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Background: Multimorbidity, characterised by the coexistence of multiple chronic conditions in an individual, is a rising public health concern. While much of the existing research has focused on cross-sectional patterns of multimorbidity, there remains a need to better understand the longitudinal accumulation of diseases. This includes examining the associations between important sociodemographic characteristics and the rate of progression of chronic conditions., Methods and Findings: We utilised electronic primary care records from 13.48 million participants in England, drawn from the Clinical Practice Research Datalink (CPRD Aurum), spanning from 2005 to 2020 with a median follow-up of 4.71 years (IQR: 1.78, 11.28). The study focused on 5 important chronic conditions: cardiovascular disease (CVD), type 2 diabetes (T2D), chronic kidney disease (CKD), heart failure (HF), and mental health (MH) conditions. Key sociodemographic characteristics considered include ethnicity, social and material deprivation, gender, and age. We employed a flexible spline-based parametric multistate model to investigate the associations between these sociodemographic characteristics and the rate of different disease transitions throughout multimorbidity development. Our findings reveal distinct association patterns across different disease transition types. Deprivation, gender, and age generally demonstrated stronger associations with disease diagnosis compared to ethnic group differences. Notably, the impact of these factors tended to attenuate with an increase in the number of preexisting conditions, especially for deprivation, gender, and age. For example, the hazard ratio (HR) (95% CI; p-value) for the association of deprivation with T2D diagnosis (comparing the most deprived quintile to the least deprived) is 1.76 ([1.74, 1.78]; p < 0.001) for those with no preexisting conditions and decreases to 0.95 ([0.75, 1.21]; p = 0.69) with 4 preexisting conditions. Furthermore, the impact of deprivation, gender, and age was typically more pronounced when transitioning from an MH condition. For instance, the HR (95% CI; p-value) for the association of deprivation with T2D diagnosis when transitioning from MH is 2.03 ([1.95, 2.12], p < 0.001), compared to transitions from CVD 1.50 ([1.43, 1.58], p < 0.001), CKD 1.37 ([1.30, 1.44], p < 0.001), and HF 1.55 ([1.34, 1.79], p < 0.001). A primary limitation of our study is that potential diagnostic inaccuracies in primary care records, such as underdiagnosis, overdiagnosis, or ascertainment bias of chronic conditions, could influence our results., Conclusions: Our results indicate that early phases of multimorbidity development could warrant increased attention. The potential importance of earlier detection and intervention of chronic conditions is underscored, particularly for MH conditions and higher-risk populations. These insights may have important implications for the management of multimorbidity., Competing Interests: JB has previously received funding for unrelated work from F. Hoffmann-La Roche Ltd. KN reports grants from NIHR, MRC, Diabetes UK, Vifor, and AstraZeneca, and personal fees from Merck Sharp & Dohme, Sanofi, and Boehringer Ingelheim, outside of and unrelated to the submitted work. TM has previously received funding for unrelated work: from Cancer Research UK and from the Health Research Board (Ireland) for advisory board participation and travel. SJG received payment from Novo Nordisk, Napp and Astra Zeneca for lectures at 6 educational events over the last 3 years. Napp supported SJG’s attendance at EASD 2018 and he received payment from Eli Lilly associated with membership of an independent data monitoring committee for a randomised trial of a medication to lower glucose. PK, SR and KN are co-investigators on the HDRUK grant titled Measuring & Understanding Multimorbidity using Routine Data in the UK (MUrMuR-UK). CY has received remuneration for unrelated consultancy services to F. Hoffmann-La Roche and Singula Bio. The other authors have declared that no competing interests exist., (Copyright: © 2023 Chen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Updatable estimates of COVID-19 onset, progression, and trajectories underpin pandemic mitigation efforts. To identify and characterise disease trajectories, we aimed to define and validate ten COVID-19 phenotypes from nationwide linked electronic health records (EHR) using an extensible framework., Methods: In this cohort study, we used eight linked National Health Service (NHS) datasets for people in England alive on Jan 23, 2020. Data on COVID-19 testing, vaccination, primary and secondary care records, and death registrations were collected until Nov 30, 2021. We defined ten COVID-19 phenotypes reflecting clinically relevant stages of disease severity and encompassing five categories: positive SARS-CoV-2 test, primary care diagnosis, hospital admission, ventilation modality (four phenotypes), and death (three phenotypes). We constructed patient trajectories illustrating transition frequency and duration between phenotypes. Analyses were stratified by pandemic waves and vaccination status., Findings: Among 57 032 174 individuals included in the cohort, 13 990 423 COVID-19 events were identified in 7 244 925 individuals, equating to an infection rate of 12·7% during the study period. Of 7 244 925 individuals, 460 737 (6·4%) were admitted to hospital and 158 020 (2·2%) died. Of 460 737 individuals who were admitted to hospital, 48 847 (10·6%) were admitted to the intensive care unit (ICU), 69 090 (15·0%) received non-invasive ventilation, and 25 928 (5·6%) received invasive ventilation. Among 384 135 patients who were admitted to hospital but did not require ventilation, mortality was higher in wave 1 (23 485 [30·4%] of 77 202 patients) than wave 2 (44 220 [23·1%] of 191 528 patients), but remained unchanged for patients admitted to the ICU. Mortality was highest among patients who received ventilatory support outside of the ICU in wave 1 (2569 [50·7%] of 5063 patients). 15 486 (9·8%) of 158 020 COVID-19-related deaths occurred within 28 days of the first COVID-19 event without a COVID-19 diagnoses on the death certificate. 10 884 (6·9%) of 158 020 deaths were identified exclusively from mortality data with no previous COVID-19 phenotype recorded. We observed longer patient trajectories in wave 2 than wave 1., Interpretation: Our analyses illustrate the wide spectrum of disease trajectories as shown by differences in incidence, survival, and clinical pathways. We have provided a modular analytical framework that can be used to monitor the impact of the pandemic and generate evidence of clinical and policy relevance using multiple EHR sources., Funding: British Heart Foundation Data Science Centre, led by Health Data Research UK., Competing Interests: Declaration of interests AB reports grants from the National Institute for Health Research (NIHR), British Medical Association, AstraZeneca, and UK Research and Innovation, outside the submitted work. BAM is an employee of the Wellcome Trust and reports grants from Health Data Research UK (HDR UK), UK Medical Research Council (MRC), and Diabetes UK. SH works as a data scientist and data curator for NHS Digital, which holds and processes the data. MAM is supported by research funding from AstraZeneca, outside the submitted work. AH is employed by Institute of Health Informatics, University College London. CS reports grants from the Wellcome Trust, MRC, HDR UK, University of Edinburgh, UK Research and Innovation (UKRI), and the BHF, outside the submitted work; participates on the data safety monitoring board for TARDIS; and has leadership or fiduciary roles with Cancer Research UK Early Detection and Diagnosis Research Committee, UKRI Expert Review Panel for Longitudinal Health & Wellbeing National Core Study, NIHR/UKRI Long COVID call Funding Review Panel, Accelerated Access Collaborative/NIHR/NHSX Artificial Intelligence (AI) in Healthcare Awards Funding Panel, Wellcome Trust Biomedical Resources Award Funding Panel, MRC strategic review Advisory Group for Maximising the opportunities from data science for innovative biomedical research, MRC Data Science Strategy Advisory Group, UKRI Digital Health Research and Innovation Strategy Expert Group, MRC Strategic Review of Units and Centres Main Panel & Population Heath Panel, Wellcome Trust Science Funding Review External advisory group, MRC Methodology Research (Better Methods Better Research) Panel, REF 2021 Subpanel - Public Health, Health Services and Primary Care, Longitudinal Health & Wellbeing COVID-19 National Core Study Strategic Advisory Board, UK Government Clinical Research Recovery Resilience and Growth programme Clinical Trials Expert Group, UK Government Scientific Advisory Group & SAGE Task and Finish Advisory Group on mass population testing for COVID-19, Scottish Government Covid-19 Data Taskforce, BHF Data Science Centre Steering Group, Our Future Health Scientific Advisory Board, Imperial College UKRI Centre for Doctoral Training in AI for Healthcare External advisory board, Swansea University UKRI Centre for Doctoral Training in AI, Machine Learning & Advanced Computing External advisory board, HDR UK Science Strategy Board / Science and Infrastructure Delivery Group, University of Bristol MRC Integrative Epidemiology Unit Scientific Advisory Board, International evaluation panel for Danish National Biobank, H2020 IMI ROADMAP Steering Committee, and the STAT-PD Steering Committee. NS reports grants from AstraZeneca, Boehringer Ingelheim, Novartis, and Roche Diagnostics; and has received consulting fees from Afimmune, Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Hanmi Pharmaceuticals, Merck Sharp & Dohme, Novartis, Novo Nordisk, Pfizer, and Sanofi, outside of the submitted work. WNW is supported by a Scottish senior clinical fellowship, Chief Scientist Office (SCAF/17/01), and the Stroke Association (SA CV 20\100018), has received consulting fees from Bayer; payment for expert testimony from UK courts; participates on the data safety monitoring or advisory board for PROTECT-U, CATIS, INTERACT-4, MOSES, and Bayer; has leadership of fiduciary roles with BIASP Scientific Committee; and is associate editor of Stroke. SD has received research funding from GlaxoSmithKline, Astra Zeneca, Bayer, and BenevolentAI. All other authors declare no competing interests, (Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

