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Deliberate self harm patients with depressive disorders: treatment and outcome
Journal of Affective Disorders 70 (2002) 57–65 www.elsevier.com / locate / jad
Research report
Deliberate self harm patients with depressive disorders: treatment and outcome a b b b, Camilla Haw , Kelly Houston , Ellen Townsend , Keith Hawton *
b
a St. Andrew’ s Hospital, Northampton, UK Centre for Suicide Research, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7 JX, UK
Received 26 September 2000; received in revised form 5 January 2001; accepted 9 January 2001
Abstract Background: Depression is the most common psychiatric disorder in deliberate self-harm (DSH) patients and in those who commit suicide. The aim of this study was to examine the treatment received by DSH patients with depression and their progress following DSH. Methods: A representative sample of 106 patients with an ICD-10 depressive episode who presented to a general hospital following an episode of DSH were investigated in terms of their treatment before and after the episode and their outcome at follow-up. Results: Prior to the index episode of DSH, 39 patients (36.8%) were receiving treatment from the psychiatric services and a further 35 (33.0%) were receiving treatment for mental health problems from their general practitioner. Fifty-two patients (49.1%) were receiving antidepressants (in therapeutic dosages in 93.6%). After the episode of DSH 94 patients (88.7%) were offered treatment with the psychiatric services, either as a new referral or continuation of treatment they were receiving prior to DSH. Of the patients who were followed-up, 36.3% remained in contact with the psychiatric services, 52.3% showed poor compliance with recommended treatment and 60.2% no longer fulfilled the diagnostic criteria for depression. Almost one-third reported a further episode of DSH during the follow-up period. Limitations: The nature and quality of non-physical treatments provided by the psychiatric services was not investigated. Reports of the treatment provided by general practitioners, the timing of improvement in symptoms and compliance with treatment largely relied on patients’ self report. Conclusions: All patients presenting following DSH need to be carefully screened for depressive illness. Randomised controlled studies need to be conducted on DSH patients with depression to determine which treatments are effective. 2002 Elsevier Science B.V. All rights reserved. Keywords: Depression; Attempted suicide; Antidepressants; Treatment
1. Introduction Depressive illness is very common among people who deliberately self-harm (DSH). Studies from *Corresponding author. Fax: 1 44-(0)-1865-226265. E-mail address: [email protected] (K. Hawton).
different countries have reported significant rates of DSM major depression (Ennis et al., 1989, 31%; Beautrais et al., 1996, 61.9%; Ferreira de Castro et al., 1998, 32.8%) and ICD-10 depressive episodes (Haw et al., 2001, 70.7%). In Finland, Suominen et al. (1996) found that two-thirds of DSH patients had either DSM-III-R major depression or depression not
0165-0327 / 02 / $ – see front matter 2002 Elsevier Science B.V. All rights reserved. PII: S0165-0327( 01 )00317-2
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otherwise specified and that few were receiving adequate treatment at the time of presentation (Suominen et al., 1998). High rates of depression have also been reported from psychological autopsy studies of completed suicides in the UK (Barraclough et al., 1974, 70%; Foster et al., 1997, 36%) and in several other countries (reviewed by ¨ Lonnqvist, 2000, 29–88%). The mortality risk for suicide among patients with major depression has been calculated to be 20 times the expected rate (Harris and Barraclough, 1997), with a recent suicide attempt being an important risk factor (Nordstrom et al., 1995). We have investigated the treatment and outcome of 106 DSH patients who were diagnosed as having a depressive illness. Specifically, we examined the psychiatric treatment these patients were receiving before an index episode of DSH, the treatment they were offered afterwards and their subsequent treatment and outcome at follow-up 12–20 months later.
1–2 days (45); 3–7 days (30); 1 week–1 month (24) and greater than 1 month (4). Details of the recruitment methods and the representative nature of the original sample of 150 DSH patients have been described in Haw et al. (2001).
2.2. Follow-up sample Eighty-six of the 106 (81.1%) depressed patients were interviewed at follow-up. The follow-up interviews took place between 12 and 16 months after the index episode of DSH in 79 cases (91.9%) and between 17 and 20 months in seven cases (8.1%). There was no difference between those followed up and those not, with respect to age, sex, previous episodes of DSH, severity of depression, or whether they were receiving psychiatric treatment at the time of the index DSH episode.
2.3. Research instruments The following schedules were used:
2. Methods
2.1. Initial sample The subjects in this study were a sub-group of 106 patients with a diagnosis of depressive disorder, 70.7% of the original sample of 150, aged 15 years and over, who presented to the district general hospital in Oxford following an episode of DSH between 10th February and 1st December 1997. The definition of DSH was as for ‘parasuicide’ in the WHO / Euro Multicentre Study on Suicidal Behaviour (previously known as the WHO / EU Study on Parasuicide) (Platt et al., 1992). The definition of DSH included acts of self-poisoning and self-injury, but excluded self-cutting that was part of a repetitive pattern of self-mutilation. Patients were excluded from the study if they lived outside Oxford District, or were unable to understand or otherwise participate in the study (e.g., medically unfit, severe learning disabilities, severe disturbance of mental state, organic brain syndrome). Two patients, one with dysthymia and one with bipolar affective disorder (in remission), were excluded from the results. The timing of the initial interviews in relation to the index episode of DSH was within 24 h (n 5 3);
2.3.1. European Parasuicide Study Interview Schedules I and II The schedules used in the WHO / Euro Multicentre Study (Kerkhof et al., 1989) were administered. Version I, used at the initial interview, included inquiry about demographic details, circumstances of current and previous DSH episodes, life events, contact with primary care and mental health services, and mental and physical health. Version II, used at the follow-up interview, included inquiry about changes in demographic characteristics, repetition of DSH since the index episode, life events and contact with primary and mental health services. Details of treatment by psychiatric services before and after the index episode, including medication, were confirmed where necessary by reference to psychiatric case notes. 2.3.2. ICD-10 Diagnostic Schedule The nature and duration of current and past psychiatric symptoms were recorded at the initial interview and at the follow-up interview using a structured interview schedule based on ICD-10 research criteria (WHO, 1993) which was developed by our group (Hawton et al., 1998b). The initial assessment was based on the period leading up to the
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index episode of DSH and the follow-up assessment was based on the month prior to the interview. The information collected included self-reported symptoms and observation of the patient at interview. At follow-up, patients were asked to rate whether their mental health had improved or worsened since the index episode of DSH. If patients reported an improvement in mental well-being they were asked when they began to feel better, and, if applicable, when they felt well. Patients were also asked about compliance with the treatment that they had been offered, including psychotropic medication. The research team identified psychiatric diagnoses at consensus meetings based on the information obtained from the diagnostic interview schedule. In a small number of cases with complex histories, psychiatric case notes were examined to aid clarification of the diagnoses. In order to assess overall reliability of the ICD-10 diagnoses, two psychiatrists working on the project independently reviewed the information obtained from the diagnostic interview for 20 cases. One psychiatrist made 32 diagnoses. The second psychiatrist was in agreement with all of these diagnoses (F code whole numbers), but also made three further diagnoses. Thus, the overall agreement was 91.4%.
2.3.3. Personality assessment schedule Personality was assessed using the self-report version of the Personality Assessment Schedule (PAS) (Tyrer et al., 1988), updated by the original authors according to ICD-10 criteria (WHO, 1993). Ratings within each personality area were classified according to the scheme of Tyrer et al. (1988), with a rating of 7 1 indicating a personality disorder. The PAS was completed at the follow-up interview so that personality was assessed at a time when psychiatric disorder was likely to be less prominent (Zimmerman, 1994). 2.4. Adequacy of antidepressant dosages For tricyclic antidepressants a dosage of 150 mg a day was considered adequate. For SSRIs and other antidepressants the dosages given in the British National Formulary 38 (BNF, 1999) were considered adequate.
