to ensure patients receive the care they need and to reduce the likelihood of repetition.

We sought to explore patients' subjective experience of accessing psychological therapies following self-harm and their views on improving practice.

Between March and November 2019, we recruited 128 patients and 23 carers aged 18 years or over from 16 English mental health trusts, from community organisations and via social media. Thematic analyses were used to interpret the data.

Participants reported long waiting times, multiple failed promises and rejection when trying to access psychological therapies following self-harm. Poor communication and information provision contributed to uncertainty, worsening mental health and further self-harm. Other barriers included: lack of tailored interventions, stigmatising responses, use of exclusionary thresholds to access services, and punitive approaches to treating these patients. Participant recommendations to improve access to psychological therapies included: (a) the importance of compassionate and informed staff; (b) having timely access to aftercare from well-funded and well-resourced teams; (c) continuity of care, improved communication, and support during waiting times and while navigating the referral process; (d) greater information on the availability and benefits of psychological therapies; and (e) greater choice and flexibility over interventions.

Our findings identify long waiting times and inadequate service provision as barriers to high-quality and safe aftercare for patients who have self-harmed. Consistent with clinical guidelines, all patients should receive prompt aftercare and access to tailored psychological treatments following a self-harm episode.

The aetiology of dual harm (co-occurring self-harm and violence towards others) is poorly understood because most studies have investigated self-harm and violence separately. We aimed to examine childhood risk factors for self-harm, violence, and dual harm, including the transition from engaging in single harm to dual harm.

Data from the Avon Longitudinal Study of Parents and Children, a UK-based birth cohort study, were used to estimate prevalence of self-reported engagement in self-harm, violence, and dual harm at ages 16 and 22 years. Risk ratios were calculated to indicate associations across various self-reported childhood risk factors and risks of single and dual harm, including the transition from single harm at age 16 years to dual harm at age 22.

At age 16 years, 18.1% of the 4176 cohort members had harmed themselves, 21.1% had engaged in violence towards others and 3.7% reported dual harm. At age 22 the equivalent prevalence estimates increased to 24.2, 25.8 and 6.8%, respectively. Depression and other mental health difficulties, drug and alcohol use, witnessing self-harm and being a victim of, or witnessing, violence were associated with higher risks of transitioning from self-harm or violence at age 16 to dual harm by age 22.

Prevalence of dual harm doubled from age 16 to 22 years, highlighting the importance of early identification and intervention during this high-risk period. Several childhood psychosocial risk factors associated specifically with dual harm at age 16 and with the transition to dual harm by age 22 have been identified.

Family involvement has been identified as a key aspect of clinical practice that may help to prevent suicide.

To investigate how families can be effectively involved in supporting a patient accessing crisis mental health services.

A multi-site ethnographic investigation was undertaken with two crisis resolution home treatment teams in England. Data included 27 observations of clinical practice and interviews with 6 patients, 4 family members, and 13 healthcare professionals. Data were analysed using framework analysis.

Three overarching themes described how families and carers are involved in mental healthcare. Families played a key role in keeping patients safe by reducing access to means of self-harm. They also provided useful contextual information to healthcare professionals delivering the service. However, delivering a home-based service can be challenging in the absence of a supportive family environment or because of practical problems such as the lack of suitable private spaces within the home. At an organisational level, service design and delivery can be adjusted to promote family involvement.

Findings from this study indicate that better communication and dissemination of safety and care plans, shared learning, signposting to carer groups and support for carers may facilitate better family involvement. Organisationally, offering flexible appointment times and alternative spaces for appointments may help improve services for patients.

Timely provision of aftercare following self-harm may reduce risks of repetition and premature death, but existing services are frequently reported as being inadequate.

To explore barriers and facilitators to accessing aftercare and psychological therapies for patients presenting to hospital following self-harm, from the perspective of liaison psychiatry practitioners.

Between March 2019 and December 2020, we interviewed 51 staff members across 32 liaison psychiatry services in England. We used thematic analyses to interpret the interview data.

Barriers to accessing services may heighten risk of further self-harm for patients and burnout for staff. Barriers included: perceived risk, exclusionary thresholds, long waiting times, siloed working and bureaucracy. Strategies to increase access to aftercare included: (a) improving assessments and care plans via input from skilled staff working in multidisciplinary teams (e.g. including social workers and clinical psychologists); (b) supporting staff to focus on assessments as therapeutic intervention; (c) probing boundaries and involving senior staff to negotiate risk and advocate for patients; and (d) building relationships and integration across services.

