Editor—Isacson and Rich offer practical guidelines for the management of deliberate self harm while highlighting the extremely weak evidence base in this area.1 They suggest that a brief hospital admission should be considered to establish a good therapeutic relationship. Yet even for an issue as fundamental as whether or not to admit these people to hospital, the benefits are uncertain and the only relevant randomised trial was too small to detect clinically important effects.2 Cost effectiveness is likely to be even more difficult to establish.
Deliberate self harm accounts for around 85 000 hospital admissions each year in England and Wales, and the proportion of patients who are admitted for it after assessment in accident and emergency departments varies widely.3,4 One study of four teaching hospitals showed a threefold variation (29% to 82%) in admissions after deliberate self harm from accident and emergency departments.4
We examined the relation between hospital admission rates for deliberate self harm and repeat deliberate self harm, using a rigorously validated deliberate self harm register based on attendances at four accident and emergency departments in one health authority from 26 May 1997 to 29 February 1999, with data being collected until 1 March 2000 to identify repeat episodes (table). We used repeat deliberate self harm as a marker of an unfavourable outcome.
The proportion of patients admitted for inpatient care after deliberate self harm varied from half to two thirds across the four hospitals (P<0.001; χ2 test with three degrees of freedom). There were much smaller differences in repeat deliberate self harm (P=0.16 with same test). The lowest repetition rates were seen in the hospital that admitted the lowest proportion of cases.
These data are insufficient for us to reach firm conclusions about the benefit or otherwise of inpatient admission for people who harm themselves. More information is needed not only about the best form of psychological treatments for these people but also about the appropriateness of hospital aftercare for initial management. Some people will require admission on medical grounds or because of psychiatric risk. For many, however, follow up could be arranged through their general practitioner or community mental health team.
Adequately powered randomised trials of the process of care as well as psychological aftercare are clearly required, as deliberate self harm is now one of the commonest reasons for emergency medical admission.
Table.
Admission rates for deliberate self harm, and repetition rates, across four NHS trusts, May 1997 to February 1999. Values are numbers (percentages) of patients
| Hospital No | Attendances at A&E because of deliberate self harm | Patients admitted | Patients with repeat episode <12 months after index episode |
|---|---|---|---|
| 1 | 515 | 255 (50) | 93 (18) |
| 2 | 365 | 203 (56) | 71 (20) |
| 3 | 305 | 160 (53) | 77 (25) |
| 4 | 600 | 393 (66) | 136 (23) |
| Total | 1785 | 1011 (57) | 377 (21) |
A&E=Accident and emergency.
References
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