Risk of suicide following hospital presentation for self-harm is very high immediately following hospital discharge, emphasising the need for provision of early follow-up care and attention to risk reduction strategies
To reduce the high risk of suicide after hospital attendance for self-harm, improved clinical management is needed for all patients – including comprehensive assessment of the patients’ mental state, needs, and risks, as well as implementation of risk reduction strategies, including safety planning.
The results are from an observational study spanning 16 years and including almost 50,000 people from five English hospitals, published in The Lancet Psychiatry journal.
“The peak in risk of suicide which follows immediately after discharge from hospital underscores the need for provision of early and effective follow-up care. Presentation to hospital for self-harm offers an opportunity for intervention, yet people in are often discharged from hospital having not received a formal assessment of their problems and needs, and without specific aftercare arrangements. As specified in national guidance, a comprehensive assessment of the patients’ mental state, needs, and risks is essential to devise an effective plan for their follow-up care,” says study author Dr. Galit Geulayov, Centre for Suicide Research, Department of Psychiatry, University of Oxford, UK.
It has been estimated that every year there are approximately 200,000 presentations to emergency departments in hospitals across England following acts of non-fatal self-harm. Self-harm is associated with increased mortality, especially by suicide. Approximately 50% of individuals who die by suicide have a history of self-harm, with hospital presentation for self-harm often occurring shortly before suicide.
The new study compared the risk of suicide following hospital presentation for self-harm according to patient characteristics, method of self-harm, and socioeconomic deprivation. It also estimated the incidence of suicide by time after hospital attendance, adjusting for gender, age, previous self-harm, and psychiatric treatment.
The study included 49,783 people aged over 15 years who presented to hospital after non-fatal self-harm a total of 90,614 times between 2000-2013. The authors followed these patients for 16 years (until the end of 2015), and the study included five hospitals (one in Oxford, three in Manchester and one in Derby).
Within the 16 year follow up, 703 out of 49,783 people died by suicide – with the incidence of suicide being 163 per 100,000 people per year.
Around a third of these deaths occurred within a year of the patient attending hospital for non-fatal self-harm (36%, 252/703 deaths), and the study confirmed the high risk of suicide in the first year after presentation to hospital for self-harm (the incidence of suicide in the year following discharge from hospital was 511 suicides per 100,000 people per year – 55.5 times higher than that of the general population).
The authors found that risk was particularly elevated in the first month (the incidence of suicide in the month following discharge from hospital was 1,787 per 100,000 people per year – close to 200 times higher than in the general population) – with 74 out of 703 people in the study dying by suicide within a month.
The authors note that men were more likely to die by suicide following hospital presentation of self-harm than women, people who attended hospital more than once for non-fatal self-harm were more likely to die by suicide than those with a single presentation, and age was associated with risk (with risk increasing 3% with each year of age).
In addition, those who lived in less deprived areas had a higher risk of death by suicide than those who lived in the most deprived areas, but this contrasts with a large body of evidence and might be explained by higher rates of psychiatric disorders in this group in this study – more research is needed. The authors also note that some forms of self-harm were more strongly linked to subsequent suicide, but advise against including detail of this kind in media reporting.
Suicide is a big issue in the LGBTQIA community. In 2018, for instance, a study found that a total of 37% of trans respondents reported having seriously considered suicide during the past 12 months and 32% had ever attempted a suicide. Offensive treatment during the past three months and lifetime exposure to trans-related violence were significantly associated with suicidality.
A study published in LGBT Health in 2016, meanwhile, emphasized the importance of strengthening family support and acceptance as part of a positive intervention.
The authors of this newer study note that holistic assessment of risk factors is required, and warn that no single characteristic will help predict later suicide.
“While awareness of characteristics which increase the risk of subsequent suicide can assist as part of this assessment, previous studies indicate that individual factors related to self-harm are a poor means to evaluate the risk of future suicide. These factors need to be considered together, followed by risk reduction strategies, including safety planning, for all patients,” says Professor Hawton, Centre for Suicide Research, Department of Psychiatry, University of Oxford, UK.