Our findings highlight practitioners’ views on barriers to accessing aftercare and strategies to circumvent some of these impediments. Provision of aftercare and psychological therapies as part of the liaison psychiatry service were deemed as an essential mechanism for optimising patient safety and experience and staff well-being. To close treatment gaps and reduce inequalities, it is important to work closely with staff and patients, learn from experiences of good practice and implement change more widely across services.

Evidence on the impact of the pandemic on healthcare presentations for self-harm has accumulated rapidly. However, existing reviews do not include studies published beyond 2020.

To systematically review evidence on presentations to health services following self-harm during the COVID-19 pandemic.

A comprehensive search of databases (WHO COVID-19 database; Medline; medRxiv; Scopus; PsyRxiv; SocArXiv; bioRxiv; COVID-19 Open Research Dataset, PubMed) was conducted. Studies published from 1 January 2020 to 7 September 2021 were included. Study quality was assessed with a critical appraisal tool.

Fifty-one studies were included: 57% (29/51) were rated as ‘low’ quality, 31% (16/51) as ‘moderate’ and 12% (6/51) as ‘high-moderate’. Most evidence (84%, 43/51) was from high-income countries. A total of 47% (24/51) of studies reported reductions in presentation frequency, including all six rated as high-moderate quality, which reported reductions of 17–56%. Settings treating higher lethality self-harm were overrepresented among studies reporting increased demand. Two of the three higher-quality studies including study observation months from 2021 reported reductions in self-harm presentations. Evidence from 2021 suggests increased numbers of presentations among adolescents, particularly girls.

Sustained reductions in numbers of self-harm presentations were seen into the first half of 2021, although this evidence is based on a relatively small number of higher-quality studies. Evidence from low- and middle-income countries is lacking. Increased numbers of presentations among adolescents, particularly girls, into 2021 is concerning. Findings may reflect changes in thresholds for help-seeking, use of alternative sources of support and variable effects of the pandemic across groups.

Evidence for risk of dying by suicide and other causes following discharge from in-patient psychiatric care throughout adulthood is sparse.

To estimate risks of all-cause mortality, natural and external-cause deaths, suicide and accidental, alcohol-specific and drug-related deaths in working-age and older adults within a year post-discharge.

Using interlinked general practice, hospital, and mortality records in the Clinical Practice Research Datalink we delineated a cohort of discharged adults in England, 2001–2018. Each patient was matched to up to 20 general population comparator patients. Cumulative incidence (absolute risks) and hazard ratios (relative risks) were estimated separately for ages 18–64 and ≥65 years with additional stratification by gender and practice-level deprivation.

The 1-year cumulative incidence of dying post-discharge was 2.1% among working-age adults (95% CI 2.0–2.3) and 14.1% (95% CI 13.6–14.5) among older adults. Suicide risk was particularly elevated in the first 3 months, with hazard ratios of 191.1 (95% CI 125.0–292.0) among working-age adults and 125.4 (95% CI 52.6–298.9) in older adults. Older patients were vulnerable to dying by natural causes within 3 months post-discharge. Risk of dying by external causes was greater among discharged working-age adults in the least deprived areas. Relative risk of suicide in discharged working-age women relative to their general population peers was double the equivalent male risk elevation.

Recently discharged adults at any age are at increased risk of dying from external and natural causes, indicating the importance of close monitoring and provision of optimal support to all such patients, particularly during the first 3 months post-discharge.

Community treatment orders (CTOs) enable patients to be treated in the community rather than under detention in hospital. Population-based studies of suicide among patients subject to a CTO are scarce.

To compare suicide rates among patients subject to a CTO with all discharged psychiatric patients and those detained for treatment but not subject to a CTO at discharge (‘CTO-eligible’ patients).

From a national case series of patients who died by suicide within 12 months of contact with mental health services in England during 2009–2018, we estimated average annual suicide rates for all discharged patients, those on a CTO at the time of suicide, those ever treated under a CTO and CTO-eligible patients.

