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Young people's contact with healthcare before and after suicidal behaviour
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
2016 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Unga människors kontakt med sjukvården före och efter suicidalt beteende (Swedish)
Abstract [en]

Background

Self-harm is a major and growing public health issue among young people worldwide. Self-harm is an important risk factor for suicide, which is one of the leading causes of death for young people. Although suicide rates are declining overall, this trend is not seen in young people. Young people with mental distress and/or suicidal thoughts are reluctant to seek help, and often drop out of treatment initiated after a self-harm episode. Many young people who self-harm have had contact with healthcare before their first self-harm episode, but often for reasons other than suicidal thoughts or psychiatric problems. In this context, physical illness is associated with increased risk for self-harm and suicide among young people. The present thesis investigated how young people perceived the help and support they received before and after an episode of self-harm. A further aim was to map the inpatient somatic healthcare contacts young patients had before an episode of self-harm, and determine any relationship to risk for self-harm and suicide.

Method

Four studies were conducted using qualitative and quantitative methods. Participants were people aged 16-24 years. The definition of self-harm was based on the intentional self-harm criteria in the International Classification of Diseases, tenth revision, which includes all forms of self-harm without ascribing suicidal intent. In the first two studies, 10 respective 9 participants with a first healthcare contact for self-harm were interviewed during 2009-2011. The interviews covered participants’ knowledge and experience of professional care before their healthcare contact for self-harm. Participants were interviewed a second time 6 months later about their experiences with professional care during the period since their initial interview. Qualitative content analysis was used for all interviews. For the next two studies, we selected 16,235 participants with a first hospitalisation for self-harm during 1999-2009 from the Swedish National Inpatient Register. These cases were compared with matched controls to determine the odds of having been admitted with a non-psychiatric diagnosis during the year preceding the self-harm admission. To assess risk for suicide, data were retrieved from the Swedish Cause of Death Register for all deceased participants until 2013, and group differences were determined using survival analysis.

Results

In the first interview, participants described how they wanted more information on where they could turn for professional help. They also wanted different help-seeking pathways and emphasised the importance of the quality of professional contact. After 6 months, participants stressed the importance of being able to rely on professionals and treatment. Their life circumstances significantly affected their treatment, and practical help was appreciated. The register studies showed that young people admitted for self-harm were more likely to have been hospitalised with symptomatic diagnoses such as abdominal pain and syncope/collapse, and somatic illnesses such as epilepsy and diabetes mellitus type 1. A higher proportion of cases (4.5%; women 2.6%, men 8.8%) died during the study period than controls (0.3%; women 0.2%, men 0.6%) (p<0.001). For both cases and controls, a higher proportion of those with a previous somatic admission died from suicide during the study period than those without a somatic admission (cases: 4.2% vs. 2.8%, p<0.05). For cases with a somatic admission, the hazard ratio was 1.43 (95% confidence interval 1.04-1.98) compared with those without somatic admissions (controlled for age, sex and psychiatric admission). Survival of cases with a previous somatic admission compared with those without was 98.4% versus 99.2% after the first year, 97.8% versus 98.9% after the second year, and 95.5% versus 96.9% after the tenth year.

Conclusion

These findings suggest that healthcare providers need to find new ways to reach young people at risk for suicidal behaviour. Access to professional help should be easy and direct. Treatment for young people after self-harm should be flexible, and be receptive to input from the patient. The importance of and need for basic practical help should not be overlooked. Somatic healthcare contact provides an opportunity for intervention, particularly as psychiatric problems can manifest as physical symptoms, and physical illness is a risk factor for self-harm and suicide.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2016. , 52 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1815
Keyword [en]
Young people, Self-harm, Interview study, Help-seeking, Treatment experiences, Case-control, Register study, Somatic disorders, Suicide risk
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
URN: urn:nbn:se:umu:diva-120699ISBN: 978-91-7601-499-8 (print)OAI: oai:DiVA.org:umu-120699DiVA: diva2:929485
Public defence
2016-06-10, Föreläsningssal A, Psykiatriska kliniken, Plan 0, Målpunkt F, Norrlands universitetssjukhus, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2016-05-20 Created: 2016-05-18 Last updated: 2016-05-26Bibliographically approved
List of papers
1. Professional Care as an Option Prior to Self-Harm A Qualitative Study Exploring Young People's Experiences
Open this publication in new window or tab >>Professional Care as an Option Prior to Self-Harm A Qualitative Study Exploring Young People's Experiences
2015 (English)In: Crisis, ISSN 0227-5910, E-ISSN 2151-2396, Vol. 36, no 3, 179-186 p.Article in journal (Refereed) Published
Abstract [en]

