Dual-harm, complex needs, and the challenges of multisectoral service coordination
Authors: Stuart A Kinner, Rohan Borschmann
Journal: The Lancet Public Health (2019)

The risk of premature death from suicide and other causes is elevated in people with a history of self-harm1Hawton K Harriss L Zahl D Deaths from all causes in a long-term follow-up study of 11,583 deliberate self-harm patients.Psychol Med. 2006; 36: 397-405Crossref PubMed Scopus (93) Google Scholar and people with a history of violence against others.2Fazel S Ramesh T Hawton K Suicide in prisons: an international study of prevalence and contributory factors.Lancet Psychiatry. 2017; 4: 946-952Summary Full Text Full Text PDF PubMed Scopus (120) Google Scholar Despite overlap in these two populations,3Hawton K Linsell L Adeniji T Sariaslan A Fazel S Self-harm in prisons in England and Wales: an epidemiological study of prevalence, risk factors, clustering, and subsequent suicide.Lancet. 2014; 383: 1147-1154Summary Full Text Full Text PDF PubMed Scopus (202) Google Scholar the study by Sarah Steeg and colleagues4Steeg S Webb RT Mok PLH et al.Risk of dying unnaturally among people aged 15–35 years who have harmed themselves and inflicted violence on others: a national nested case-control study.Lancet Public Health. 2019; 4: e220-e228Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar in The Lancet Public Health is the first to examine the risk of unnatural death in people who have engaged in both behaviours—ie, those with a history of so-called dual-harm. By using linked administrative data (an important method for examining health outcomes in marginalised, inclusion health populations),5Aldridge RW Story A Hwang SW et al.Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis.Lancet. 2018; 391: 241-250Summary Full Text Full Text PDF PubMed Scopus (347) Google Scholar the authors found that although the risk of unnatural death is elevated among people with a history of violence (incidence rate ratio [IRR] 5·19, 95% CI 4·45–6·06) or self-harm (12·65, 10·84–14·77), the risk is considerably higher among people with both behaviours (29·37, 23·08–37·38). Although this outcome might be expected, the magnitude of the elevation in risk of unnatural death in the dual-harm group is marked, and highlights a need for targeted, multisectoral responses for this complex group. More than a quarter (26·9%) of the 2246 observed deaths in Steeg and colleagues' study, and more than half (52·3%; 150/287) of deaths in the self-harm only group, were due to suicide. Preventing both suicide and subsequent self-harm episodes among people who present to the hospital for self-harm is contingent on appropriate psychiatric assessment and referral in the hospital setting, and ongoing mental health and psychosocial support after discharge. Previous research has shown that the incidence of self-harm following an emergency department presentation for self-harm is significantly higher among those who do not receive a psychiatric assessment.7Hickey L Hawton K Fagg J Weitzel H Deliberate self-harm patients who leave the accident and emergency department without a psychiatric assessment: a neglected population at risk of suicide.J Psychosom Res. 2001; 50: 87-93Crossref PubMed Scopus (166) Google Scholar A data linkage study from Australia found that, among people released from prison who presented to the emergency department after self-harm, only 29% received a mental health assessment during their stay, and 39% had no record of contact with mental health services within 30 days of their emergency department presentation.8Borschmann R Thomas E Moran P et al.Self harm following release from prison: a prospective data linkage study.Aust N Z J Pyschiatry. 2017; 51: 250-259Crossref PubMed Scopus (37) Google Scholar The strong association between hospital-treated self-harm and subsequent death by suicide in Steeg and colleagues' study is consistent with previous research6Hawton K Zahl D Weatherall R Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital.Br J Psychiatry. 2003; 182: 537-542Crossref PubMed Scopus (508) Google Scholar and indicates an unmet need for assessment, referral, and treatment for this high-risk population. Although only 14·0% (314/2246) of deaths in the cohort were due to unintentional self-poisoning (ie, overdose), this was the underlying cause of 52·4% of deaths in the dual-harm group, and these individuals were almost 200 times (IRR 195·50, 95% CI 110·23–346·74) more likely than controls matched for age and sex to die by overdose. Overdose appears to be a key driver of preventable death among people with dual-harm histories and, as such, should be a priority for prevention. Two-thirds of cases with a dual-harm history had a history of treatment for a substance use disorder, and two-thirds of those with a dual-harm history who died by overdose had a history of treatment for multiple substances. The most common drugs of concern in the latter group were alcohol (38·2%) and cannabis (34·2%), with around one in five (21·1%) having a history of treatment for opioid use. Most cases with a dual-harm history (87·6%) had received treatment for at least one mental disorder. Particularly among justice-involved populations, efforts to prevent acute drug-related death have tended to focus on opioid overdose.9WHOPrevention of acute drug-related mortality in prison populations during the immediate post-release period. World Health Organization, Geneva2010Google Scholar However, polydrug use is a key driver of overdose death,10Darke S Polydrug use and overdose: overthrowing old myths.Addiction. 2003; 98: 711Crossref PubMed Scopus (28) Google Scholar and dual diagnosis of mental illness and substance use disorder is associated with increased risk of both non-fatal injury11Young JT Heffernan E Borschmann R et al.Dual diagnosis of mental illness and substance use disorder and injury in adults recently released from prison: a prospective cohort study.Lancet Public Health. 