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ObjectivesSelf-harm is a major health problem in many countries, with potential adverse outcomes including suicide and other causes of premature death. It is important to monitor national trends in this behaviour. We examined trends in non-fatal self-harm and its management in England during the 13-year period, 2000–2012.Design and settingThis observational study was undertaken in the three centres of the Multicentre Study of Self-harm in England. Information on all episodes of self-harm by individuals aged 15 years and over presenting to five general hospitals in three cities (Oxford, Manchester and Derby) was collected through face-to-face assessment or scrutiny of emergency department electronic databases. We used negative binomial regression models to assess trends in rates of self-harm and logistic regression models for binary outcomes (eg, assessed vs non-assessed patients).ParticipantsDuring 2000–2012, there were 84 378 self-harm episodes (58.6% by females), involving 47 048 persons.ResultsRates of self-harm declined in females (incidence rate ratio (IRR) 0.98; 95% CI 0.97 to 0.99, p<0.0001). In males, rates of self-harm declined until 2008 (IRR 0.96; 95% CI 0.95 to 0.98, p<0.0001) and then increased (IRR 1.05; 95% CI 1.02 to 1.09, p=0.002). Rates of self-harm were strongly correlated with suicide rates in England in males (r=0.82, p=0.0006) and females (r=0.74, p=0.004). Over 75% of self-harm episodes were due to self-poisoning, mainly with analgesics (45.7%), antidepressants (24.7%) and benzodiazepines (13.8%). A substantial increase in self-injury occurred in the latter part of the study period. This was especially marked for self-cutting/stabbing and hanging/asphyxiation. Psychosocial assessment by specialist mental health staff occurred in 53.2% of episodes.ConclusionsTrends in rates of self-harm and suicide may be closely related; therefore, self-harm can be a useful mental health indicator. Despite national guidance, many patients still do not receive psychosocial assessment, especially those who self-injure.

Background Risk scales are used widely in the management of patients presenting to hospital following self-harm. However, there is evidence that their diagnostic accuracy in predicting repeat self-harm is limited. Their predictive accuracy in population settings, and in identifying those at highest risk of suicide is not known. Method We compared the predictive accuracy of the Manchester Self-Harm Rule (MSHR), ReACT Self-Harm Rule (ReACT), SAD PERSONS Scale (SPS) and Modified SAD PERSONS Scale (MSPS) in an unselected sample of patients attending hospital following self-harm. Data on 4000 episodes of self-harm presenting to Emergency Departments (ED) between 2010 and 2012 were obtained from four established monitoring systems in England. Episodes were assigned a risk category for each scale and followed up for 6 months. Results The episode-based repeat rate was 28% (1133/4000) and the incidence of suicide was 0.5% (18/3962). The MSHR and ReACT performed with high sensitivity (98% and 94% respectively) and low specificity (15% and 23%). The SPS and the MSPS performed with relatively low sensitivity (24–29% and 9–12% respectively) and high specificity (76–77% and 90%). The area under the curve was 71% for both MSHR and ReACT, 51% for SPS and 49% for MSPS. Differences in predictive accuracy by subgroup were small. The scales were less accurate at predicting suicide than repeat self-harm. Conclusions The scales failed to accurately predict repeat self-harm and suicide. The findings support existing clinical guidance not to use risk classification scales alone to determine treatment or predict future risk.

