Hospital-treated deliberate self harmin Irelandin Ireland

Paul Corcoran National Suicide Research Foundation

14 September 2011National Mental Healthcare Conference, Dublin

Acknowledgements

Data Registration Officers

Other Registry and NSRF colleagues

Health Service Executive

Department of Health and Children

Introduction

Deliberate self harm is the single most important risk factor for suicide and a significant public health problem in its own right

Reliable national level data on deliberate self harm are lacking internationally

The incidence of hospital treated self harm is an important population level indicator of mental health and wellbeing

For the individual patient self harm may be associated with multiple difficulties and may cause significant morbidity

Registry objectives

Establish the incidence of hospital treated deliberate self harm

To describe the pattern of presentations and the nature of the self harm behaviour involved

To monitor trends over time and by area

To estimate the risk of repeated self harm presenting to hospital

National Registry ofDeliberate Self Harm Coverage HSE Dublin/

Mid-Leinster

HSE Dublin/North East

HSE South

HSE West

All 38 hospital emergency departments

Systematic monitoring of attendances to hospital emergency departments by data registration officers (DROs)

DROs operate independently of the hospitals, follow standard operating procedures and show high levels of agreement in case-ascertainment

Identification of deliberate self harm presentations in accordance with an internationally-recognised definition (Platt et al, 1992)

Non-fatal outcome, deliberately initiated, varying intentions (e.g. wish to die, self-punishment)

Data entry via form on laptop computer and electronic data transfer to stand alone computer in the NSRF offices

Registry Methods

Number of deliberate self harm presentations and patients

YearYear PresentationsPresentations % diff% diff PersonsPersons % diff% diff

20022002 10,537 - 8,421 -

20032003 11,204 +6% 8,805 +5%

20042004 11,092 -1% 8,610 -2%

20052005 10,789 -3% 8,594 -

20062006 10,688 -1% 8,218 -4%

20072007 11,084 +4% 8,598 +5%

20082008 11,700 +6% 9,218 +7%

20092009 11,966 +2% 9,493 +3%

20102010 11,966 - 9,630 +1%

Trend in deliberate self harm rate

0

25

50

75

100

125

150

175

200

225

250

2002 2003 2004 2005 2006 2007 2008 2009 2010

Ag

e-s

tan

da

rdis

ed

ra

te p

er

10

0,0

00

Female

Male

Trend in deliberate self harm rateamong 20-24 year-olds

0

50

100

150

200

250

300

350

400

450

500

550

600

650

2002 2003 2004 2005 2006 2007 2008 2009 2010

Ag

e-s

pe

cific

ra

te p

er

10

0,0

00

Male

Female

0

100

200

300

400

500

600

7001

0-1

4yr

s

15

-19

yrs

20

-24

yrs

25

-29

yrs

30

-34

yrs

35

-39

yrs

40

-44

yrs

45

-49

yrs

50

-54

yrs

55

-59

yrs

60

-64

yrs

65

-69

yrs

70

-74

yrs

75

-79

yrs

80

-84

yrs

85

yrs+

Rate

per

100,0

00

Male

Female

Incidence rate by age and gender

Incidence rate by single year of age and gender for 10-24 year-olds

0

100

200

300

400

500

600

700

800

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Age (years)

Rat

e pe

r 10

0,00

0

Male

Female

Time of deliberate self harm presentation to hospital

0

50

100

150

200

250

300

350

400

8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 0 1 2 3 4 5 6 7

Time (24hr)