Suicide rates for patients on a CTO at the time of suicide (191.3 per 100 000 patients) were lower than all discharged patients (482.3 per 100 000 discharges). Suicide rates were similar in those ever treated under a CTO (350.1 per 100 000 CTOs issued) and in CTO-eligible patients (382.9 per 100 000 discharges). Suicide rates within 12 months of discharge were higher in persons ever under a CTO (205.1 per 100 000 CTOs issued) than CTO-eligible patients (161.5 per 100 000 discharges), but this difference was reversed for rates after 12 months of discharge (153.2 per 100 000 CTOs issued v. 223.4 per 100 000 discharges).

CTOs may be effective in reducing suicide risk. The relative benefits of CTOs and intensive aftercare may be time-dependent, with the benefit of a CTO being less before 12 months after discharge but greater thereafter. CTO utilisation requires a careful balancing of patient safety versus autonomy.

Many studies report an ethnic density effect whereby psychosis incidence among ethnic minority groups is higher in low co-ethnic density areas. It is unclear whether an equivalent density effect applies with other types of socioeconomic disadvantages.

We followed a population cohort of 2 million native Danes comprising all those born on 1st January 1965, or later, living in Denmark on their 15th birthday. Socioeconomic disadvantage, based on parents' circumstances at age 15 (low income, manual occupation, single parent and unemployed), was measured alongside neighbourhood prevalence of these indices.

Each indicator was associated with a higher incidence of non-affective psychosis which remained the same, or was slightly reduced, if neighbourhood levels of disadvantage were lower. For example, for individuals from a low-income background there was no difference in incidence for those living in areas where a low-income was least common [incidence rate ratio (IRR) 1.01; 95% confidence interval (CI) 0.93–1.10 v. those in the quintile where a low income was most common. Typically, differences associated with area-level disadvantage were the same whether or not cohort members had a disadvantaged background; for instance, for those from a manual occupation background, incidence was lower in the quintile where this was least v. most common (IRR 0.83; 95% CI 0.71–0.97), as it was for those from a non-manual background (IRR 0.77; 95% CI 0.67–0.87).

We found little evidence for group density effects in contrast to previous ethnic density studies. Further research is needed with equivalent investigations in other countries to see if similar patterns are observed.

Concerns have been raised about the utility of self-report assessments in predicting future suicide attempts. Clinicians in pediatric emergency departments (EDs) often are required to assess suicidal risk. The Death Implicit Association Test (IAT) is an alternative to self-report assessment of suicidal risk that may have utility in ED settings.

A total of 1679 adolescents recruited from 13 pediatric emergency rooms in the Pediatric Emergency Care Applied Research Network were assessed using a self-report survey of risk and protective factors for a suicide attempt, and the IAT, and then followed up 3 months later to determine if an attempt had occurred. The accuracy of prediction was compared between self-reports and the IAT using the area under the curve (AUC) with respect to receiver operator characteristics.

A few self-report variables, namely, current and past suicide ideation, past suicidal behavior, total negative life events, and school or social connectedness, predicted an attempt at 3 months with an AUC of 0.87 [95% confidence interval (CI), 0.84–0.90] in the entire sample, and AUC = 0.91, (95% CI 0.85–0.95) for those who presented without reported suicidal ideation. The IAT did not add significantly to the predictive power of selected self-report variables. The IAT alone was modestly predictive of 3-month attempts in the overall sample ((AUC = 0.59, 95% CI 0.52–0.65) and was a better predictor in patients who were non-suicidal at baseline (AUC = 0.67, 95% CI 0.55–0.79).

In pediatric EDs, a small set of self-reported items predicted suicide attempts within 3 months more accurately than did the IAT.

Some people diagnosed with schizophrenia are more prone to committing acts of serious violence, especially in the presence of drug or alcohol misuse. The rarity of homicide has meant that no large controlled study has previously examined clinical risk factors.

To determine the risk factors for homicide by males diagnosed with schizophrenia.

A national nested case–control study of all previously admitted males diagnosed with schizophrenia, convicted of homicide between 1 January 1997 and 31 December 2012. Univariate and multivariable conditional logistic regression models were fitted to identify predictors of homicide in this population.

During the observation period 160 male patients with schizophrenia and a history of psychiatric admission were convicted of homicide, and they were matched with 542 male control patients who had not been convicted of homicide. Patients who committed homicide were more likely to have a history of violence and comorbid personality disorder or drug misuse. They were more likely to have missed their last contact with services prior to the offence and to have been non-adherent with their treatment plan. Almost all (94%) of homicides were committed by patients who had a history of alcohol or drug misuse and/or who were not in receipt of planned treatment.