2018; 3: e237-e248Summary Full Text Full Text PDF PubMed Scopus (37) Google Scholar and preventable mortality12Chang Z Lichtenstein P Larsson H Fazel S Substance use disorders, psychiatric disorders, and mortality after release from prison: a nationwide longitudinal cohort study.Lancet Psychiatry. 2015; 2: 422-430Summary Full Text Full Text PDF PubMed Scopus (85) Google Scholar in people released from prison. As such, the findings by Steeg and colleagues further underscore the importance of ensuring that people with a dual-harm history receive coordinated treatment for mental illness and all substances of concern, in addition to therapeutic input to address issues relating to anger and impulsivity. Steeg and colleagues note that individuals in their study with a dual-harm history had previous contact with both health and criminal justice agencies, providing "multiple opportunities for enhanced monitoring, assessment, and intervention".4Steeg S Webb RT Mok PLH et al.Risk of dying unnaturally among people aged 15–35 years who have harmed themselves and inflicted violence on others: a national nested case-control study.Lancet Public Health. 2019; 4: e220-e228Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar Although undoubtedly true, seizing these opportunities will require systemic reform. For example, although people convicted of violent offences have, by definition, been identified as such by the criminal justice system, self-harm history is markedly under-ascertained in criminal justice settings,13Borschmann R Young JT Moran P et al.The accuracy and predictive value of incarcerated adults' accounts of their self-harm histories: findings from an Australian data linkage study.CMAJ Open. 2017; 5: e694-e701Crossref PubMed Scopus (21) Google Scholar due in part to the inherent limitations associated with how self-harm is assessed. Similarly, screening for history of violence in hospital settings is not routine, might not be feasible in some settings, and would probably under-ascertain a history of violence. One partial solution to this challenge might be to improve routine sharing of information between health and criminal justice agencies. For example, given that dual-harm history is such a strong risk factor for unnatural death, routine sharing of basic information regarding history of violent offending with health agencies would facilitate identification of people with a dual-harm history in health settings. Conversely, routine use of linked administrative health data would increase ascertainment of self-harm history in criminal justice settings.13Borschmann R Young JT Moran P et al.The accuracy and predictive value of incarcerated adults' accounts of their self-harm histories: findings from an Australian data linkage study.CMAJ Open. 2017; 5: e694-e701Crossref PubMed Scopus (21) Google Scholar Finally, adequate ascertainment of dual-harm history is a necessary, but not sufficient, condition for preventing unnatural deaths in this group. Cases with a dual-harm history in Steeg and colleagues' study were distinguished by a high prevalence of mental disorder, polydrug use, and socioeconomic disadvantage, in addition to self-harm and violence perpetration. Effective responses to these complex and probably syndemic needs will require coordination across multiple sectors including the criminal justice system, mental health services, alcohol and other drug treatment services, and welfare services. Unfortunately, it is often precisely these highly stigmatised individuals who have low engagement with such services, or fall in the cracks between service silos. Increased investment in more targeted approaches, including multisectoral case management, will be required to improve morbidity and mortality outcomes for people with a dual-harm history. This online publication has been corrected. The corrected version first appeared at thelancet.com/public-health on May 30, 2019 This online publication has been corrected. The corrected version first appeared at thelancet.com/public-health on May 30, 2019 We declare no competing interests. Risk of dying unnaturally among people aged 15–35 years who have harmed themselves and inflicted violence on others: a national nested case-control studyAmong individuals with co-occurring self-harm and violence, the risk of accidental death, particularly accidental self-poisoning, should be considered to be as important as the risk of suicide. People with a history of both behaviours who also have a substance misuse disorder are at particularly high risk of dying from external causes. Strategies should be designed to be accessible for people facing turbulent lives with multiple problems. Individuals in this group with both behaviours are likely to be treated by health-care services for self-harm and have contact with criminal justice services, providing multiple opportunities for proactive intervention. Full-Text PDF Open AccessCorrection to Lancet Public Health 2019; 4: e210–11Kinner SA, Borschmann R. Dual-harm, complex needs, and the challenges of multisectoral service coordination. Lancet Public Health 2019; 4: e210–11—In this Comment, the third sentence should read 'By using linked administrative data (an important method for examining health outcomes in marginalised, inclusion health populations),5 the authors found that although the risk of unnatural death is elevated among people with a history of violence (incidence rate ratio [IRR] 5·19, 95% CI 4·45–6·06) or self-harm (12·65, 10·84–14·77), the risk is considerably higher among people with both behaviours (29·37, 23·08–37·38).' These corrections have been made to the online version as of May 30, 2019. Full-Text PDF Open Access