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2.5. Statistical analyses The analyses were conducted using the Statistical Package for the Social Sciences (SPSS Inc., 1999) and EPI info (Dean et al., 1994). The x 2 test was used, with Yates’ correction. 3. Results
3.1. Patient characteristics The demographic and psychiatric characteristics of the 106 patients diagnosed with a depressive episode are summarised in Table 1. Eighty-six patients were interviewed at follow-up (31 male, 55 female). The PAS was completed for 82 of these. Self-poisoning was the most common method of DSH (n 5 98; 92.5%). Of the 61 patients prescribed psychotropic medication, 44 (72.1%) used their medication in the overdose. Of the 52 patients prescribed antidepressants, 25 (48.1%) took overdoses involving antidepressants. There was a previous history of DSH in 73 cases (68.9%). Fifty (47.2%) of the depressive episodes were severe (two being psychotic), 45 (42.5%) moderate, 3 (2.8%) mild and 8 (7.5%) of unknown or unspecified severity. There was no gender difference with respect to the severity of the depressive episode. The length of the depressive episode was 2–4 weeks in 17 cases (16.2%), 2–6 months in 38 (36.2%), 7–12 months in 18 (17.1%) and greater than 1 year in 32 (30.5%). In one case it was not possible to ascertain the duration. Forty-one patients (38.7%) had a past history of one or more depressive episodes and 32 (30.2%) had previously undergone inpatient psychiatric treatment. None of the 106 patients had bipolar affective disorder.
3.2. Comorbidity Forty-seven (44.3%) patients were suffering from depression alone, 46 (43.4%) from depression together with one other psychiatric disorder and 13 (12.3%) from depression with two or more other psychiatric disorders. The most common psychiatric comorbidity with depression was alcohol abuse or dependence (30; 28.3%), followed by neurotic disorder (23; 21.7%), eating disorder (13; 12.3%) and
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Table 1 Characteristics of DSH patients with a depressive episode at the index presentation Demographics
Female (n 5 65) n%
Male (n 5 41) n%
Total (n 5 106) n%
Age 15–24 25–34 35–54 55 and over
26 (40.0) 17 (26.2) 18 (27.7) 4 (6.2)
13 (31.7) 11 (26.8) 14 (34.1) 3 (7.3)
39 28 32 7
(36.8) (26.4) (30.2) (6.6)
Marital status Single Married Widowed Divorced Separated
34 (52.3) 14 (21.5) 3 (4.6) 9 (13.8) 5 (7.7)
18 (43.9) 9 (22.0) 0 (0.0) 7 (17.1) 7 (17.1)
52 23 3 16 12
(49.1) (21.7) (2.8) (15.1) (11.3)
Previous DSH None 1 2–4 51 NK
19 (29.7) 15 (23.4) 17 (26.6) 13 (20.3) 1
12 (30.0) 11 (27.5) 8 (20.0) 9 (22.5) 1
31 26 25 22 2
(29.8) (25.0) (24.0) (21.2)
Severity of depressive episode ( ICD-10) Mild F32.0 Moderate F32.1 Severe / psychotic F32.2 /3 Unspecified / unknown F32.8 /9
0 (0.0) 25 (38.5) 35 (53.8) 5 (7.7)
3 (7.3) 20 (48.8) 15 (36.6) 3 (7.3)
3 45 50 8
(2.8) (42.5) (47.2) (7.5)
Duration of depressive episode 2 weeks–1 month 2–6 months 7 months–1 year . 1 year NK
9 (13.8) 27 (41.5) 10 (15.4) 19 (29.2) 0
8 (20.0) 11 (27.5) 8 (20.0) 13 (32.5) 1
17 38 18 32 1
(16.2) (36.2) (17.1) (30.5)
drug abuse or dependence (7; 6.6%). Comorbidity of depression and personality disorder was present in 40 patients (48.8%). Overall 73 patients (68.9%) had another psychiatric disorder or a personality disorder. There were no gender differences in comorbidity.
3.3. Psychiatric treatment at the time of the index episode of DSH At the time of the index episode of DSH, 39 patients (36.8%) were receiving treatment from the psychiatric services (Table 2). Nine (8.5%) were inpatients and 30 (28.3%) were receiving outpatient treatment (contact with a psychiatrist, clinical psy-
chologist or other member of a community mental health team or attendance at a day hospital). We were unable to investigate the nature and quality of nonphysical treatments. Of the 35 depressed patients with alcohol or drug problems, six (17.1%) were receiving specialist treatment for their substance abuse. Thirty patients (28.3%) were receiving treatment for their mental health problems from their general practitioner, a general practice counsellor or both and 35 (33.0%) were not receiving any mental health treatment from primary or secondary services. There were no gender differences with respect to being in treatment at the time of the index episode of DSH.
C. Haw et al. / Journal of Affective Disorders 70 (2002) 57 – 65
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Table 2 Treatment status and severity of depression at the time of the index episode of DSH, treatment offered after the index episode and treatment status and severity of depression at the time of follow-up At index episode (n 5 106) n%
After index episode (n 5 106) n%
At follow-up (n 5 86) n%
Treatment for psychiatric problems None General practitioner Out-patient In-patient Other NK
35 30 30 9 2 0
2 8 77 17 2 0
39 12 25 4 0 6
Psychotropic medication Yes No NK
65 (61.3) 41 (38.7) 0
70 (68.0) 33 (32.0) 3
37 (43.5) 48 (56.5) 1
Antidepressants Yes No NK
52 (49.1) 54 (50.9) 0
58 (56.3) 45 (43.7) 3
28 (32.9) 57 (67.1) 1
Therapeutic dose of antidepressants Yes No NK
n 5 52 44 (93.6) 3 (6.4) 5
n 5 58 49 (92.5) 4 (7.5) 5
n 5 28 24 (96.0) 1 (4.0) 3
Severity of depressive episode ( ICD-10) Mild F32.0 Moderate F32.1 Severe / psychotic F32.2 /3 Other / unspecified F32.8 /9 No depressive episode NK
3 45 50 8 0
(33.0) (28.3) (28.3) (8.5) (1.9)
(2.8) (42.5) (47.2) (7.5) (0.0)
Sixty-five patients (61.3%) were being prescribed psychotropic medication, with 52 (49.1%) receiving antidepressants. Somewhat more females than males were prescribed antidepressants but this difference did not reach statistical significance (56.9% vs. 36.6%) ( x 2 5 3.39, P , 0.07). SSRIs were the most frequently prescribed antidepressants (34 cases, 65.4%), followed by tricyclics (15, 28.8%) (five patients were prescribed both a tricyclic and an SSRI), and the newer antidepressants (lofepramine, trazodone and venlafaxine) in six cases (11.5%). The majority of the antidepressant prescriptions were for therapeutic dosages (93.6%). Three (2.8%) patients were also prescribed mood stabilisers (lithium or carbamazepine). No patients were receiving ECT.