Background There is robust evidence reflecting that individuals with PTSD are significantly more at risk of engaging in self-harm and suicidal behaviours. Trauma-focused interventions for PTSD, however, predominantly focus on PTSD symptomology-related outcomes. Therefore, there is a dearth of knowledge regarding the treatment effects of psychological interventions in individuals with PTSD examining self-harm-related outcomes. This evidence synthesis will identify studies that investigate interventional effects on self-harm, non-suicidal self-injury (NSSI), and suicide attempts. Methods A comprehensive bibliographic search will be conducted to identify eligible randomised controlled trials (RCTs) and non-RCT evaluation studies indexed in Ovid MEDLINE, Embase (Ovid), PTSDPubs (ProQuest), APA PsycInfo (Ovid), PubMed (NOT MEDLINE[SB]), Web of Science Core Collection (CPCI-SSH), CENTRAL, WHO ICTRP, and ClinicalTrials.gov from inception to present day. A range of supplementary search techniques will also be employed to reduce the file drawer effect. Two independent reviewers will screen records at a title/abstract and full-text level, with 50% extracted data being cross-checked by an independent reviewer. Eligible studies will be assessed for risk-of-bias (RoB) using Cochrane’s RoB 2.0 for RCTs and ROBINS-I for non-RCTs. A combination of random- and fixed-effects meta-analytic models will be performed separately for RCTs and non-RCTs, and for post-intervention and follow-up periods for self-harm, NSSI, and suicide attempts separately and in aggregate, using d -family effect sizes (including Hedges’ g ) and risk ratio/odds ratio for continuous and binary outcome data, respectively, with associated 95% confidence intervals. Sensitivity analyses will be performed to examine if methodological decisions impact on summary effects. Potential sources of heterogeneity will be examined as moderators (e.g. adults versus non-adults, intervention delivery, and complex PTSD versus PTSD) using mixed-effect meta-regression models. The evaluation of certainty of evidence of all main outcomes will be conducted using the GRADE approach. The review will be reported in accordance with PRISMA-S and PRISMA 2020 guidelines. Discussion This systematic review and meta-analysis of RCTs and non-RCTs will provide a comprehensive synthesis of treatment effects of psychological interventions on self-harm related outcomes among individuals with PTSD. The results may increase a better understanding of which interventions are best suited to targeting self-harm outcomes in this population. The completed review will be published in a peer-reviewed journal. Systematic review registration PROSPERO CRD42024598594

Background Binge Eating Disorder (BED) and self-harm often co-occur and cause great distress. BED is often poorly understood and under-represented in research, despite high prevalence. It is unclear how self-harm in BED populations compares to rates of self-harm in other eating disorder populations or control groups. A systematic review and meta-analysis were undertaken with the aim of investigating how often self-harm occurs along with BED compared to other eating disorders and control groups. Method The protocol for this review was pre-registered (PROSPERO reference: CRD42023466201). Online databases, PsycINFO, MEDLINE and Web of Science, were searched using key terms relating to BED and self-harm, for publications dating up to February 2025. Inclusion criteria were studies that measured BED and self-harm. Titles, abstracts and full texts were screened by independent screeners. Sixteen studies were identified. Meta-analyses were completed to determine the odds of self-harm in BED groups compared to other eating disorders and non-clinical control groups. Risk of bias and publication bias were assessed. Results There was no difference in rate of self-harm between people experiencing BED compared to those experiencing Anorexia Nervosa (Odds Ratio [OR] = 0.7, 95% Confidence Interval [CI] = 0.4–1.2) or Other Specified Feeding and Eating Disorders (OR = 0.7, 95% CI = 0.4-1.0). Self-harm was 1.6 times more likely in BED groups compared to non-clinical controls (OR = 1.6, 95% CI = 1.0-2.5), and almost half as likely compared to Bulimia Nervosa groups (OR = 0.6, 95% CI = 0.4–0.8). Conclusions BED is associated with a higher prevalence of self-harm compared to non-clinical populations and should be approached similarly to other eating disorders in this regard. Increased awareness of the potential for self-harm in BED groups is vital to ensure interventions for eating disorders integrate self-harm prevention. Further research is required in non-western communities and across sexes and gender identities. Plain English summary Binge Eating Disorder (BED) is a common but often poorly understood mental health problem. There is some evidence that people experiencing BED often also self-harm. This review investigated how BED and self-harm co-occur, compared to self-harm in other eating disorders. Sixteen studies were identified that investigated BED and self-harm. Self-harm in those experiencing BED did not significantly differ to those who experience Anorexia Nervosa or Other Specified Feeding and Eating Disorders. Self-harm was a lot more common in BED groups than people who do not experience an eating disorder, and a lot less common compared to people who experience Bulimia Nervosa. In conclusion, BED co-occurs with self-harm and should be given similar care as other eating disorders. Most studies identified were based in Western female populations. More research is needed in non-western populations and across sexualities and gender identities. Being more aware of self-harm rates in BED groups helps to improve the care available. It is vital treatments for those who experience BED also consider self-harm prevention.

