Recent Submissions

  • Feasibility and acceptability of experience sampling among LGBTQ+ young people with self-harmful thoughts and behaviours

    Arcelus, Jon (2022)
    This study was the first to determine whether it was feasible and acceptable to use experience sampling methods (ESM) among LGBTQ+ young people, who had current experiences of self-harm. Sixteen LGBTQ+ young people (16–25 years old) took part in the experience sampling study. This included a baseline assessment, a 7-day ESM assessment (participants were sampled six times a day using a phone app), and the option of an interview at the end of the 7-day ESM assessment. Feasibility data was descriptively analysed, with pilot ESM data presented. Qualitative data was thematically analysed to determine the acceptability (barriers and facilitators) of taking part in this study. Study feasibility was assessed by enrolment rate (55.2%), participant retention across assessment period (100%), ESM app feasibility (87.5%), and good adherence to total number of ESM surveys (67.6%). Individual study adherence ranged between 43 and 95.2%. Study acceptability was assessed by participant interviews. Thematic analysis indicated four superordinate themes; (i) Self-reflection and awareness; (ii) Practicalities of ESM surveys; (iii) Daily timeframes; and (iv) Suggestions for future studies. Pilot ESM data demonstrates that there was fluctuation of depressive and anxiety symptoms within- and between- participants over the course of the study, however, greater sample power is needed for full analysis. This study demonstrated that ESM designs are feasible and acceptable among LGBTQ+ young people with current experiences of self-harm. Pilot data indicated that specific experiences and moods are likely to be important to self-harm. These potentially have a temporal influence on self-harm behaviour or ideation, and therefore should be examined in a fully powered sample.
  • Investigating the relationship between bullying involvement and self-harmful thoughts and behaviour in young people: A systematic review

    Sayal, Kapil (2022)
    BACKGROUND: There is a complex and inconsistent relationship between bullying involvement and self-harmful thoughts and behaviour (SHTB) in young people. This novel systematic review aims to establish key interacting, moderating and mediating variables associated with SHTB in young people involved in bullying. METHODS: The systematic review was registered with PROSPERO: CRD42020192023. A search was conducted (until February 2021) across databases: PubMed/MEDLINE, EMBASE, PsycINFO (Ovid), Cochrane Library, Scopus (Elsevier), Web of Science, ERIC and CINAHL (EBSCOhost). Observational studies containing quantitative primary or secondary data analyses were included in the review, on the basis that they examined interactions, moderators, or mediators between bullying involvement and SHTB in young people. Versions of the Newcastle-Ottawa Scale were used to assess risk of bias in the included studies. RESULTS: A total of 57 studies were included. Overall, 3 studies identified interactions, 25 studies identified moderators and 21 studies identified mediators. 9 studies identified moderator-mediators. The findings were categorised as either self-harmful thoughts or self-harmful behaviours and synthesised under the following themes: socio-demographic; depression; parental; personality/psychological; and social/environmental. LIMITATIONS: This review uncovered significant heterogeneity and a paucity of replicated studies in the field, therefore, tentative conclusions have been drawn. CONCLUSIONS: This comprehensive review highlights the key role of depression as a mediator between traditional/cyber victimisation and SHTB in young people. The moderating effects of gender on mediation models investigating the role of depression suggest the possibility that females involved in bullying may be at increased suicide risk.
  • Psychopathy in women: insights from neuroscience and ways forward for research

    Tully, John (2021)
    Suicide rates among adolescents and young adults have been increasing in the last decade. The current knowledge of the warning signs, risk factors, and the use of screening tools has many gaps. There are many views from within, critics, survivors, and advocacy groups to focus more on the contextual understanding of symptomatology. In clinical practice, many of these high-risk groups fail to raise the red flags due to the complex and ambigious nature of presentations. Therefore, these groups need greater attention, and given their counterinitiative nature they challenge the current approaches to address suicidality in adolescents and yound adults.
  • The relationships between childhood abuse and neglect, sub-clinical symptoms of psychosis and self-harm in a non-clinical community sample