The authors note that their study focuses on three cities in England and the findings may not necessarily apply to the whole of the country.
Writing in a linked comment, Dr. Annette Erlangsen, Danish Research Institute for Suicide Prevention, Denmark, notes that there is a range of treatment options available following presentation of self-harm in emergency departments (including referrals to psychiatric wards after psychosocial assessments, outpatient treatment for patients not under immediate risk of self-harming, and – in some countries – specialized suicide prevention clinics) but many countries send patients home with a referral to their GP or do not refer at all.
She says: “The bottom line is–while the body of evidence of effective intervention is growing, we need to help people who present with self-harm. Operating in such a scenario is challenging but the numbers are clear; we need to ensure that patients receive support immediately when presenting and implement a continuation of care after discharge.”
Having less sex linked to earlier menopause
Women who reported engaging in sexual activity weekly were 28% less likely to have experienced menopause at any given age than women who engaged in sexual activity less than monthly.
Women who engage in sexual activity weekly or monthly have a lower risk of entering menopause early relative to those who report having some form of sex less than monthly, according to a new UCL study.
The researchers observed that women, who reported engaging in sexual activity weekly, were 28% less likely to have experienced menopause at any given age than women who engaged in sexual activity less than monthly. Sexual activity includes sexual intercourse, oral sex, sexual touching and caressing or self-stimulation.
The research, published in Royal Society Open Science, is based on data from the USA’s Study of Women’s Health Across the Nation (SWAN). It’s the largest, most diverse and most representative longitudinal cohort study available to research aspects of the menopause transition.
First author on the study, PhD candidate Megan Arnot (UCL Anthropology), said: “The findings of our study suggest that if a woman is not having sex, and there is no chance of pregnancy, then the body ‘chooses’ not to invest in ovulation, as it would be pointless. There may be a biological energetic trade-off between investing energy into ovulation and investing elsewhere, such as keeping active by looking after grandchildren.
“The idea that women cease fertility in order to invest more time in their family is known as the Grandmother Hypothesis, which predicts that the menopause originally evolved in humans to reduce reproductive conflict between different generations of females, and allow women to increase their inclusive fitness through investing in their grandchildren.”
During ovulation, the woman’s immune function is impaired, making the body more susceptible to disease. Given a pregnancy is unlikely due to a lack of sexual activity, then it would not be beneficial to allocate energy to a costly process, especially if there is the option to invest resources into existing kin.
The research is based on data collected from 2,936 women, recruited as the baseline cohort for the SWAN study in 1996/1997.
The mean age at first interview was 45 years old. Non-Hispanic Caucasian women were most represented in the sample (48%), and the majority of women were educated to above a high school level. On average they had two children, were mostly married or in a relationship (78%), and living with their partner (68%).
The women were asked to respond to several questions, including whether they had engaged in sex with their partner in the past six months, the frequency of sex including whether they engaged in sexual intercourse, oral sex, sexual touching or caressing in the last six months and whether they had engaged in self-stimulation in the past six months. The most frequent pattern of sexual activity was weekly (64%).
None of the women had yet entered menopause, but 46% were in early peri-menopause (starting to experience menopause symptoms, such as changes in period cycle and hot flashes) and 54% were pre-menopausal (having regular cycles and showing no symptoms of peri-menopause or menopause).
Interviews were carried out over a ten-year follow-up period, during which 1,324 (45%) of the 2,936 women experienced a natural menopause at an average age of 52.
By modelling the relationship between sexual frequency and the age of natural menopause, women of any age who had sex weekly had a hazard ratio of 0.72, whereas women of any age who had sex monthly had a hazard ratio of 0.81.
This provided a likelihood whereby women of any age who had sex weekly were 28% less likely to experience the menopause compared to those who had sex less than monthly. Likewise, those who had sex monthly were 19% less likely to experience menopause at any given age compared to those who had sex less than monthly.
The researchers controlled for characteristics including oestrogen level, education, BMI, race, smoking habits, age at first occurrence of menstruation, age at first interview and overall health.
