Identifying risk of deliberate self-harm through longitudinal monitoring of psychological distress in an inpatient psychiatric population

Kashyap et al. BMC Psychiatry (2015) 15:81 DOI 10.1186/s12888-015-0464-3 RESEARCH ARTICLE Open Access Identifying risk of deliberate self-harm through longitudinal monitoring of psychological distress in an inpatient psychiatric population Shraddha Kashyap1*, Geoffrey R Hooke2 and Andrew C Page3 Abstract Background: While cross-sectional correlates of deliberate self-harm, such as psychological distress, have been identified; it is still difficult to predict which individuals experiencing distress will engage in deliberate self-harm, and when this may occur. Therefore, this study aimed to explore the ability of longitudinal measurements of psychological distress to predict deliberate self-harm in a psychiatric population. Method: Participants (N = 933; age range 14–93 (M = 38.95, SD = 14.64; 70% female) were monitored daily in terms of suicidal ideation, depression, anxiety, worthlessness and perceptions of not coping. Latent Growth Curve Analysis was used to check if groups of inpatients reporting suicidal ideation, who shared early change in measures of psychological distress, existed. Logistic regression tested whether different groups were at higher (or lower) risks of deliberate self-harm. Results: Four groups were found. Of these, Non-Responders (high symptoms, remaining high) were more likely to engage in deliberate self-harm than patients with high, medium and low symptoms which improved over one week. Group membership was a greater predictor of deliberate self-harm than initial distress scores. Females and patients with personality disorders were significantly more likely to be Non-Responders. Conclusions: Continuous monitoring and subsequent grouping of inpatients according to their early change in psychological distress provides a novel and practical approach to risk management. A lack of early improvement in psychological distress may indicate a higher risk of deliberate self-harm. Keywords: Deliberate self-harm, Risk management, Suicidal ideation, Longitudinal measures Background Deliberate Self-Harm (including both suicidal behaviours and non-suicidal deliberate self-harm) is hard to predict and this makes it a difficult area of clinical case management. Non-suicidal deliberate self-harm refers to deliberate, self-inflicted harm on body tissue; not socially/ culturally sanctioned and without the intent to die [1,2]. Suicide attempts refer to deliberate, self-inflicted, nonlethal injuries, with the intent to die [1]. Although nonsuicidal deliberate self-harm differs from suicidal attempts in terms of the intent to die [3,4]; non-suicidal deliberate self-harm either separately or combined with previous * Correspondence: 1 School of Psychology, The University of Western Australia, 35 Stirling Highway, Crawley 6009, Western Australia Full list of author information is available at the end of the article suicide attempts can significantly increase the risk of future suicidal behaviour [5-7]. For example, individuals with multiple previous incidents of deliberate self-harm, a history of psychiatric admissions, substance abuse [5,8], and those who engaged in more severe cutting and burning [9] can be at risk of progressing to further suicidal behaviours. Theoretical frameworks have been proposed to explain the link between non-suicidal deliberate self-harm, suicide attempts and future suicidal behaviour. For example, the Interpersonal Theory of suicide posits that while perceived burdensomeness and thwarted belongingness can lead to suicidal ideation as a first step, individuals need to acquire the capacity to harm themselves to act on those suicidal thoughts [10]. This capacity to harm oneself can be acquired either through non-suicidal deliberate self-harm, © 2015 Kashyap et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kashyap et al. BMC Psychiatry (2015) 15:81 previous suicidal behaviour, or both forms of deliberate self-harm [2]. For example, the progression from less lethal deliberate self-harm to more lethal deliberate selfharm might occur through the habituation to physical pain [11,12]. This view has been supported by findings where previous non-suicidal deliberate self-harm was a strong predictor of future suicidal behaviour [4,13]. For example, non-suicidal deliberate self-harm was found to predict suicidal behaviour after controlling for depression [9,13,14], previous suicidal behaviour [13], hopelessness and symptoms of borderline personality disorder [14]. Finally, a prospective study found that non-suicidal deliberate self-harm in adolescents remained a significant predictor of future suicidal behaviour after accounting for depression and previous suicidality [15]. Therefore, exploring predictors of non-suicidal deliberate selfharm among people at risk of suicidal behaviour (e.g., those experiencing suicidal ideation) may help predict and prevent suicidal behaviour. That is, if a first step towards suicidal behaviour is to have thoughts about suicide, and the next step is to acquire the capacity (such as through non-suicidal deliberate self-harm); examining factors associated with non-suicidal deliberate self-harm amongst individuals who already report suicidal ideation might add to the precision with which future suicidal behaviour can be predicted. Indeed, since both nonsuicidal deliberate self-harm and suicidal behaviour can increase the risk of future suicidal behaviour (e.g. [15]), both forms of self-injury are referred to as deliberate selfharm for the purposes of this study. However, one difficulty with prediction may be the focus on taking cross-sectional measurements of potential risk factors of deliberate self-harm, such as psychiatric disorders and psychological distress [16], and expecting them to predict levels of a behaviour which might change over time. For example, a systematic review suggested that while most correlates of deliberate self-harm such as indicators of psychological distress have been recognized retrospectively, there is a lack of knowledge around proximal predictors, which require longitudinal studies to be identified [17]. It has also been argued that further research is needed to identify causal links between risk factors and deliberate self-harm [18]. For example, it is widely known that depression is associated with suicidal ideation, but it is difficult to predict which people with depression who are considering deliberate selfharm will actually engage in deliberate self-harm [18]. The difficulties in prediction may arise because factors influencing the risk of delib (...truncated)