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Suicide and Self-Harm Related Internet Use: a Cross-Sectional Study and Clinician Focus Groups Padmanathan, P., Biddle, L., Carroll, R., Derges, J., Potokar, J., & Gunnell, D. (2018). Suicide and self-harm related internet use: a cross-sectional study and clinician focus groups. Crisis: Journal of Crisis Intervention and Suicide Prevention. https://doi.org/10.1027/0227-5910/a000522 Publisher's PDF, also known as Version of record License (if available): CC BY-NC Link to published version (if available): 10.1027/0227-5910/a000522 Link to publication record in Explore Bristol Research PDF-document University of Bristol - Explore Bristol Research General rights This document is made available in accordance with publisher policies. Please cite only the published version using the reference above. Full terms of use are available: http://www.bristol.ac.uk/red/research-policy/pure/user-guides/ebr-terms/ Research Trends Suicide and Self-Harm Related Internet Use A Cross-Sectional Study and Clinician Focus Groups Prianka Padmanathan1,2, Lucy Biddle1, Robert Carroll1,3, Jane Derges1, John Potokar1,4, and David Gunnell1,5 1 School of Social and Community Medicine, University of Bristol, Bristol, UK 2 Avon and Wiltshire Mental Health Partnership NHS Trust, UK 3 Real World Evidence, Evidera, London, UK 4 University Hospitals Bristol NHS Foundation Trust, Bristol, UK 5 NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK Abstract. Background: The rise in Internet use adds a new dimension to suicide prevention. We investigated suicide/self-harm (S/Sh)-related Internet use among patients presenting to hospital with self-harm. Method: We asked 1,198 adult and 315 child and adolescent patients pre- senting to hospital following self-harm in a city in South West England about Internet use associated with their hospital presentation. Associa- tions between Internet use and sociodemographic and clinical characteristics were investigated using multivariable logistic regression models. Focus groups with clinicians explored the acceptability and utility of asking about Internet use. Results: The prevalence of S/Sh-related Internet use was 8.4% (95% CI: 6.8–10.1%) among adult hospital presentations and 26.0% (95% CI = 21.3–31.2%) among children’s hospital presenta- tions. In both samples, S/Sh-related Internet use was associated with higher levels of suicidal intent. Mostly, clinicians found it acceptable to ask about Internet use during psychosocial assessments and believed this could inform perceptions of risk and decision-making. Limitations: It is unclear whether the findings in this study are applicable to the general self-harm patient population because only those who had psy- chosocial assessments were included. Conclusion: S/Sh-related Internet use is likely to become increasingly relevant as the Internet-native generation matures. Furthermore, Internet use may be a proxy marker for intent. Keywords: suicidal intent, psychosocial assessment, hospital presentation, epidemiology The rise in Internet use in recent years adds a new dimen- cohort study has demonstrated increasing suicidal idea- sion to suicide prevention. Most recent data indicates that tion among people reporting S/Sh-related Internet use in 90% of UK households have access to the Internet, as do the months following usage, compared with those who had at least 86% and 77% of households in Australia and the not used the Internet in relation to their self-harm. (Sueki, United States, respectively (Australian Bureau of Statistics, Yonemoto, Takeshima, & Inagaki, 2014) Clinical reports 2016; Office for National Statistics, 2017a; Ryan & Lewis, indicate that S/Sh-related Internet use preceded 2% of 2017). Use of the Internet within the previous 3 months suicides among people with mental illness in England be- was reported by 89% of adults and 99% of young adults in tween 2011 and 2013 (University of Manchester, 2015). the UK (Office for National Statistics, 2017b). A later study in England between 2014 and 2015, based In a recent population-based study of 21-year-olds in on data from investigations carried out by a range of offi- England, 22.5% reported suicide/self-harm (S/Sh)-related cial bodies including Child Death Overview Panels, found ${protocol}://econtent.hogrefe.com/doi/pdf/10.1027/0227-5910/a000522 - Tuesday, August 07, 2018 2:32:47 AM IP Address:137.222.155.15 Internet use (Mars et al., 2015); this figure includes those that 23% of suicides among under-25-year-olds followed who inadvertently came across the information as well as suicide-related Internet use (University of Manchester, those who actively sought it. Cross-sectional studies us- 2016). Studies focusing on new and emerging high-lethal- ing online surveys have varied in their findings but have ity suicide methods have reported evidence that choice shown higher rates of social anxiety, depression, or suicid- of method was influenced by Internet searching (Gunnell al ideation in people who report S/Sh-related Internet use et al., 2015). compared with those who do not (Bell, Mok, Gardiner, & While some evidence indicates an increase