The study also tested whether living with a male partner affected menopause as a proxy to test whether exposure to male pheromones delayed menopause. The researchers found no correlation, regardless of whether the male was present in the household or not. Last author, Professor Ruth Mace (UCL Anthropology), added: “The menopause is, of course, an inevitability for women, and there is no behavioural intervention that will prevent reproductive cessation. Nonetheless, these results are an initial indication that menopause timing may be adaptive in response to the likelihood of becoming pregnant.”
Transgender students face higher levels of substance abuse
This misuse of drugs by transgender individuals is thought not to be anything to do with their non-gender conformity but with the discrimination that they, as transgender individuals, face on a daily basis.
A study by The Journal of School Health has found transgender students to be 2.5 times more likely to try and use drugs such as methamphetamines and cocaine than their non-transgender peers. Transgender students were also found to be twice as likely to misuse prescription medication than other students their age.
This misuse of drugs by transgender individuals is thought not to be anything to do with their non-gender conformity but with the discrimination that they, as transgender individuals, face on a daily basis, with stigma being one of the primary drivers of transgender mental health issues across the world.
In the US more than 50% of transgender individuals report suffering from depression or anxiety and LGBTQ individuals are also 7 times more likely to consider death by suicide than heterosexual gender-conforming individuals.
At home, 19% of transgender individuals have experienced domestic violence as a result of their gender nonconformity and at work, more than 50% of transgender individuals have experienced discrimination.
With so much stigma at home, on the street and in the workplace it’s no wonder that some transgender individuals are turning to narcotics as a way to numb the pain and escape their realities.
Dr. Pedro, a scientist who helped conduct the drug use study has said “When it comes to transgender teens, it’s the transphobia that impacts [their use of drugs], not being transgender. In order to reduce the likelihood of a kid to resort to drugs as a means to cope, there has to be some sort of social support mechanism,”
Evidence from initiatives in the US supports the idea that better support systems and less stigmatizing communities can have a positive impact on the mental health of transgender individuals. Simply providing transgender individuals with appropriate toilet facilities was found to reduce the likelihood of transgender teens committing suicide by a staggering 45% and the introduction of same-sex marriage saw a huge drop in suicide attempts by 134,000.
So what else can be done to help support transgender individuals and reduce their need to rely on narcotics?
The evidence provided by initiatives in the US proves that removing the stigma surrounding being transgender is key to reducing suicide rates and improving transgender mental health but this won’t happen overnight. We need to see an introduction of more support systems for transgender people in the form of support groups and access to counseling and we need to provide transgender people with access to inpatient drug rehab centers if they have already fallen too far.
To remove stigma in the community, schools and governors need to focus on transgender awareness and education, helping friends, families, and co-workers to understand what it means to be transgender and how they can help to ease the weight that their loved one, friend or colleague is carrying. Education also needs to start far earlier and be taught in schools to help students grow up into compassionate individuals with a wider understanding of the LGBTQ community and the challenges it faces.
Hidden sexual-arousal disorder can compromise mental health
It’s important that people know of this medical condition and that it is primarily a neurological problem, not a psychiatric one.
Persistent genital arousal disorder (PGAD)–which is almost exclusively experienced by females and characterized by spontaneous and unwanted sexual arousal unrelated to desire–can compromise individuals’ mental health and well-being and severely damage relationships with partners. Results from a new study by investigators at Massachusetts General Hospital (MGH) indicate that PGAD can be caused by altered firing of nerves that carry sensations from the genitalia or by damage to the lowest parts of the spinal cord. The study also found that neurological treatments benefit many patients.
“It’s important that people know of this medical condition and that it is primarily a neurological problem, not a psychiatric one,” said senior author Bruce Price, MD, an MGH Department of Neurology investigator who is also chief of Neurology at McLean Hospital. “Many affected women are silent and undercover–it’s in no way a fun condition, and it is difficult for patients to address their symptoms with their doctors, who have typically never heard of PGAD.” The problem can be especially troubling for adolescents, causing confusion, shame, and fear.