    Green, Kathleen; Webster, Anthony (2021)
    There is now substantial evidence that childhood adverse events are a significant risk factor for symptoms of psychosis in both clinical and community samples. Both childhood trauma and positive symptoms of psychosis are associated with an increased risk of self-harming behaviours. Therefore the current study aimed to consider the relationship between retrospective reports of childhood adversity, sub-clinical positive symptoms of psychosis and self-harm in a non-clinical community sample. The study employed a cross-sectional survey design, distributed online. Participants were asked to complete psychometric assessments relating to: demographic characteristics including past-year substance misuse; childhood adversity; sub-clinical symptoms of psychosis (delusions and hallucinations) and self-harming behaviours. The results found that, after controlling for substance misuse, childhood adversity predicted significant variance in sub-clinical delusions and hallucinations in the general population. Both symptoms of psychosis and childhood adversity increased the risk of self-harming behaviours. Positive symptoms partially mediated the relationship between early adversity and self-harming behaviours. For some people, the sequelae of early adversity including sub-clinical delusions and hallucinations may increase the risk of self-harming behaviours. Future research would benefit from considering the role of dissociation in these relationships and the affective impact of pseudo-psychotic experiences. Practitioners should consider the impact of childhood adversity, unusual perceptual experiences and distorted beliefs when working with people who self-harm. The current research was limited by the cross-sectional survey design and non-random sampling methodology.
  • Helping with the pressures of the past: Service-user perspectives of the sensory approaches within the National High Secure Healthcare Service for Women

    Wilkinson, Dawn; Beryl, Rachel (2021)
    Purpose This paper aims to explore service-user perspectives of sensory approaches introduced and promoted by the trauma and self-injury service within the National High Secure Healthcare Service for Women (NHSHSW) at Rampton Hospital. Design/methodology/approach This cross-sectional descriptive study used a semi-structured questionnaire, which was devised for this evaluation and included both open and closed questions. The data collected were then analysed using descriptive statistics and thematic analysis. Findings The paper evaluates the current use of sensory approaches within the NHSHSW. Sensory approaches were widely used across the service, with essential oils being the most commonly used sensory approach. The use of sensory approaches can be understood according to the following three themes: independence, accessibility and self-regulation. The self-regulation theme contained three sub-themes as follows: safety-seeking, relaxation and reducing distress. The evaluation also highlighted barriers to using sensory approaches and sought service-user feedback as to how these may be overcome. Practical implications Participants’ feedback informed changes to practice, such as introducing sensory approaches to service-users earlier in their care pathway and increasing the accessibility of sensory items. These approaches may be of relevance to service provision in other forensic or inpatient settings. Originality/value This paper offers a unique contribution to the current literature with its focus on using sensory approaches to ameliorate trauma symptoms, in the context of a forensic setting.
  • Referrals to liaison services for older adults with deliberate self harm during the SARS-CoV-2 national lockdown - a collaborative service evaluation using liaison referral data

    Junaid, Kehinde; Deylami, Rogin; Sawle, Tristan (2021)
    Aims Social isolation and living alone have been associated with increased suicidality in older adults. During the SARS-CoV-2 pandemic, older adults were advised to keep isolated and maintain social distancing. Lockdown periods in England may have led to increased isolation and loneliness in older people, possibly resulting in an increased rates of DSH and suicide. This study aimed to explore whether numbers of older adults referred to liaison services with deliberate self harm changed during the SARS-CoV-2 pandemic. Method Reason for referral and total number of referrals to liaison services for older adults data were collected across 6 mental health trusts who had access to robust data sets. Data were collected prospectively for three months from the start of the UK national lockdown and for the corresponding 3 month period in 2019, via trust reporting systems. This study was registered as service evaluation within each of the participating mental health trusts. Result Overall numbers of referrals to older adult liaison services went down, but the proportion of referrals for older adults with DSH increased. Across the six mental health trusts there there were a total of 2167 referrals over the first three month lockdown period in 2020, and 170 (7.84%) of these referrals were for deliberate self harm. During a corresponding time period in 2019, there were a total of 3416 referrals and 155 (4.54%) of these referrals were for deliberate self harm Conclusion Although numbers of referrals for older adults with delberate self harm appeared to stay the same, the severity of these presentations is not clear. Outcomes of referrals and severity of self harm could be explored by examining individual case records. As there have been subsequent lockdowns the data collection period should also be extended to include these. Triangulation with national and local datasets on completed suicide is planned.
  • Factors associated with increased suicidality risk following referral for isotretinoin commencement

