Article The implementation and first insights of the French-speaking Swiss programme for monitoring self-harm OSTERTAG, Louise, et al. Abstract Self-harm is a major risk factor for suicide but remains poorly documented. No data on self-harm in French-speaking Switzerland exist. To address this deficiency, the Swiss Federal Office of Public Health commissioned a specific self-harm monitoring programme. We present and discuss its implementation and first findings. Reference OSTERTAG, Louise, et al. The implementation and first insights of the French-speaking Swiss programme for monitoring self-harm. Swiss Medical Weekly, 2019, vol. 149, p. w20016 DOI : 10.4414/smw.2019.20016 PMID : 30715721 Available at: http://archive-ouverte.unige.ch/unige:144753 Disclaimer: layout of this document may differ from the published version. 1 / 1 Original article | Published 04 February 2019 | doi:10.4414/smw.2019.20016 Cite this as: Swiss Med Wkly. 2019;149:w20016 The implementation and first insights of the French-speaking Swiss programme for monitoring self-harm Ostertag Louisea, Golay Philippea, Dorogi Yvesa, Brovelli Sebastie§na, Bertran Martaa, Cromec Ioanb, Van Der Vaeren Bénédicteb, Khan Riazc, Costanza Alessandrac, Wyss Karinec, Edan Anned, Assandri Francescade, Barbe Rémyd, Lorillard Solennd, Saillant Stéphanef, Michaud Laurentae a Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland b Psychiatry and Psychotherapy Pole, Valais Hospital, Sion, Switzerland c Emergency Psychiatry Department, Geneva University Hospitals, Geneva, Switzerland d Division of Child and Adolescent Psychiatry, Geneva University Hospital, Geneva, Switzerland e McGill Group for Suicide Studies, McGill University, Montreal, Canada f Centre for Psychiatric Emergencies and Liaison Psychiatry, Neuchâtel Psychiatry Centre, Neuchâtel, Switzerland Summary than in Neuchâtel (1.6% and 4.9%, Fisher’s exact test, p = 0.006). AIMS OF THE STUDY: Self-harm is a major risk factor for suicide but remains poorly documented. No data on CONCLUSIONS: Our results are globally consistent with self-harm in French-speaking Switzerland exist. To ad- previous research on self-harm. We found significant inter- dress this deficiency, the Swiss Federal Office of Public site differences in methods, suicidal intent and self-harm Health commissioned a specific self-harm monitoring pro- rates. Our findings highlight the importance of implement- gramme. We present and discuss its implementation and ing local self-harm monitoring to identify specific at-risk first findings. groups and develop targeted preventive intervention. METHODS: Every patient aged 18–65 years presenting Keywords: epidemiology, monitoring, self-harm, suicide, for self-harm to the emergency departments of the Lau- suicide attempt, suicide prevention sanne and Neuchâtel general hospitals were included in the monitoring programme over a 10-month period (De- Introduction cember 2016 to September 2017). Clinicians collected Suicide is among the top 20 causes of death worldwide. anonymous sociodemographic and clinical data. According to the World Health Organization (WHO), near- RESULTS: The sample included 490 patients (54.9% fe- ly one million people die from suicide every year [1]. Self- male and 45.1% male) for 554 episodes of self-harm, harm is one of the strongest predictors of completed sui- showing a higher proportion of patients aged 18–34 cide [2–5]. Although high-quality data exist for completed (49.2%) than older age groups (35–49, 33.7% and 50–65, suicide, self-harm remains poorly documented worldwide, 17.1%). Patients were mostly single (56.1%) and in prob- and the WHO recommends monitoring self-harm in order lematic socioeconomic situations (65.7%). Self-poisoning to target prevention [1, 6, 7]. Emergency services are one was the most commonly used method (58.2%) and was of the best places to establish such monitoring systems, preferred by women (71% of females and 42.5% of males, since the large majority of those who attempt suicide and Fisher’s exact test, p <0.001) and the majority of patients people who conduct self-harm need medical care [8, 9]. (53.3%) had experienced at least one previous episode Previous monitoring systems have been established in the of self-harm. The self-harm rate was 220 per 100,000 in- United Kingdom (UK), first in Oxford [10–12] in the habitants in Lausanne and 140 in Neuchâtel. Suicidal in- 1970s and later in Manchester and Leeds, allowing be- tent was clear for 50.6% of the overall sample, unclear tween-site comparisons [13, 14]. Ireland is one of the few for 25.1% and absent for 24.3%. It differed significantly countries with national registration [15, 16]. Numerous ex- between sites (χ2(2) = 9.068, p = 0.011) as Lausanne isting systems were introduced in