The study, published in PAIN Reports, included 10 females whose PGAD symptoms began between ages 11 to 70 years. Although the study involved only a small number of patients, it’s still one of the first to carefully examine PGAD in a thorough and scientific manner.
Spinal nerve-root cysts were detected in four patients and generalized sensory nerve damage (neuropathy) in two. One patient with symptoms since childhood was born with a small defect in her lowest spinal cord, one had a lumbosacral herniated disc in the lower back, and another developed short-lived PGAD when she abruptly stopped a prescribed antidepressant medication.
All psychiatric and gynecological treatments were ineffective, and injecting local anesthetics had no lasting benefit. In contrast, neurological treatments–such as cyst removal and treating nerve damage–were effective in 80% of patients.
“Physicians need to be aware of PGAD and inquire about it when patients experience other pelvic pain or urological symptoms that often accompany PGAD,” said first author Anne Louise Oaklander, MD, PhD, an investigator in the Department of Neurology at MGH. “It’s treatable, but the treatment depends on the cause. By identifying some common causes–and localizing them to specific regions of the sacral nervous system–our study provides direction on how to help patients and to guide future research.”
Women with single dose of HPV vaccine gain similar protection as multiple doses
While results of the paper showed that a single dose may be as effective as the currently recommended two- or three-dose series, it’s too early for people to rely on a single dose of the vaccine for protection.
A new study revealed that one dose of the HPV vaccine may prevent infection from the potential cancer-causing virus, according to research published in JAMA Network Open from The University of Texas Health Science Center at Houston (UTHealth).
According to the Centers for Disease Control (CDC), 34,800 new cancer diagnoses are linked to human papillomavirus (HPV) annually. The virus is thought to account for more than 90% of all cervical and anal cancers, more than 60% of all penile cancers, and approximately 70% of all oral cancers.
While results of the paper showed that a single dose may be as effective as the currently recommended two- or three-dose series, it’s too early for people to rely on a single dose of the vaccine for protection, according to senior author Ashish A. Deshmukh, PhD, MPH, an assistant professor at UTHealth School of Public Health.
“HPV vaccine coverage is less than 10% globally because of poor vaccine uptake rates in many resource-limited countries. Ensuring boys and girls receive their first dose is a big challenge in several countries and a majority of adolescents are not able to complete the recommended series due to a lack of intensive infrastructure needed to administer two or three doses,” Deshmukh said. “If ongoing clinical trials provide evidence regarding sustained benefits of a one-dose regimen, then implications of single-dose strategy could be substantial for reducing the burden of these cancers globally.”
Although the study participants included only women, the CDC recommends a two-dose regimen for all children starting the series before age 15 or a three-dose regimen if the series is started between ages 16 to 26. The latest generation of HPV vaccine can protect against nearly 90% of cancer-causing HPV infections. Yet, current vaccinations rates are less than ideal – half of people in the U.S. are not vaccinated against this common sexually transmitted infection.
“The current HPV vaccine dosing regimen can be cumbersome for people to understand. If one dose is proven effective in trials, the vaccine regimen will be simplified. This will help improve the coverage rate among adolescents that are currently below the Healthy People 2020 goal and possibly will also increase the momentum of uptake in the newly approved age group,” said lead author Kalyani Sonawane, PhD, who is an assistant professor at UTHealth School of Public Health.
Michael D. Swartz, PhD, of UTHealth co-authored the study, along with Alan G. Nyitray, PhD, of the Medical College of Wisconsin; and Gizem S. Nemutlu, PhD, and Jagpreet Chhatwal, PhD, from Harvard Medical School.
Diet has rapid effects on sperm quality
Sperm quality can be harmed by several environmental and lifestyle factors, of which obesity and related diseases, such as type 2 diabetes, are well-known risk factors for poor sperm quality.
Sperm are influenced by diet, and the effects arise rapidly. This is the conclusion of a study by researchers at Linköping University, in which healthy young men were fed a diet rich in sugar. The study, which has been published in PLOS Biology, gives new insight into the function of sperm, and may in the long term contribute to new diagnostic methods to measure sperm quality.