ObjectiveTo explore the acceptability of the Community Outpatient Psychotherapy Engagement Service for Self-harm (COPESS) intervention and trial procedures for participants.DesignA mixed-method approach and a single-blind randomised controlled trial design with 1:1 allocation to either COPESS plus treatment as usual or treatment as usual alone.SettingPrimary care.ParticipantsFifteen semistructured interviews were conducted with participants in the COPESS trial; eight were randomised to the intervention arm, and seven were randomised to the treatment-as-usual arm. Interviews lasted 30–60 min.InterventionCOPESS is a brief, relational psychotherapy delivered over 4 weekly sessions plus a follow-up, focusing on understanding difficult emotional states and their links to self-harm through here-and-now relational and emotional processes.AnalysisThematic analysis allowed exploration of themes important to participants in their experiences in the COPESS trial and their experiences of care for self-harm more generally.FindingsFive themes were identified as associated with the acceptability of the COPESS intervention and trial: self-harm as a primary problem, what I needed when I needed it, being heard and understood, online delivery of the intervention and lasting impacts. Participants generally expressed positive views about the intervention, citing a need for services that specifically target self-harm and an appreciation of the rapid access to help. Strong relationships with the therapist were highly valued and not diminished by online delivery of the intervention. Positive impacts continued post therapy sessions.ConclusionsThese results support the acceptability of the COPESS intervention, the need for self-harm specific services and support moving forward to a full trial.Trial registrationPre-registered on clinicaltrials.gov (NCT04191122) on 9 December 2019.

Background Bipolar and other psychiatric disorders are associated with considerably increased risk of suicidal behaviour, which may include self-poisoning with medication used to treat the disorder. Therefore, choice of medication for treatment should include consideration of toxicity, especially for patients at risk. The aim of this study was to estimate the relative toxicity of specific drugs within two drug categories, antipsychotics and mood stabilizers, using large-scale databases to provide evidence that could assist clinicians in making decisions about prescribing, especially for patients at risk of suicidal behaviour. Method Two indices were used to assess relative toxicity of mood stabilisers and antipsychotics: case fatality (the ratio between rates of fatal and non-fatal self-poisoning) and fatal toxicity (the ratio between rates of fatal self-poisoning and prescription). Mood stabilisers assessed included lithium [reference], sodium valproate, carbamazepine, and lamotrigine, while antipsychotics included chlorpromazine [reference], clozapine, olanzapine, quetiapine and risperidone. Fatal self-poisoning (suicide) data were provided by the Office for National Statistics (ONS), non-fatal self-poisoning data by the Multicentre Study of Self-harm in England, and information on prescriptions by the Clinical Practice Research Datalink. The primary analysis focussed on deaths due to a single drug. Cases where the drug of interest was listed as the likely primary toxic agent in multiple drug overdoses were also analysed. The study period was 2005–2012. Results There appeared to be little difference in toxicity between the mood stabilisers, except that based on case fatality where multiple drug poisonings were considered, carbamazepine was over twice as likely to result in death relative to lithium (OR 2.37 95% CI 1.16–4.85). Of the antipsychotics, clozapine was approximately18 times more likely to result in death when taken in overdose than chlorpromazine (single drug case fatality: OR 18.53 95% CI 8.69–39.52). Otherwise, only risperidone differed from chlorpromazine, being less toxic (OR 0.06 95% CI 0.01–0.47). Conclusions There was little difference in toxicity of the individual mood stabilisers. Clozapine was far more toxic than the other antipsychotics. The findings are relevant to prescribing policy, especially for patients at particular risk of suicidal behaviour.

