Keith Waters - Academia.edu (original) (raw)

Papers by Keith Waters

Communications of the ACM, Jun 1, 1992

William M HSU Gudrun Klinker Richard SsellskC Keith Waters Michael Doyle Jim Cettys Krlsten M. Ha... more William M HSU Gudrun Klinker Richard SsellskC Keith Waters Michael Doyle Jim Cettys Krlsten M. Harris Thomas M. Levergood Ricky Palmed Larry Palmer Marc Picart DemetrC Terzopoulos David Tonnesen Michael vannier Greg Wallace tlon and interpretation of emplrlial data. Our long-term vision Is a collaborative sclentlflc vlsuallzatlon envlronment, where sclentlsts, engineers, and physicians work together on modeling and analvzlng emplrlcal data uslng an Integrated set of tools and techniques from computer graph& ...

Limnology and Oceanography, 1996

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, a... more JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.

International Journal of Psychiatry in Clinical Practice, 2006

Background. This study investigates deliberate self-harm (DSH) presentations to Southern Derbyshi... more Background. This study investigates deliberate self-harm (DSH) presentations to Southern Derbyshire hospitals from 1990 to 1997. Methods. Retrospective evaluation of deliberate self-harm rates and socio-demographic variables associated with DSH in 9961 consecutive attendances at Derby's two district general hospitals. Results. A significant rise in the rates of DSH in Derbyshire was noted (82%). The gender ratio has changed, with rising numbers of DSH episodes in males. The ratio of DSH episodes to the total Accident & Emergency (A&E) attendances changed from 1.54 to 2.42, with a 36% (95% CI 32-40%) rise in DSH presentations. Overdose remains the most common method of DSH (F = 85%, M = 78%). Two-thirds of the DSH presentations were first DSH attempts. Conclusions. Overall DSH rates are increasing especially in men. In contrast, official suicide rates have reduced during the same period. The increase in DSH rates has implications for already overworked A&E Departments, as well as other emergency and psychiatric services. Service provision and organisation should be reviewed in light of this increasing demand.

The British Journal of Psychiatry, 2000

Bmc Public Health 2011 11 460, Jun 10, 2011

Background: In order to reduce fatal self-poisoning legislation was introduced in the UK in 1998 ... more Background: In order to reduce fatal self-poisoning legislation was introduced in the UK in 1998 to restrict pack sizes of paracetamol sold in pharmacies (maximum 32 tablets) and non-pharmacy outlets (maximum 16 tablets), and in Ireland in 2001, but with smaller maximum pack sizes (24 and 12 tablets). Our aim was to determine whether this resulted in smaller overdoses of paracetamol in Ireland compared with the UK. Methods: We used data on general hospital presentations for non-fatal self-harm for 2002 -2007 from the Multicentre Study of Self-harm in England (six hospitals), and from the National Registry of Deliberate Self-harm in Ireland. We compared sizes of overdoses of paracetamol in the two settings. Results: There were clear peaks in numbers of non-fatal overdoses, associated with maximum pack sizes of paracetamol in pharmacy and non-pharmacy outlets in both England and Ireland. Significantly more pack equivalents (based on maximum non-pharmacy pack sizes) were used in overdoses in Ireland (mean 2.63, 95% CI 2.57-2.69) compared with England (2.07, 95% CI 2.03-2.10). The overall size of overdoses did not differ significantly between England (median 22, interquartile range (IQR) 15-32) and Ireland (median 24, IQR 12-36). Conclusions: The difference in paracetamol pack size legislation between England and Ireland does not appear to have resulted in a major difference in sizes of overdoses. This is because more pack equivalents are taken in overdoses in Ireland, possibly reflecting differing enforcement of sales advice. Differences in access to clinical services may also be relevant.