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: Incidence and risk factors for self-harm vary according to ethnicity. People who self-harm have been shown to have increased risk of premature death, but little is known about mortality following self-harm in ethnic minority groups., Methods: A prospective cohort study of self-harm presentations to three English cities (Derby, Manchester, Oxford) between 2000 and 2010. We linked to a national mortality dataset to investigate premature death in South Asian and Black people in comparison with White people to the end of 2012., Results: Ethnicity was known for 72% of the 28,512 study cohort members: 88% were White, 5% were South Asian, and 3% were Black. After adjusting for age, gender and area-level socioeconomic deprivation, the risk of all-cause mortality was lower in South Asian (hazard ratio [HR] 0.51, 95% confidence interval [CI] 0.42 - 0.62) and Black people (HR 0.46, 95% CI 0.39 - 0.55) versus White people. Suicide risk was significantly lower in Black people (HR 0.43, 95% CI 0.19 - 0.97) than in White people. Prevalence of risk factors for premature death, such as previous self-harm, psychiatric treatment or concurrent alcohol misuse, was lower in South Asian and Black people than in White people., Conclusions: The risk of death following self-harm is lower in South Asian and Black people than White people in the UK, and they also have lower prevalence of risk factors for premature death. Awareness of both protective and risk factors might help to inform clinical decisions following assessment.

Objectives: Alcohol use and misuse are strongly associated with self-harm and increased risk of future self-harm and suicide. The UK general population prevalence of alcohol use, misuse and alcohol-attributable harm has been rising. We have investigated the prevalence of and trends in alcohol use and misuse in self-harm patients and their associations with repeat self-harm and subsequent death., Methods: We used patient data from the Multicentre Study of Self-Harm in England for 2000-2009 and UK mortality data for patients presenting from 2000 to 2007 who were followed up to the end of 2009., Results: Alcohol involvement in acts of self-harm (58.4%) and alcohol misuse (36.1%) were somewhat higher than found previously in self-harm patients. Alcohol involvement and misuse were most frequent in men, those aged 35-54 years and those from white ethnicities. The frequency of alcohol misuse increased between 2000 and 2009, especially in women. Repetition of self-harm was associated with alcohol involvement in self-harm and particularly with alcohol misuse. Risk of suicide was increased significantly in women misusing alcohol., Conclusions: Alcohol use and misuse in self-harm patients appears to have increased in recent years, particularly in women. The association of alcohol with greater risk of self-harm repetition and mortality highlights the need for clinicians to investigate alcohol use in self-harm patients. Ready availability of alcohol treatment staff in general hospitals could facilitate appropriate aftercare and the prevention of adverse outcomes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Self-poisoning and self-injury have widely differing incidences in hospitals and in the community, which has led to confusion about the concept of self-harm. Categorising self-harm simply by a method may be clinically misleading because many hospital-attending patients switch from one method of harm to another on subsequent episodes. The study set out to determine the frequency, pattern, determinants and characteristics of method-switching in self-harm episodes presenting to the general hospital., Methods: The pattern of repeated self-harm was established from over 33,000 consecutive self-harm episodes in a multicentre English cohort, categorising self-harm methods as poisoning, cutting, other injury, and combined methods., Results: Over an average of 30 months of follow-up, 23% of people repeated self-harm and one-third of them switched method, often rapidly, and especially where the person was male, younger, or had self-harmed previously. Self-poisoning was far less likely than other methods to lead on to switching., Limitations: Self-harm episodes that do not lead to hospital attendance are not included in these findings but people who self-harmed and went to hospital but were not admitted from the emergency department to the general hospital, or did not receive designated psychosocial assessment are included. People in the study were a mix of prevalent as well as incident cases., Conclusions: Method of self-harm is fluctuating and unpredictable. Clinicians should avoid false assumptions about people׳s risks or needs based simply on the method of harm., (Crown Copyright © 2015. Published by Elsevier B.V. All rights reserved.)