    Lappas, Andreas S.; Edwards Suarez, Lori; Morton, Sally; Schofield, Christopher; Christodoulou, Nikos G. (2021)
    OBJECTIVE: To establish whether there is a significant change in suicidality risk following psychiatric assessment for commencement of isotretinoin and identify factors that underpin any potential risk change. METHOD: Retrospective cohort study. Suicidality risk was defined as a combination of the following: (i) actual/intended self-harm and/or attempted/completed suicide, and (ii) increased service utilisation associated with suicidal ideation/behaviour. All patients referred to Psychiatry for assessment prior to commencement of isotretinoin between 2014 and 2019 were examined. Inclusion criteria: >16 years of age, assessed for commencement of isotretinoin, complete clinical records. Data were collected by reviewing the Electronic Patient Records. Fifty-seven patients were eligible. We employed descriptive statistics, parametric/non-parametric/normality tests and logistic regression analysis, using socio-demographic and clinical characteristics as independent parameters, and suicidality risk as the dependent parameter. RESULTS: Actual/intended self-harm/attempted suicide decreased significantly following assessment without significant change in service utilisation. Female gender, absence of protective factors and assessment by Consultation-Liaison Psychiatry were linked to increased suicidality risk, after controlling for age, ethnicity, recommendation for isotretinoin, and substance misuse. CONCLUSIONS: Psychiatric assessment is helpful before commencing isotretinoin. Female gender, and absence of ongoing psychopharmacological and/or psychological intervention and/or regular psychiatric follow-up predict increased suicidality risk among patients assessed for prescription of isotretinoin.
  • A systematic review and meta-analysis of victimisation and mental health prevalence among LGBTQ+ young people with experiences of self-harm and suicide

    Arcelus, Jon (2021)
    BACKGROUND: LGBTQ+ youth have higher rates of self-harm and suicide than cisgender, heterosexual peers. Less is known about prevalence of risks within these populations. OBJECTIVES: The first systematic review and meta-analysis to investigate the prevalence of risks among young people throughout the LGBTQ+ umbrella with experiences across the dimension of self-harm, suicidal ideation and suicide behaviour; and how they may differ between LGBTQ+ umbrella groups. DATA SOURCES: MEDLINE, Scopus, EMBASE, PsycINFO, and Web of Science searches were run to identify quantitative research papers (database inception to 31st January, 2020). STUDY ELIGIBILITY CRITERIA: Articles included were empirical quantitative studies, which examined risks associated with self-harm, suicidal ideation or suicidal behaviour in LGBTQ+ young people (12-25 years). SYNTHESIS METHODS: 2457 articles were identified for screening which was completed by two independent reviewers. 104 studies met inclusion criteria of which 40 had data which could be meta-analysed in a meaningful way. This analysis represents victimisation and mental health difficulties as risks among LGBTQ+ youth with self-harm and suicide experiences. Random-effects modelling was used for the main analyses with planned subgroup analyses. RESULTS: Victimisation and mental health were key risk factors across the dimension self-harm and suicide identified through all analyses. A pooled prevalence of 0.36 was indicated for victimisation and 0.39 for mental health difficulties within LGBTQ+ young people with experiences of self-harm or suicide. Odds ratios were calculated which demonstrated particularly high levels of victimisation (3.74) and mental health difficulties (2.67) when compared to cisgender, heterosexual counterparts who also had these experiences. CONCLUSIONS: Victimisation and mental health difficulties are highly prevalent among LGBTQ+ youth with experiences of self-harm and suicide. Due to inconsistency of reporting, further risk synthesis is limited. Given the global inclusion of studies, these results can be considered across countries and inform policy and suicide prevention initiatives. PROSPERO REGISTRATION NUMBER: CRD42019130037.
  • What young people say about impulsivity in the short-term build up to self-harm: A qualitative study using card-sort tasks