(1.9) (7.5) (72.6) (16.0) (1.9)
10 15 7 1 50 3
(48.8) (15.0) (31.3) (5.0) (0.0)
(12.0) (18.1) (8.4) (1.2) (60.2)
3.4. Treatment offered after the index episode of DSH Ninety-five (89.6%) of the depressed patients were assessed following the index DSH episode by a clinician from the general hospital psychiatric service. At the time of the index episode, 39 (36.8%) patients were already in contact with the psychiatric services (Table 2). Of the remainder, eight were offered inpatient treatment and 47 were offered outpatient treatment. Thus overall, 94 (88.7%) patients were offered some form of treatment from the mental health services. Fifteen (42.9%) of the 35 patients with drug or alcohol problems were offered specialist treatment for their substance abuse.
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Twenty-nine patients (27.4%) were offered outpatient treatment by the general hospital psychiatric service and 33 (31.1%) were offered telephone open access to the service. Eight patients (7.5%) were returned to the care of their general practitioner, of whom six were being prescribed psychotropic medication and two were seeing a general practice counsellor. After the index episode of DSH, there was a small increase in the proportion of patients prescribed antidepressants (49.1% to 56.3%). Significantly more women than men were prescribed antidepressants (64.1% vs. 43.6%) ( x 2 5 4.13, P , 0.05). SSRIs remained the most frequently prescribed antidepressants (36 cases, 62.1%), followed by tricyclics (13 cases, 22.4%) (four patients were prescribed both an SSRI and a tricyclic) and the newer antidepressants (10 cases, 17.2%). The antidepressant prescription was for a therapeutic dose in 92.5% of cases. Three patients (2.8%) remained on mood stabilisers. Four patients were offered but declined psychotropic medication. Two patients (1.9%) accepted a course of ECT.
3.5. Treatment status at follow-up Of the 86 patients who were seen at follow-up, 29 (36.3%) were still in contact with the psychiatric services, of whom four were psychiatric inpatients. Twelve patients (15.0%) were receiving treatment for their mental health problems from their general practitioner alone, all of whom were receiving psychotropic medication. Thirty-nine patients (48.8%) were no longer receiving any specific treatment for their mental health, although ten of these (25.6%) still reached the criteria for a depressive episode. Thirty-seven patients (43.5%) were receiving psychotropic medication. Twenty-eight patients (32.9%) were being prescribed antidepressants, with the majority receiving therapeutic dosages (96.0%). Two patients were receiving mood stabilising drugs. No patients were undergoing ECT.
3.6. Non-compliance with recommended psychiatric aftercare Twelve (12.6%) of the 95 patients assessed by the general hospital psychiatric service refused some or
all of the treatment recommended. Of the 86 patients seen at follow-up, 22 (25.6%) had defaulted from treatment and 25 (29.1%) had been non-compliant with prescribed medication. In total, 45 (52.3%) of the 86 patients seen at follow-up showed some ‘non-compliance’ (refusal of recommended treatment, default from aftercare or non-compliance with psychotropic medication). Although information was not available on all 20 patients not seen at follow-up, there was evidence from psychiatric case notes that at least 10 had not complied with the recommended treatment plan. Overall at least 55 (51.9%) of patients were known to have been poorly compliant with recommended treatment. This figure is likely to be an underestimate as we could not access primary health care records nor all psychiatric case notes.
3.7. Outcome at follow-up The ICD-10 diagnostic schedule was completed for 83 patients at the follow-up interview. Fifty (60.2%) patients no longer fulfilled the diagnostic criteria for a depressive episode. Of those who still met the diagnostic criteria, 17 (51.5%) were rated as being less severely depressed than at the initial assessment, 13 (39.4%) were unchanged and three (9.1%) were more severely depressed. Slightly more men than women were rated as being depressed at the follow-up interview but this difference was not statistically significant (55.1% vs. 31.5%) ( x 2 5 3.49, P 5 0.06). Twenty-seven patients (31.4%) reported a further episode of DSH during the follow-up period and one had committed suicide. Somewhat more patients who still met the diagnostic criteria for a depressive episode at follow-up reported a further episode of DSH in the follow-up period than those patients who no longer met the diagnostic criteria, but the difference was of borderline statistical significant (42.4% vs. 20.0%) ( x 2 5 3.83, P 5 0.05). Sixty-six patients (79.5%) reported an improvement in mood. Patients stated their mood began to improve within 3 months of the index episode in 23 cases, within 4–6 months in 18 and after 7 months or more in 25 cases. Twenty patients (23.3%) reported feeling well at the follow-up assessment. Of these, three felt fully recovered between 1 and 3 months
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after the index episode, five between 4 and 6 months and 12 after 7 months or more. Those who reported feeling well or better were significantly less likely to report a further episode of DSH during the follow-up period than those who reported feeling the same or worse (21.7% vs. 69.2%) ( x 2 5 9.73, P , 0.002)
4. Discussion This study is of DSH patients with a depressive episode, which in the majority of cases was moderate or severe. In our representative sample of DSH patients the prevalence of depression was considerable (70.7%) and similar to that reported in a similar study by Suominen et al. (1996) in Finland (66.7%). Comorbidity of depression with another psychiatric illness, or with personality disorder, was very common in this study. The most common psychiatric comorbidity was depression and alcohol abuse or dependence, as was found by Suominen et al. (1996). The presence of comorbid alcohol-related disorders makes the treatment of depression more complicated and difficult. Despite our careful screening for mood disorders in this study, none of the patients with a depressive illness were found to have bipolar affective disorder, although there was one bipolar patient in the original sample of 150 DSH patients who appeared to be in remission. Bipolar disorder was uncommon in two other studies of DSH patients (Ennis et al., 1989, 1.4% and Suominen et al., 1996, 2.6%), although Beautrais et al. (1996) reported a frequency of 14.6%. Other studies do not appear to have distinguished bipolar patients from those with depression. There were no gender differences in the prevalence of depressive illness in this study, in treatment status at the time of the index episode of DSH, in the treatment offered after the index episode, or in the treatment status at follow-up. However, more women than men were prescribed antidepressants after the index episode. At the time of the index episode of DSH, twothirds of patients were receiving treatment for their mental health problems, either from the psychiatric services or from their general practitioner, and half were receiving antidepressants, in the majority of cases in adequate dosages. We know of only one
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other published study examining the treatment of depression before and after an episode of DSH (Suominen et al., 1998). This also found two-thirds of patients were receiving treatment for their mental health problems prior to an episode of DSH. However, in contrast to our findings, only 16% of patients were receiving adequate dosages of antidepressants and 1 month after the episode of DSH only 17% of patients were receiving adequate dosages. We used a similar threshold as Suominen et al. (1998) for defining adequate antidepressant dosage. However, SSRI antidepressants were more commonly prescribed to patients in our study and inadequate dose levels are much less likely than with tricyclics. Low levels of antidepressant prescribing at the time of admission to hospital (15%) were also reported in a study of depressed patients, both with and without a history of DSH, who required inpatient treatment for major depression (Oquendo et al., 1999). The apparent lack of efficacy of the antidepressant treatment in preventing DSH in this study suggests other treatments may be needed for this group, for example psychological interventions such as problem solving techniques (Hawton and Kirk, 1989; Heard, 2000), or perhaps more complex therapy for those with comorbidity (Linehan et al. 2000). However, at present it is not clear which interventions are beneficial in reducing repetition rates (Hawton et al., 1998a). Interventions in depressed DSH patients require evaluation in randomised controlled trials. Comorbidity of psychiatric and personality disorder and compliance with treatment are important variables which need to be studied. A high proportion of patients were offered some form of treatment by the secondary psychiatric services after the index episode of DSH. While caution is necessary in interpreting outcome findings from a naturalistic study, there was some evidence that the treatment offered had resulted in some benefits, with 60.2% of those seen at follow-up no longer fulfilling the diagnostic criteria for depression. However, in contrast, there was a substantial repetition rate of 31.4% in the follow-up period after the index episode of DSH. Non-compliance with recommended treatment was substantially more of a problem in this study in comparison to that reported by Suominen et al. (1998), in which only one of their 40 patients did not attend the recommended aftercare.
