February 13, 2014

expert reaction to diabetes, epilepsy, asthma and self-harm

Research in the Journal of the Royal Society of Medicine found common physical illnesses such as diabetes, epilepsy and asthma were associated with a moderately elevated risk of self-harm.

Dr Amrit Sachar, consultant liaison psychiatrist, West London Mental Health NHS Trust and Imperial College London, said:

“This is a timely paper highlighting the complex interplay between the mind and the body. Chronic physical illness, with the accompanying pain, disability, fear and feeling disempowered can lead to depression, anxiety, memory problems and poorer self-care. These issues are often missed because professionals are concentrating on the physical problem during their assessments.

“Self-harm can be used as a coping strategy when people feel helpless or a form of communication when they feel unheard. The paper highlights the needs for further exploration of this area but also the need for integrating physical and mental health care. I would add it highlights the need for integrating medical education and improving emotional support for people with chronic physical illness like that in cancer services which interestingly, in this study showed low risk of suicide and self-harm.”

Q&A with two of the authors:

Prof Keith Hawton, Director of the Centre for Suicide Research, Oxford University and Consultant Psychiatrist, Oxford Health NHS Foundation Trust

Prof Michael Goldacre, Director of the Unit of Health-Care Epidemiology, University of Oxford

Q: Just how big an increase in risk is this?

A: “For psychiatric disorders the increase in risk in relative terms, compared with the general population of the same age, is between five and fifteen times higher (depending on the condition) than that in the general population. In absolute terms, considering the years covered by the study, this means an episode of self-harm, at some time, in around 5-10% of all people with one of the psychiatric disorders studied.

“For the physical diseases, like asthma or diabetes, the increase in risk compared with the general population is two-fold or less. In absolute terms this means an episode of self-harm in about 1% of the population of these patients.”

Q: Does an increase in likelihood to self-harm also mean a greater risk of suicide?

A: “It does; but at a much lower absolute level than non-fatal self-harm. For example, for people with asthma in our analysis, the risk of suicide was about 50 times lower than that for non-fatal self-harm. It was, nonetheless, a little higher than that in people without asthma.”

Q: Is the evidence showing that even any incidence of epilepsy/asthma/eczema etc increases the risk, or is it restricted to sustained or severe cases?

A: “Our results may only apply to people with more severe physical illnesses because people were only included in this study if they had actually been admitted to hospital for their physical disorder, or at least seen as a day case.  We were unable to include those who were seen as outpatients or just seen by their GPs, or indeed not seen by a doctor at all, so cannot say whether the findings apply to those with less severe disorders.”

Q: How does having one of these physical illnesses compare to other risk factors?

A: “The risks of self-harm, and indeed suicide, associated with physical illnesses are far lower than those related to psychiatric disorders, especially depression, bipolar disorder, severe anxiety disorders and, in women, eating disorders. 

“However, while it was difficult to show this in this study, other research shows that the risk of suicidal behaviour associated with physical disorders is often due to related psychiatric disorder, especially depression. In other words, the risk is often due to combined physical and psychiatric disorder, with usually the physical illness and its effect having caused the psychiatric disorder.”

Q: Is there evidence of causation or correlation?

A: “This study cannot address the nature of the association, i.e. whether the physical illnesses actually caused people to contemplate self-harm or suicide. To study this one would ideally need to follow a very large series of people with a particular physical illness over time to see who died and what was the sequence of events related to their illness that might indicate if suicide was related to, for example, worsening of the disorder or development of a psychiatric disorder. 

“Having said that, however, the study was designed such that we were investigating the occurrence of self-harm after diagnosis of physical disorders i.e. the association was not a reverse one or likely to be spurious.”

Q: Who should be paying attention to this research? Are these findings of most significance to health professionals, policy makers or people in the street? In short, should parents be worried?

A: “The greatest significance of these findings is for clinicians. Thus GPs and physicians and their colleagues need to be aware of the importance of considering psychiatric disorders in the context of physical illnesses, and mental health staff need to be aware of extra risks that physical illnesses may convey in their patients. 

“The findings are also relevant to policy makers, particularly at this time when there is far greater recognition of the importance of greater integration of physical and mental healthcare. This is something that is emphasised in the recently released policy document from the Department of Health, Closing the Gap: Priorities for essential change in mental health” (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/273649/Closing_the_gap.pdf)

Q: Does something need to be done to reduce the likelihood of self-harm?

A: “Greater awareness of how people are responding psychologically to long-term physical disorders and more careful investigation of those who may be coping badly, including asking about attitudes to the future, should be an integral component of trying to identify those at risk and hence to try and prevent both self-harm and suicide.”

Dr Paul Moran, Reader and Consultant Psychiatrist, King’s College London, Institute of Psychiatry, said:

“The Oxford team have produced an interesting epidemiological study, which sheds new light on the risk of self-harm and suicide among people admitted to hospital for physical disorders. We already know that people with mental health problems are at substantially higher risk of self-harm. Now, using routine data collected on hospitalised patients, the Oxford team have shown that people with chronic physical conditions, such as epilepsy, asthma and migraine, are at increased risk of later having an admission to hospital for self-harm.

“The study found that the risks of self-harm associated with psychiatric disorders were consistently much higher than those associated with physical disorders. However, the associated risk with physical disorders was still statistically significant and was not explained by the effects of age or deprivation.

“Readers of the paper need to bear in mind that by definition, hospital populations are skewed towards sicker individuals.  We therefore cannot assume that the associations detected in this study will necessarily apply to people with chronic physical disorders living in the community. In addition, the study was unable to tease out why people with physical disorders are at increased risk of self-harm. We know that long-term physical conditions are associated with an increased risk of mental health problems and the occurrence of depression seems to explain most of the increased suicide risk among physically ill people. Self-harm is invariably associated with mental distress and so doctors will only uncover this if they enquire about their patient’s mental state.”

‘Risk of self-harm and suicide in people with specific psychiatric and physical disorders: comparisons between disorders using English national record linkage’ by Singhal et al. published in the Journal of the Royal Society of Medicine on Thursday 13^th  February.