Factors Associated With Hospital Presentation of Self-Harm Among Older Canadians in Long-Term Care: A 12-Year Cohort Study

ObjectivesThis study aimed to examine the incidence of, and factors associated with, hospital presentation for self-harm among older Canadians in long-term care (LTC).DesignRetrospective cohort study.Setting and ParticipantsThe LTC data were collected using Resident Assessment Instrument–Minimum Data Set (RAI-MDS) and Resident Assessment Instrument–Home Care (RAI-HC), and linked to the Discharge Abstract Database (DAD) with hospital records of self-harm diagnosis. Adults aged 60+ at first assessment between April 1, 2003, and March 31, 2015, were included.MethodsAdjusted hazard ratios (HRs) of self-harm for potentially relevant factors, including demographic, clinical, and psychosocial characteristics, were calculated using Fine & Gray competing risk models.ResultsRecords were collated of 465,870 people in long-term care facilities (LTCF), and 773,855 people receiving home care (HC). Self-harm incidence per 100,000 person-years was 20.76 [95% confidence interval (CI) 20.31–25.40] for LTCF and 46.64 (44.24–49.12) for HC. In LTCF, the strongest risks were younger age (60–74 years vs 90+: HR, 6.00; 95% CI, 3.24–11.12), psychiatric disorders (bipolar disorder: 3.46; 2.32–5.16; schizophrenia: 2.31; 1.47–3.62; depression: 2.29; 1.80–2.92), daily severe pain (2.01; 1.30–3.11), and daily tobacco consumption (1.78; 1.29–2.45). For those receiving HC, the strongest risk factors were younger age (60–74 years vs 90+: 2.54; 1.97–3.28), psychiatric disorders (2.20; 1.93–2.50), daily tobacco consumption (2.08; 1.81–2.39), and frequent falls (1.98; 1.46–2.68). All model interactions between setting and factors were significant.Conclusions and ImplicationsThere was lower incidence of hospital presentation for self-harm for LTCF residents than HC recipients. We found sizable risks of self-harm associated with several modifiable risk factors, some of which can be directly addressed by better treatment and care (psychiatric disorders and pain), whereas others require through more complex interventions that target underlying factors and causes (tobacco and falls). The findings highlight a need for setting- and risk-specific prevention strategies to address self-harm in the older populations.     

Infections,Anti-infective Agents,and Risk of Deliberate Self-harm and Suicide in a Young Cohort: A Nationwide Study

Background

Evidence links infections to mental disorders and suicidal behavior. However, knowledge is sparse regarding less severe infections, anti-infective treatment, and deliberate self-harm. Using nationwide Danish longitudinal registers, we estimated associations between infections treated with anti-infective agents and infections requiring hospitalization with the risk of deliberate self-harm.

Sex and age differences in symptoms in borderline personality symptomatology

Objective. Variations in the symptoms of borderline personality disorder (BPD) as a function of sex and age remain unclear. In this study, we examined sex and age differences with regard to various symptoms encountered in BPD. Methods. Using a compilation of four samples, all cross-sectional from the same recruitment site and with identical self-report measures for borderline personality symptomatology (BPS), we examined sex- and age-related differences with regard to borderline personality among 1,503 primary care patients. Results. Men and women did not differ significantly in their overall scores or rates of BPS. With regard to sex differences in symptoms among respondents with substantial BPS, engagement in sexually abusive relationships was more common among women than men. Overall scores and rates of BPS were greater among younger respondents compared to older respondents. With regard to age differences among those with substantial BPS, self-cutting and scratching were more common in younger individuals whereas finding life dull and meaningless was more common among older individuals. Conclusions. There appear to be few overall symptomatic differences among individuals with borderline personality with regard to sex and age.     