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5. Conclusions All patients who present following an episode of DSH should be assessed for the presence of depressive illness and other psychiatric disorders. Given the substantial repetition rate, those antidepressants that are less toxic in overdose are preferable for this patient group. Comorbidity with alcohol abuse or personality disorder and poor compliance with treatment may be important factors complicating therapy in many depressed patients in this population. Antidepressant treatment alone was clearly insufficient for many patients in this study. Depressed DSH patients may require further specific interventions but at present it is not clear which treatments are beneficial. Additional interventions for depressed DSH require evaluation in randomised controlled treatment trials.
Acknowledgements This study and the Oxford Monitoring System for Attempted Suicide was funded by Anglia and Oxford and South East NHSE Regional Research Committees. Keith Hawton is also supported by Oxfordshire Mental Healthcare Trust. Camilla Haw is supported by St Andrew’s Hospital, Northampton. We would like to thank the staff in the Department of Psychological Medicine (Dr Christopher Bass, Karen Carroll, Barbara Chishom, Sharon Codd, Dr Eleanor Feldman, Dave Roberts, Jill Roberts, Heather Weitzel and Linda Whitehead) for their considerable assistance with the study and also Louise Harriss for her help with the analysis of data from the Monitoring System. Oxford is the UK centre in the WHO / Euro Multicentre Study of Suicidal Behaviour.
References Barraclough, B., Bunch, J., Nelson, B., Sainsbury, P., 1974. A hundred cases of suicide: clinical aspects. Br. J. Psychiatry 125, 355–373. Beautrais, A., Joyce, P., Mulder, R., Fergusson, D.M., Deavoll, B.J., Nightingale, S.K., 1996. Prevalence and comorbidity of mental disorders in persons making serious suicide attempts: a case-control study. Am. J. Psychiatry 153, 1009–1014.
British Medical Association and Royal Pharmaceutical Society of Great Britain, 1999. British National Formulary Number 38. BMJ Books, Pharmaceutical Press, Wallingford, pp. 179–189. Dean, A., Dean, J., Coulombier, D., Brendel, K.A., Smith, D.C., Burton, A.H., Dicker, R.C., Sullivan, K., Fagan, R.F., Arner, T.G., 1994. Epi Info Version 6: A Word Processing Database and Statistics Program for Epidemiology on Microcomputers. Centers for Disease Control and Prevention, Atlanta, Georgia. Ennis, J., Barnes, R., Kennedy, S., Trachtenberg, D., 1989. Depression in self-harm patients. Br. J. Psychiatry 154, 41–47. Ferreira de Castro, E., Cunha, M., Pimenta, F., Costa, I., 1998. Parasuicide and mental disorders. Acta Psychiatr. Scand. 97, 25–31. Foster, T., Gillespie, K., McClelland, R., 1997. Mental disorders and suicide in Northern Ireland. Br. J. Psychiatry 170, 447– 452. Harris, C., Barraclough, B., 1997. Suicide as an outcome for mental disorders. Br. J. Psychiatry 170, 205–228. Haw, C., Hawton, K., Houston, K., Townsend, E., 2001. Psychiatric and personality disorders in deliberate self-harm patients. Br. J. Psychiatry 178, 48–54. Hawton, K., Kirk, J., 1989. Problem solving. In: Hawton, K., Salkovskis, P., Kirk, J., Clark, D. (Eds.), Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide. Oxford University Press, Oxford, pp. 406–426. Hawton, K., Arensman, E., Townsend, E., Bremner, S., Feldman, E., Goldney, R., Gunnell, D., Hazell, P., van Heeringen, K., ¨ House, A., Owens, D., Sakinofsky, I., Traskman-Bendz, L., 1998a. Deliberate self harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition. Br. Med. J. 317, 441–447. Hawton, K., Simkin, S., Malmberg, A., Fagg, J., Harriss, L., 1998b. Suicide and Stress in Farmers. The Stationery Office, London. Heard, H., 2000. Psychotherapeutic approaches to suicidal ideation and behaviour. In: Hawton, K., van Hearigen, K. (Eds.) The International Handbook of Suicide and Attempted Suicide. John Wiley & Sons, Chichester, pp. 503–518. Kerkhof, A., Bernasco, W., Bille-Brahe, U., Platt, S., Schmidtke, A., 1989. WHO / EU Multicentre Study on Parasuicide: European Parasuicide Study Interview Schedule (EPSIS). Department of Clinical, Health and Personality Psychology, Leiden University, Leiden. Linehan, M., Rizvi, S., Shaw Welch, S., Page, B., 2000. Psychiatric aspects of suicidal behaviour: personality disorders. In: Hawton, K., van Heeringen, K. (Eds.), The International Handbook of Suicide and Attempted Suicide. John Wiley & Sons, Chichester, pp. 147–178. ¨ Lonnqvist, J., 2000. Psychiatric aspects of suicidal behaviour: depression. In: Hawton, K., van Heeringen, K. (Eds.), The International Handbook of Suicide and Attempted Suicide. John Wiley & Sons, Chichester, pp. 107–120. ˚ ˚ ¨ P., Asberg, Nordstrom, M., Aberg-Wistedt, A., Nordin, C., 1995. Attempted suicide predicts suicide risk in mood disorders. Acta Psychiatr. Scand. 92, 345–350. Oquendo, M., Malone, K., Ellis, S., Sackeim, H., Mamm, J., 1999. Inadequacy of antidepressant treatment for patients with major
C. Haw et al. / Journal of Affective Disorders 70 (2002) 57 – 65 depression who are at risk for suicidal behavior. Am J Psychiatry 156, 190–194. Platt, S., Bille-Brahe, U., Kerkhof, A., Schmidtke, A., Bjerke, T., ¨ Crepet, P., DeLeo, D., Haring, C., Lonnqvist, J., Michel, K., Philippe, A., Pommereau, X., Querejeta, I., Salander-Renberg, E., Temesvary, B., Wasserman, D., Sampaio Faria, J., 1992. Parasuicide in Europe: the WHO / EURO multicentre study on parasuicide. I. Introduction and preliminary analysis for 1989. Acta Psychiatr. Scand. 85, 97–104. ¨ E., Ostamo, Suominen, K., Henriksson, M., Suokas, J., Isometsa, ¨ A., Lonnqvist, J., 1996. Mental disorders and comorbidity in attempted suicide. Acta Psychiatr. Scand. 94, 234–240. ¨ E., Henriksson, M., Ostamo, A., Suominen, K., Isometsa, ¨ Lonnqvist, J., 1998. Inadequate treatment for major depression
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both before and after attempted suicide. Am. J. Psychiatry 155, 1778–1780. SPSS Inc, 1999. SPSS Base 9.0 Users Guide. Prentice Hall, New Jersey. Tyrer, P., Alexander, J., Ferguson, B., 1988. Personality assessment schedule (PAS). In: Tyrer, P. (Ed.), Personality Disorder: Diagnosis, Management and Course. Butterworth / Wright, London, pp. 140–167. WHO, 1993. The ICD-10 Classification of Mental and Behavioural Disorders; Diagnostic Criteria for Research. World Health Organization, Geneva. Zimmerman, M., 1994. Diagnosing personality disorders: a review of issues and research methods. Arch. Gen. Psychiatry 51, 225–245.