In England and Wales, homicides by patients with schizophrenia without substance misuse and in receipt of planned care are exceptionally rare. To prevent serious violence, mental health services should focus on drug and alcohol misuse, treatment adherence and maintaining contact with services.

Little is known internationally about return to prison from in-patient psychiatric services, including: circumstances leading to return, aftercare services and subsequent patient outcomes.

To examine and describe: (a) circumstances leading to return to prison from medium secure services; (b) available aftercare and early outcomes of returned persons; and (c) implications for policy development.

Prospective cohort design with all patients (n = 96) returned to prisons from 33 National Health Service (NHS) medium secure services over a 6-month period in England and Wales. Follow-up was conducted for 1 year post-remittal, across 60 prisons.

Less than 20% of patients with legal entitlement to section 117 aftercare under the Mental Health Act 1983 were receiving care managed/delivered via the care programme approach. Subsequent pathways included: inter-prison transfer (30%), use of the Assessment, Care in Custody and Teamwork process (49%), referral to secure services (21%) and community release (30%). Less than half of community releases were referred to a community mental health team.

Findings suggest that persons returned to prison are a vulnerable group of patients, many of whom require intervention (e.g. enhanced monitoring, admission to a healthcare wing, readmission to secure mental health services) on return to prison in the absence of targeted aftercare services. More robust guidance for discharge and aftercare planning procedures for persons remitted to prison should be developed to ensure that the benefits of in-patient admission are maintained and that individuals’ legal rights to ongoing aftercare are upheld.

Individual- and area-level risk factors for suicide are relatively well-understood but the role of macro social factors such as alienation, social fragmentation or ‘anomie’ is relatively underresearched. Voting choice in the 2016 referendum on the UK's membership of the European Union (EU) provides a potential measure of anomie.

To examine associations between percentage ‘Leave’ votes in the EU referendum and suicide rates in 2015–2017, the period just prior to, and following, the referendum.

National cross-sectional ecological study of 315 English local authority populations. Associations between voting choice in the EU referendum and age-standardised suicide rates, averaged for the years 2015, 2016 and 2017, were examined.

Overall there was a weak, but statistically significant, positive correlation between the local authority-level percentage ‘Leave’ vote in 2016 and the suicide rate 2015–2017: Pearson's correlation coefficient, r = 0.17; P = 0.003. This relationship was explained by populations having an older age distribution, being more deprived and lacking ethnic diversity. However, there was divergence (likelihood ratio test for interaction, χ2 = 7.2, P = 0.007) in the observed associations between London and the provincial regions with Greater London having a moderately strong negative association (r = −0.40; P = 0.02) and the rest of England a weak positive association (r = 0.17; P = 0.004).

Deprivation, older age distribution and a lack of ethnic diversity seems to explain raised suicide risk in Brexit-voting communities. A greater sense of alienation among people feeling ‘left behind’/‘left out’ may have had some influence too, although multilevel modelling of individual- versus area-level data are needed to examine these complex relationships. The incongruent ecological relationship observed for London likely reflect its distinct social, economic and health context.

To investigate the spatial distribution of self-harm incidence rates, their socioeconomic correlates and sex/age differences using data on self-harm presentations to emergency departments from The Manchester Self-Harm Project (2003–2013).

Smoothed standardised incidence ratios for index self-harm episodes (n = 14 771) and their associations with area-level socioeconomic factors across 258 small areas (median population size = 1470) in the City of Manchester municipality were estimated using Bayesian hierarchical models.

Higher numbers and rates of self-harm were found in the north, east and far southern zones of the city, in contrast to below average rates in the city centre and the inner city zone to the south of the centre. Males and females aged 10–24, 25–44 and 45–64 years showed similar geographical patterning of self-harm. In contrast, there was no clear pattern in the group aged 65 years and older. Fully adjusted analyses showed a positive association of self-harm rates with the percentage of the unemployed population, households privately renting, population with limiting long-term illness and lone-parent households, and a negative association with the percentage of ethnicity other than White British and travel distance to the nearest hospital emergency department. The area-level characteristics investigated explained a large proportion (four-fifths) of the variability in area self-harm rates. Most associations were restricted to those aged under 65 years and some associations (e.g. with unemployment) were present only in the youngest age group.

The findings have implications for allocating prevention and intervention resources targeted at high-risk groups in high incidence areas. Targets for area-based interventions might include tackling the causes and consequences of joblessness, better treatment of long-term illness and consideration of the accessibility of health services.