Background: Deliberate self-harm (DSH) is a growing problem among young people and is a major risk factor for suicide. Young adults experiencing mental distress and suicidal ideation are reluctant to seek help, requiring new strategies to reach this group. Aims: The present study explored young people's views of professional care before first contact for DSH, and factors that influenced the establishing of contact. Method: Interviews with 10 young individuals, shortly after they had harmed themselves, were analyzed using qualitative content analysis. Results: The participants emphasized the importance of receiving more knowledge on where to turn, having different help-seeking options, and receiving immediate help. Family and friends were vital for support and making health care contact. The quality of the professional contact was stressed. Several reasons for not communicating distress were mentioned. Two themes were identified: "A need for a more flexible, available and varied health care" and "A struggle to be independent and yet being in need of reliable support." Conclusion: These findings suggest that easy and direct access to professional help is a decisive factor for young people experiencing psychological problems and that health services must find new ways of communicating information on seeking mental health help.

Place, publisher, year, edition, pages
Hogrefe Publishing, 2015
Keyword
young people's experiences, deliberate self-harm, qualitative, help-seeking
National Category
Psychiatry
Identifiers
urn:nbn:se:umu:diva-109393 (URN)10.1027/0227-5910/a000310 (DOI)000360771700004 ()26088828 (PubMedID)
Available from: 2015-09-29 Created: 2015-09-25 Last updated: 2017-12-01Bibliographically approved
2. Professional care after deliberate self-harm: a qualitative study of young people's experiences
Open this publication in new window or tab >>Professional care after deliberate self-harm: a qualitative study of young people's experiences
2015 (English)In: Patient Preference and Adherence, ISSN 1177-889X, E-ISSN 1177-889X, Vol. 9, 199-207 p.Article in journal (Refereed) Published
Abstract [en]

Background: Deliberate self-harm (DSH) is increasingly common among young people. At the same time, treatment and support after DSH are often hampered by low compliance. Aim: To explore young people's perceptions of care and support during a 6-month period following their first contact for DSH. Methods: We conducted nine semistructured interviews with young people aged 16-24 years 6 months after their first contact for DSH. The interviews were analyzed using qualitative content analysis. Results: Three main themes were extracted from the interviews. "Am I really in good hands?" describes whether the participants felt they were being listened to and taken seriously and whether they could rely on the competence of the professionals and the appropriateness of treatment, including keeping agreements and communication with other relevant agencies. "Help should match life circumstances" comprises how basic practicalities such as travel possibilities affect treatment and concomitant assistance in everyday living. Financial matters and jobseeking were perceived as necessary for optimal treatment and well-being. "Making yourself better" includes participants' efforts to manage on their own, through realizing their own responsibility to be engaged and actively take part in treatment planning. Conclusion: Flexibility and responsiveness to young people's own views and specific needs in treatment arrangements are of crucial importance. The significance of basic practical help cannot be underestimated and should not be overlooked.

Keyword
young adults, deliberate self-harm, qualitative, treatment experiences
National Category
Psychiatry
Identifiers
urn:nbn:se:umu:diva-100141 (URN)10.2147/PPA.S76244 (DOI)000348433600001 ()25670889 (PubMedID)
Available from: 2015-02-26 Created: 2015-02-24 Last updated: 2017-12-04Bibliographically approved
3. Non-psychiatric inpatient care preceding admission for self-harm in young people
Open this publication in new window or tab >>Non-psychiatric inpatient care preceding admission for self-harm in young people
2016 (English)In: Journal of Psychosomatic Research, ISSN 0022-3999, E-ISSN 1879-1360, Vol. 88, 8-13 p.Article in journal (Refereed) Published
Abstract [en]

Objective

Many young people contact health services before they harm themselves intentionally. However, they often seek care for non-suicidal or non-psychiatric causes despite having suicidal thoughts. We investigated the non-psychiatric hospital diagnoses received by young people during the year before their first admission to hospital for self-harm.