Research report
Deliberate self harm patients with depressive disorders: treatment and outcome a b b b, Camilla Haw , Kelly Houston , Ellen Townsend , Keith Hawton *
b
a St. Andrew’ s Hospital, Northampton, UK Centre for Suicide Research, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7 JX, UK
Received 26 September 2000; received in revised form 5 January 2001; accepted 9 January 2001
Abstract Background: Depression is the most common psychiatric disorder in deliberate self-harm (DSH) patients and in those who commit suicide. The aim of this study was to examine the treatment received by DSH patients with depression and their progress following DSH. Methods: A representative sample of 106 patients with an ICD-10 depressive episode who presented to a general hospital following an episode of DSH were investigated in terms of their treatment before and after the episode and their outcome at follow-up. Results: Prior to the index episode of DSH, 39 patients (36.8%) were receiving treatment from the psychiatric services and a further 35 (33.0%) were receiving treatment for mental health problems from their general practitioner. Fifty-two patients (49.1%) were receiving antidepressants (in therapeutic dosages in 93.6%). After the episode of DSH 94 patients (88.7%) were offered treatment with the psychiatric services, either as a new referral or continuation of treatment they were receiving prior to DSH. Of the patients who were followed-up, 36.3% remained in contact with the psychiatric services, 52.3% showed poor compliance with recommended treatment and 60.2% no longer fulfilled the diagnostic criteria for depression. Almost one-third reported a further episode of DSH during the follow-up period. Limitations: The nature and quality of non-physical treatments provided by the psychiatric services was not investigated. Reports of the treatment provided by general practitioners, the timing of improvement in symptoms and compliance with treatment largely relied on patients’ self report. Conclusions: All patients presenting following DSH need to be carefully screened for depressive illness. Randomised controlled studies need to be conducted on DSH patients with depression to determine which treatments are effective. 2002 Elsevier Science B.V. All rights reserved. Keywords: Depression; Attempted suicide; Antidepressants; Treatment
1. Introduction Depressive illness is very common among people who deliberately self-harm (DSH). Studies from *Corresponding author. Fax: 1 44-(0)-1865-226265. E-mail address: [email protected] (K. Hawton).
different countries have reported significant rates of DSM major depression (Ennis et al., 1989, 31%; Beautrais et al., 1996, 61.9%; Ferreira de Castro et al., 1998, 32.8%) and ICD-10 depressive episodes (Haw et al., 2001, 70.7%). In Finland, Suominen et al. (1996) found that two-thirds of DSH patients had either DSM-III-R major depression or depression not
0165-0327 / 02 / $ – see front matter 2002 Elsevier Science B.V. All rights reserved. PII: S0165-0327( 01 )00317-2
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otherwise specified and that few were receiving adequate treatment at the time of presentation (Suominen et al., 1998). High rates of depression have also been reported from psychological autopsy studies of completed suicides in the UK (Barraclough et al., 1974, 70%; Foster et al., 1997, 36%) and in several other countries (reviewed by ¨ Lonnqvist, 2000, 29–88%). The mortality risk for suicide among patients with major depression has been calculated to be 20 times the expected rate (Harris and Barraclough, 1997), with a recent suicide attempt being an important risk factor (Nordstrom et al., 1995). We have investigated the treatment and outcome of 106 DSH patients who were diagnosed as having a depressive illness. Specifically, we examined the psychiatric treatment these patients were receiving before an index episode of DSH, the treatment they were offered afterwards and their subsequent treatment and outcome at follow-up 12–20 months later.
1–2 days (45); 3–7 days (30); 1 week–1 month (24) and greater than 1 month (4). Details of the recruitment methods and the representative nature of the original sample of 150 DSH patients have been described in Haw et al. (2001).
2.2. Follow-up sample Eighty-six of the 106 (81.1%) depressed patients were interviewed at follow-up. The follow-up interviews took place between 12 and 16 months after the index episode of DSH in 79 cases (91.9%) and between 17 and 20 months in seven cases (8.1%). There was no difference between those followed up and those not, with respect to age, sex, previous episodes of DSH, severity of depression, or whether they were receiving psychiatric treatment at the time of the index DSH episode.
2.3. Research instruments The following schedules were used:
2. Methods
2.1. Initial sample The subjects in this study were a sub-group of 106 patients with a diagnosis of depressive disorder, 70.7% of the original sample of 150, aged 15 years and over, who presented to the district general hospital in Oxford following an episode of DSH between 10th February and 1st December 1997. The definition of DSH was as for ‘parasuicide’ in the WHO / Euro Multicentre Study on Suicidal Behaviour (previously known as the WHO / EU Study on Parasuicide) (Platt et al., 1992). The definition of DSH included acts of self-poisoning and self-injury, but excluded self-cutting that was part of a repetitive pattern of self-mutilation. Patients were excluded from the study if they lived outside Oxford District, or were unable to understand or otherwise participate in the study (e.g., medically unfit, severe learning disabilities, severe disturbance of mental state, organic brain syndrome). Two patients, one with dysthymia and one with bipolar affective disorder (in remission), were excluded from the results. The timing of the initial interviews in relation to the index episode of DSH was within 24 h (n 5 3);
2.3.1. European Parasuicide Study Interview Schedules I and II The schedules used in the WHO / Euro Multicentre Study (Kerkhof et al., 1989) were administered. Version I, used at the initial interview, included inquiry about demographic details, circumstances of current and previous DSH episodes, life events, contact with primary care and mental health services, and mental and physical health. Version II, used at the follow-up interview, included inquiry about changes in demographic characteristics, repetition of DSH since the index episode, life events and contact with primary and mental health services. Details of treatment by psychiatric services before and after the index episode, including medication, were confirmed where necessary by reference to psychiatric case notes. 2.3.2. ICD-10 Diagnostic Schedule The nature and duration of current and past psychiatric symptoms were recorded at the initial interview and at the follow-up interview using a structured interview schedule based on ICD-10 research criteria (WHO, 1993) which was developed by our group (Hawton et al., 1998b). The initial assessment was based on the period leading up to the
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index episode of DSH and the follow-up assessment was based on the month prior to the interview. The information collected included self-reported symptoms and observation of the patient at interview. At follow-up, patients were asked to rate whether their mental health had improved or worsened since the index episode of DSH. If patients reported an improvement in mental well-being they were asked when they began to feel better, and, if applicable, when they felt well. Patients were also asked about compliance with the treatment that they had been offered, including psychotropic medication. The research team identified psychiatric diagnoses at consensus meetings based on the information obtained from the diagnostic interview schedule. In a small number of cases with complex histories, psychiatric case notes were examined to aid clarification of the diagnoses. In order to assess overall reliability of the ICD-10 diagnoses, two psychiatrists working on the project independently reviewed the information obtained from the diagnostic interview for 20 cases. One psychiatrist made 32 diagnoses. The second psychiatrist was in agreement with all of these diagnoses (F code whole numbers), but also made three further diagnoses. Thus, the overall agreement was 91.4%.
2.3.3. Personality assessment schedule Personality was assessed using the self-report version of the Personality Assessment Schedule (PAS) (Tyrer et al., 1988), updated by the original authors according to ICD-10 criteria (WHO, 1993). Ratings within each personality area were classified according to the scheme of Tyrer et al. (1988), with a rating of 7 1 indicating a personality disorder. The PAS was completed at the follow-up interview so that personality was assessed at a time when psychiatric disorder was likely to be less prominent (Zimmerman, 1994). 2.4. Adequacy of antidepressant dosages For tricyclic antidepressants a dosage of 150 mg a day was considered adequate. For SSRIs and other antidepressants the dosages given in the British National Formulary 38 (BNF, 1999) were considered adequate.
