Title: Self-harm in primary care patients: a nationally representative cohort study examining patterns of attendance, treatment and referral, and risk of self-harm repetition, suicide and other causes of premature death
Funder: Department of Health (England)

Abstract: Background : Around 220,000 people annually in England attend hospital immediately after harming themselves. However, very little is known about their subsequent healthcare trajectories and the evidence-base concerning self-harming primary care patients is thin. We need to know more about the self-harm rates among these individuals, their patterns of attendance, treatment and referral, and their subsequent risks of self-harm repetition, completed suicide and premature death from other causes. We need to quantify how frequently patients attend their general practice following self-harm, and the extent to which those who do attend receive effective treatment and / or referral. Aims : We will estimate the self-harm rate in these patients. For those who have self-harmed we will examine patterns of attendance to delineate three distinct groups: (i) regular attendees; (ii) irregular attendees; (iii) those who disengage completely. We will profile these groups by their clinical and socio-demographic characteristics. We will assess patterns of psychiatric diagnosis, treatment and referral, focusing particularly on the main categories of prescribed psychotropic drugs, and the specific medication types most likely to be fatally toxic in overdose. We will quantify risk and identify predictors of self-harm repetition. We will explore effect modification by age, gender and socioeconomic status. Finally, we will examine premature death by suicide and other causes. Research plan & methods of investigation : The Clinical Practice Research Datalink (CPRD) is the world's largest longitudinal primary care database. It routinely records all consultations, with comprehensive clinical coding for diagnoses, treatment and referral. Recent complete linkage to national mortality registration data has enabled the conduct of robust cause-specific mortality analyses. Professor Darren Ashcroft, one of the co-applicants, has electronic access to the CPRD at the University of Manchester. Our initial coding set identified a study cohort of N=47,427 patients with a first diagnosis of self-harm during 1st January 2001 to 31st December 2011. Applying an open cohort design, we will model time-to-event data using survival analysis to investigate factors associated with elevated risk of self-harm repetition as our primary outcome. Research team : dr Webb will lead the research team. He is an expert in conducting large epidemiological studies using routinely collected population-based data sources. Professor Ashcroft is a pharmacoepidemiologist with in-depth knowledge of using complex healthcare datasets, including the CPRD. dr Kontopantelis is a biostatistician with considerable experience in evaluating complex interventions and conducting longitudinal studies using large databases, in a primary care context. He conducted CPRD-based research since 2007. Professor Kapur (academic psychiatrist) and dr Cooper (academic mental health nurse) will provide clinical and research expertise in self-harm and attempted suicide, whilst Professor Chew-Graham will give her expert input as an academic GP with a particular interest in the management of mental illness in primary care and the associated risk of self-harm. Mrs Awenat will provide additional clinical and academic knowledge of mental illness and self-harm, and she will also lead on disseminating our findings effectively to patient groups and to the wider public. Potential impact / influence : We aim to generate novel findings for an important topic for which limited evidence currently exists. We plan to publish our findings in leading general medical, mental health, primary care or public health academic journals. This array of journals reflects the wide range of professionals who will benefit from learning about our findings. We will also strive to influence the development of new clinical guidelines disseminated by organisations such as NICE and the relevant medical Royal Colleges. We are well positioned to maximise the impact of our findings. One of the co-applicants, Professor Kapur, chaired the Guideline Development Group for NICE self-harm guidelines (for longer-term management).


Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;7.3 MANAGEMENT AND DECISION MAKING
Health categories: MENTAL HEALTH