    Lockwood, Joanna; Townsend, Ellen; Daley, David; Sayal, Kapil (2020)
    Youth who self-harm report high levels of trait impulsivity and identify impulsive behaviour as a proximal factor directly preceding a self-harm act. Yet, impulsivity is a multidimensional construct and distinct impulsivity-related facets relate differentially to self-harm outcomes. Studies have yet to examine if and how a multidimensional account of impulsivity is meaningful to individual experiences and understandings of self-harm in youth. We explored the salience and context of multidimensional impulsivity within narratives of self-harm, and specifically in relation to the short-term build-up to a self-harm episode. Fifteen community-based adolescents (aged 16-22 years) attending Further Education (FE) colleges in the UK took part in individual face-to-face sessions (involving exploratory card-sort tasks and semi-structured interviews) which explored factors relating to self-harm, impulsivity and the broader emotional, developmental and cognitive context. Session data were analysed thematically. Two overarching themes, and associated subthemes, were identified: 'How I respond to strong negative emotions'; and 'Impulse versus deliberation- How much I think through what I'm doing before I do it'. Self-harm was typically a quick, impulsive act in the context of overwhelming emotion, underpinned by cognitive processing deficits. The dynamic tension between emotion-based impulsivity and controlled deliberation was articulated in the immediate moments before self-harm. However, impulsive responses were perceived as modifiable. Where self-harm patterns were established, these related to habitual behaviour and quick go-to responses. Young people identified with a multidimensional conception of impulsivity and described the impulsive context of a self-harm act as dynamic, contextual, and developmentally charged. Findings have implications for youth-focused work. Card-task frameworks are recommended to scaffold and facilitate discussion with young people, particularly where topics are sensitive, complex and multifactorial.
  • Impulsivity as a predictor of self-harm onset and maintenance in young adolescents: a longitudinal prospective study

    Lockwood, Joanna; Townsend, Ellen; Daley, David; Sayal, Kapil (2020)
    Background: Rates of self-harm in young adolescents are increasing and self-harm typically emerges at this developmental stage. Greater specificity of impulsivity as a multifaceted construct is enabling investigation of links between individual impulsivity facets and self-harm outcomes. However, studies have yet to adequately explore these associations in young adolescents, and prospective relationships between multidimensional impulsivity and self-harm in younger adolescents remain untested. This study investigates unidimensional facets of impulsivity as risk-factors for the emergence and maintenance of self-harm, specifically within young community-based adolescents. Methods: A school-based sample of 594 adolescents (aged 13-15 years) provided data at two time points, 12 weeks apart. Logistic regression analyses determined associations between impulsivity-related facets (as delineated by the UPPS-P scale) and self-harm outcomes over time. Results: Overall, 23.6% of young people reported lifetime self-harm. A higher tendency towards Sensation Seeking was associated with self-harm onset over the study-period (OR 1.19, 95% CI 1.017-1.401). Deficits in Premeditation predicted maintained (versus remitted) self-harm behaviour during this time (OR 1.16, 95% CI 1.013-1.328). Negative Urgency was a significant cross-sectional correlate, but did not offer prospective predictive utility. Limitations: The study relied on self-report. Interpretations are cautious given low incidence of self-harm outcomes over the course of the study. Conclusions: Separate pathways to impulsive behaviour describe the psychological context in which self-harm starts and develops in young people. Findings support differential treatment targets and developmentally-focused early intervention. The predictive utility of impulsivity was inconsistent between cross-sectional and longitudinal analyses, underlining the role for temporality in the establishment of risk of self-harm. © 2020 Elsevier B.V.
  • What do young people who self-harm find helpful? A comparative study of young people with and without experience of being looked after in care