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2.5. Statistical analyses The analyses were conducted using the Statistical Package for the Social Sciences (SPSS Inc., 1999) and EPI info (Dean et al., 1994). The x 2 test was used, with Yates’ correction. 3. Results
3.1. Patient characteristics The demographic and psychiatric characteristics of the 106 patients diagnosed with a depressive episode are summarised in Table 1. Eighty-six patients were interviewed at follow-up (31 male, 55 female). The PAS was completed for 82 of these. Self-poisoning was the most common method of DSH (n 5 98; 92.5%). Of the 61 patients prescribed psychotropic medication, 44 (72.1%) used their medication in the overdose. Of the 52 patients prescribed antidepressants, 25 (48.1%) took overdoses involving antidepressants. There was a previous history of DSH in 73 cases (68.9%). Fifty (47.2%) of the depressive episodes were severe (two being psychotic), 45 (42.5%) moderate, 3 (2.8%) mild and 8 (7.5%) of unknown or unspecified severity. There was no gender difference with respect to the severity of the depressive episode. The length of the depressive episode was 2–4 weeks in 17 cases (16.2%), 2–6 months in 38 (36.2%), 7–12 months in 18 (17.1%) and greater than 1 year in 32 (30.5%). In one case it was not possible to ascertain the duration. Forty-one patients (38.7%) had a past history of one or more depressive episodes and 32 (30.2%) had previously undergone inpatient psychiatric treatment. None of the 106 patients had bipolar affective disorder.
3.2. Comorbidity Forty-seven (44.3%) patients were suffering from depression alone, 46 (43.4%) from depression together with one other psychiatric disorder and 13 (12.3%) from depression with two or more other psychiatric disorders. The most common psychiatric comorbidity with depression was alcohol abuse or dependence (30; 28.3%), followed by neurotic disorder (23; 21.7%), eating disorder (13; 12.3%) and
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Table 1 Characteristics of DSH patients with a depressive episode at the index presentation Demographics
Female (n 5 65) n%
Male (n 5 41) n%
Total (n 5 106) n%
Age 15–24 25–34 35–54 55 and over
26 (40.0) 17 (26.2) 18 (27.7) 4 (6.2)
13 (31.7) 11 (26.8) 14 (34.1) 3 (7.3)
39 28 32 7
(36.8) (26.4) (30.2) (6.6)
Marital status Single Married Widowed Divorced Separated
34 (52.3) 14 (21.5) 3 (4.6) 9 (13.8) 5 (7.7)
18 (43.9) 9 (22.0) 0 (0.0) 7 (17.1) 7 (17.1)
52 23 3 16 12
(49.1) (21.7) (2.8) (15.1) (11.3)
Previous DSH None 1 2–4 51 NK
19 (29.7) 15 (23.4) 17 (26.6) 13 (20.3) 1
12 (30.0) 11 (27.5) 8 (20.0) 9 (22.5) 1
31 26 25 22 2
(29.8) (25.0) (24.0) (21.2)
Severity of depressive episode ( ICD-10) Mild F32.0 Moderate F32.1 Severe / psychotic F32.2 /3 Unspecified / unknown F32.8 /9
0 (0.0) 25 (38.5) 35 (53.8) 5 (7.7)
3 (7.3) 20 (48.8) 15 (36.6) 3 (7.3)
3 45 50 8
(2.8) (42.5) (47.2) (7.5)
Duration of depressive episode 2 weeks–1 month 2–6 months 7 months–1 year . 1 year NK
9 (13.8) 27 (41.5) 10 (15.4) 19 (29.2) 0
8 (20.0) 11 (27.5) 8 (20.0) 13 (32.5) 1
17 38 18 32 1
(16.2) (36.2) (17.1) (30.5)
drug abuse or dependence (7; 6.6%). Comorbidity of depression and personality disorder was present in 40 patients (48.8%). Overall 73 patients (68.9%) had another psychiatric disorder or a personality disorder. There were no gender differences in comorbidity.
3.3. Psychiatric treatment at the time of the index episode of DSH At the time of the index episode of DSH, 39 patients (36.8%) were receiving treatment from the psychiatric services (Table 2). Nine (8.5%) were inpatients and 30 (28.3%) were receiving outpatient treatment (contact with a psychiatrist, clinical psy-
chologist or other member of a community mental health team or attendance at a day hospital). We were unable to investigate the nature and quality of nonphysical treatments. Of the 35 depressed patients with alcohol or drug problems, six (17.1%) were receiving specialist treatment for their substance abuse. Thirty patients (28.3%) were receiving treatment for their mental health problems from their general practitioner, a general practice counsellor or both and 35 (33.0%) were not receiving any mental health treatment from primary or secondary services. There were no gender differences with respect to being in treatment at the time of the index episode of DSH.
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Table 2 Treatment status and severity of depression at the time of the index episode of DSH, treatment offered after the index episode and treatment status and severity of depression at the time of follow-up At index episode (n 5 106) n%
After index episode (n 5 106) n%
At follow-up (n 5 86) n%
Treatment for psychiatric problems None General practitioner Out-patient In-patient Other NK
35 30 30 9 2 0
2 8 77 17 2 0
39 12 25 4 0 6
Psychotropic medication Yes No NK
65 (61.3) 41 (38.7) 0
70 (68.0) 33 (32.0) 3
37 (43.5) 48 (56.5) 1
Antidepressants Yes No NK
52 (49.1) 54 (50.9) 0
58 (56.3) 45 (43.7) 3
28 (32.9) 57 (67.1) 1
Therapeutic dose of antidepressants Yes No NK
n 5 52 44 (93.6) 3 (6.4) 5
n 5 58 49 (92.5) 4 (7.5) 5
n 5 28 24 (96.0) 1 (4.0) 3
Severity of depressive episode ( ICD-10) Mild F32.0 Moderate F32.1 Severe / psychotic F32.2 /3 Other / unspecified F32.8 /9 No depressive episode NK
3 45 50 8 0
(33.0) (28.3) (28.3) (8.5) (1.9)
(2.8) (42.5) (47.2) (7.5) (0.0)
Sixty-five patients (61.3%) were being prescribed psychotropic medication, with 52 (49.1%) receiving antidepressants. Somewhat more females than males were prescribed antidepressants but this difference did not reach statistical significance (56.9% vs. 36.6%) ( x 2 5 3.39, P , 0.07). SSRIs were the most frequently prescribed antidepressants (34 cases, 65.4%), followed by tricyclics (15, 28.8%) (five patients were prescribed both a tricyclic and an SSRI), and the newer antidepressants (lofepramine, trazodone and venlafaxine) in six cases (11.5%). The majority of the antidepressant prescriptions were for therapeutic dosages (93.6%). Three (2.8%) patients were also prescribed mood stabilisers (lithium or carbamazepine). No patients were receiving ECT.
(1.9) (7.5) (72.6) (16.0) (1.9)
10 15 7 1 50 3
(48.8) (15.0) (31.3) (5.0) (0.0)
(12.0) (18.1) (8.4) (1.2) (60.2)
3.4. Treatment offered after the index episode of DSH Ninety-five (89.6%) of the depressed patients were assessed following the index DSH episode by a clinician from the general hospital psychiatric service. At the time of the index episode, 39 (36.8%) patients were already in contact with the psychiatric services (Table 2). Of the remainder, eight were offered inpatient treatment and 47 were offered outpatient treatment. Thus overall, 94 (88.7%) patients were offered some form of treatment from the mental health services. Fifteen (42.9%) of the 35 patients with drug or alcohol problems were offered specialist treatment for their substance abuse.
