The role of primary care in reducing the risk of premature death in patients with history of self-harm: lessons from a cohort study
Problem
Self-harm is a major risk factor for suicide and other causes of premature death. Around 220,000 people in England attend a hospital immediately after harming themselves. Most of the research conducted on people who harm themselves has been undertaken in secondary healthcare settings, and little is known about the frequency of self-harm in primary care patient populations. This is the first study to describe the epidemiology of self-harm presentations to primary care using broadly representative national data from across the United Kingdom.
Approach
The data source for this study, the Clinical Practice Research Datalink (CPRD), is a continually updated nationally representative electronic repository of patient records inputted by GPs and other primary healthcare practitioners during routine consultations. Using CPRD, we calculated directly standardised rates of incidence and annual presentation during 2001-2013.Rates were compared by gender and age and across the nations of the UK, and by degree of socioeconomic deprivation measured ecologically at general practice level. We also profiled clinical management in the year after an index self-harm episode, and we examined cause-specific mortality and self-harm repetition. Following NICE guidelines (CG16, CG133), we defined self-harm as "any act of self-poisoning or self-injury, irrespective of the apparent purpose".
Findings
We found higher rates of self-harm when comparing Northern Ireland, Scotland, and Wales with England, and increasing rates of presentation over time for all four nations. We observed higher rates with increasing levels of deprivation - most vs. least deprived patients. The highest rate of self-harm was in females aged 15-24 years.Self-harm repetition occurred for one in 5 of the cohort within the year.Patients at practices in more deprived areas were less likely to be referred to mental health services. 10% patients had one or more psychotropic medication prescribed with no psychiatric diagnosis or mental health referral, and 9.6% were prescribed a tricyclic antidepressant within a year of self-harm. All-cause mortality was elevated following self-harm, with risk of death particularly raised in first year of follow-up, with increased risks of dying from suicide, accidents, alcohol or drug-related causes, respiratory disease and lung cancer.
Consequences
Our findings could potentially inform public health programmes as well as primary care towards the targeting of high-risk groups with the ultimate goal of lowering risk of self-harm repetition and premature death in this population. People who attend primary care following self-harm have a markedly increased mortality rate that is most pronounced within the first year - GPs can intervene and potentially make a difference. Alcohol misuse or dependence was the strongest predictor of all-cause mortality, emphasizing the need for GPs to assess the risk of self-harm in patients with alcohol problems.