“We see that diet influences the motility of the sperm, and we can link the changes to specific molecules in them. Our study has revealed rapid effects that are noticeable after one to two weeks”, says Anita Öst, senior lecturer in the Department of Clinical and Experimental Medicine at Linköping University, and head of the study.
Sperm quality can be harmed by several environmental and lifestyle factors, of which obesity and related diseases, such as type 2 diabetes, are well-known risk factors for poor sperm quality. The research group that carried out the new study is interested in epigenetic phenomena, which involve physical properties or levels of gene expression changing, even when the genetic material, the DNA sequence, is not changed. In certain cases such epigenetic changes can lead to properties being transferred from a parent to offspring via the sperm or the egg.
In a previous study, the scientists showed that male fruit flies which had consumed excess sugar shortly before mating more often produced offspring who became overweight. Similar studies on mice have suggested that small fragments of RNA known as tsRNA play a role in these epigenetic phenomena that appear in the next generation. These RNA fragments are present in unusually large amounts in the sperm of many species, including humans, fruit flies and mice. So far, their function has not been examined in detail. Scientists have speculated that the RNA fragments in sperm may be involved in epigenetic phenomena, but it is too early to say whether this is the case in humans. The new study was initiated by the researchers to investigate whether a high consumption of sugar affects the RNA fragments in human sperm.
The study examined 15 normal, non-smoking young men, who followed a diet in which they were given all food from the scientists for two weeks. The diet was based on the Nordic Nutrition Recommendations for healthy eating with one exception: during the second week the researchers added sugar, corresponding to around 3.5 litres of fizzy drinks, or 450 grammes of confectionery, every day. The sperm quality and other indicators of the participants’ health were investigated at the start of the study, after the first week (during which they ate a healthy diet), and after the second week (when the participants had additionally consumed large amounts of sugar).
At the beginning of the study, one third of the participants had low sperm motility. Motility is one of several factors that influence sperm quality, and the fraction of people with low sperm motility in the study corresponded to that in the general population. The researchers were surprised to discover that the sperm motility of all participants became normal during the study.
“The study shows that sperm motility can be changed in a short period, and seems to be closely coupled to diet. This has important clinical implications. But we can’t say whether it was the sugar that caused the effect, since it may be a component of the basic healthly diet that has a positive effect on the sperm”, says Anita Öst.
The researchers also found that the small RNA fragments, which are linked to sperm motility, also changed. They are now planning to continue the work and investigate whether there is a link between male fertility and the RNA fragments in sperm. They will also determine whether the RNA code can be used for new diagnostic methods to measure sperm quality during in vitro fertilisation.
The study has been carried out in collaboration with the Reproductive Medicine Center at Linköping University Hospital, with financial support from the Swedish Research Council, the Knut and Alice Wallenberg Foundation, and the Ragnar Söderberg Foundation.
The article – “Human Sperm Displays Rapid Responses to Diet” by Daniel Nätt, Unn Kugelberg, Eduard Casas, Elizabeth Nedstrand, Stefan Zalavary, Pontus Henriksson, Carola Nijm, Julia Jäderquist, Johanna Sandborg, Eva Flinke, Rashmi Ramesh, Lovisa Örkenby, Filip Appelkvist, Thomas Lingg, Nicola Guzzi, Cristian Bellodi, Marie Löf, Tanya Vavouri and Anita Öst -= appeared in PLOS Biology.
Depression and suicide risk linked to air pollution
Reducing global average exposure to fine particulate matter (PM2.5) air pollution from 44 micrograms per metre cubed (μg/m3) to 25μg/m3 could result in a 15% reduction in depression risk worldwide.
People exposed to higher levels of air pollution are more likely to experience depression or die by suicide, finds a new analysis led by UCL.
The first systematic review and meta-analysis of evidence connecting air pollution and a range of mental health problems, published in Environmental Health Perspectives, reviewed study data from 16 countries.
The researchers found that, if the relationship with depression reported in some of these studies is causal, then reducing global average exposure to fine particulate matter (PM2.5) air pollution from 44 micrograms per metre cubed (μg/m3) to 25μg/m3 could result in a 15% reduction in depression risk worldwide.
