Review
Psychiatric disorders in patients presenting to hospital following self-harm: A systematic review

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Abstract

Background

Psychiatric disorders occur in approximately 90% of individuals dying by suicide. The prevalence of psychiatric disorders in people who engage in non-fatal self-harm has received less attention.

Method

Systematic review using electronic databases (Embase, PsychINFO and Medline) for English language publications of studies in which psychiatric disorders have been assessed using research or clinical diagnostic schedules in self-harm patients of all ages presenting to general hospitals, followed by meta-analyses using random effects methods.

Results

A total of 50 studies from 24 countries were identified. Psychiatric (Axis I) disorders were identified in 83.9% (95% CI 74.7–91.3%) of adults and 81.2% (95% CI 60.9–95.5%) of adolescents and young persons. The most frequent disorders were depression, anxiety and alcohol misuse, and additionally attention deficit hyperactivity disorder (ADHD) and conduct disorder in younger patients. Personality (Axis II) disorders were found in 27.5% (95% CI 17.6–38.7%) of adult patients. Psychiatric disorders were somewhat more common in patients in Western (89.6%, 95% CI 83.0–94.7%) than non-Western countries (70.6%, 95% CI 50.1–87.6%).

Limitations

Heterogeneity between study results was generally high. There were differences between studies in identification of study participants and diagnostic procedures.

Conclusions

Most self-harm patients have psychiatric disorders, as found in people dying by suicide. Depression and anxiety disorders are particularly common, together with ADHD and conduct disorder in adolescents. Psychosocial assessment and aftercare of self-harm patients should include careful screening for such disorders and appropriate therapeutic interventions. Longitudinal studies of the progress of these disorders are required.

Declaration of interests

None.

Section snippets

Background

Suicide and self-harm can result from a wide range of contributory factors (Hawton and Van Heeringen, 2009, Skegg, 2005). These include genetic, biological, childhood, psychological, psychiatric and social influences. The importance of psychiatric disorders in completed suicide has long been recognised (Barraclough et al., 1974, Harris and Barraclough, 1998) and been confirmed in many psychological autopsy studies (Cavanagh et al., 2003). On average, at least 90% of individuals dying by suicide

Method

We sought to identify all relevant studies of psychiatric disorders in individuals who had presented to general hospitals following an episode of self-harm. The latter included intentional self-poisoning or self-injury, irrespective of suicidal intent, and also attempted suicide and parasuicide. We included studies of individuals of all ages but aimed to report separately those of adults or mixed samples, those of adolescents and young people (up to age 25 years), and those of older persons

Included studies

The flow diagram for identification of studies for the review is shown in Fig. 1. We identified a total of 50 studies reported in 53 papers which met our inclusion criteria (Table 1). The studies were conducted in 24 countries. Seven of the studies were from the UK, five from India, four from the USA, three each from China, Hungary, Italy and Greece, two each from Denmark, Iran, Spain, Sweden, and Switzerland and one each from New Zealand, Australia, Hong Kong, Canada, Turkey, Finland, France,

Discussion

We have conducted a systematic review and meta-analyses of 50 studies conducted in 24 countries in which psychiatric disorders have been assessed in self-harm patients presenting to general hospitals.

Conclusions

Psychiatric disorders are found in over 80% of self-harm patients presenting to general hospitals, with depression, anxiety disorders and alcohol misuse being particularly common. This is similar to what has been found in people dying by suicide. Mental illness appears to be as prevalent in children and adolescents, in whom ADHD and conduct disorders are also quite common. Psychosocial assessment of self-harm patients should include careful screening for psychiatric disorder. In future, more

Role of funding source

There was no specific funding for this project. KH is funded by Oxford Health NHS Foundation Trust, AT by Oxford Health NHS Foundation Trust and the Medical Research Council, KS by the Oxfordshire Health Services Research Committee and CH by St Andrews Healthcare. None of these funders had any role in the study design, the collection, analysis and interpretation of the data, writing of the report, and the decision to submit the paper for publication. The views and opinions expressed herein are

Conflict of interest

KH is a member of the National Suicide Prevention Strategy for England Advisory Group and an advisor to the National Institute for Health and Care Excellence regarding self-harm. The other authors declare no conflict of interest.

Acknowledgements

We thank the following for providing us with extra information about studies: Paul Blenkiron, Gregory Carter, Evan Forman, Heidi Hjelmeland, Iveta Krivonos, Massimo Mauri, Peter Osvath, John Tiller, Ian Whyte, Kiloe Ortigo, Vivian Gonzalez, and Enrique Baca-Garcia. We also thank Matthew Taylor for advice on the statistical analyses. KH is a National Institute of Health Senior Investigator.

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