Background: There has been little previous research on self-harm among people of Chinese origin living in the UK, although this population has grown substantially in recent years and China is now the largest source of international students at UK universities., Methods: We conducted a prospective cohort study using self-harm presentation data (1997-2011) collected from three hospitals in the City of Manchester, which has the largest Chinese population across all UK Local Authorities. Rate ratios between the Chinese and White groups were calculated using Poisson regression models. Chi-square tests (or Fisher's exact tests), logistic regression, and log-binomial regression were used to examine differences in characteristics and clinical management between groups., Results: Ethnicity was known in the study cohort for 23,297 (87%) amongst 26,894 individuals aged 15 years and above. A total number of 97/23,297 (0.4%) people of Chinese ethnic origin presented with self-harm over the study period and 20,419 (88%) were White people. Incidence of self-harm in the Chinese group (aged 16-64 years) was less than one fifth of that found in White people (0.6 versus 3.2 per 1000 person-years; rate ratio 0.18, 95% confidence interval 0.13-0.24), and was particularly low amongst men of Chinese origin. Individuals of Chinese origin who presented with self-harm were younger, more likely to be female and students, and more likely to self-injure and describe relationship problems as a precipitant than White people. They were less likely to have clinical risk factors such as drug/alcohol misuse and receiving psychiatric treatment, and were rated to have lower risk of self-harm repetition by treating clinicians., Conclusion: Future research needs to investigate whether the low incidence of self-harm presenting to hospitals amongst people of Chinese origin truly reflects a lower frequency of self-harm, or alternatively is due to markedly different post-episode help-seeking behaviours or student overrepresentation in this ethnic group. Relevant healthcare professionals need to be aware of the risk characteristics of people of Chinese origin who self-harm.

Background: To investigate the variation between coroners in the verdicts given to deaths thought by researchers to be probable suicides and analyse factors associated with the coroners' verdict., Methods: Data were collected from 12 English coroner districts on all deaths in 2005 given a suicide, open, accidental or narrative verdict where suicide was considered a possibility. The data were reviewed by three experienced suicide researchers. Regression models were used to investigate factors associated with the coroners' verdict., Results: The researchers classified 593 deaths as suicide, of which 385 (65.4%) received a suicide verdict from the coroner. There was marked variation between coroner districts in the verdicts they gave. The suicide method was associated strongly with the coroners' verdict; deaths from poisoning and drowning were the least likely to be given suicide verdicts. The other factors strongly associated with a coroner's verdict of suicide were: whether a note was left, age over 60 years and being married or widowed compared with being single., Conclusion: Coroners vary considerably in the verdicts they give to individuals who probably died by suicide. This may compromise the usefulness of suicide statistics for assessing area differences in rates for public health surveillance., (© The Author 2014. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To investigate the extent to which risk scales were used for the assessment of self-harm by emergency department clinicians and mental health staff, and to examine the association between the use of a risk scale and measures of service quality and repeat self-harm within 6 months., Design: Observational study., Setting: A stratified random sample of 32 hospitals in England., Participants: 6442 individuals presenting with self-harm to 32 hospital services during a 3-month period between 2010 and 2011., Outcomes: 21-item measure of service quality, repeat self-harm within 6 months., Results: A variety of different risk assessment tools were in use. Unvalidated locally developed proformas were the most commonly used instruments (reported in n=22 (68.8%) mental health services). Risk assessment scales were used in one-third of services, with the SAD PERSONS being the single most commonly used scale. There were no differences in service quality score between hospitals which did and did not use scales as a component of risk assessment (median service quality score (IQR): 14.5 (12.8, 16.4) vs 14.5 (11.4, 16.0), U=121.0, p=0.90), but hospitals which used scales had a lower median rate of repeat self-harm within 6 months (median repeat rate (IQR): 18.5% vs 22.7%, p=0.008, IRR (95% CI) 1.18 (1.00 to 1.37). When adjusted for differences in casemix, this association was attenuated (IRR=1.13, 95% CI (0.98 to 1.3))., Conclusions: There is little consensus over the best instruments for risk assessment following self-harm. Further research to evaluate the impact of scales following an episode of self-harm is warranted using prospective designs. Until then, it is likely that the indiscriminant use of risk scales in clinical services will continue.

Background: Evidence to guide clinical management of self-harm is sparse, trials have recruited selected samples, and psychological treatments that are suggested in guidelines may not be available in routine practice., Aims: To examine how the management that patients receive in hospital relates to subsequent outcome., Methods: We identified episodes of self-harm presenting to three UK centres (Derby, Manchester, Oxford) over a 10 year period (2000 to 2009). We used established data collection systems to investigate the relationship between four aspects of management (psychosocial assessment, medical admission, psychiatric admission, referral for specialist mental health follow up) and repetition of self-harm within 12 months, adjusted for differences in baseline demographic and clinical characteristics., Results: 35,938 individuals presented with self-harm during the study period. In two of the three centres, receiving a psychosocial assessment was associated with a 40% lower risk of repetition, Hazard Ratios (95% CIs): Centre A 0.99 (0.90-1.09); Centre B 0.59 (0.48-0.74); Centre C 0.59 (0.52-0.68). There was little indication that the apparent protective effects were mediated through referral and follow up arrangements. The association between psychosocial assessment and a reduced risk of repetition appeared to be least evident in those from the most deprived areas., Conclusion: These findings add to the growing body of evidence that thorough assessment is central to the management of self-harm, but further work is needed to elucidate the possible mechanisms and explore the effects in different clinical subgroups.

Background: Official suicide statistics for England are based on deaths given suicide verdicts and most cases given an open verdict following a coroner's inquest. Previous research indicates that some deaths given accidental verdicts are considered to be suicides by clinicians. Changes in coroners' use of different verdicts may bias suicide trend estimates. We investigated whether suicide trends may be over- or underestimated when they are based on deaths given suicide and open verdicts. Method Possible suicides assessed by 12 English coroners in 1990/91, 1998 and 2005 and assigned open, accident/misadventure or narrative verdicts were rated by three experienced suicide researchers according to the likelihood that they were suicides. Details of all suicide verdicts given by these coroners were also recorded., Results: In 1990/91, 72.0% of researcher-defined suicides received a suicide verdict from the coroner, this decreased to 65.4% in 2005 (p trend < 0.01); equivalent figures for combined suicide and open verdicts were 95.4% (1990/91) and 86.7% (2005). Researcher-defined suicides with a verdict of accident/misadventure doubled over that period, from 4.6% to 9.1% (p < 0.01). Narrative verdict cases rose from zero in 1990/91 to 25 in 2005 (4.2% of researcher-defined suicides that year). In 1998 and 2005, 50.0% of the medicine poisoning deaths given accidental/misadventure verdicts were rated as suicide by the researchers., Conclusions: Between 1990/91 and 2005, the proportion of researcher-defined suicides given a suicide verdict by coroners decreased, largely due to an increased use of accident/misadventure verdicts, particularly for deaths involving poisoning. Consideration should be given to the inclusion of 'accidental' deaths by poisoning with medicines in the statistics available for monitoring suicides rates.