Crisis, Mar 3, 2015

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

The British Journal of Psychiatry the Journal of Mental Science, May 1, 2010

Self-poisoning is a common method of suicide, especially in women. 1 Antidepressants are frequent... more Self-poisoning is a common method of suicide, especially in women. 1 Antidepressants are frequently used for self-poisoning, being involved in around 20% of all poisoning suicides in the UK 1 and in 20-30% of non-fatal overdoses. 2 This reflects the facts that depression is the most frequent psychiatric disorder in people dying by suicide, 3 the method used for suicidal acts is often determined by availability, 4 and self-poisoning in individuals with depression often involves antidepressants prescribed for them. 5 Relative toxicity is an important factor likely to determine the outcome of an antidepressant overdose. Studies using different approaches have shown wide variation in the relative toxicity of antidepressants, 6,7 with the older tricyclic antidepressants (TCAs) generally being more toxic than the newer selective serotonin reuptake inhibitors (SSRIs). We have used two approaches to assessing the relative toxicity of classes of antidepressants and individual antidepressants. The first approach was to relate drug-specific poisoning mortality rates to prescription ratestermed the 'fatal toxicity index'. 8 The second, and generally less used approach, is to compare the rate of death with the rate of non-fatal self-poisoning, 7,9 which generates a 'case fatality' index. The fatal toxicity index approach is probably less accurate because it is more heavily influenced by prescribing policies, including use of some antidepressants for conditions other than depression, 10 and selective prescribing, for example, based on the clinician's assessment of suicide risk i.e. 'confounding by indication'. The specific aims of the study were to provide up-to-date information on the relative toxicity of individual antidepressants that may assist clinicians in making decisions about prescribing and inform interventions by regulatory authorities.

BMJ open, 2016

Self-harm is a major health problem in many countries, with potential adverse outcomes including ... more Self-harm is a major health problem in many countries, with potential adverse outcomes including suicide and other causes of premature death. It is important to monitor national trends in this behaviour. We examined trends in non-fatal self-harm and its management in England during the 13-year period, 2000-2012. This observational study was undertaken in the three centres of the Multicentre Study of Self-harm in England. Information on all episodes of self-harm by individuals aged 15 years and over presenting to five general hospitals in three cities (Oxford, Manchester and Derby) was collected through face-to-face assessment or scrutiny of emergency department electronic databases. We used negative binomial regression models to assess trends in rates of self-harm and logistic regression models for binary outcomes (eg, assessed vs non-assessed patients). During 2000-2012, there were 84 378 self-harm episodes (58.6% by females), involving 47 048 persons. Rates of self-harm declined i...

BMJ open, 2016

Rates of hospital presentation for self-harm in England were compared using different national an... more Rates of hospital presentation for self-harm in England were compared using different national and local data sources. The study was descriptive and compared bespoke data collection methods for recording self-harm presentations to hospital with routinely collected hospital data. Local area data on self-harm from the 3 centres of the Multicentre Study of Self-harm in England (Oxford, Manchester and Derby) were used along with national and local routinely collected data on self-harm admissions and emergency department attendances from Hospital Episode Statistics (HES). Rate ratios were calculated to compare rates of self-harm generated using different data sources nationally and locally (between 2010 and 2012) and rates of hospital presentations for self-harm were plotted over time (between 2003 and 2012), based on different data sources. The total number of self-harm episodes between 2010 and 2012 was 13 547 based on Multicentre Study data, 9600 based on HES emergency department data...

British Journal of Clinical Pharmacology 2009 68 618 29, Oct 1, 2009

• Ecological studies have shown conflicting evidence in relation to associations between trends i... more • Ecological studies have shown conflicting evidence in relation to associations between trends in selective serotonin reuptake inhibitor (SSRI) prescription rates and suicide rates in adolescents. • After regulatory warnings in the UK against SSRI use in children and adolescents, prescribing of antidepressants in general declined in this group; there were no related changes in rates of suicide or hospital admissions for self-harm.

Plos One 2013 8 1 7, Aug 1, 2013

Background: Evidence to guide clinical management of self-harm is sparse, trials have recruited s... more Background: Evidence to guide clinical management of self-harm is sparse, trials have recruited selected samples, and psychological treatments that are suggested in guidelines may not be available in routine practice.