in the acces- Pirkis, 2017; Mok, Jorm, & Pirkis, 2016; Niederkroten- sibility of suicide-promoting information online (Biddle thaler, Haider, Till, Mok, & Pirkis, 2017). Furthermore, a et al., 2016), the Internet also increases access to helpful © 2018 Hogrefe Publishing. Crisis 2018 Distributed under the Hogrefe OpenMind License (https://doi.org/10.1027/a000001) https://doi.org/10.1027/0227-5910/a000522 2 P. Padmanathan et al., Suicide and Self-Harm Related Internet Use information such as links to support services and advice Internet Use about managing mental health problems (Daine et al., 2013; Mars et al., 2015). Additionally, it provides oppor- Information regarding Internet use was recorded during a tunities to deliver suicide prevention interventions, par- psychosocial assessment by the Liaison Psychiatry team. A ticularly to populations that may otherwise be difficult to psychosocial assessment is performed on approximately engage (Lai, Maniam, Chan, & Ravindran, 2014; Mewton 65% of SH presentations at the adult hospital and 82% of & Andrews, 2015; van Spijker, van Straten, & Kerkhof, presentations at the children’s hospital (Carroll & Gunnell, 2014, 2015). 2015). The most common reason for a lack of psychosocial Recent reviews, however, have highlighted that empiri- assessment is self-discharge prior to the assessment being cal research in this area is limited (Daine et al., 2013; Mok, carried out. However, levels of psychosocial assessment in Jorm, & Pirkis, 2015). Important information, such as the Bristol are higher than the national average (Cooper et al., estimated proportion of people accessing suicide-related 2013). material online and the type of information accessed when The psychosocial assessments involve face-to-face in- feeling suicidal, is currently unknown. The aims of this terviews using a standardized proforma, which also in- cross-sectional study were to: (a) estimate the frequency cludes questions about sociodemographics, method of of S/Sh-related Internet use among patients presenting to self-harm, and clinical characteristics. From November the emergency department (ED) who have self-harmed; (b) 2012 the proforma was updated to include the question, explore the sociodemographic and clinical characteristics “In the period leading up to your attempt, did you use the of these patients; and (c) explore clinicians’ views on the Internet for any reasons associated with this episode (e.g., acceptability and utility of asking patients about S/Sh-re- as a source of help or to investigate self-harm, suicide or lated Internet use during psychosocial assessments. To our suicide methods)? Y/N.” A follow-up question allowed free knowledge, this is the first study investigating S/Sh-related text responses: “If yes, how?” This study therefore investi- Internet use in a cohort of hospital-presenting self-harm gates patient-defined S/Sh-related Internet use. patients. The study aims to inform suicide prevention pol- icy as well as assist clinicians in assessing this group of pa- tients when presenting to hospital. Clinical and Sociodemographic Characteristics Method Sociodemographic and clinical characteristics investigat- ed included: age (adults: 15–24, 25–34, 35+ years), em- ployment, ethnicity, gender, past psychiatric history, and Sample past self-harm. For children’s hospital presentations we se- lected the age categories 8–12, 13–14, and 15–18 years in Information on individuals presenting following self-harm order to investigate trend in frequency of use while ensur- to the adult and children’s EDs of the Bristol Royal Infir- ing reasonable numbers in each category. However, when mary (BRI) and Bristol Royal Hospital for Children (BRHC) exploring associations, the lower two age categories were is recorded on a self-harm surveillance register (Carroll & combined owing to a low number of children reporting S/ Gunnell, 2015). All data from presentations that had a psy- Sh-related Internet use in these age groups. chosocial assessment between January 2013 and Decem- The clinical features of the self-harm investigated were: ber 2015 at the adult hospital and September 2013 and nature of self-harm (method and Beck Suicide Intent Scale; November 2015 at the children’s hospital were analyzed. Beck, Schuyler, & Herman, 1974); and severity of under- Only a patient’s first hospital presentation during this pe- lying mental health problem as indexed by Crisis Team riod was included, so as to avoid our estimates being dis- referral and admission to a psychiatric hospital (adult pa- torted by a small number of frequent attenders. Start dates tients only). Method data were categorized as self-poison- ${protocol}://econtent.hogrefe.com/doi/pdf/10.1027/0227-5910/a000522 - Tuesday, August 07, 2018 2:32:47 AM IP Address:137.222.155.15 were based on when information on S/Sh-related Internet ing, self-injury, self-poisoning and self-injury combined, use (see next section) began to be collected consistently and high-lethality method (drowning; hanging and suf- in each hospital. End dates were the latest date for which focation; jumping; gassing).
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