    Holland, Josephine; Sayal, Kapil; Majumder, Pallab; Armstrong, Marie (2020)
    Background: Self-harm amongst young people is an increasing problem, with looked-after young people at higher risk. Despite this, little research exists on what young people who self-harm find helpful. Method: One hundred and twenty-six 11–21 year olds (53 who had experience of the care system and 73 who did not) were recruited from the community and NHS. All participants had self-harmed in the past 6 months. Participants completed an Audio Computer-Assisted Self-interview (ACASI) regarding their views about the support they had received, how helpful it was, and what further help they felt they needed. Results: Looked-after young people reported the three most helpful sources of support were Child and Adolescent Mental Health Services (CAMHS), friends and pets and the least helpful were CAMHS, Accident and Emergency (A&E) and Social services. For non-looked-after young people, CAMHS, counselling and Harmless (user-led support service for self-harm) were most helpful and CAMHS, cognitive behavioural therapy (CBT) and general practitioner (GP) were the least. Compared with the other group, more looked-after young people had received help from A&E and CAMHS, whereas more non-looked-after young people had accessed GPs, parents, psychological therapies, self-help books and websites. More looked-after young people found support groups helpful, and more non-looked-after young people reported that distraction techniques, medication and their siblings were helpful. Conclusion: Young people who self-harm have mixed views about CAMHS. Differences in the pattern of access and preferences for support between looked-after and non-looked-after young people should be reflected in service availability and commissioning. © 2020 Association for Child and Adolescent Mental Health
  • The national suicide prevention strategy for England: The reality of a national strategy for the nursing profession

    Anderson, Martin (2006)
    Suicide is recognized as a global phenomenon and many countries now have national suicide prevention strategies. International guidance on suicide prevention and accepted epidemiological and treatment-based research underpins healthcare policy relating to suicide reduction. There has been an established comprehensive strategy in England since 2002. However, the rate of suicide continues to be a concern and nurses hold a key role in the implementation of national, regional and local policy into practice. The aim of this paper is to consider the current implications of the national suicide prevention strategy in England for nursing. This discussion paper draws upon both empirical evidence-based literature, governmental guidance and policy-related documentation. The national suicide prevention strategy for England currently continues to have a multifaceted impact on the nursing profession. This ranges from clinical practice issues such as risk assessment through to broader public health responsibilities. If nurses and allied health professionals are to be effective in their role within suicide prevention, they will need to be supported in building awareness of the wider context of the national policy. In particular, this will mean working effectively and collaboratively with the voluntary sector, service users and other non-medical agencies.
  • Examining risk factors for self-harm and suicide in LGBTQ+ young people: a systematic review protocol

    Arcelus, Jon (2019)
    INTRODUCTIONYoung people who identify as Lesbian, Gay, Bisexual, Transgender, Queer or Questioning (LGBTQ+) are at increased risk for self-harm, suicide ideation and behaviours. However, there has yet to be a comprehensive understanding of what risk factors influence these behaviours within LGBTQ+ young people as a whole. The purpose of this systematic review is to examine risk factors associated with self-harm, suicidal ideation and behaviour in LGBTQ+) young people.METHODS AND ANALYSISA systematic review will be conducted, conforming to the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. Electronic databases (MEDLINE, Scopus, EMBASE, PsycINFO and Web of Science) will be systematically searched for cross-sectional, prospective, longitudinal, cohort and case-control designs which examine risk factors for self-harm and/or suicidal ideation and behaviour in LGBTQ+ young people (aged 12-25 years). Only studies published in English will be included. No date restrictions will be applied. Study quality assessment will be conducted using the original and modified Newcastle-Ottawa Scales. Meta-analysis or narrative synthesis will be used, dependent on findings.ETHICS AND DISSEMINATIONThis is a systematic review of published literature and thereby ethical approval was not sought. The review will be submitted to a peer-reviewed journal, be publicly disseminated at conferences focusing on mental health, self-harm and suicide prevention. The findings will also be shared through public engagement and involvement, particularly those related to young LGBTQ+ individuals.PROSPERO REGISTRATION NUMBERCRD42019130037.
  • CAMHS self-harm teams and crisis/liaison teams; What CAMH nurses bring to the acute moments in young people's lives

    Armstrong, Marie (2019)
    This chapter focuses on one of the places where young people who self-harm are in contact with services, the general hospital. This includes their experience in the Emergency Department and on hospital wards-usually paediatric wards where young people under the age of 16 are admitted overnight, as recommended by NICE guidelines (NICE 2004).
  • Feasibility of a randomised controlled trial of remotely delivered problem-solving cognitive behaviour therapy versus usual care for young people with depression and repeat self-harm: lessons learnt (e-DASH)