Lancet 2012 380 1568 74, Mar 11, 2012

Background People who self-harm have an increased risk of premature death. The aim of this study ... more Background People who self-harm have an increased risk of premature death. The aim of this study was to investigate cause-specifi c premature death in individuals who self-harm, including associations with socioeconomic deprivation.

Journal of Affective Disorders, 2015

Economic recessions are associated with increases in suicide rates but there is little informatio... more Economic recessions are associated with increases in suicide rates but there is little information for non-fatal self-harm. To investigate the impact of the recent recession on rates of self-harm in England and problems faced by patients who self-harm. Analysis of data from the Multicentre Study of Self-harm in England for 2001-2010 and local employment statistics for Oxford, Manchester and Derby, including interrupted time series analyses to estimate the effect of the recession on rates of self-harm. Rates of self-harm increased in both genders in Derby and in males in Manchester in 2008-2010, but not in either gender in Oxford, results which largely followed changes in general population unemployment. More patients who self-harm were unemployed in 2008-10 compared to before the recession. The proportion in receipt of sickness or disability allowances decreased. More patients of both genders had employment and financial problems in 2008-2010 and more females also had housing problems, changes which were also largely found in employed patients. We have assumed that the recession began in 2008 and information on problems was only available for patients having a psychosocial assessment. Increased rates of self-harm were found in areas where there were greater rises in rates of unemployment. Work, financial and housing problems increased in people who self-harmed. Changes in welfare benefits may have contributed. None.

BMC Psychiatry, 2015

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

Social psychiatry and psychiatric epidemiology, Jan 25, 2015

Self-harm is a major clinical problem and is strongly linked to suicide. It is important to under... more Self-harm is a major clinical problem and is strongly linked to suicide. It is important to understand the problems faced by those who self-harm to design effective clinical services and suicide prevention strategies. We investigated the life problems experienced by patients presenting to general hospitals for self-harm. Data for 2000-2010 from the Multicentre Study of Self-harm in England were used to investigate life problems associated with self-harm and their relationship to patient and clinical characteristics, including age, gender, repeat self-harm and employment status. Of 24,598 patients (36,431 assessed episodes), 57 % were female and with a mean age of 33.1 years (SD 14.0 years), 92.6 % were identified as having at least one contributing life problem. The most frequently reported problems at first episode of self-harm within the study period were relationship difficulties (especially with partners). Mental health issues and problems with alcohol were also very common (esp...

The Lancet Psychiatry, 2015

Self-poisoning and self-injury are associated with a high risk of suicide or death from any cause... more Self-poisoning and self-injury are associated with a high risk of suicide or death from any cause but the effect of routine aspects of hospital management on mortality risk is unknown. We did a prospective cohort study using data for adults who had self-harmed presenting to five emergency departments in the UK between 2000 and 2010. We assessed the relation between four aspects of management (psychosocial assessment, medical admission, psychiatric admission, referral for mental health follow-up) and death by suicide or any cause within 12 months of presentation. Of 38 415 individuals presenting with self-harm, 261 (0·7%) died by suicide and 832 (2·2%) died from any cause within 12 months. Most aspects of management were associated with a higher mortality risk in unadjusted analyses. Psychiatric admission was associated with the highest risks for both suicide (hazard ratio 2·35, 95% CI 1·59-3·45) and all-cause mortality (2·35, 2·04-2·72). After adjustment for baseline variables, the hazard ratios were generally smaller, particularly for psychiatric admission. There were significant interactions by sex, age, and history of self-harm. This was an observational study and so we cannot infer causation. However, our finding that clinical services seem to reserve the most intensive levels of treatment for patients at highest risk is reassuring. Aspects of routine management might be associated with a lower mortality risk but these effects vary by clinical subgroup. UK Department of Health.