The World Health Organization guidelines recommend that fine particulate matter pollution – small airborne particles that can include dust and soot – should be kept under 10μg/m3.
“We already know that air pollution is bad for people’s health, with numerous physical health risks ranging from heart and lung disease to stroke and a higher risk of dementia,” said the study’s lead author, Dr Isobel Braithwaite (UCL Psychiatry and UCL Institute of Health Informatics). “Here, we’re showing that air pollution could be causing substantial harm to our mental health as well, making the case for cleaning up the air we breathe even more urgent.”
The research team searched for studies that had investigated the association between particulate matter pollution and five different adverse mental health outcomes in adults. They identified 25 studies that fitted their criteria, nine of which were included in the primary analyses.
Five studies looking at long-term particulate matter exposure and depression were included in one meta-analysis. By pooling the results, they found that a 10μg/m3 (microgram per metre cubed) increase in the average level of fine particulate matter (PM2.5) air pollution people were exposed to over long periods was associated with an approximately 10% increase in their odds of depression.
“We found quite consistent results across the studies we reviewed that analysed the relationship between long-term air pollution exposure and depression, even after adjustment for many other factors which could explain the association. The association seems to be similar in magnitude to those that have been found for some physical health impacts of particulate matter, such as all-cause mortality,” Dr Braithwaite said.
Global city PM2.5 levels range from 114 and 97 in Delhi and Dhaka, to 6 in Ottawa and Wellington.
In UK cities, the average particulate matter level that people are exposed to is 12.8μg/m3. The researchers estimate that lowering average air pollution levels to the WHO recommended limit of 10μg/m3 could reduce urban UK residents’ depression risk by roughly 2.5%.
The researchers also found evidence of a connection between short-term changes in coarse particulate air pollution (PM10)* exposure and the number of suicides, from pooling the results of four different studies in a meta-analysis. The risk of suicide appears to be measurably higher on days when PM10 levels have been high over a three-day period than after less polluted periods.
The studies into short-term changes in suicide risk accounted for confounding factors such as weather changes, and day of the week. The relationship is not affected by other neighbourhood or socioeconomic factors given that the comparisons being made are among the same individuals on days with different pollution levels.
The researchers say the evidence was particularly strong for the suicide risk link, but the effect was smaller than for depression (an increase in suicide risk of 2% for each 10μg/m3 increase in the average coarse particulate pollution level over a three-day period).
The researchers say they cannot yet confirm whether air pollution directly causes mental ill health, but say there is evidence to suggest possible causal mechanisms.
“We know that the finest particulates from dirty air can reach the brain via both the bloodstream and the nose, and air pollution has been implicated in increased neuroinflammation, damage to nerve cells and to changes in stress hormone production, which have been linked to poor mental health,” Dr Braithwaite said.
The study’s senior author, Dr Joseph Hayes (UCL Psychiatry and Camden and Islington NHS Foundation Trust), said: “Our findings correspond with other studies that have come out this year, with further evidence in young people and in other mental health conditions. While we cannot yet say that this relationship is causal, the evidence is highly suggestive that air pollution itself increases the risk of adverse mental health outcomes.”
He added: “A lot of what we can do to reduce air pollution can also benefit our mental health in other ways, such as enabling people to cycle or walk rather than drive, and enhancing access to parks, so this adds support to the promotion of active travel and urban green spaces.”
Despite global issues re the environment, it is worth noting that the earth may be facing a major crisis, and yet there are some men who do not want to do anything because they are afraid that people may think they are gay. This is according to research published in Sex Roles, which noted that many men opt out from recycling and using cotton bags because they’re afraid of what people may think of them by questioning their… masculinity.
*The two main types of particulate matter pollution are differentiated by being under 2.5 micrometres in diameter (fine particulate matter, or PM2.5), and between 2.5 and 10 micrometres in diameter (coarse particulate matter, or PM10). Some, like smoke, are visible, while others are too small to be seen by the naked eye. Sources can include road transport, burning of fuels such as for heating or cooking, heavy industry and more.