Many people presenting to emergency departments after self-harm do not receive adequate care, even in well-resourced health systems.

To identify patterns of health care service use across two periods: (a) during and (b) up to 1 year after an index emergency department self-harm presentation.

A retrospective population-based cohort study including 4668 individuals aged ≥9 years who presented to the Royal Melbourne Hospital emergency department for self-harm between January 2012 and December 2019. Linked administrative data captured >1.3 million records across primary care, pharmacy, specialist mental and physical health services and emergency departments. Sequential pattern mining identified longitudinal service-use clusters. Multinomial regression explored associations with demographic, clinical, psychosocial and presentation characteristics. Cox proportional hazards models assessed associations between clusters and all-cause and suicide mortality.

Emergency department self-harm presentations triggered short-term increases in multi-sector contacts. However, most (68.7%) reverted to the same service-use cluster observed prior to their index presentation. Suicide risk was highest within 1 year, particularly among those in the specialist mental health services cluster (4.5% of the cohort).

A small subgroup engage intensively with specialist mental health services yet remain at high suicide risk, while one in ten remain disengaged altogether, suggesting that an acute presentation of self-harm often fails to alter patients’ care trajectories long-term. Policy alignment with national recommendations for integrated, community-based care could improve sustained, evidence-based support beyond acute crises.

Globally, suicide is more prevalent in older adults compared with any other age group. Although some research has identified risk and protective factors for suicidal behaviour in older adults, further research is needed to provide an up-to-date overview to inform service delivery.

This study protocol describes mixed-methods research that will examine and identify factors associated with self-harm and suicide in older adults (aged 60 years and older) living in Ireland.

Four stages will be conducted. First, data from the National Self-Harm Registry of Ireland (NSHRI), will be used to examine recent hospital self-harm presentations of older adults, including during the COVID-19 pandemic. Second, a case-series study will examine the adverse life events and psychosocial factors experienced by older adults before dying by suicide, using data from closed coronial files, through the Irish Probable Suicide Deaths Study (IPSDS). Third, risk of suicide following hospital-presenting self-harm will be examined among older adults via data linkage of the NSHRI and IPSDS. Finally, using semi-structured interviews, the service needs of older adults with suicidal behaviour will be explored from the perspectives of older adults, carers and healthcare practitioners.

A comprehensive understanding of adverse events and psychosocial factors associated with the suicidal behaviour of older adults is needed to inform service provision. This proposed research is aligned with (inter)national priorities, mental health promotion and suicide reduction policies. It aims to address gaps in mental healthcare interventions for older adults at risk of suicide.

Homelessness is increasing and associated with poor mental health (MH). Few studies have examined how experiences of homelessness and sexual identity intersect to effect MH. We used an intersectional approach to examine MH inequalities related to sexual identity and past homelessness in a nationally representative private household sample, and whether associations were explained by discrimination.

Analysis of the 2007 and 2014 Adult Psychiatric Morbidity Surveys included 10,428 individuals aged 16–64 (58% female/3.8% non-heterosexual). The Clinical Interview Schedule-Revised (CIS-R) identified common mental disorders (CMDs). Self-harm, attempted suicide, alcohol dependence, substance use, sexual identity, discrimination/bullying, past homelessness and health behaviours were self-reported. Associations between sexual identity and homelessness were examined using multivariable Poisson regression. Prevalence ratios (PRs) for MH and health behaviours by intersectional sexual identity-past homelessness were examined using Poisson regression and adjusted for age, sex, area-level deprivation and further for discrimination/bullying.

Bisexual (adjusted PR [aPR]: 2.52, 95% CI: 1.48–4.29) and gay/lesbian (aPR: 1.76, 0.97–3.19) individuals were more likely to report past homelessness than heterosexual peers. Sexual minority (SM) and heterosexual individuals with past homelessness had higher prevalence of all MH outcomes compared to heterosexual peers without homelessness, with associations strongest in the SM-homelessness group (e.g., CMD: aPR: 2.67 [2.37–3.01] for heterosexual-homeless, aPR: 4.11 [3.00–5.63] for SM-homeless, aPR: 1.82 [1.45–2.28] for SM-not homeless groups), and similarly for depression/self-harm/attempted suicide. Likewise, the SM-homeless group had highest prevalence for drug dependence (aPR, 7.38 [3.15–17.29]) compared to the heterosexual-homeless (aPR, 4.03 [3.00–5.42]) and SM-not homeless (aPR, 2.19 [1.27–3.79]) groups. Adjustment for discrimination and bullying substantially attenuated point estimates, with the greatest attenuation (30–50%) in the SM-homeless compared to the heterosexual-homeless groups.