Journal of affective disorders, Jan 3, 2015

Self-poisoning and self-injury have widely differing incidences in hospitals and in the community... more Self-poisoning and self-injury have widely differing incidences in hospitals and in the community, which has led to confusion about the concept of self-harm. Categorising self-harm simply by a method may be clinically misleading because many hospital-attending patients switch from one method of harm to another on subsequent episodes. The study set out to determine the frequency, pattern, determinants and characteristics of method-switching in self-harm episodes presenting to the general hospital. The pattern of repeated self-harm was established from over 33,000 consecutive self-harm episodes in a multicentre English cohort, categorising self-harm methods as poisoning, cutting, other injury, and combined methods. Over an average of 30 months of follow-up, 23% of people repeated self-harm and one-third of them switched method, often rapidly, and especially where the person was male, younger, or had self-harmed previously. Self-poisoning was far less likely than other methods to lead ...

JRSM open, 2014

To assess alcohol-related premature death in people who self-harm compared to the general populat... more To assess alcohol-related premature death in people who self-harm compared to the general population, including variation by socioeconomic deprivation. A retrospective longitudinal cohort analysis from the Multicentre Study of self-harm in England, 1 January 2000 to 31 December 2010, with cause-specific mortality follow-up through to 31 December 2012. Six emergency departments in Oxford, Manchester and Derby. All individuals aged 15 years or more who presented with self-harm (n = 39,014) to general hospital emergency departments, together with follow-up mortality information from the Data Linkage Service of the Health and Social Care Information Centre. STANDARDISED MORTALITY RATIOS (OBSERVED/EXPECTED NUMBER OF DEATHS: SMRs) and mean number of years of life lost (YLL) were estimated for alcohol-related mortality. Patients' characteristics and clinical management following self-harm were also examined. After 7.5 years' (median) follow-up, 2695 individuals (6.9%) had died, sig...

Journal of Affective Disorders, 2015

Self-harm is a key risk factor for suicide and it is important to have contemporary information o... more Self-harm is a key risk factor for suicide and it is important to have contemporary information on the extent of risk. Mortality follow-up to 2012 of 40,346 self-harm patients identified in the three centres of the Multicentre Study of Self-harm in England between 2000 and 2010. Nineteen per cent of deaths during the study period (N=2704) were by suicide, which occurred in 1.6% of patients (2.6% of males and 0.9% of females), during which time the risk was 49 times greater than the general population risk. Overall, 0.5% of individuals died by suicide in the first year, including 0.82% of males and 0.27% of females. While the absolute risk of suicide was greater in males, the risk relative to that in the general population was higher in females. Risk of suicide increased with age. While self-poisoning had been the most frequent method of self-harm, hanging was the most common method of subsequent suicide, particularly in males. The number of suicides was probably a considerable underestimate as there were also a large number of deaths recorded as accidents, the majority of which were poisonings, these often involving psychotropic drugs. The study was focussed entirely on hospital-presenting self-harm. The findings underline the importance of prevention initiatives focused on the self-harm population, especially during the initial months following an episode of self-harm. Estimates using suicide and open verdicts may underestimate the true risk of suicide following self-harm; inclusion of accidental poisonings may be warranted in future risk estimates.

Emergency medicine journal : EMJ, Jan 6, 2015

Alcohol use and misuse are strongly associated with self-harm and increased risk of future self-h... more Alcohol use and misuse are strongly associated with self-harm and increased risk of future self-harm and suicide. The UK general population prevalence of alcohol use, misuse and alcohol-attributable harm has been rising. We have investigated the prevalence of and trends in alcohol use and misuse in self-harm patients and their associations with repeat self-harm and subsequent death. We used patient data from the Multicentre Study of Self-Harm in England for 2000-2009 and UK mortality data for patients presenting from 2000 to 2007 who were followed up to the end of 2009. Alcohol involvement in acts of self-harm (58.4%) and alcohol misuse (36.1%) were somewhat higher than found previously in self-harm patients. Alcohol involvement and misuse were most frequent in men, those aged 35-54 years and those from white ethnicities. The frequency of alcohol misuse increased between 2000 and 2009, especially in women. Repetition of self-harm was associated with alcohol involvement in self-harm ...

