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EDITORIALS: Udo Reulbach and Stefan Bleich Suicide risk after a suicide attempt BMJ 2008; 337: a2512 [Full text]

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Self-Harm may have Physical Basis

Andrew J Ashworth, Philip V.Dutton   (10 December 2008)

Managing Self-Harm: Does Research uniformly translate into Clinical Practice?

Nitin Gupta   (10 December 2008)

History of suicide attempt increased the risk of suicide

Paul YIP   (11 December 2008)

Self-Harm may have Physical Basis 10 December 2008
Andrew J Ashworth, General Practitioner Davidson's Mains Medical Centre, 5 Quality Street, EDINBURGH, EH4 5BP, Philip V.Dutton Send response to journal: Re: Self-Harm may have Physical Basis	While the two studies quoted are linked through Psychiatric Morbidity, and Readmission, unless we accept that all, or even most, self-harm events are suicidal attempts, the findings are otherwise unrelated. We have argued previously (1) that self-harm and attempted suicide may be separate clinical entities and offered a neurochemical hypothesis (2) that is consistent with clinical findings in the former. The fundamental basis of this hypothesis is that, in those who self-harm, endogenous opioid kappa activity is high leading to reduced dopamine activity in reward centres; behaviours leading to increased opioid mu activity act to normalize dopamine secretion and so, though behaviourally aberrant, are quite rational psychologically. If self-harm by methods that increase endogenous mu activity (such as cutting and scratching) are included with those that do not (such as poisoning) and then assumed to be the same as genuine suicide attempts, our understanding of both suicide and self-harm will be poorer. 1. Philip V Dutton and Andrew J Ashworth Suicidal and self-harming behaviours may be distinct BMJ 2007;334:327 (17 February), doi:10.1136/bmj.39121.857569.1F 2. Andrew J Ashworth Why let fact interfere with a good theory? http://bmj.com/cgi/eletters/335/7618/464-a#176174, 7 Sep 2007 Competing interests: None declared
Managing Self-Harm: Does Research uniformly translate into Clinical Practice? 10 December 2008
Nitin Gupta, Consultant Psychiatrist-South Staffordshire & Shropshire Healthcare NHS Foundation Trust Margaret Stanhope Centre, Belvedere Road, Burton upon Trent, DE13 0RB Send response to journal: Re: Managing Self-Harm: Does Research uniformly translate into Clinical Practice?	The editorial by Reulbach & Bleich (1) discusses two studies on suicidal attempts and self-harm in the same issue of the BMJ, and mentions about the practical implications for clinicians. They further mention about lack of comprehensive and/or specialist assessment for such individuals. I would like to raise an important issue regarding the practical value of such type of high-quality and painstaking research, like the one by Gunnell et al (2). I would argue that various acute and mental health NHS trusts may not be actually using such research evidences and/or guidelines to develop/deliver adequate and clinically appropriate self- harm services. A recent study auditing self-harm against NICE guidelines in their local general teaching hospital showed that such guidance was only partially being met (3). The Council Report by The Royal College of Psychiatrists (4) clearly outlines the background, need, and management guidance for people with self-harm. This report further outlines the need for ensuring proper implementation and commissioning of service delivery models within a robust clinical governance framework (4). This is also principally reflected by policy documents/guidance from other bodies i.e. NICE, National Confidential Enquiry into Suicide and Homicide by People with Mental Illness (5). One of the tasks of the National Enquiry is to monitor specialist services and assess them regarding implementation of the inquiry recommendations (5). Cooper et al (3) have also recommended an audit using a national sample of NHS Trusts to understand the extent and variability of the implementation of guidelines. It would be interesting to have this kind of data available and appropriately disseminated for implementation in order to ensure uniform, quality-driven services for people with self- harm across the UK. This, in my opinion, appears a logical step as self- harm is the most significant risk factor for suicide (4). If one has to further reduce the suicide rate, then appropriate management (both short-term and long-term) and reduction of self-harm needs to be given more emphasis by clinical services (i.e. acute and mental health Trusts) across the NHS, with more stringent monitoring by the concerned stakeholders/authorities. References [1] Reulbach U, Bleich S. Suicide risk after a suicide attempt. BMJ 2008; 337: a2512. [2] Gunnell D, Hawton K, Ho D, Evans J, O’Connor S, Potokar J, et al. Hospital admissions for self harm after discharge from psychiatric inpatient care: cohort study. BMJ 2008; 337: a2278. [3] Cooper J, Murphy EEK, Jordan R, Mackway-Jones KK. Communication between secondary and primary care following self-harm: are National Institute of Clinical Excellence (NICE) guidelines being met? Ann Gen Psychiatry 2008; 7: 21. [4] The Royal College of Psychiatrists. CR122. Assessment following self-harm in adults. The Royal College of Psychiatrists, London, 2004. [5] Swinson N, Ashim B, Windfuhr K, Kapur N, Appleby L, Shaw J. National Confidential Enquiry into Suicide and Homicide by People with Mental Illness: new directions. Psychiatric Bull 2007; 31: 161-3. Competing interests: None declared
History of suicide attempt increased the risk of suicide 11 December 2008
Paul YIP, Director and Professor Centre for Suicide Research and Prevention, The University of Hong Kong Send response to journal: Re: History of suicide attempt increased the risk of suicide	The increase of the suicide risk after a suicide attempt has also found support in non-western studies. In the first territory wide psycho- autopsy study in Hong Kong, the odd ratio of previous suicide attempt towards the risk of suicide is 24.78 (CI 4.04, 152) (Chen et al., 2006, CSRP, 2008) In another study on monitoring the deliberate self harm patients being admitted to Accident and Emergency Department in one of the regional hospitals, it is shown that the odds ratio of having previous self harm to the reattempt rate in the next six months is 4.24 (1.40, 20.4). Apparently, the population of having a history of self attempt or self harm is indeed a target group for more innovative intervention especially during the discharge period. Yim et al (2004) showed that 80% of suicide deaths among the discharge occurred in the first 4 weeks which seems to be the crucial period for active engaging to the patients in a non-hospital and community setting. Chen et al (2006)Suicide in Hong Kong: a case-control psychological autopsy study CSRP (2008) A final report on suicide prevention in Hong Kong. Hong Kong Jockey Club of the Centre for Suicide Research and Prevention, The University of Hong Kong, Hong Kong Yim et al. (2004). Suicide after discharge from psychiatric inpatient care: a case-control study in Hong Kong. Australian and New Zealand Journal of Psychiatry, 38, 65-72. Competing interests: None declared