Europe, following the reported more incidents of unclear intent (27.7% versus WHO’s international programmes (Multicentre Study on Correspondence: 17.4% in Neuchâtel) and Neuchâtel more incidents with Suicidal Behaviour, MONitoring SUicidal Behaviour in Laurent Michaud, Départe- absence of intent (33.1% versus 21.3% in Lausanne). In Europe, Suicide Prevention – Multisite Intervention Study ment de psychiatrie CHUV, Lausanne, patients more frequently resorted to methods on Suicidal Behaviours) [17, 18], in, for example, some Bâtiment les Cèdres, such as jumping from a height (11.4%) and hanging (9%) cities in France [19] and Italy [20]. CH-1008 Prilly, lau- rent.michaud[at]chuv.ch Swiss Medical Weekly · PDF of the online version · www.smw.ch Page 1 of 9 Published under the copyright license “Attribution – Non-Commercial – No Derivatives 4.0”. No commercial reuse without permission. See http://emh.ch/en/services/permissions.html. Original article Swiss Med Wkly. 2019;149:w20016 Results of these monitoring systems showed, for instance, Procedure that females [11, 13, 15, 17–22], young people [13, 17, 18, Monitoring was first implemented in two sites, Lausanne 21, 23], single persons (especially men) [17, 24–27], im- and Neuchâtel (see “sample” section for site details), in migrants [27–29], and people with a low level of education December 2016, and was expanded to Valais (June 2017) [30] or unemployed [1, 30] are more at risk for self-harm. and Geneva (mid-July 2017). At the included sites, each These systems also established remarkable gender differ- patient presenting with self-harm was evaluated by a resi- ences [31, 32] regarding the selection of methods: self-poi- dent in psychiatry or psychology or by a psychiatric nurse, soning appears to be more likely in females than in males, under the supervision of a trained psychiatrist. Data collec- whereas ‘violent’ methods such as hanging or jumping tion was carried out using the information gathered during from a height are more common among males [19, 31, this clinical evaluation. One coordinator was designated 32]. Identifying specific risk factors enables the develop- to supervise and control the quality of the data collection ment of recommendations for public health strategies and process for each site. In addition, regularly scheduled re- the implementation of new interventions. In England, for search team meetings were planned in order to facilitate example, offering specific support for alcohol misuse or the implementation of the monitoring as well as the group relationship problems as issues surrounding self-harm has training sessions for every caregiver collecting data. Con- been identified as a relevant preventive measure [33]. Fol- sidering staff turnover, these group sessions were planned lowing self-harm monitoring in German-speaking Switzer- every six months at each site. They included (i) informa- land, recommendations were made to keep as low as pos- tion on the epidemiology of suicide and self-harm, (ii) a sible the package size and dosage of specific drugs used by presentation about the monitoring project, and (iii) training people who self-harm [29]. These monitoring systems and sessions with feedback on the data collection procedure. interventions are not only relevant for developing suicide prevention strategies, but also to prevent self-harm itself. Sample As well as suffering, self-harmers are prone to endure stig- Every patient presenting for self-harm in the selected ma [34] which can lead to struggles with help-seeking [35]. emergency departments (see below) was included. Self- Preventing self-harm also has an impact on public health harm was defined as “all non-fatal intentional acts of self- costs. In Switzerland, costs related to hospitalisation due to poisoning or self-injury, irrespective of degree of suicidal self-harm approximate 200 million Swiss francs per year intent or other types of motivation” [10], thus including [36]. both DSM 5 non-suicidal self-injury [39] and other acts of In Switzerland, although suicide is the fourth leading cause self-harm with various suicidal intents, following a dimen- of early death [37] and more than 10,000 persons seek sional rather than categorical approach to the phenomenon medical treatment after a suicide attempt every year [36], [6, 12]. Suicidal intent was nonetheless recorded in order no systematic monitoring currently exists for self-harm at to distinguish between non-suicidal self-injury and suicidal national level [36]; previous monitoring systems were con- behaviour disorder. ducted in small geographical areas by the multi-centred Four sites representing four regions that encompassed ur- monitoring projects WHO/MONSUE in Bern (2004–2010 ban and rural areas as well as all patient