Communications of the ACM, Jun 1, 1992

William M HSU Gudrun Klinker Richard SsellskC Keith Waters Michael Doyle Jim Cettys Krlsten M. Ha... more William M HSU Gudrun Klinker Richard SsellskC Keith Waters Michael Doyle Jim Cettys Krlsten M. Harris Thomas M. Levergood Ricky Palmed Larry Palmer Marc Picart DemetrC Terzopoulos David Tonnesen Michael vannier Greg Wallace tlon and interpretation of emplrlial data. Our long-term vision Is a collaborative sclentlflc vlsuallzatlon envlronment, where sclentlsts, engineers, and physicians work together on modeling and analvzlng emplrlcal data uslng an Integrated set of tools and techniques from computer graph& ...

Limnology and Oceanography, 1996

JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, a... more JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range of content in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new forms of scholarship. For more information about JSTOR, please contact support@jstor.org.

International Journal of Psychiatry in Clinical Practice, 2006

Background. This study investigates deliberate self-harm (DSH) presentations to Southern Derbyshi... more Background. This study investigates deliberate self-harm (DSH) presentations to Southern Derbyshire hospitals from 1990 to 1997. Methods. Retrospective evaluation of deliberate self-harm rates and socio-demographic variables associated with DSH in 9961 consecutive attendances at Derby's two district general hospitals. Results. A significant rise in the rates of DSH in Derbyshire was noted (82%). The gender ratio has changed, with rising numbers of DSH episodes in males. The ratio of DSH episodes to the total Accident & Emergency (A&E) attendances changed from 1.54 to 2.42, with a 36% (95% CI 32-40%) rise in DSH presentations. Overdose remains the most common method of DSH (F = 85%, M = 78%). Two-thirds of the DSH presentations were first DSH attempts. Conclusions. Overall DSH rates are increasing especially in men. In contrast, official suicide rates have reduced during the same period. The increase in DSH rates has implications for already overworked A&E Departments, as well as other emergency and psychiatric services. Service provision and organisation should be reviewed in light of this increasing demand.

The British Journal of Psychiatry, 2000

Bmc Public Health 2011 11 460, Jun 10, 2011

Background: In order to reduce fatal self-poisoning legislation was introduced in the UK in 1998 ... more Background: In order to reduce fatal self-poisoning legislation was introduced in the UK in 1998 to restrict pack sizes of paracetamol sold in pharmacies (maximum 32 tablets) and non-pharmacy outlets (maximum 16 tablets), and in Ireland in 2001, but with smaller maximum pack sizes (24 and 12 tablets). Our aim was to determine whether this resulted in smaller overdoses of paracetamol in Ireland compared with the UK. Methods: We used data on general hospital presentations for non-fatal self-harm for 2002 -2007 from the Multicentre Study of Self-harm in England (six hospitals), and from the National Registry of Deliberate Self-harm in Ireland. We compared sizes of overdoses of paracetamol in the two settings. Results: There were clear peaks in numbers of non-fatal overdoses, associated with maximum pack sizes of paracetamol in pharmacy and non-pharmacy outlets in both England and Ireland. Significantly more pack equivalents (based on maximum non-pharmacy pack sizes) were used in overdoses in Ireland (mean 2.63, 95% CI 2.57-2.69) compared with England (2.07, 95% CI 2.03-2.10). The overall size of overdoses did not differ significantly between England (median 22, interquartile range (IQR) 15-32) and Ireland (median 24, IQR 12-36). Conclusions: The difference in paracetamol pack size legislation between England and Ireland does not appear to have resulted in a major difference in sizes of overdoses. This is because more pack equivalents are taken in overdoses in Ireland, possibly reflecting differing enforcement of sales advice. Differences in access to clinical services may also be relevant.