    Sayal, Kapil; Roe, James; Ball, Harriet M.; Atha, Christopher; Kaylor-Hughes, Catherine; Guo, Boliang; Townsend, Ellen; Morriss, Richard K. (2019)
    BACKGROUND: Self-harm and depression are strong risk factors for repeat self-harm and suicide. We aimed to investigate the feasibility of a randomised controlled trial (RCT) of remotely delivered problem-solving cognitive behaviour therapy (PSCBT) plus treatment as usual (TAU) versus TAU in young people with repeat self-harm and depression. METHODS: Single-blind multi-centre RCT with an internal pilot, pre-set stop-go criteria and qualitative semi-structured interviews. Eligible participants (aged 16-30 years) were recruited from 9 adult or child and adolescent self-harm and crisis services; had >/= 2 lifetime self-harm episodes, one in the preceding 96 h; and Beck Depression Inventory-II (BDI-II) score >/= 17. Participants were randomised (1:1) to either TAU or TAU and 10-12 sessions of PSCBT delivered by mobile phone or video-calling. RESULTS: Twenty-two participants were recruited (11 in each arm), 10 (46%) completed follow-up at 6 months, 9 (82%) started the PSCBT and 4 (36%) completed it. The study did not meet three of its four stop-go criteria, reflecting considerable barriers to recruitment and retention. Participants had severe depression symptoms: with mean BDI-II 38.9 in the PSCBT and 37.2 in TAU groups, respectively. Three (14%) unblindings occurred for immediate safety concerns. Barriers to recruitment and retention included lack of agency for participants, severity of depression, recency of crisis with burden for participants and clinicians who diagnosed depression according to pervasiveness. CONCLUSIONS: RCTs of PSCBT for young people with depression and self-harm are not feasible using recruitment through mental health services that conduct assessments following self-harm presentations. Clinician assessment following self-harm presentation mainly identifies those with severe rather than mild-moderate depression. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02377011 ); Date of registration: March 3rd 2015. Retrospectively registered: within 21 days of recruitment of the first participant.
  • Childhood determinants of suicidality: comparing males in military and civilian employed populations

    Syed Sheriff, Rebecca (2018)
    BackgroundTo better understand the associations of childhood trauma and childhood disorder with past-year suicidality (thoughts, plans or attempts), we compared male military and civilian populations aged 18–60 years old.MethodsData derived from the 2010 Australian Defence Force (ADF) Mental Health Prevalence and Wellbeing Study and the 2007 Australian Bureau of Statistics Australian National Survey of Mental Health and Wellbeing were compared using logistic regression and Generalized Structural Equation Modelling (GSEM).ResultsA greater proportion of the ADF experienced suicidality than civilians. Those who experienced childhood trauma that was not interpersonal in nature were not at increased odds of suicidality, in either population. A higher proportion of the ADF experienced three or more types of trauma in childhood and first experienced three or more types of trauma in adulthood. Both were associated with suicidality in the ADF and civilians. Childhood anxiety had a strong and independent association with suicidality in the ADF (controlling for demographics and childhood trauma, adult trauma and adult onset disorder). Childhood anxiety fully mediated the relationship between childhood trauma and suicidality in the ADF, but not in civilians.ConclusionsThese data highlight the need to take a whole life approach to understanding suicidality, and the importance of categorizing the nature of childhood trauma exposure. Importantly, childhood anxiety was not only associated with suicidality, it fully mediated the relationship between childhood trauma and suicidality in the more trauma exposed (military) population only. These findings have the potential to inform the development of strategies for suicide prevention.
  • Reducing relapse and suicide in bipolar disorder: practical clinical approaches to identifying risk, reducing harm and engaging service users in planning and delivery of care - the PARADES (Psychoeducation, Anxiety, Relapse, Advance Directive Evaluation and Suicidality) programme