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Twenty-nine patients (27.4%) were offered outpatient treatment by the general hospital psychiatric service and 33 (31.1%) were offered telephone open access to the service. Eight patients (7.5%) were returned to the care of their general practitioner, of whom six were being prescribed psychotropic medication and two were seeing a general practice counsellor. After the index episode of DSH, there was a small increase in the proportion of patients prescribed antidepressants (49.1% to 56.3%). Significantly more women than men were prescribed antidepressants (64.1% vs. 43.6%) ( x 2 5 4.13, P , 0.05). SSRIs remained the most frequently prescribed antidepressants (36 cases, 62.1%), followed by tricyclics (13 cases, 22.4%) (four patients were prescribed both an SSRI and a tricyclic) and the newer antidepressants (10 cases, 17.2%). The antidepressant prescription was for a therapeutic dose in 92.5% of cases. Three patients (2.8%) remained on mood stabilisers. Four patients were offered but declined psychotropic medication. Two patients (1.9%) accepted a course of ECT.
3.5. Treatment status at follow-up Of the 86 patients who were seen at follow-up, 29 (36.3%) were still in contact with the psychiatric services, of whom four were psychiatric inpatients. Twelve patients (15.0%) were receiving treatment for their mental health problems from their general practitioner alone, all of whom were receiving psychotropic medication. Thirty-nine patients (48.8%) were no longer receiving any specific treatment for their mental health, although ten of these (25.6%) still reached the criteria for a depressive episode. Thirty-seven patients (43.5%) were receiving psychotropic medication. Twenty-eight patients (32.9%) were being prescribed antidepressants, with the majority receiving therapeutic dosages (96.0%). Two patients were receiving mood stabilising drugs. No patients were undergoing ECT.
3.6. Non-compliance with recommended psychiatric aftercare Twelve (12.6%) of the 95 patients assessed by the general hospital psychiatric service refused some or
all of the treatment recommended. Of the 86 patients seen at follow-up, 22 (25.6%) had defaulted from treatment and 25 (29.1%) had been non-compliant with prescribed medication. In total, 45 (52.3%) of the 86 patients seen at follow-up showed some ‘non-compliance’ (refusal of recommended treatment, default from aftercare or non-compliance with psychotropic medication). Although information was not available on all 20 patients not seen at follow-up, there was evidence from psychiatric case notes that at least 10 had not complied with the recommended treatment plan. Overall at least 55 (51.9%) of patients were known to have been poorly compliant with recommended treatment. This figure is likely to be an underestimate as we could not access primary health care records nor all psychiatric case notes.
3.7. Outcome at follow-up The ICD-10 diagnostic schedule was completed for 83 patients at the follow-up interview. Fifty (60.2%) patients no longer fulfilled the diagnostic criteria for a depressive episode. Of those who still met the diagnostic criteria, 17 (51.5%) were rated as being less severely depressed than at the initial assessment, 13 (39.4%) were unchanged and three (9.1%) were more severely depressed. Slightly more men than women were rated as being depressed at the follow-up interview but this difference was not statistically significant (55.1% vs. 31.5%) ( x 2 5 3.49, P 5 0.06). Twenty-seven patients (31.4%) reported a further episode of DSH during the follow-up period and one had committed suicide. Somewhat more patients who still met the diagnostic criteria for a depressive episode at follow-up reported a further episode of DSH in the follow-up period than those patients who no longer met the diagnostic criteria, but the difference was of borderline statistical significant (42.4% vs. 20.0%) ( x 2 5 3.83, P 5 0.05). Sixty-six patients (79.5%) reported an improvement in mood. Patients stated their mood began to improve within 3 months of the index episode in 23 cases, within 4–6 months in 18 and after 7 months or more in 25 cases. Twenty patients (23.3%) reported feeling well at the follow-up assessment. Of these, three felt fully recovered between 1 and 3 months
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after the index episode, five between 4 and 6 months and 12 after 7 months or more. Those who reported feeling well or better were significantly less likely to report a further episode of DSH during the follow-up period than those who reported feeling the same or worse (21.7% vs. 69.2%) ( x 2 5 9.73, P , 0.002)
4. Discussion This study is of DSH patients with a depressive episode, which in the majority of cases was moderate or severe. In our representative sample of DSH patients the prevalence of depression was considerable (70.7%) and similar to that reported in a similar study by Suominen et al. (1996) in Finland (66.7%). Comorbidity of depression with another psychiatric illness, or with personality disorder, was very common in this study. The most common psychiatric comorbidity was depression and alcohol abuse or dependence, as was found by Suominen et al. (1996). The presence of comorbid alcohol-related disorders makes the treatment of depression more complicated and difficult. Despite our careful screening for mood disorders in this study, none of the patients with a depressive illness were found to have bipolar affective disorder, although there was one bipolar patient in the original sample of 150 DSH patients who appeared to be in remission. Bipolar disorder was uncommon in two other studies of DSH patients (Ennis et al., 1989, 1.4% and Suominen et al., 1996, 2.6%), although Beautrais et al. (1996) reported a frequency of 14.6%. Other studies do not appear to have distinguished bipolar patients from those with depression. There were no gender differences in the prevalence of depressive illness in this study, in treatment status at the time of the index episode of DSH, in the treatment offered after the index episode, or in the treatment status at follow-up. However, more women than men were prescribed antidepressants after the index episode. At the time of the index episode of DSH, twothirds of patients were receiving treatment for their mental health problems, either from the psychiatric services or from their general practitioner, and half were receiving antidepressants, in the majority of cases in adequate dosages. We know of only one
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other published study examining the treatment of depression before and after an episode of DSH (Suominen et al., 1998). This also found two-thirds of patients were receiving treatment for their mental health problems prior to an episode of DSH. However, in contrast to our findings, only 16% of patients were receiving adequate dosages of antidepressants and 1 month after the episode of DSH only 17% of patients were receiving adequate dosages. We used a similar threshold as Suominen et al. (1998) for defining adequate antidepressant dosage. However, SSRI antidepressants were more commonly prescribed to patients in our study and inadequate dose levels are much less likely than with tricyclics. Low levels of antidepressant prescribing at the time of admission to hospital (15%) were also reported in a study of depressed patients, both with and without a history of DSH, who required inpatient treatment for major depression (Oquendo et al., 1999). The apparent lack of efficacy of the antidepressant treatment in preventing DSH in this study suggests other treatments may be needed for this group, for example psychological interventions such as problem solving techniques (Hawton and Kirk, 1989; Heard, 2000), or perhaps more complex therapy for those with comorbidity (Linehan et al. 2000). However, at present it is not clear which interventions are beneficial in reducing repetition rates (Hawton et al., 1998a). Interventions in depressed DSH patients require evaluation in randomised controlled trials. Comorbidity of psychiatric and personality disorder and compliance with treatment are important variables which need to be studied. A high proportion of patients were offered some form of treatment by the secondary psychiatric services after the index episode of DSH. While caution is necessary in interpreting outcome findings from a naturalistic study, there was some evidence that the treatment offered had resulted in some benefits, with 60.2% of those seen at follow-up no longer fulfilling the diagnostic criteria for depression. However, in contrast, there was a substantial repetition rate of 31.4% in the follow-up period after the index episode of DSH. Non-compliance with recommended treatment was substantially more of a problem in this study in comparison to that reported by Suominen et al. (1998), in which only one of their 40 patients did not attend the recommended aftercare.