ObjectivesThis study aims to examine the proportions of patients referred to mental health, social and voluntary, community and social enterprise (VCSE) services and general practice and to assess care gaps among people presenting to the hospital following self-harm.DesignPopulation-based observational study. Data were extracted from hospital records.SettingThree emergency departments (EDs) in Manchester, UK.Participants26 090 patients aged 15+ years who presented to participating EDs following self-harm and who received a psychosocial assessment by a mental health specialist.Primary and secondary outcome measuresPrimary outcome measures are as follows: care gaps, estimated from the proportion of patients with evidence of social and mental health needs with no new or active referral to mental health, social and VCSE services. Secondary outcome measures are as follows: proportions of referrals by groups of patients, estimated mental health and social needs of patients. Indicators of mental health and social need were developed with academic clinicians (psychiatrist, general practitioner and social worker) and expert lived experience contributors.Results96.2% (25 893/26 909) of individuals were estimated as having mental health needs. Among this group, 29.9% (6503/21 719) had no new or active referral to mental health services (indicating a care gap). Mental healthcare gaps were greater in men and those who were aged under 35 years, from a black, South Asian or Chinese ethnic group, living in the most deprived areas and had no mental health diagnosis, or alcohol, substance misuse, anxiety or trauma-related disorder. 52.8% (14 219/26 909) had social needs, with care gaps greater for men, individuals aged 45–64 and those who were unemployed or had a diagnosed mental disorder.ConclusionsCare gaps were higher among hospital-presenting groups known to have increased risks of suicide: men, those in middle age, unemployed individuals and those misusing substances. Improved access to mental health, social and VCSE services and general practice care is vital to reduce inequities in access to self-harm aftercare.

Guidance in England recommends psychosocial assessment when presenting to hospital following self-harm but adherence is variable. There is some evidence suggesting that psychosocial assessment is associated with lower risk of subsequent presentation to hospital for self-harm, but the potential cost-effectiveness of psychosocial assessment for hospital-presenting self-harm is unknown. A three-state four-cycle Markov model was used to assess cost-effectiveness of psychosocial assessment after self-harm compared with no assessment over 2 years. Data on risk of subsequent self-harm and hospital costs of treating self-harm were drawn from the Multicentre Study of Self-Harm in England, while estimates of effectiveness of psychosocial assessment on risk of self-harm, quality of life, and other costs were drawn from literature. Incremental cost-effectiveness ratios (ICERs) for cost per Quality Adjusted Life Year (QALY) gained were estimated. Parameter uncertainty was addressed in univariate and probabilistic sensitivity analyses. Cost per QALY gained from psychosocial assessment was £10,962 (95% uncertainty interval [UI] £15,538-£9,219) from the National Health Service (NHS) perspective and £9,980 (95% UI £14,538-£6,938) from the societal perspective. Results were generally robust to changes in model assumptions. The probability of the ICER being below £20,000 per QALY gained was 78%, rising to 91% with a £30,000 threshold. Psychosocial assessment as implemented in the English NHS is likely to be cost-effective. This evidence could support adherence to NICE guidelines. However, further evidence is needed about the precise impacts of psychosocial assessment on self-harm repetition and costs to individuals and their families beyond immediate hospital stay.

ObjectivePeople with bipolar disorder are known to be at high risk of engaging in suicidal behaviours, and those who die by suicide have often been in recent contact with mental health services. The objective of this study was to explore suicidal behaviour in bipolar disorder and how this is monitored and managed by mental health services.AimsTo identify themes within relatives’ and service users’ accounts of mental healthcare, related to management and prevention of suicidal behaviour in bipolar disorder.DesignThematic analysis of 22 semistructured interviews.ParticipantsParticipants were aged 18 years or over, fluent in written and spoken English, and either had bipolar disorder with a history of suicidal behaviour, or were relatives of people with bipolar disorder who had died by suicide.SettingEngland, UK.Primary outcomeThemes identified from participants’ accounts of mental healthcare for suicidal behaviours in bipolar disorder.ResultsTwo main themes were identified. ‘Access to care’ was characterised by a series or cycle of potential barriers to care (eg, gate-keepers, lack of an accurate diagnosis) which had the potential to increase risk of suicidal behaviour if failure to access care continued over time. ‘Problems with communication’ captured the importance of maintaining open routes of communication between all parties involved in care to ensure successful monitoring and management of suicidal behaviours in bipolar disorder.ConclusionsMental health services need to be accessible and respond rapidly to people with suicidal behaviour in bipolar disorder. Open communication and inclusion of relatives in care, where appropriate, could help closer monitoring of changes in symptoms that indicate increased risk.