Individuals with past experiences of homelessness have significantly worse MH than heterosexuals without homelessness, with associations highest in the SM-homeless group. Considering experiencing homelessness and SM identity together identifies a group facing particular adversity, which is often lost when examined separately. Discrimination and bullying explained much of the worse MH in SM- and heterosexual-homeless groups, but especially the former. Investigation into the mechanisms leading to MH inequalities is needed, alongside policies and services to support this group.

In The Netherlands, it is unknown whether the number of youth suicide-related emergency department visits has changed over time. Also, insight is needed in the hospital costs for managing these patients, as a first step toward the economic evaluation of suicide prevention measures.

This study examines (a) changes in emergency department-recorded suicide attempts, suicidal ideation and non-suicidal self-injury in youth, including repeat emergency department visits; and (b) related hospital costs for these patients, from a health insurer perspective.

In this cross-sectional study, data from various sources was combined to identify all youth aged ≤27 years visiting a Dutch inner-city emergency department between 2016 and 2023 for a suicide attempt, suicidal ideation or non-suicidal self-injury. Hospital records were reviewed manually to determine inclusion. Ambiguities were discussed within an expert panel and descriptive analyses, Poisson regression and logistic regression analyses were performed. For a subset of 30 patients, invoiced costs were determined.

The number of suicide attempts increased by approximately 5% annually, peaking in 2022 (n = 172); there were significantly more female patients (71%), and the median age was 21 years. Cases of suicidal ideation showed a similar trend, whereas the number of recorded non-suicidal self-injuries reduced. A total of 28.5% of all patients (n = 281) had one or multiple repeat visits for the above reasons. Median suicide attempt-related costs per case were €930, range €385–€33 473.

Since 2016, an increasing number of youth visited the emergency department of a Dutch hospital after a suicide attempt, but this increase does not seem to continue after 2022. Hospital-invoiced costs differ substantially between patients.

The school environment plays a key role in adolescents’ emotional development and well-being, yet little research has compared self-harm and related psychosocial problems across different secondary school types.

Using data from the Growing Up in Ireland (GUI) longitudinal cohort, this study examined differences in the prevalence of self-harm and psychosocial risk factors across different school types: single-sex versus coeducational, fee-paying versus non-fee-paying, disadvantaged versus non-disadvantaged, and schools with different religious ethos. Multilevel regression models distinguished school-level from individual-level effects.

Almost all variance in self-harm and most of the variance in psychosocial problems associated with self-harm occurred at the individual level. Higher self-harm prevalence in single-sex girls’ schools was accounted for by the greater concentration of girls, who had over twice the odds of self-harm compared with boys (OR 2.1, 95% CI 1.71–2.69). No significant differences in self-harm were found by school socio-economic status or religious ethos. Disadvantaged schools showed higher prevalence in seven of nine psychosocial problems, although only internalising problems and truancy/absenteeism remained significantly associated with disadvantaged schools in the fully adjusted models. Adolescents whose parents reported having a religion were less likely to self-harm (OR 0.62, 95% CI 0.50–0.75).

Although schools are important settings for self-harm prevention, findings indicate that interventions should primarily target individuals and high-risk groups. Girls, in particular, may benefit from supports addressing self-harm. Disadvantaged schools, where well-established psychosocial risk factors for self-harm are more common, may benefit from well-being programmes targeting internalising problems and truancy/absenteeism.

Emergency department mental health practitioners (MHPs) decide onward care for individuals presenting with self-harm or suicidal ideation. However, their experiences and practices in making these decisions remain underexplored.

To synthesise research on MHPs’ experiences and practices in making decisions about onward care for patients presenting to emergency departments with self-harm or suicidal ideation.

We searched six databases (inception to July 2024) for empirical studies of MHPs making care decisions for self-harm or suicidal patients in emergency departments. We used a segregated mixed-methods design, applying narrative synthesis of quantitative data and thematic synthesis of qualitative data.

Eleven studies were included (one quantitative, one mixed-methods, nine qualitative). Narrative synthesis of quantitative data produced two themes: (a) subjective decision-making and variability among MHPs and (b) impact of the institutional mandate to discharge within 4 h on referral outcomes. Thematic synthesis of qualitative data generated five themes: (a) risk-centric culture is anti-therapeutic and shapes defensive practice, scepticism toward patients and burnout; (b) time and environmental pressures impact therapeutic potential of assessments; (c) ‘battling’ to access services: gatekeeping, cycles of repeat attendances affecting patient safety and staff moral injury; (d) strategies to facilitate access and extending care to overcome challenges in the emergency department and (e) potential for training to counter negative attitudes and stereotypes.