Nu

mb

er

of

pre

sen

tatio

ns

Male

Female

Self harm presentations by day in January

0

10

20

30

40

50

60

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Nu

mb

er

of

pre

sen

tatio

ns

Self harm presentations by day in March

0

10

20

30

40

50

60

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31

Nu

mb

er

of

pre

sen

tatio

ns

Method of self harm by sex and age

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<15yrs 15-24yrs

25-34yrs

35-44yrs

45-54yrs

55-64yrs

65yrs+

Other

Attempteddrowning only

Attemptedhanging only

Overdose &self-cutting

Self-cuttingonly

Drugoverdose only

Men Women

Alcohol was involved in 44% of male and 37% of female acts

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<15yrs 15-24yrs

25-34yrs

35-44yrs

45-54yrs

55-64yrs

65yrs+

Trend in acts involvingattempted hanging

0

50

100

150

200

250

300

350

400

450

2004 2005 2006 2007 2008 2009 2010

Nu

mb

er

of

pre

sen

tatio

ns

Male

Female

0 5 10 15 20 25 30 35 40 45

Salicylate

SalicylateCompound

Paracetamol

ParacetamolCompound

Opiate

Opiate Compound

NSAIDS and otheranalgesics

Minor Tranquilliser

Major Tranquilliser

SSRI

TCAD

Other anti-depressants

Anti-epileptics/Barbiturates

Other Drugs

Street Drugs

Herbal/Homeopathic

% of overdose acts

Male

Female

Drugs used in intentional overdose acts

Trend in overdose actsinvolving street drugs

0

50

100

150

200

250

300

350

400

450

500

2004 2005 2006 2007 2008 2009 2010

Nu

mb

er

of

pre

sen

tatio

ns

Male

Female

Repeated deliberate self harm presentations

29% of deliberate self harm presentations are followed by a repeat presentation within 12 months

Risk of repetition highest shortly after an index presentation

Cumulative risk of a repeated presentation

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0 3 6 9 12

Time to DSH (months)

K ap lan -M e ier f ailu re e st im at es

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0 3 6 9 12

Time to DSH (months)

K ap lan -M e ier f ailu re e st im at es

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0 3 6 9 12

Time to DSH (months)

K ap lan -M e ier f ailu re e st im at es

Time to DSH (months)

35-44yrs45-54yrs25-34yrs55-64yrs15-24yrs<15yrs65yrs+

Self-cutting & overdoseSelf-cutting onlyOtherAttempted drowningAttempted hangingDrug overdose only

Four previous DSH presentationsThree previous DSH presentationsTwo previous DSH presentationsOne previous DSH presentationNo previous DSH presentation

The burden of repeated deliberate self harm presentations

Number of DSH acts in 2003-2009

Persons Presentations

Number (%) Number (%)

One 37690 (78.2%) 37690 (50.2%)

Two 5874 (12.2%) 11748 (15.6%)

Three 2023 (4.2%) 6069 (8.1%)

Four 881 (1.8%) 3524 (4.7%)

Five 496 (1.0%) 2480 (3.3%)

Six 345 (0.7%) 2070 (2.8%)

Seven 203 (0.4%) 1421 (1.9%)

Eight 132 (0.3%) 1056 (1.4%)

Nine 109 (0.2%) 981 (1.3%)

10 or more 453 (0.9%) 8080 (10.8%)

Next care following treatment in the emergency department, 2010

44%

15% 1%

11%

30%

General admission

Psychiatric admission

Patient would notallow admission

Patient left beforerecommedation

Not admitted

Next care by HSE Hospitals Group

12% 15%26% 29% 34% 38% 41%

56%

11%19%

9% 2%

12% 9%10%

10%

1%

2%2%

1%

24%16%

10% 16%

13% 11%

17%

10%52% 49%56% 53%

40% 42%29% 23%

0%

20%

40%

60%

80%

100%

Notadmitted

Patient left

Patientrefused

Psychiatricadmission

Generaladmission

Summary and considerations Summary and considerations

The Irish rate of hospital-treated deliberate self harm is increasing

Our rate is high in the European context but lower than in the UK

Repetition is common and most likely in the days and weeks after a presentation.

A small number of self harm patients account for many presentations.

Care after emergency treatment varies substantially across Ireland and a relatively high proportion of patients leave early.

Selected recommendations

Implementation of clinical guidelines for assessment and aftercare of self harm patients

Increase the range and availability of evidence-based treatment interventions for self harm patients

Increase community mental health services for 16-18 year-olds

For further information

Paul Corcoran

National Suicide Research Foundation

1 Perrott Avenue, College Road, Cork

021 4277499

paul.corcoran@nsrf.ie

www.nsrf.ie