Methods

From a national register, we selected people who were hospitalised for an episode of self-harm during the period 1999-2009, at which time they were aged 16 to 24. We compared them with matched controls regarding the probability for being admitted with different diagnoses during the year preceding the self-harm admission.

Results

The study included 48,705 young people (16,235 cases and 32,470 controls). Those admitted for self-harm were more likely than controls to have been hospitalised for non-psychiatric reasons, which included symptomatic diagnoses such as abdominal pain, syncope/collapse, unspecified convulsions, and chest pain. Certain chronic somatic illnesses were also overrepresented, such as epilepsy, diabetes mellitus type 1, and asthma.

Conclusions

Symptomatic diagnoses were more common in those who had been admitted for self-harm. It is possible that psychiatric problems could have been the cause of the symptoms in some of these admissions where no underlying illness could be found, and if this was not uncovered it might lead to a delay in suicide risk assessment. For several chronic illnesses, when admitted to hospital, a psychiatric evaluation might be indicated.

Keyword
Case-control, Register study, Self-harm, Somatic disorders, Suicide attempt, Young people
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:umu:diva-120695 (URN)10.1016/j.jpsychores.2016.06.011 (DOI)000381841600002 ()27521645 (PubMedID)
Note

Originally included in thesis in manuscript form.

Available from: 2016-05-18 Created: 2016-05-18 Last updated: 2017-11-30Bibliographically approved
4. Are non-psychiatric hospitalisations before self-harm associated with an increased risk for suicide among young people?
Open this publication in new window or tab >>Are non-psychiatric hospitalisations before self-harm associated with an increased risk for suicide among young people?
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Aims

We aimed to test two hypotheses: 1. There is a higher proportion of suicides among those who have been admitted for self-harm compared with controls from the general population. 2. There is higher risk for suicide among cases with somatic inpatient admissions before self-harm than among cases with no such admissions.

Method

For this nested case-control study we selected 16,235 cases with a first admission for self-harm during the period 1999–2009, at which time they were 16-24 years old. Next, 32,465 controls – matched for sex, age and home municipality – were randomly selected from the Total Population Register. From the Swedish National Inpatient Register, we registered all admissions and diagnoses from the year preceding cases first admission for self-harm. Subjects were followed until death or end of study (end of 2013) and diagnoses from the Cause of Death Register for all deceased was noted. Group differences were analysed using survival analysis with death by suicide as primary outcome.

Results

A higher proportion of cases (4.5%; women 2.6%, men 8.8%) died during the study period than controls (0.3%; women 0.2%, men 0.6%) (p<0.001). During the year before cases’ first admission for self-harm 6.0% of the cases and 2.3% of the controls had somatic admissions. For both cases and controls, a higher proportion of those with a previous somatic admission died from suicide during the study period than those without a somatic admission (cases: 4.2% vs. 2.8%, p<0.05). For cases with a somatic admission, the hazard ratio was 1.43 (95% confidence interval 1.04-1.98) compared with those without somatic admissions (controlled for age, sex and psychiatric admission). Survival of cases with a previous somatic admission compared with those without was 98.4% versus 99.2% after the first year, 97.8% versus 98.9% after the second year, and 95.5% versus 96.9% after the tenth year.

Conclusions

This study suggests that admission for physical illness before self-harm is associated with a higher risk for suicide among young people. At the same time their contact with healthcare due to their physical problems should provide an excellent opportunity to screen for psychiatric problems and risk for suicide.

Keyword
Young people, Self-harm, Case-control, Register study, Somatic disorders, Suicide risk
National Category
Psychiatry
Research subject
Psychiatry
Identifiers
urn:nbn:se:umu:diva-120696 (URN)
Available from: 2016-05-18 Created: 2016-05-18 Last updated: 2016-05-19

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