    Bartlett, Peter; Morriss, Richard K. (2018)
    BACKGROUND: Bipolar disorder (BD) costs pound5.2B annually, largely as a result of incomplete recovery after inadequate treatment. OBJECTIVES: A programme of linked studies to reduce relapse and suicide in BD. DESIGN: There were five workstreams (WSs): a pragmatic randomised controlled trial (RCT) of group psychoeducation (PEd) versus group peer support (PS) in the maintenance of BD (WS1); development and feasibility RCTs of integrated psychological therapy for anxiety in bipolar disorder (AIBD) and integrated for problematic alcohol use in BD (WS2 and WS3); survey and qualitative investigations of suicide and self-harm in BD (WS4); and survey and qualitative investigation of service users' (SUs) and psychiatrists' experience of the Mental Capacity Act 2005 (MCA), with reference to advance planning (WS5). SETTING: Participants were from England; recruitment into RCTs was limited to certain sites [East Midlands and North West (WS1); North West (WS2 and WS3)]. PARTICIPANTS: Aged >/= 18 years. In WS1-3, participants had their diagnosis of BD confirmed by the Structural Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. INTERVENTIONS: In WS1, group PEd/PS; in WS3 and WS4, individual psychological therapy for comorbid anxiety and alcohol use, respectively. MAIN OUTCOME MEASURES: In WS1, time to relapse of bipolar episode; in WS2 and WS3, feasibility and acceptability of interventions; in WS4, prevalence and determinants of suicide and self-harm; and in WS5, professional training and support of advance planning in MCA, and SU awareness and implementation. RESULTS: Group PEd and PS could be routinely delivered in the NHS. The estimated median time to first bipolar relapse was 67.1 [95% confidence interval (CI) 37.3 to 90.9] weeks in PEd, compared with 48.0 (95% CI 30.6 to 65.9) weeks in PS. The adjusted hazard ratio was 0.83 (95% CI 0.62 to 1.11; likelihood ratio test p = 0.217). The interaction between the number of previous bipolar episodes (1-7 and 8-19, relative to 20+) and treatment arm was significant (chi(2) = 6.80, degrees of freedom = 2; p = 0.034): PEd with one to seven episodes showed the greatest delay in time to episode. A primary economic analysis indicates that PEd is not cost-effective compared with PS. A sensitivity analysis suggests potential cost-effectiveness if decision-makers accept a cost of pound37,500 per quality-adjusted life-year. AIBD and motivational interviewing (MI) cognitive-behavioural therapy (CBT) trials were feasible and acceptable in achieving recruitment and retention targets (AIBD: n = 72, 72% retention to follow-up; MI-CBT: n = 44, 75% retention) and in-depth qualitative interviews. There were no significant differences in clinical outcomes for either trial overall. The factors associated with risk of suicide and self-harm (longer duration of illness, large number of periods of inpatient care, and problems establishing diagnosis) could inform improved clinical care and specific interventions. Qualitative interviews suggested that suicide risk had been underestimated, that care needs to be more collaborative and that people need fast access to good-quality care. Despite SUs supporting advance planning and psychiatrists being trained in MCA, the use of MCA planning provisions was low, with confusion over informal and legally binding plans. LIMITATIONS: Inferences for routine clinical practice from WS1 were limited by the absence of a 'treatment as usual' group. CONCLUSION: The programme has contributed significantly to understanding how to improve outcomes in BD. Group PEd is being implemented in the NHS influenced by SU support. FUTURE WORK: Future work is needed to evaluate optimal approaches to psychological treatment of comorbidity in BD. In addition, work in improved risk detection in relation to suicide and self-harm in clinical services and improved training in MCA are indicated. TRIAL REGISTRATION: Current Controlled Trials ISRCTN62761948, ISRCTN84288072 and ISRCTN14774583. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 6, No. 6. See the NIHR Journals Library website for further project information.
  • Risk assessment and suicide prevention in primary care