Background: Suicide by carbon monoxide poisoning from burning barbecue charcoal has become a common method of suicide in several Asian countries over the last 15 years. The characteristics of people using this method in Western countries have received little attention., Method: We reviewed the inquest reports of 12 English Coroners (11% of all Coroners) to identify charcoal-burning suicides. We compared socio-demographic and clinical characteristics of suicide by charcoal burning occurring between 2005 and 2007 with suicides using other methods in 2005., Results: Eleven charcoal-burning suicides were identified; people using this method were younger (mean age 33.4 versus 44.8 years, P = 0.02), and more likely to be unemployed (70.0 versus 30.1%, P = 0.01) and unmarried (100 versus 70%, P = 0.04) than those using other methods. Charcoal-burning suicides had higher levels of contact with psychiatric services (80.0 versus 59.1%) and previous self-harm (63.6 versus 53.0%) compared with suicides using other methods, but these differences did not reach conventional levels of statistical significance. Over one-third of people dying by charcoal burning obtained information on this method from the Internet., Conclusions: Working with media, including Internet Service Providers, and close monitoring of changes in the incidence of suicide using this method might help prevent an epidemic of charcoal-burning suicides such as that seen in some Asian countries.

Background: Little information is available to inform clinical assessments on risk of self-harm repetition in ethnic minority groups., Methods: In a prospective cohort study, using data collected from six hospitals in England for self-harm presentations occurring between 2000 and 2007, we investigated risk factors for repeat self-harm in South Asian and Black people in comparison to Whites., Results: During the study period, 751 South Asian, 468 Black and 15,705 White people presented with self-harm in the study centres. Repeat self-harm occurred in 4379 individuals, which included 229 suicides (with eight of these fatalities being in the ethnic minority groups). The risk ratios for repetition in the South Asian and Black groups compared to the White group were 0.6, 95% CI 0.5-0.7 and 0.7, 95% CI 0.5-0.8, respectively. Risk factors for repetition were similar across all three groups, although excess risk versus Whites was seen in Black people presenting with mental health symptoms, and South Asian people reporting alcohol use and not having a partner. Additional modelling of repeat self-harm count data showed that alcohol misuse was especially strongly linked with multiple repetitions in both BME groups., Limitations: Ethnicity was not recorded in a third of cases which may introduce selection bias. Differences may exist due to cultural diversity within the broad ethnic groups., Conclusion: Known social and psychological features that infer risk were present in South Asian and Black people who repeated self-harm. Clinical assessment in these ethnic groups should ensure recognition and treatment of mental illness and alcohol misuse., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: Self-harm (intentional self-poisoning and self-injury) in children and adolescents is often repeated and is associated with increased risk of future suicide. We have investigated factors associated with these outcomes., Method: We used data collected in the Multicentre Study of Self-harm in England on all self-harm hospital presentations by individuals aged 10-18 years between 2000 and 2007, and national death information on these individuals to the end of 2010. Cox hazard proportional models were used to identify independent and multivariable predictors of repetition of self-harm and of suicide., Results: Repetition of self-harm occurred in 27.3% of individuals (N = 3920) who presented between 2000 and 2005 and were followed up until 2007. Multivariate analysis showed that repetition was associated with age, self-cutting, and previous self-harm and psychiatric treatment. Of 51 deaths in individuals who presented between 2000 and 2007 and were followed up to 2010 (N = 5133) half (49.0%) were suicides. The method used was usually different to that used for self-harm. Multivariate analysis showed that suicide was associated with male gender [Hazard ratio (HR) = 2.4, 95% CI 1.2-4.8], self-cutting (HR = 2.1, 95% CI 1.1-3.7) and prior psychiatric treatment at initial presentation (HR = 4.2, 95% CI 1.7-10.5). It was also associated with self-cutting and history of psychiatric treatment at the last episode before death, and history of previous self harm., Conclusions: Self-cutting as a method of self-harm in children and adolescents conveys greater risk of suicide (and repetition) than self-poisoning although different methods are usually used for suicide. The findings underline the need for psychosocial assessment in all cases., (© 2012 The Authors. Journal of Child Psychology and Psychiatry © 2012 Association for Child and Adolescent Mental Health.)

Background: Self-harm is a common reason for Emergency Department (ED) attendance. We aimed to develop a clinical tool to help identify patients at higher risk of repeat self-harm, or suicide, within 6 months of an ED self-harm presentation., Method: The tool, the ReACT Self-Harm Rule, was derived using multicentre data from a prospective cohort study. Binary recursive partitioning was applied to data from two centres, and data from a separate centre were used to test the tool. There were 29 571 self-harm presentations to five hospital EDs between January 2003 and June 2007, involving 18 680 adults aged ⩾16 years. We estimated sensitivity, specificity and positive and negative predictive values to measure the performance of the tool., Results: A self-harm presentation was classified as higher risk if at least one of the following factors was present: recent self-harm (in the past year), living alone or homelessness, cutting as a method of harm and treatment for a current psychiatric disorder. The rule performed with 95% sensitivity [95% confidence interval (CI) 94-95] and 21% specificity (95% CI 21-22), and had a positive predictive value of 30% (95% CI 30-31) and a negative predictive value of 91% (95% CI 90-92) in the derivation centres; it identified 83/92 of all subsequent suicides., Conclusions: The ReACT Self-Harm Rule might be used as a screening tool to inform the process of assessing self-harm presentations to ED. The four risk factors could also be used as an adjunct to in-depth psychosocial assessment to help guide risk formulation. The use of multicentre data helped to maximize the generalizability of the tool, but we need to further verify its external validity in other localities.

We examined epidemiology and characteristics of self-harm in adolescents and impact of national guidance on management. Data were collected in six hospitals in three centres between 2000 and 2007 in the Multicentre Study of Self-harm in England. Of 5,205 individuals (7,150 episodes of self-harm), three-quarters were female. The female:male ratio in 10-14 year-olds was 5.0 and 2.7 in 15-18 year-olds. Rates of self-harm varied somewhat between the centres. In females they averaged 302 per 100,000 (95 % CI 269-335) in 10-14 year-olds and 1,423 (95 % CI 1,346-1,501) in 15-18 year-olds, and were 67 (95 % CI 52-82) and 466 (95 % CI 422-510), respectively, in males. Self-poisoning was the most common method, involving paracetamol in 58.2 % of episodes. Presentations, especially those involving alcohol, peaked at night. Repetition of self-harm was frequent (53.3 % had a history of prior self-harm and 17.7 % repeated within a year). Relationship problems were the predominant difficulties associated with self-harm. Specialist assessment occurred in 57 % of episodes. Self-harm in children and adolescents in England is common, especially in older adolescents, and paracetamol overdose is the predominant method. National guidance on provision of psychosocial assessment in all cases of self-harm requires further implementation.

Background: Older adults have elevated suicide rates. Self-harm is the most important risk factor for suicide. There are few population-based studies of self-harm in older adults., Aims: To calculate self-harm rates, risk factors for repetition and rates of suicide following self-harm in adults aged 60 years and over., Method: We studied a prospective, population-based self-harm cohort presenting to six general hospitals in three cities in England during 2000 to 2007., Results: In total 1177 older adults presented with self-harm and 12.8% repeated self-harm within 12 months. Independent risk factors for repetition were previous self-harm, previous psychiatric treatment and age 60-74 years. Following self-harm, 1.5% died by suicide within 12 months. The risk of suicide was 67 times that of older adults in the general population. Men aged 75 years and above had the highest suicide rates., Conclusions: Older adults presenting to hospital with self-harm are a high-risk group for subsequent suicide, particularly older men.