Crisis, Mar 3, 2015

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

The British Journal of Psychiatry the Journal of Mental Science, May 1, 2010

Self-poisoning is a common method of suicide, especially in women. 1 Antidepressants are frequent... more Self-poisoning is a common method of suicide, especially in women. 1 Antidepressants are frequently used for self-poisoning, being involved in around 20% of all poisoning suicides in the UK 1 and in 20-30% of non-fatal overdoses. 2 This reflects the facts that depression is the most frequent psychiatric disorder in people dying by suicide, 3 the method used for suicidal acts is often determined by availability, 4 and self-poisoning in individuals with depression often involves antidepressants prescribed for them. 5 Relative toxicity is an important factor likely to determine the outcome of an antidepressant overdose. Studies using different approaches have shown wide variation in the relative toxicity of antidepressants, 6,7 with the older tricyclic antidepressants (TCAs) generally being more toxic than the newer selective serotonin reuptake inhibitors (SSRIs). We have used two approaches to assessing the relative toxicity of classes of antidepressants and individual antidepressants. The first approach was to relate drug-specific poisoning mortality rates to prescription ratestermed the 'fatal toxicity index'. 8 The second, and generally less used approach, is to compare the rate of death with the rate of non-fatal self-poisoning, 7,9 which generates a 'case fatality' index. The fatal toxicity index approach is probably less accurate because it is more heavily influenced by prescribing policies, including use of some antidepressants for conditions other than depression, 10 and selective prescribing, for example, based on the clinician's assessment of suicide risk i.e. 'confounding by indication'. The specific aims of the study were to provide up-to-date information on the relative toxicity of individual antidepressants that may assist clinicians in making decisions about prescribing and inform interventions by regulatory authorities.

BMJ open, 2016

Self-harm is a major health problem in many countries, with potential adverse outcomes including ... more Self-harm is a major health problem in many countries, with potential adverse outcomes including suicide and other causes of premature death. It is important to monitor national trends in this behaviour. We examined trends in non-fatal self-harm and its management in England during the 13-year period, 2000-2012. This observational study was undertaken in the three centres of the Multicentre Study of Self-harm in England. Information on all episodes of self-harm by individuals aged 15 years and over presenting to five general hospitals in three cities (Oxford, Manchester and Derby) was collected through face-to-face assessment or scrutiny of emergency department electronic databases. We used negative binomial regression models to assess trends in rates of self-harm and logistic regression models for binary outcomes (eg, assessed vs non-assessed patients). During 2000-2012, there were 84 378 self-harm episodes (58.6% by females), involving 47 048 persons. Rates of self-harm declined i...

BMJ open, 2016

Rates of hospital presentation for self-harm in England were compared using different national an... more Rates of hospital presentation for self-harm in England were compared using different national and local data sources. The study was descriptive and compared bespoke data collection methods for recording self-harm presentations to hospital with routinely collected hospital data. Local area data on self-harm from the 3 centres of the Multicentre Study of Self-harm in England (Oxford, Manchester and Derby) were used along with national and local routinely collected data on self-harm admissions and emergency department attendances from Hospital Episode Statistics (HES). Rate ratios were calculated to compare rates of self-harm generated using different data sources nationally and locally (between 2010 and 2012) and rates of hospital presentations for self-harm were plotted over time (between 2003 and 2012), based on different data sources. The total number of self-harm episodes between 2010 and 2012 was 13 547 based on Multicentre Study data, 9600 based on HES emergency department data...

British Journal of Clinical Pharmacology 2009 68 618 29, Oct 1, 2009

• Ecological studies have shown conflicting evidence in relation to associations between trends i... more • Ecological studies have shown conflicting evidence in relation to associations between trends in selective serotonin reuptake inhibitor (SSRI) prescription rates and suicide rates in adolescents. • After regulatory warnings in the UK against SSRI use in children and adolescents, prescribing of antidepressants in general declined in this group; there were no related changes in rates of suicide or hospital admissions for self-harm.

Plos One 2013 8 1 7, Aug 1, 2013

Background: Evidence to guide clinical management of self-harm is sparse, trials have recruited s... more Background: Evidence to guide clinical management of self-harm is sparse, trials have recruited selected samples, and psychological treatments that are suggested in guidelines may not be available in routine practice.