    Milton, John; Ferguson, Brian G. (1999)
    General practitioners (GPs) are assumed to occupy an important position in the prevention of suicide through the introduction of risk assessment techniques commonly used in psychiatric practice. Despite this theoretical role for primary care services, it remains unclear how frequently GPs implement risk assessment in patients who may be vulnerable to suicide. To address this, a retrospective survey of probable suicides was conducted within a primary care setting utilizing a questionnaire of GPs who had experienced a patient suicide and was augmented by hospital and coroners' records. 85% of questionnaires were returned and 61 deaths were adjudged as suicides during the year long census period. 75% of suicides were male and 54% were aged under 35.28% were in contact with psychiatric services prior to death, although 60% had some diagnosis of mental disorder. GPs had little knowledge of a patient's life circumstances in up to half of cases. Recording of risk assessment occurred in 38% of subjects, was positively associated with prior psychiatric contact (p = 0.001) but negatively associated with presence of physical illness (p = 0.004), older patient age (p = 0.04), and GPs length in practice (p = 0.05). One GP felt their suicide case was preventable. The low rate of risk assessment and limited knowledge of patient lifestyle point to the need for active engagement of GPs in future suicide prevention strategies and should influence the content of training programs in primary care.
  • An electronic clinical decision support system for the assessment and management of suicidality in primary care: Protocol for a mixed-methods study

    Horrocks, Matthew; Aubeeluck, Aimee; Wright, Nicola; Morriss, Richard K. (2018)
    Background: Suicide is a global public health concern, but it is preventable. Increased contact with primary care before the suicide or attempted suicide raises opportunities for intervention and prevention. However, suicide assessment and management is an area that many General Practitioners (GPs) find particularly challenging. Previous research has indicated significant variability in how GPs understand, operationalise and assess suicide risk which subsequently has an impact on clinical decision making. Clinical Decision Support systems (CDSS) have been widely implemented across different healthcare settings, including primary care to support practitioners in clinical decision making. CDSS may reduce inconsistencies in the identification, assessment and management of suicide risk by GPs by guiding them through the consultation and generating a risk assessment plan that can be shared with a service user or with specialised mental health services. Objective: To co-develop and test with end users (e.g. GPs, primary care attendees, mental health professionals) an e-CDSS to support GPs in the identification, assessment and management of suicidality in primary care. Methods: An ongoing embedded mixed methods study with four phases: 1) Qualitative interviews with GPs to explore their views on the content, format and use of the e-CDSS; consultation with two service user advisory groups (people aged ≤ 25 and people aged ≥25) to inform the content of the e-CDSS including phrasing of items and clarity; 2) Participatory co-production workshops with GPs, service users and clinical experts in suicidality to determine the content and format of the e-CDDS; gain consensus of the relevance of items; establish content validity (CVI) and identify pathways to implementation, using the Consolidated Framework for Implementation Research; 3) Building the e-CDSS so that it guides the GP through a consultation and 4) Usability testing of the e-CDSS with GPs and service users in one primary care practice involving a non-live and a live stage. Results: This is an ongoing study. The findings will enable us to evaluate the feasibility, acceptability and usability of a suicide specific electronic guided decision support system in primary care. Conclusions: This study will be the first to explore the feasibility, acceptability and usability of electronic guided decision support system for use in primary care consultations for the improved assessment and management of suicidality.
  • Self-harm among UK female prisoners: A cross-sectional study

    Vollm, Birgit A. (2009)
    Psychiatric morbidity and suicide rates in prisoners are high. The detection of mental illness and its associated risks in prison are low. The aim of this study was to ascertain the prevalence of psychiatric symptomatology, needs and self-harming behaviour among UK female prisoners and to identify differences between individuals with and without a history of self-harm. We conducted a cross-sectional study including 638 female prisoners from two prisons in the North-West of England. Outcome measures used were the Prison Screening Questionnaire (PriSnQuest), a questionnaire on self-harming behaviour and suicidal ideation and the Camberwell Assessment of Need ? Forensic Version (CANFOR). 241 women (37.8%) screened positive on the PriSnQuest; 281 women (45.9%) had a history of self-harm. An average of 8.5 needs was identified with more than half of those needs classified as unmet. Differences between women with and without history of self-harm were identified on offending history, PriSnQuest scores and the CANFOR total and unmet needs. Previous contact with a psychiatrist, total and symptoms of depression on the PriSnQuest were independently associated with a history of self-harm. This study confirmed that the prevalence of psychiatric symptomatology and self-harm in female UK prisoners is high. Individuals at risk of self-harming behaviour may be identified using screening questionnaires.

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