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5. Conclusions All patients who present following an episode of DSH should be assessed for the presence of depressive illness and other psychiatric disorders. Given the substantial repetition rate, those antidepressants that are less toxic in overdose are preferable for this patient group. Comorbidity with alcohol abuse or personality disorder and poor compliance with treatment may be important factors complicating therapy in many depressed patients in this population. Antidepressant treatment alone was clearly insufficient for many patients in this study. Depressed DSH patients may require further specific interventions but at present it is not clear which treatments are beneficial. Additional interventions for depressed DSH require evaluation in randomised controlled treatment trials.
Acknowledgements This study and the Oxford Monitoring System for Attempted Suicide was funded by Anglia and Oxford and South East NHSE Regional Research Committees. Keith Hawton is also supported by Oxfordshire Mental Healthcare Trust. Camilla Haw is supported by St Andrew’s Hospital, Northampton. We would like to thank the staff in the Department of Psychological Medicine (Dr Christopher Bass, Karen Carroll, Barbara Chishom, Sharon Codd, Dr Eleanor Feldman, Dave Roberts, Jill Roberts, Heather Weitzel and Linda Whitehead) for their considerable assistance with the study and also Louise Harriss for her help with the analysis of data from the Monitoring System. Oxford is the UK centre in the WHO / Euro Multicentre Study of Suicidal Behaviour.
References Barraclough, B., Bunch, J., Nelson, B., Sainsbury, P., 1974. A hundred cases of suicide: clinical aspects. Br. J. Psychiatry 125, 355–373. Beautrais, A., Joyce, P., Mulder, R., Fergusson, D.M., Deavoll, B.J., Nightingale, S.K., 1996. Prevalence and comorbidity of mental disorders in persons making serious suicide attempts: a case-control study. Am. J. Psychiatry 153, 1009–1014.
British Medical Association and Royal Pharmaceutical Society of Great Britain, 1999. British National Formulary Number 38. BMJ Books, Pharmaceutical Press, Wallingford, pp. 179–189. Dean, A., Dean, J., Coulombier, D., Brendel, K.A., Smith, D.C., Burton, A.H., Dicker, R.C., Sullivan, K., Fagan, R.F., Arner, T.G., 1994. Epi Info Version 6: A Word Processing Database and Statistics Program for Epidemiology on Microcomputers. Centers for Disease Control and Prevention, Atlanta, Georgia. Ennis, J., Barnes, R., Kennedy, S., Trachtenberg, D., 1989. Depression in self-harm patients. Br. J. Psychiatry 154, 41–47. Ferreira de Castro, E., Cunha, M., Pimenta, F., Costa, I., 1998. Parasuicide and mental disorders. Acta Psychiatr. Scand. 97, 25–31. Foster, T., Gillespie, K., McClelland, R., 1997. Mental disorders and suicide in Northern Ireland. Br. J. Psychiatry 170, 447– 452. Harris, C., Barraclough, B., 1997. Suicide as an outcome for mental disorders. Br. J. Psychiatry 170, 205–228. Haw, C., Hawton, K., Houston, K., Townsend, E., 2001. Psychiatric and personality disorders in deliberate self-harm patients. Br. J. Psychiatry 178, 48–54. Hawton, K., Kirk, J., 1989. Problem solving. In: Hawton, K., Salkovskis, P., Kirk, J., Clark, D. (Eds.), Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide. Oxford University Press, Oxford, pp. 406–426. Hawton, K., Arensman, E., Townsend, E., Bremner, S., Feldman, E., Goldney, R., Gunnell, D., Hazell, P., van Heeringen, K., ¨ House, A., Owens, D., Sakinofsky, I., Traskman-Bendz, L., 1998a. Deliberate self harm: systematic review of efficacy of psychosocial and pharmacological treatments in preventing repetition. Br. Med. J. 317, 441–447. Hawton, K., Simkin, S., Malmberg, A., Fagg, J., Harriss, L., 1998b. Suicide and Stress in Farmers. The Stationery Office, London. Heard, H., 2000. Psychotherapeutic approaches to suicidal ideation and behaviour. In: Hawton, K., van Hearigen, K. (Eds.) The International Handbook of Suicide and Attempted Suicide. John Wiley & Sons, Chichester, pp. 503–518. Kerkhof, A., Bernasco, W., Bille-Brahe, U., Platt, S., Schmidtke, A., 1989. WHO / EU Multicentre Study on Parasuicide: European Parasuicide Study Interview Schedule (EPSIS). Department of Clinical, Health and Personality Psychology, Leiden University, Leiden. Linehan, M., Rizvi, S., Shaw Welch, S., Page, B., 2000. Psychiatric aspects of suicidal behaviour: personality disorders. In: Hawton, K., van Heeringen, K. (Eds.), The International Handbook of Suicide and Attempted Suicide. John Wiley & Sons, Chichester, pp. 147–178. ¨ Lonnqvist, J., 2000. Psychiatric aspects of suicidal behaviour: depression. In: Hawton, K., van Heeringen, K. (Eds.), The International Handbook of Suicide and Attempted Suicide. John Wiley & Sons, Chichester, pp. 107–120. ˚ ˚ ¨ P., Asberg, Nordstrom, M., Aberg-Wistedt, A., Nordin, C., 1995. Attempted suicide predicts suicide risk in mood disorders. Acta Psychiatr. Scand. 92, 345–350. Oquendo, M., Malone, K., Ellis, S., Sackeim, H., Mamm, J., 1999. Inadequacy of antidepressant treatment for patients with major
C. Haw et al. / Journal of Affective Disorders 70 (2002) 57 – 65 depression who are at risk for suicidal behavior. Am J Psychiatry 156, 190–194. Platt, S., Bille-Brahe, U., Kerkhof, A., Schmidtke, A., Bjerke, T., ¨ Crepet, P., DeLeo, D., Haring, C., Lonnqvist, J., Michel, K., Philippe, A., Pommereau, X., Querejeta, I., Salander-Renberg, E., Temesvary, B., Wasserman, D., Sampaio Faria, J., 1992. Parasuicide in Europe: the WHO / EURO multicentre study on parasuicide. I. Introduction and preliminary analysis for 1989. Acta Psychiatr. Scand. 85, 97–104. ¨ E., Ostamo, Suominen, K., Henriksson, M., Suokas, J., Isometsa, ¨ A., Lonnqvist, J., 1996. Mental disorders and comorbidity in attempted suicide. Acta Psychiatr. Scand. 94, 234–240. ¨ E., Henriksson, M., Ostamo, A., Suominen, K., Isometsa, ¨ Lonnqvist, J., 1998. Inadequate treatment for major depression
65
both before and after attempted suicide. Am. J. Psychiatry 155, 1778–1780. SPSS Inc, 1999. SPSS Base 9.0 Users Guide. Prentice Hall, New Jersey. Tyrer, P., Alexander, J., Ferguson, B., 1988. Personality assessment schedule (PAS). In: Tyrer, P. (Ed.), Personality Disorder: Diagnosis, Management and Course. Butterworth / Wright, London, pp. 140–167. WHO, 1993. The ICD-10 Classification of Mental and Behavioural Disorders; Diagnostic Criteria for Research. World Health Organization, Geneva. Zimmerman, M., 1994. Diagnosing personality disorders: a review of issues and research methods. Arch. Gen. Psychiatry 51, 225–245.