Lancet 2012 380 1568 74, Mar 11, 2012

Background People who self-harm have an increased risk of premature death. The aim of this study ... more Background People who self-harm have an increased risk of premature death. The aim of this study was to investigate cause-specifi c premature death in individuals who self-harm, including associations with socioeconomic deprivation.

Journal of Affective Disorders, 2015

Economic recessions are associated with increases in suicide rates but there is little informatio... more Economic recessions are associated with increases in suicide rates but there is little information for non-fatal self-harm. To investigate the impact of the recent recession on rates of self-harm in England and problems faced by patients who self-harm. Analysis of data from the Multicentre Study of Self-harm in England for 2001-2010 and local employment statistics for Oxford, Manchester and Derby, including interrupted time series analyses to estimate the effect of the recession on rates of self-harm. Rates of self-harm increased in both genders in Derby and in males in Manchester in 2008-2010, but not in either gender in Oxford, results which largely followed changes in general population unemployment. More patients who self-harm were unemployed in 2008-10 compared to before the recession. The proportion in receipt of sickness or disability allowances decreased. More patients of both genders had employment and financial problems in 2008-2010 and more females also had housing problems, changes which were also largely found in employed patients. We have assumed that the recession began in 2008 and information on problems was only available for patients having a psychosocial assessment. Increased rates of self-harm were found in areas where there were greater rises in rates of unemployment. Work, financial and housing problems increased in people who self-harmed. Changes in welfare benefits may have contributed. None.

BMC Psychiatry, 2015

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

Social psychiatry and psychiatric epidemiology, Jan 25, 2015

Self-harm is a major clinical problem and is strongly linked to suicide. It is important to under... more Self-harm is a major clinical problem and is strongly linked to suicide. It is important to understand the problems faced by those who self-harm to design effective clinical services and suicide prevention strategies. We investigated the life problems experienced by patients presenting to general hospitals for self-harm. Data for 2000-2010 from the Multicentre Study of Self-harm in England were used to investigate life problems associated with self-harm and their relationship to patient and clinical characteristics, including age, gender, repeat self-harm and employment status. Of 24,598 patients (36,431 assessed episodes), 57 % were female and with a mean age of 33.1 years (SD 14.0 years), 92.6 % were identified as having at least one contributing life problem. The most frequently reported problems at first episode of self-harm within the study period were relationship difficulties (especially with partners). Mental health issues and problems with alcohol were also very common (esp...

The Lancet Psychiatry, 2015

Self-poisoning and self-injury are associated with a high risk of suicide or death from any cause... more Self-poisoning and self-injury are associated with a high risk of suicide or death from any cause but the effect of routine aspects of hospital management on mortality risk is unknown. We did a prospective cohort study using data for adults who had self-harmed presenting to five emergency departments in the UK between 2000 and 2010. We assessed the relation between four aspects of management (psychosocial assessment, medical admission, psychiatric admission, referral for mental health follow-up) and death by suicide or any cause within 12 months of presentation. Of 38 415 individuals presenting with self-harm, 261 (0·7%) died by suicide and 832 (2·2%) died from any cause within 12 months. Most aspects of management were associated with a higher mortality risk in unadjusted analyses. Psychiatric admission was associated with the highest risks for both suicide (hazard ratio 2·35, 95% CI 1·59-3·45) and all-cause mortality (2·35, 2·04-2·72). After adjustment for baseline variables, the hazard ratios were generally smaller, particularly for psychiatric admission. There were significant interactions by sex, age, and history of self-harm. This was an observational study and so we cannot infer causation. However, our finding that clinical services seem to reserve the most intensive levels of treatment for patients at highest risk is reassuring. Aspects of routine management might be associated with a lower mortality risk but these effects vary by clinical subgroup. UK Department of Health.

