Clinical management following self-harm in a UK-wide primary care cohort

Abstract

Background: Little is known about the clinical management of patients in primary care following self-harm.

Methods: A descriptive cohort study using data from 684 UK general practices that contributed to the Clinical Practice Research Datalink (CPRD) during 2001-2013. We identified 49,970 patients with a self-harm episode, 41,500 of whom had one complete year of follow-up.

Results: Among those with complete follow-up, 26,065 (62.8%, 62.3-63.3) were prescribed psychotropic medication and 6318 (15.2%, 14.9-15.6) were referred to mental health services; 4105 (9.9%, CI 9.6-10.2) were medicated without an antecedent psychiatric diagnosis or referral, and 4,506 (10.9%, CI 10.6-11.2) had a diagnosis but were not subsequently medicated or referred. Patients registered at practices in the most deprived localities were 27.1% (CI 21.5-32.2) less likely to be referred than those in the least deprived. Despite a specifically flagged NICE 'Do not do' recommendation in 2011 against prescribing tricyclic antidepressants following self-harm because of their potentially lethal toxicity in overdose, 8.8% (CI 7.8-9.8) of individuals were issued a prescription in the subsequent year. The percentage prescribed Citalopram, an SSRI antidepressant with higher toxicity in overdose, fell sharply during 2012/2013 in the aftermath of a Medicines and Healthcare products Regulatory Agency (MHRA) safety alert issued in 2011.

Conclusions: A relatively small percentage of these vulnerable patients are referred to mental health services, and reduced likelihood of referral in more deprived localities reflects a marked health inequality. National clinical guidelines have not yet been effective in reducing rates of tricyclic antidepressant prescribing for this high-risk group.

Keywords: Diagnoses; Medication; Primary care; Referrals; Self-harm.

Fig. 1

Percentage of patients referred to mental health services during the 1 year follow-up compared with number who self-harmed by deprivation quintile.

Fig. 2

Venn diagram showing percentage values for patients with antecedent or new psychiatric diagnoses and with mental health service referrals or psychotropic drug prescriptions during the 1 year follow-up.

Fig. 3

a. Temporal trends in the percentage of cohort members prescribed tricyclics, SSRIs and other antidepressants during the 1 year follow-up. 3b. Temporal trends in the percentage of cohort members prescribed particular types of SSRI antidepressants during the 1 year follow-up. Footnote: The x-axis values show the calendar year period when index self-harm episodes occurred. Each cohort member was followed up for 1 complete year. Thus, an individual born on 31st December 2012 was followed up to 31st December 2013, which was the final date of observation in our study.