Background: Mortality, including suicide and accidents, is elevated in self-harm populations. Although risk factors for suicide following self-harm are often investigated, rarely have those for accidents been studied. Our aim was to compare risk factors for suicide and accidents., Method: A prospective cohort (n=30 202) from the Multicentre Study of Self-harm in England, 2000-2007, was followed up to 2010 using national death registers. Risk factors for suicide (intentional self-harm and undetermined intent) and accidents (narcotic poisoning, non-narcotic poisoning, and non-poisoning) following the last hospital presentation for self-harm were estimated using Cox models., Results: During follow-up, 1833 individuals died, 378 (20.6%) by suicide and 242 (13.2%) by accidents. Independent predictors of both suicide and accidents were: male gender, age 35 years (except accidental narcotic poisoning) and psychiatric treatment (except accidental narcotic poisoning). Factors differentiating suicide from accident risk were previous self-harm, last method of self-harm (twofold increased risks for cutting and violent self-injury versus self-poisoning) and mental health problems. A risk factor specific to accidental narcotic poisoning was recreational/illicit drug problems, and a risk factor specific to accidental non-narcotic poisoning and non-poisoning accidents was alcohol involvement with self-harm., Conclusions: The similarity of risk factors for suicide and accidents indicates common experiences of socio-economic disadvantage, life problems and psychopathology resulting in a variety of self-destructive behaviour. Of factors associated with the accidental death groups, those for non-narcotic poisoning and other accidents were most similar to suicide; differences seemed to be related to criteria coroners use in reaching verdicts. Our findings support the idea of a continuum of premature death.

Objective: Self-harm is closely related to completed suicide, especially in older age. As empirical research of self-harm in older age is scarce, with no studies confined to first-ever episodes in older age, we examined the clinical characteristics and the risk of repetition in first-ever self-harm in older age., Method: The Manchester Self-Harm (MaSH) project, a prospective cohort study, gathered data from September 1, 1997, through August 31, 2007, for individuals presenting with self-harm at emergency departments of 3 large hospitals in North West England. The characteristics of older patients (aged ≥ 55 years) who presented with a first-ever episode of self-harm are described and compared to those of middle-aged patients (35-54 years) presenting with a first-ever episode of self-harm. Following each episode, the MaSH form, a standard assessment form developed for the MaSH project, was completed by a clinician. Potential risk factors for repetition were examined by Cox regression analyses., Results: A total of 374 older patients and 1,937 middle-aged patients presented with a first-ever episode of self-harm. The circumstances at the time of self-harm suggested higher suicidal intent in older age. In comparison with middle-aged patients, the rate of repetition in older-aged patients was lower (15.4% versus 11.8%, respectively; hazard ratio for older age = 0.65; 95% CI, 0.45-0.93; P = .019), although repetition was more often fatal among the older group (3.3% versus 13.6%, respectively; P = .009). The most important predictor of repetition in older age, ie, physical health problems, had no predictive value in middle-aged patients, whereas psychiatric characteristics had little impact on the risk of repetition in old age., Conclusions: High suicidal intent and different predictors of repetition in first-ever self-harm in older age highlight the need for age-specific interventions beyond the scope of psychiatric care alone., (© Copyright 2011 Physicians Postgraduate Press, Inc.)

Aim: This paper is a report of a study conducted to compare risk assessments by psychiatrists and mental health nurses following an episode of self-harm., Background: Self-harm assessments by nurses and psychiatrists are similar in terms of overall content, but risk assessment may vary by professional discipline. To our knowledge previous researchers have not compared the positive predictive value of risk assessments by nurses and psychiatrists, the factors that inform those assessments in clinical practice or the management of people assessed as being at high risk., Methods: We conducted a prospective cohort study (2002-2006) of 3491 individuals presenting with self-harm to three hospitals in the North West of England. A standard assessment form including detailed demographic and clinical data was completed by the assessing psychiatrist or nurse., Results: The positive predictive value of risk assessments for self-harm repetition was 25% (95% CI: 20-31) among nurses and 23% (95% CI: 13-37) among psychiatrists. There was strong agreement on factors associated with high risk assessment by both professions. Following assessment of high risk, psychiatrists were much more likely than nurses to admit people for inpatient treatment (RR=5.6, 95% CI: 3.2-9.7). This difference remained highly statistically significant after controlling for case-mix differences (RR=4.3, 95% CI: 2.4-7.7)., Conclusion: Our finding that risk assessments were comparable by profession supports the provision of nurse-led assessment services. However, inpatient admission was influenced largely by assessor type rather than patient characteristics. This has important implications for equity of care and may reflect professional differences in referral practices., (© 2010 Blackwell Publishing Ltd.)

Background: In early 2005 the UK Committee on Safety of Medicines (CSM) announced gradual withdrawal of the analgesic co-proxamol because of its adverse benefit/safety ratio, especially its use for intentional and accidental fatal poisoning. Prescriptions of co-proxamol were reduced in the 3-year withdrawal phase (2005 to 2007) following the CSM announcement., Aims: To assess the impact of the CSM announcement in January 2005 to withdraw co-proxamol on nonfatal self-poisoning with co-proxamol and other analgesics., Methods: Interrupted time series analysis of general hospital presentations for nonfatal self-poisoning (five hospitals in three centers in England), comparing the 3-year withdrawal period 2005-2007 with 2000-2004., Results: A marked reduction in the number of episodes of nonfatal self-poisoning episodes involving co-proxamol was found following the CSM announcement (an estimated 62% over the period 2005 to 2007 compared to 2000 to 2004). There was no evidence of an increase in nonfatal self-poisoning episodes involving other analgesics (co-codamol, codeine, co-dydramol, dihydrocodeine, and tramadol) in relation to the CSM announcement over the same period, nor a change in the number of all episodes of self-poisoning., Limitations: Data were from three centers only., Conclusions: The impact of the policy appears to have reduced nonfatal self-poisoning with co-proxamol without significant substitution with other analgesics. This finding is in keeping with that for suicide.