Three assessment tools for deliberate self-harm and suicide behavior: evaluation and psychopathological correlates

OBJECTIVE: The aims of this study are to adapt two validated self-report questionnaires of deliberate self-harm and suicidal behavior to German, to investigate their psychometric properties and agreement with clinician-administered ratings, and to examine their psychopathological correlates. METHODS: The Deliberate Self-Harm Inventory [Gratz KL. Measurement of deliberate self-harm: preliminary data on the deliberate self-harm inventory. J Psychopathol Behav 2001;23:253-263] and the Self-Harm Behavior Questionnaire [Guttierez PM, Osman A, Barrios FX, Kopper BA. Development and initial validation of the self-harm behavior questionnaire. J Pers Assess 2001;77:475-490] were completed by 361 patients hospitalized for depressive, anxiety, adjustment, somatoform, and/or eating disorders. A clinician-administered rating scale of self-destructive behavior was included. Psychopathological variables were assessed by standardized questionnaires. RESULTS: The self-report questionnaires demonstrated good reliability (alpha=.81-.96, split-half r=.78-.98, test-retest r=.65-.91). Reliability of the clinician-administered ratings was acceptable (interrater kappa=.46-.77, test-retest kappa=.35-.48). Intraclass correlations (ICC=.68) for all three instruments were satisfactory. Rates of self-harm and associations between self-harm and suicidal behaviors are reported. The findings support the hypotheses of a higher degree of psychiatric symptomatology in patients with self-harm behavior compared to those without. CONCLUSION: The two questionnaire adaptations are reliable and valid self-report scales for the assessment of self-harm and past suicidal behavior.     

Do ‘no‐suicide’ contracts work?

Suicide is the main cause of premature death in mental health service users, and the prevention of suicide is a major, global concern. An intervention designed to address this concern is the 'no-suicide' contract (NSC) – an agreement, usually written, between a mental health service user and clinician, whereby the service user pledges not to harm himself or herself. Following a review of the literature on NSCs, this paper argues that there is a lack of quantitative evidence to support such contracts as clinically effective tools and that there is strong opposition to the tool, from both service users and nurses. Moreover, important ethical and conceptual issues in the use of such contracts have been identified, including the potential for coercion from the clinician for their own protection and the ethical implications of restricting a service user's choices when they may be already struggling for control. In light of these findings, the paper discusses alternative interventions aimed at preventing self-harm and suicide. Although a number of other interventions are available to clinicians, further research is required to test the effectiveness of these as viable alternatives to the NSC.     

Can mainstream health services provide meaningful care for people who self‐harm? A critical reflection

People who self-harm currently access health care based in a wide variety of settings. These include primary care, accident and emergency departments, and specialist mental health providers. This paper considers whether meaningful care for people who self-harm can be provided within these mainstream health services. The paper begins by clarifying the meaning of self-harm and distinguishes self-harm from suicide. Four treatment models applied in clinical practice are identified: (i) psychodynamic, (ii) behavioural, (iii) biosocial and (iv) feminist. Each of these is critically considered in terms of practical utility, professional attitudes and wider organizational/policy context.     

Integration of a suicide risk assessment and intervention approach: the perspective of youth

The process of suicide risk assessment is often a challenge for mental health nurses, especially when working with an adolescent population. Adolescents who are struggling with particular problems, stressors and life events may exhibit challenging and self-harm behaviour as a means of communication or a way of coping. Current literature provides limited exploration of the effects of loss, separation and divorce, blended families, conflict and abuse on child and adolescent development and the increased vulnerability of at-risk youth. There is also limited research that provides clear and practical models for the assessment and management of youth suicidal ideation and behaviour. This paper will discuss the integration of a number of theories to establish a comprehensive assessment of risk. The research study described the perspective of youth and their families who had experienced this particular model; however, this paper will discuss only the youth perspective. In order for this model to be successful, it is important for mental health nurses to make a connection with the youth and begin to understand the self-harm behaviour in context of the adolescents' family, and their social and school experiences. It also requires recognition that adolescents with challenging and self-harm behaviour are hurting and troubled adolescents with hurtful and troublesome behaviour.     

Factors Associated with Treatment Compliance in Young People Following an Emergency Department Presentation for Deliberate Self-Harm

This study investigated factors associated with patient non-compliance with follow-up treatment after a presentation to an Emergency Department (ED) for deliberate self-harm (DSH). 56 patients under 24 years and 20 parents participated in this study. Subjects were interviewed by telephone after they had attended or missed a follow-up appointment following a presentation to an ED for DSH. Convenience of the appointment time and the patients' beliefs about whether counseling would help them were found to differentiate attending and non-attending patients. The attitudes of parents also had a major influence on decisions to attend or not attend an appointment. These results support the use of a therapeutic intervention in the ED, targeting both patients and their parents' attitudes toward counseling.