Intersecting institutional, systemic and emotional pressures shape MHPs’ practices, undermining assessment quality and access to care. System-level reforms and training should promote relational, compassionate care. Limited quantitative evidence restricted integration, and the review reflects high-income Western settings.

To examine the impact the COVID-19 pandemic in Ireland on symptoms and functioning in individuals across a range of mental health disorders.

A systematic bibliographic search of case reports, cross-sectional and longitudinal studies was conducted between March 12th, 2020, and December 20th, 2024, among studies evaluating the impact of the COVID-19 pandemic on symptoms and functioning for individuals with pre-existing mental health disorders and for those who presented with self-harm or died by probable suicide in the Republic of Ireland. Studies were independently screened by two reviewers according to inclusion and exclusion criteria, with selected variables extracted and summarised. Risk of bias assessments and narrative synthesis of included studies were conducted.

Twenty-eight studies met inclusion criteria. Findings were heterogeneous and disorder specific. An increase in presentations of self-harm, anxiety disorders, and eating disorders to child and adolescent mental health services and emergency departments was noted, with relative stability of symptoms in other cohorts including bipolar disorder and treatment-resistant schizophrenia. Significant symptom deterioration, with poor quality of life and functioning was demonstrated in individuals with emotionally unstable personality disorder both cross-sectionally and longitudinally.

Most people with pre-existing mental disorders did not experience significant exacerbation associated with the pandemic, with exception of those with eating disorders and EUPD.

Understanding the economic cost of self-harm is essential for evaluating intervention cost-effectiveness and guiding funding allocation and service planning.

To estimate the cost associated with self-harm presentations to hospital emergency departments and investigate key predictors of cost.

Data on presentations to hospital for self-harm in all Irish emergency departments were analysed for 2018 and 2019. Costs of hospital treatment following self-harm were identified (in 2019 euros) using top-down and bottom-up approaches. The perspective taken was that of the health service. Factors associated with costs were investigated using generalised linear models.

There were 25 053 self-harm presentations from 2018 to 2019. The average annual cost of self-harm was approximately €26.5 million; almost half of the total cost was due to repeat self-harm presentations (47.3%). The mean cost per presentation was €2117 (s.d. €1845), which incorporates acute hospital costs (mean €2067, s.d. €2127) and those of initial aftercare (mean €50, s.d. €69). Psychiatric and medical admissions were associated with highest costs, three times that of presentations resulting in emergency department discharge (incidence rate ratio (IRR) 3.01, 95% CI 2.72–3.36 and IRR 2.88, 95% CI 2.72–3.36, respectively). Other factors associated with higher costs included older age, emergency department medical assessment unit admission, receiving a psychosocial assessment and self-harm involving a firearm. Demographic and clinical predictors of cost varied according to care pathway.

Significant costs associated with repeat attendances and hospital admission provide evidence for investment in emergency department services providing comprehensive care for those presenting with self-harm, as well as in community-based mental health services.

Little is known about self-harm in children involved in family justice proceedings, particularly in private family courts in England and Wales.

To examine records of self-harm in children involved in private and public law proceedings using population-level linked data.

A retrospective e-cohort study of children aged under 18 years, using linked health and family justice (Cafcass Cymru) data (2011–2018). Family court involvement was recorded from age 0 to 17 years. Incidence of self-harm was recorded from age 10 to 17 years to fit with the standard definition of self-harm. Annual incidence of self-harm over time across general practitioner (GP), emergency department and hospital admissions for individual children in private and public law proceedings were compared with a non-court cohort using Poisson regression. Self-harm following court proceedings was compared with an age- and gender-matched non-court cohort using Cox regression.

Adjusted self-harm rates were higher in court-involved children than the non-court cohort (incident rate ratios (IRRs) (95% CI), private: GP 1.8 (1.6–2.1); emergency department 1.4 (1.2–1.7); admissions 1.8 (1.5–2.1); public: GP 4.6 (4.1–5.3); emergency department 5.0 (4.3–5.8); admissions 5.0 (4.3–5.8)). Compared with matched comparison children, risk of self-harm was higher following private (adjusted hazard ratios 2.0 (1.7–2.2)) and public court proceedings (hazard ratio 2.3 (2.7–3.8)). Hazard ratios were greater for those from less deprived areas and those with no history of self-harm.

The elevated risk of self-harm in children involved in public law proceedings is well recognised. Our study highlights risk in children in private family justice proceedings. Elevated risk among those from less deprived areas and those with no history of self-harm may reflect circumstances associated with family justice involvement, resulting in rates comparable to children with other pre-existing vulnerabilities. Contact with family justice is an opportunity to offer preventative support.