Background: Self-harm is a common reason for presentation to the Emergency Department. An important question is whether psychosocial assessment reduces risk of repeated self-harm. Repetition has been investigated with survival analysis using various models, though many are not appropriate for recurrent events., Methods: Survival analysis was used to investigate associations between psychosocial assessment following an episode of self-harm and subsequent repetition, including (i) one repeat, and (ii) recurrent repetition (≤5 repeats) using (a) an independent episodes model, and (b) a stratified episodes model based on a conditional risk set. Data were from the Multicentre Study on Self-harm in England, 2000 to 2007., Results: Psychosocial assessment following an index episode of self-harm was associated with a 51% (95% CI 42%-58%) decreased risk of a repeat episode in persons with no psychiatric treatment history, and 26% (95% CI 8%-34%) decreased risk in those with a treatment history. For recurrent repetition, assessment was associated with a 57% (95% CI 51%-63%) decreased risk of repetition assuming independent episodes, and 13% (95% CI 1%-24%) decreased risk accounting for ordering and correlation of episodes by the same person (stratified episodes model). All models controlled for age, gender, method, history of self-harm, and centre differences., Limitations: Some missing data on psychiatric treatment for non-assessed patients., Conclusions: Psychosocial assessment appeared to be beneficial in reducing the risk of repetition, especially in the short-term. Findings for recurrent repetition were highly dependent on model assumptions. Analyses should fully account for ordering and correlation of episodes by the same person., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Background: Self-harm is a common reason for presentation to a general hospital, with a strong association with suicide. Trends in self-harm are an important indicator of community psychopathology, with resource implications for health services and relevance to suicide prevention policy. Previous reports in the UK have come largely from single centres., Aims: To investigate trends in non-fatal self-harm in six general hospitals in three centres from the Multicentre Study of Self-harm in England, and to relate these to trends in suicide., Method: Data on self-harm presentations to general hospital emergency departments in Oxford (one), Manchester (three) and Derby (two) were analysed over the 8-year period 1 January 2000 to 31 December 2007., Results: Rates of self-harm declined significantly over 8 years for males in three centres (Oxford: -14%; Manchester: -25%; Derby: -18%) and females in two centres (Oxford: -2% (not significant); Manchester: -13%; Derby: -17%), in keeping with national trends in suicide. A decreasing proportion and number of episodes involved self-poisoning alone, and an increasing proportion and number involved other self-injury (e.g. hanging, jumping, traffic related). Episodes involving self-cutting alone showed a slight decrease in numbers over time. Trends in alcohol use at the time of self-harm and repetition within 1 year were stable., Conclusions: There were decreasing rates of non-fatal self-harm over the study period that paralleled trends in suicide in England. This was reflected mainly in a decline in emergency department presentations for self-poisoning.

Background: Studies of self-harm in Black and minority ethnic (BME) groups have been restricted to single geographical areas, with few studies of Black people., Aims: To calculate age- and gender-specific rates of self-harm by ethnic group in three cities and compare characteristics and outcomes., Method: A population-based self-harm cohort presenting to five emergency departments in three English cities during 2001 to 2006., Results: A total of 20 574 individuals (16-64 years) presented with self-harm; ethnicity data were available for 75%. Rates of self-harm were highest in young Black females (16-34 years) in all three cities. Risk of self-harm in young South Asian people varied between cities. Black and minority ethnic groups were less likely to receive a psychiatric assessment and to re-present with self-harm., Conclusions: Despite the increased risk of self-harm in young Black females fewer receive psychiatric care. Our findings have implications for assessment and appropriate management for some BME groups following self-harm.

Background: Antidepressants are used frequently in non-fatal self-poisoning. There are national guidelines for prescribing antidepressants. There have been few investigations of how non-fatal self-poisoning with antidepressants varies in relation to prescribing and to patient characteristics., Methods: A comparative study of the use of specific antidepressants (amitriptyline and dosulepin (tricyclics), citalopram, fluoxetine, paroxetine and sertraline (selective serotonin reuptake inhibitors) and venlafaxine (serotonin norepinephrine reuptake inhibitor)) for non-fatal self-poisoning (episode-based), relative to prescribing, in three centres in England, 2004 to 2006., Results: There was marked variation between centres in the ratio of rates of self-poisoning to prescribing for specific antidepressants. Higher rates of self-poisoning relative to prescribing for all antidepressants combined, and for venlafaxine, were found in the centre with greater proportions of patients with a history of self-harm and/or previous psychiatric treatment. Within each centre, higher rates of self-poisoning relative to prescribing were found for citalopram and fluoxetine than amitriptyline. However, rates of self-poisoning relative to prescribing for either amitriptyline or dosulepin were also similar to sertraline, which is of concern given the known toxicity of tricyclics., Limitations: An ecological study, where prescriptions were for all indications and not specifically for the patients who self-poisoned., Conclusions: Marked differences found in ratios of self-poisoning with antidepressants to levels of prescribing, in three centres in England, are likely to reflect differences in both prescribing practices (despite clear national guidance) and patient characteristics. Risk of overdose and toxicity should be considered when local prescribing policy and clinical practice relating to antidepressants are under review., (Copyright 2009 Elsevier B.V. All rights reserved.)

Background: Self-poisoning is a common method of suicide and often involves ingestion of antidepressants. Information on the relative toxicity of antidepressants is therefore extremely important., Aims: To assess the relative toxicity of specific tricyclic antidepressants (TCAs), a serotonin and noradrenaline reuptake inhibitor (SNRI), a noradrenergic and specific serotonergic antidepressant (NaSSA), and selective serotonin reuptake inhibitors (SSRIs)., Method: Observational study of prescriptions (UK), poisoning deaths involving single antidepressants receiving coroners' verdicts of suicide or undetermined intent (England and Wales) and non-fatal self-poisoning episodes presenting to six general hospitals (in Oxford, Manchester and Derby) between 2000 and 2006. Calculation of fatal toxicity index based on ratio of rates of deaths to prescriptions, and case fatality based on ratio of rates of deaths to non-fatal self-poisonings., Results: Fatal toxicity and case fatality indices provided very similar results (rho for relative ranking of indices 0.99). Case fatality rate ratios showed greater toxicity for TCAs (13.8, 95% CI 13.0-14.7) than the SNRI venlafaxine (2.5, 95% CI 2.0-3.1) and the NaSSA mirtazapine (1.9, 95% CI 1.1-2.9), both of which had greater toxicity than the SSRIs (0.5, 95% CI 0.4-0.7). Within the TCAs, compared with amitriptyline both dosulepin (relative toxicity index 2.7) and doxepin (2.6) were more toxic. Within the SSRIs, citalopram had a higher case fatality than the other SSRIs (1.1, 95% CI 0.8-1.4 v. 0.3, 95% CI 0.2-0.4)., Conclusions: There are wide differences in toxicity not only between classes of antidepressants, but also within classes. The findings are relevant to prescribing decisions, especially in individuals at risk, and to regulatory policy.

Comparisons of psychiatric patients who die by suicide using different methods are scarce. We aimed to establish the methods of suicide used by those who are currently or have recently been in contact with mental health services in England and Wales (N = 6,203), and describe the social and clinical characteristics of suicides by different methods. We found that hanging, self-poisoning, and jumping (from a height or in front of a moving vehicle) were the most common methods of suicide, accounting for 79% of all deaths. The implications of these and other findings are discussed.