Journal of affective disorders, Jan 3, 2015

Self-poisoning and self-injury have widely differing incidences in hospitals and in the community... more Self-poisoning and self-injury have widely differing incidences in hospitals and in the community, which has led to confusion about the concept of self-harm. Categorising self-harm simply by a method may be clinically misleading because many hospital-attending patients switch from one method of harm to another on subsequent episodes. The study set out to determine the frequency, pattern, determinants and characteristics of method-switching in self-harm episodes presenting to the general hospital. The pattern of repeated self-harm was established from over 33,000 consecutive self-harm episodes in a multicentre English cohort, categorising self-harm methods as poisoning, cutting, other injury, and combined methods. Over an average of 30 months of follow-up, 23% of people repeated self-harm and one-third of them switched method, often rapidly, and especially where the person was male, younger, or had self-harmed previously. Self-poisoning was far less likely than other methods to lead ...

JRSM open, 2014

To assess alcohol-related premature death in people who self-harm compared to the general populat... more To assess alcohol-related premature death in people who self-harm compared to the general population, including variation by socioeconomic deprivation. A retrospective longitudinal cohort analysis from the Multicentre Study of self-harm in England, 1 January 2000 to 31 December 2010, with cause-specific mortality follow-up through to 31 December 2012. Six emergency departments in Oxford, Manchester and Derby. All individuals aged 15 years or more who presented with self-harm (n = 39,014) to general hospital emergency departments, together with follow-up mortality information from the Data Linkage Service of the Health and Social Care Information Centre. STANDARDISED MORTALITY RATIOS (OBSERVED/EXPECTED NUMBER OF DEATHS: SMRs) and mean number of years of life lost (YLL) were estimated for alcohol-related mortality. Patients' characteristics and clinical management following self-harm were also examined. After 7.5 years' (median) follow-up, 2695 individuals (6.9%) had died, sig...

Journal of Affective Disorders, 2015

Self-harm is a key risk factor for suicide and it is important to have contemporary information o... more Self-harm is a key risk factor for suicide and it is important to have contemporary information on the extent of risk. Mortality follow-up to 2012 of 40,346 self-harm patients identified in the three centres of the Multicentre Study of Self-harm in England between 2000 and 2010. Nineteen per cent of deaths during the study period (N=2704) were by suicide, which occurred in 1.6% of patients (2.6% of males and 0.9% of females), during which time the risk was 49 times greater than the general population risk. Overall, 0.5% of individuals died by suicide in the first year, including 0.82% of males and 0.27% of females. While the absolute risk of suicide was greater in males, the risk relative to that in the general population was higher in females. Risk of suicide increased with age. While self-poisoning had been the most frequent method of self-harm, hanging was the most common method of subsequent suicide, particularly in males. The number of suicides was probably a considerable underestimate as there were also a large number of deaths recorded as accidents, the majority of which were poisonings, these often involving psychotropic drugs. The study was focussed entirely on hospital-presenting self-harm. The findings underline the importance of prevention initiatives focused on the self-harm population, especially during the initial months following an episode of self-harm. Estimates using suicide and open verdicts may underestimate the true risk of suicide following self-harm; inclusion of accidental poisonings may be warranted in future risk estimates.

Emergency medicine journal : EMJ, Jan 6, 2015

Alcohol use and misuse are strongly associated with self-harm and increased risk of future self-h... more Alcohol use and misuse are strongly associated with self-harm and increased risk of future self-harm and suicide. The UK general population prevalence of alcohol use, misuse and alcohol-attributable harm has been rising. We have investigated the prevalence of and trends in alcohol use and misuse in self-harm patients and their associations with repeat self-harm and subsequent death. We used patient data from the Multicentre Study of Self-Harm in England for 2000-2009 and UK mortality data for patients presenting from 2000 to 2007 who were followed up to the end of 2009. Alcohol involvement in acts of self-harm (58.4%) and alcohol misuse (36.1%) were somewhat higher than found previously in self-harm patients. Alcohol involvement and misuse were most frequent in men, those aged 35-54 years and those from white ethnicities. The frequency of alcohol misuse increased between 2000 and 2009, especially in women. Repetition of self-harm was associated with alcohol involvement in self-harm ...