Aftercare and self-harm repetition following high-risk self-harm: a mixed methods study
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Date
2021-03-19
Authors
Cully, Grace
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Publisher
University College Cork
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Abstract
Background: Existing research on individuals presenting to hospital with self-harm of high lethality or high suicidal intent indicates that they are a population with enduring mental health conditions (1-4) and a high risk of subsequent suicide (4-11). Despite this, there are gaps in the research relating to this subgroup of high-risk self-harm (HRSH) patients. Specifically, there is a paucity of prospective research examining rates and predictors of self-harm repetition following HRSH. Furthermore, knowledge of current approaches to aftercare following HRSH and the impact of these approaches on patient outcomes is limited.
Aim: The aims of this research were to describe demographic, clinical and psychosocial factors associated with HRSH, to investigate the allocation and impact of aftercare for HRSH patients, and to examine predictors of self-harm repetition.
Methods: The thesis used a mixed methods approach and is comprised of three quantitative studies (Studies 1-3) and one mixed-methods study (Study 4). Primary data collection was conducted as part of the Improving Prediction and Risk Assessment of Self-harm and Suicide (IMPRESS) study. This included: quantitative data collected from hospital records; qualitative and quantitative data collected via semi-structured interviews; and data linkage with the National Self-Harm Registry Ireland (NSHRI). The quantitative studies employed a prospective cohort design, and the mixed methods study used a sequential qualitatively led design.
Results: Study 1 included hospital presented self-harm and found that intentional drug overdoses (IDOs) involving psychotropic drugs and multiple drug IDOs were associated with increased repetition risk. Study 2 demonstrated that one in nine self-harm patients attending the EDs during the study period presented with HRSH and factors associated with this were age (45-64 years), a history of recent self-harm presentations and alcohol involvement in the self-harm act. Individuals presenting with HRSH had a significantly lower risk of not receiving a biopsychosocial assessment, compared with individuals presenting with lower severity self-harm. Risk of non-assessment was highest among patients with a history of multiple recent self-harm presentations. HRSH patients showed the same risk of prospective non-fatal self-harm repetition as lower severity self-harm patients. Study 3 found that four out of five HRSH patients had a history of treatment for mental health issues. A high level of psychotropic drug prescribing was observed and most IDOs among HRSH patients involved multiple drugs, including drug(s) prescribed for the person. In a multivariable analysis using propensity score methods, HRSH patients admitted to a psychiatric inpatient setting following their self-harm act had similar risk of repeated self-harm as those who were not admitted. Factors that conferred greater risk of repeated self-harm following HRSH were recent self-harm history, particularly multiple recent presentations, young age (18-24 years) and a history of previous psychiatric admission. Study 4 identified considerable variation in satisfaction with aftercare following HRSH. Timely and comprehensive care involving supportive and compassionate relationships with healthcare professionals was considered essential following a HRSH episode by most participants. Individuals with a history of self-harm and mental health service engagement were more likely to report dissatisfaction with care provided. Those who described unsupportive relationships more frequently reported repeated self-harm, alcohol misuse and hopelessness at follow-up.
Conclusions: HRSH patients are a vulnerable group with psychiatric conditions and psychosocial difficulties, many of whom feel unsupported in the current healthcare system. Throughout this research, the vulnerability of self-harm repeaters was highlighted; those with a history of self-harm were more likely to present with HRSH acts, receive substandard care, and engage in further repeated acts of self-harm. Conducting a biopsychosocial assessment needs to be prioritised among individuals with a history of self-harm and/or mental health treatment each time they present to the emergency department. The overall findings arising from this thesis underline the importance of ongoing skills training for healthcare professionals in optimising assessment and management of HRSH patients, and in safe prescribing practices.
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Keywords
Self-harm , Aftercare , Assessment , High lethality , Suicidal intent , Healthcare services , High-risk self-harm , Repetition
Citation
Cully, G. 2021. Aftercare and self-harm repetition following high-risk self-harm: a mixed methods study. PhD Thesis, University College Cork.