Aims: To assess the impact of the UK Medicines and Healthcare products Regulatory Authority (MHRA) warning in December 2003 not to prescribe selective serotonin reuptake inhibitor (SSRI) antidepressants, except fluoxetine, to under-18-year-olds., Methods: Interrupted time series analysis of prescriptions (UK) and general hospital presentations for nonfatal self-poisoning (three centres in England) for 2000-2006., Results: Following the MHRA warning in December 2003 there were significant decreases in prescribing of SSRI antidepressants (conservative estimate 51%) to young people aged 12-19 years. Surprisingly, this decrease also affected fluoxetine (conservative estimate 20%) and tricyclics (conservative estimate 27%). Nonfatal self-poisoning in this age group following the warning also declined significantly for SSRIs (conservative estimate 44%), but not for fluoxetine, tricyclic antidepressants, or all drugs and other substances. Rates of nonfatal self-harm did not change significantly over the study period., Conclusions: The reduction in both prescribing and self-poisoning with SSRI antidepressants (except fluoxetine) following the MHRA warning is in keeping with reduced availability of these drugs. There was some evidence of substitution from other SSRIs to fluoxetine for use in self-poisoning. Importantly, overall rates of nonfatal self-harm and self-poisoning did not change, indicating no substitution of method or increases in self-injury.

Aims: To examine the changes in coronary, all-cause, and cancer mortality in patients with heterozygous familial hypercholesterolaemia (FH) before and after lipid-lowering therapy with statins., Methods and Results: A total of 3382 patients (1650 men) aged <80 years were recruited from 21 lipid clinics in the United Kingdom and followed prospectively between 1980 and 2006 for 46 580 person-years. There were 370 deaths, including 190 from coronary heart disease (CHD) and 90 from cancer. The standardized mortality ratio (compared with the population in England and Wales) was calculated before and from 1 January 1992. In patients aged 20-79 years, CHD mortality fell significantly by 37% (95% CI = 7-56) from 3.4- to 2.1-fold excess. Primary prevention resulted in a 48% reduction in CHD mortality from 2.0-fold excess to none, with a smaller reduction of nearly 25% in patients with established disease. Coronary mortality was reduced more in women than in men. In patients without known CHD at registration, all-cause mortality from 1992 was 33% (21-43), lower than in the general population, mainly due to a 37% (21-50) lower risk of fatal cancer., Conclusion: The results emphasize the importance of early identification of FH and treatment with statins.

Objective: To assess the feasibility of deriving patient safety indicators for England from routine hospital data and whether they can indicate adverse outcomes for patients., Design: Nine patient safety indicators developed by the United States Agency for Healthcare Research and Quality (AHRQ) were derived using hospital episode statistics for England for 2003-4, 2004-5, and 2005-6. A case-control analysis was undertaken to compare length of stay and mortality between cases (patients experiencing the particular safety event measured by an indicator) and controls matched for age, sex, health resource group (standard groupings of clinically similar treatments that use similar levels of healthcare resource), main specialty, and trust. Comparisons were undertaken with US data., Setting: All NHS trusts in England., Participants: Inpatients in NHS trusts., Results: There was fair consistency in national rates for the nine indicators across three years. For all but one indicator, hospital stays were longer in cases than in matched controls (range 0.2-17.1 days, P<0.001). Mortality in cases was also higher than in controls (5.7-27.1%, P<0.001), except for the obstetric trauma indicators. Excess length of stay and mortality in cases was greatest for postoperative hip fracture and sepsis. England's rates were lower than US rates for these indicators. Increased length of stay in cases was generally greater in England than in the US. Excess mortality was also higher in England than in the US, except for the obstetric trauma indicators where there were few deaths in both countries. Differences between England and the US in excess length of stay and mortality were most marked for postoperative hip fracture., Conclusions: Hospital administrative data provide a potentially useful low burden, low cost source of information on safety events. Indicators can be derived with English data and show that cases have poorer outcomes than matched controls. These data therefore have potential for monitoring safety events. Further validation, for example, of individual cases, is needed and levels of event recording need to improve. Differences between England and the US might reflect differences in the depth of event coding and in health systems and patterns of healthcare provision.

Background: Quantitative research about self-harm largely deals with self-poisoning, despite the high incidence of self-injury., Aims: We compared patterns of hospital care and repetition associated with self-poisoning and self-injury., Method: Demographic and clinical data were collected in a multicentre, prospective cohort study, involving 10,498 consecutive episodes of self-harm at six English teaching hospitals., Results: Compared with those who self-poisoned, people who cut themselves were more likely to have self-harmed previously and to have received support from mental health services, but they were far less likely to be admitted to the general hospital or receive a psychosocial assessment. Although only 17% of people repeated self-harm during the 18 months of study, survival analysis that takes account of all episodes revealed a repetition rate of 33% in the year following an episode: 47% after episodes of self-cutting and 31% after self-poisoning (P<0.001). Of those who repeated, a third switched method of self-harm., Conclusions: Hospital services offer less to people who have cut themselves, although they are far more likely to repeat, than to those who have self-poisoned. Attendance at hospital should result in psychosocial assessment of needs regardless of method of self-harm.

Background: Self-harm is a major healthcare problem in the United Kingdom, but monitoring of hospital presentations has largely been done separately in single centres. Multicentre monitoring of self-harm has been established as a result of the National Suicide Prevention Strategy for England., Method: Data on self-harm presentations to general hospitals in Oxford (one hospital), Manchester (three hospitals) and Leeds (two hospitals), collected through monitoring systems in each centre, were analysed for the 18-month period March 2000 to August 2001., Results: The findings were based on 7344 persons who presented following 10,498 episodes of self-harm. Gender and age patterns were similar in the three centres, 57.0% of patients being female and two-thirds (62.9%) under 35 years of age. The largest numbers by age groups were 15-19 year-old females and 20-24 year-old males. The female to male ratio decreased with age. Rates of self-harm were higher in Manchester than Oxford or Leeds, in keeping with local suicide rates. The proportion of patients receiving a specialist psychosocial assessment varied between centres and was strongly associated with admission to the general hospital. Approximately 80% of self-harm involved self-poisoning. Overdoses of paracetamol, the most frequent method, were more common in younger age groups, antidepressants in middle age groups, and benzodiazepines and sedatives in older age groups. Alcohol was involved in more than half (54.9%) of assessed episodes. The most common time of presentation to hospital was between 10 pm and 2 am., Conclusions: Multicentre monitoring of self-harm in England has demonstrated similar overall patterns of self-harm in Oxford, Manchester and Leeds, with some differences reflecting local suicide rates. Diurnal variation in time of presentation to hospital and the need for assessment of non-admitted patients have implications for service provision.