Fatigue syndromes (FSs) affect large numbers of individuals, yet evidence from epidemiological studies on adverse outcomes, such as premature death, is limited.

Cohort study involving 385 general practices in England that contributed to the Clinical Practice Research Datalink (CPRD) with linked inpatient Hospital Episode Statistics (HES) and Office for National Statistics (ONS) cause of death information. A total of 10 477 patients aged 15 years and above, diagnosed with a FS during 2000–2014, were individually matched with up to 20 comparator patients without a history of having a FS. Prevalence ratios (PRs) were estimated to compare the FS and comparison cohorts on clinical characteristics. Adjusted hazard ratios (HRs) for subsequent adverse outcomes were estimated from stratified Cox regression models.

Among patients diagnosed with FSs, we found elevated baseline prevalence of: any psychiatric illness (PR 1.77; 95% CI 1.72–1.82), anxiety disorders (PR 1.92; 1.85–1.99), depression (PR 1.89; 1.83–1.96), psychotropic prescriptions (PR 1.68; 1.64–1.72) and comorbid physical illness (PR 1.28; 1.23–1.32). We found no significant differences in risks for: all-cause mortality (HR 0.99; 0.91–1.09), natural death (HR 0.99; 0.90–1.09), unnatural death (HR 1.00; 0.59–1.72) or suicide (HR 1.68; 0.78–3.63). We did, however, observe a significantly elevated non-fatal self-harm risk: HR 1.83; 1.56–2.15.

The absence of elevated premature mortality risk is reassuring. The raised prevalence of mental illness and increased non-fatal self-harm risk indicate a need for enhanced assessment and management of psychopathology associated with fatigue syndromes.

We aimed to spatially describe mental illness prevalence in England at small-area geographical level, as measured by prevalence of depression, severe mental illness (SMI) and antidepressant prescription volume in primary care records, and how much of their variation was explained by deprivation, social fragmentation and sociodemographic characteristics.

Information on prevalence of depression and SMI was obtained from the Quality and Outcomes Framework (QOF) administrative dataset for 2015/16 and the national dispensing dataset for 2015/16. Linear regression models were fitted to examine ecological associations between deprivation, social fragmentation, other sociodemographic characteristics and mental illness prevalence.

Mental illness prevalence varied within and between regions, with clusters of high prevalence identified across England. Our models explained 33.4–68.2% of variability in prevalence, but substantial variability between regions remained after adjusting for covariates. People in socially cohesive and socially deprived areas were more likely to be diagnosed with depression, while people in more socially fragmented and more socially deprived areas were more likely to be diagnosed with SMI.

Our findings suggest that to tackle mental health inequalities, attention needs to be targeted at more socially deprived localities. The role of social fragmentation warrants further investigation, and it is possible that depression remains undiagnosed in more socially fragmented areas. The wealth of routinely collected data can provide robust evidence to aid optimal resource allocation. If comparable data are available in other countries, similar methods could be deployed to identify high prevalence clusters and target funding to areas of greater need.

Pay-for-performance policies aim to improve population health by incentivising improvements in quality of care.

To assess the relationship between general practice performance on severe mental illness (SMI) and depression indicators under a national incentivisation scheme and suicide risk in England for the period 2006–2014.

Longitudinal spatial analysis for 32 844 small-area geographical units (lower super output areas, LSOAs), using population-structure adjusted numbers of suicide as the outcome variable. Negative binomial models were fitted to investigate the relationship between spatially estimated recorded quality of care and suicide risk at the LSOA level. Incidence rate ratios (IRRs) were adjusted for deprivation, social fragmentation, prevalence of depression and SMI as well as other 2011 Census variables.

No association was found between practice performance on the mental health indicators and suicide incidence in practice localities (IRR=1.000, 95% CI 0.998–1.002). IRRs indicated elevated suicide risks linked with area-level social fragmentation (1.030; 95% CI 1.027–1.034), deprivation (1.013, 95% CI 1.012–1.014) and rurality (1.059, 95% CI 1.027–1.092).

Primary care has an important role to play in suicide prevention, but we did not observe a link between practices' higher reported quality of care on incentivised mental health activities and lower suicide rates in the local population. It is likely that effective suicide prevention needs a more concerted, multiagency approach. Better training in suicide prevention for general practitioners is also essential. These findings pertain to the UK but have relevance to other countries considering similar programmes.

None.