Background: Rates of self-harm appear high in South Asian young women in the United Kingdom (UK) although previous studies were mostly small. Data on treatment and outcomes for South Asians are lacking. This study compared rates of self-harm, socio-demographic and clinical characteristics, provision of services and risk of repetition by ethnicity., Method: A prospective cohort of adult self-harm attendees (n = 7185), aged 15 and over presenting to four emergency departments in the cities of Manchester and Salford, UK over a 4-year period., Results: The study included 299 South Asians. South Asian women aged 16-24 years were more likely to self-harm than Whites of the same age group (1010.9 vs. 754 per 100,000). Across all age groups the rates of self-harm were lower in South Asian men compared to White men and to South Asian women. South Asian women were significantly more likely to report relationship problems within the family than White women (32% vs. 19%, P = <0.001). South Asians were less likely than Whites to report depressive symptoms and to be offered specialist mental health services (Rate ratio = 0.75), and more likely to be referred back to the GP (Rate ratio = 1.83). South Asians were less likely to attend with a repeat episode (Rate ratio = 0.56)., Conclusions: Young South Asian women are at high risk of self-harm, but their clinical risk appears to be lower in terms of the accepted contextual factors contributing to risk. Potentially useful service provision may include an interpersonal problem solving approach although to be effective, interventions would need to be acceptable to South Asian women and culturally appropriate.

Objectives: To determine the proportion of individuals who repeated nonfatal suicidal behavior within 12 months of an index episode, to investigate the timing of repetition, and to investigate risk factors associated with repetition and their population impact., Method: We carried out a prospective cohort study (1997-2002) in 4 large hospitals in North West England. We included subjects aged 15 years and over who attended with "self-harm" (an act of intentional self-poisoning or injury irrespective of the apparent purpose of the act). Following the episode, a standard assessment form, which included detailed demographic and clinical data, was completed by a clinician., Results: 9213 individuals presented during the study period. The incidence of repetition within 12 months of the index episode was 13.6% (95% CI: 12.9% to 14.4%). The median time to first repetition was 73.5 days (interquartile range, 20 to 187 days). One in 10 subjects repeated within 5 days of the index episode. Independent risk factors for repetition included previous suicidal behavior, psychiatric treatment, being unemployed or registered sick, self-injury, alcohol misuse, and reporting suicidal plans or hallucinations at the time of the index episode. The combined population attributable fraction (an indicator of the potential population impact) for these variables was 65%., Conclusion: The repetition of suicidal behavior is common and occurs quickly. On a population level, our study suggests that the most important strategies to reduce repetition might include primary prevention of suicidal behavior, targeting psychiatric illness, and tackling social factors such as unemployment. Specific interventions may be required for individual subgroups.

Study Objective: Our aim is to develop a risk-stratification model for use by emergency department (ED) clinical staff in the assessment of patients attending with self-harm., Methods: Participants were patients who attended 5 EDs in Manchester and Salford, England, after self-harm between September 1, 1997, and February 28, 2001. Social, demographic, and clinical information was collected for each patient at each attendance. With data from the Manchester and Salford Self-Harm Project, a clinical decision rule was derived by using recursive partitioning to discriminate between patients at higher and lower risk of repetition or subsequent suicide occurring within 6 months. Data from 3 EDs were used for the derivation set. The model was validated with data from the remaining 2 EDs., Results: Data for 9,086 patients who presented with self-harm were collected during this study period, including 17% that reattended within 6 months and 22 patients who died by suicide within 6 months. A 4-question rule, with a sensitivity of 94% (92.1-95.0% [95% confidence interval]) and specificity of 25% (24.2-26.5% [95% confidence interval]), was derived to identify patients at higher risk of repetition or suicide., Conclusion: Application of this simple, highly sensitive rule may facilitate assessment in the ED and help to focus psychiatric resources on patients at higher risk.

Objective: The purposes of this study were to estimate suicide rates up to 4 years after a deliberate self-harm episode, to investigate time-period effects on the suicide rate over the follow-up period, and to examine potential sociodemographic and clinical predictors of suicide within this cohort., Method: This prospective cohort study included 7,968 deliberate self-harm attendees at the emergency departments of four hospital trusts in the neighboring cities of Manchester and Salford, in northwest England, between September 1, 1997, and August 31, 2001. Suicide rates and standardized mortality ratios (SMRs) for the cohort were calculated. Potential risk factors were investigated by using Cox's proportional hazards models., Results: Sixty suicides occurred in the cohort during the follow-up period. An approximately 30-fold increase in risk of suicide, compared with the general population, was observed for the whole cohort. The SMR was substantially higher for female patients than for male patients. Suicide rates were highest within the first 6 months after the index self-harm episode. The independent predictors of subsequent suicide were avoiding discovery at the time of self-harm, not living with a close relative, previous psychiatric treatment, self-mutilation, alcohol misuse, and physical health problems., Conclusions: The results highlight the importance in a suicide prevention strategy of early intervention after an episode of self-harm. Treatment should include attention to physical illness, alcohol problems, and living circumstances. Self-harm appears to confer a particularly high risk of suicide in female patients.

Background: In the past two decades the suicide rate in young people has risen in the UK and other countries., Aims: To identify the characteristics of people aged under 35 who commit suicide., Method: Psychological autopsy study with case-control design. Cases were 84 suicides and probable suicides (open verdicts). Controls were 64 age- and gender-matched non-suicides obtained through the general practices of the matched cases., Main Variables: social, including employment status, marital status and living circumstances; life events and interpersonal difficulties; clinical, including current psychiatric disorder, alcohol and drug misuse, previous self-harm and personality disorder., Results: A large number of highly significant social, interpersonal and clinical differences between suicides and controls was found. Factor analysis identified two groups of variables within each of the social, interpersonal and clinical domains which were independently linked to suicide, corresponding to: acute, severe mental disorder and chronic disorder of behaviour; rootlessness and social withdrawal; chronic and recent interpersonal problems., Conclusions: A broad prevention strategy is needed to reverse the recent rise in the suicide rate in young people.

A five day course of clavulanate-potentiated amoxicillin (Augmentin) has been compared with a single oral dose of fosfomycin trometamol in the treatment of patients complaining of symptoms suggesting urinary tract infection. The study took place in a single urban general practice of 15,000 patients in Cheshire. The microbiology was performed at a London Teaching Hospital. 141 patients entered the trial. 65 had a significant bacteriuria, 62 of which were assessable for the ability of the trial drugs to eradicate bacteriuria: 29 patients received clavulanate-potentiated amoxicillin and 33 fosfomycin trometamol. The cure rates, assessed at five to ten days and at four to six weeks post treatment, were 72% and 65%, respectively for clavulanate-potentiated amoxicillin and 85% and 81%, respectively for fosfomycin trometamol. Side effects, assessed in all 141 patients, occurred in 11.6% receiving clavulanate-potentiated amoxicillin and in 8.3% receiving fosfomycin. Statistically there is no difference between any of these findings and the effect of sample size is discussed. 69 patients were symptomatic but did not have a significant bacteriuria ("urethral syndrome"). These patients were assessed for the effect of treatment in relieving symptoms: 33 received fosfomycin trometamol and 36 clavulanate-potentiated amoxicillin. The success and speed of relieving the symptoms were very similar in the two groups. The finding that both groups responded equally well appears to refute an aetiological role for lactobacilli and diphtheroids in the "urethral syndrome", since these organisms are resistant to fosfomycin but sensitive to clavulanate-potentiated amoxicillin.