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Biomedical subjects

D Gunnell

Publications and source records attributed to D Gunnell.

At least 73 records · Page 4Linked to original sources
PubMed2001

Psychosocial and pharmacological treatment of patients following deliberate self-harm: the methodological issues involved in evaluating effectiveness.

Development of effective treatments for patients following deliberate self-harm (self-poisoning or self-injury) is a very important element in suicide prevention. The randomized controlled trial (RCT) is the mainstay of evaluation of treatments. In a systematic review of the literature, the effectiveness of treatments based on RCTs was examined and the quality of the RCTs was assessed. Twenty trials were identified, and where possible, these were grouped on the basis of similarities among the types of treatment. In this paper, we examine the methodological aspects of the trials and consider what may be learned that will assist in the design of future studies in this field. The methodological quality of the trials was reasonable, but most trials included too few participants to detect clinically important differences in rates of repeated self-harm. In planning future trials, the following major issues should be addressed: investigators should perform power calculations to determine the number of subjects necessary to detect clinically important effects, provide information on method of randomization and interventions, use standard measures of outcome, and focus on homogeneous subgroups of patients. Improving the methodology of future studies in this field will be essential if sound evidence is to be obtained which can inform effective service provision for deliberate self-harm patients.

Humans↗
PubMed2000

Psychosocial versus pharmacological treatments for deliberate self harm.

OBJECTIVES: To identify and synthesise the findings from all randomised controlled trials that have examined the effectiveness of treatments of patients who have deliberately harmed themselves. SEARCH STRATEGY: Electronic databases screened: MEDLINE (from 1966-February 1999); PsycLit (from 1974-March 1999); Embase (from 1980-January 1999); The Cochrane Controlled Trials Register (CCTR) No.1 1999. Ten journals in the field of psychiatry and psychology were hand searched for the first version of this review. We have updated the hand search of three specialist journals in the field of suicidal research until the end of 1998. Reference lists of papers were checked and trialists contacted. SELECTION CRITERIA: All RCTs of psychosocial and/or psychopharmacological treatment versus standard or less intensive types of aftercare for patients who shortly before entering a study engaged in any type of deliberately initiated self-poisoning or self-injury, both of which are generally subsumed under the term deliberate self-harm. DATA COLLECTION AND ANALYSIS: Data were extracted from the original reports independently by two reviewers. Studies were categorized according to type of treatment. The outcome measure used to assess the efficacy of treatment interventions for deliberate self-harm was the rate of repeated suicidal behaviour. We have been unable to examine other outcome measures as originally planned (e.g. compliance with treatment, depression, hopelessness, suicidal ideation/thoughts, change in problems/problem resolution). MAIN RESULTS: A total of 23 trials were identified in which repetition of deliberate self-harm was reported as an outcome variable. The trials were classified into 11 categories. The summary odds ratio indicated a trend towards reduced repetition of deliberate self-harm for problem-solving therapy compared with standard aftercare (0.70; 0.45 to 1.11) and for provision of an emergency contact card in addition to standard care compared with standard aftercare alone (0.45; 0.19 to 1.07). The summary odds ratio for trials of intensive aftercare plus outreach compared with standard aftercare was 0.83 (0.61 to 1.14), and for antidepressant treatment compared with placebo was 0.83 (0. 47 to 1.48). The remainder of the comparisons were in single small trials. Significantly reduced rates of further self-harm were observed for depot flupenthixol vs. placebo in multiple repeaters (0. 09; 0.02 to 0.50), and for dialectical behaviour therapy vs. standard aftercare (0.24; 0.06 to 0.93). REVIEWER'S CONCLUSIONS: There still remains considerable uncertainty about which forms of psychosocial and physical treatments of self-harm patients are most effective, inclusion of insufficient numbers of patients in trials being the main limiting factor. There is a need for larger trials of treatments associated with trends towards reduced rates of repetition of deliberate self-harm. The results of small single trials which have been associated with statistically significant reductions in repetition must be interpreted with caution and it is desirable that such trials are also replicated.

Cognitive Behavioral Therapy↗
PubMed2000

Method availability and the prevention of suicide--a re-analysis of secular trends in England and Wales 1950-1975.

BACKGROUND: In England and Wales in the 1960s there were marked declines in suicide rates. These reductions were partly attributable to the detoxification of the domestic gas supplies; however, their extent varied by age and gender, with the most striking effects seen in older men. The objective of this study was to investigate method-specific trends in suicide between 1950 and 1975 to elucidate possible explanations for the patterns seen in different demographic groups. METHODS: An analysis of age-standardised method-specific suicide rates for England and Wales between 1950 and 1975 was carried out using routinely available mortality and population statistics. RESULTS: As has previously been shown, there were marked reductions in suicides by gassing in men and women of all ages between 1960 and 1975. In women and younger men, the effects of these reductions on overall suicide rates were partially offset by rises in drug overdose deaths (method substitution), but there were no immediate increases in the use of other suicide methods. In contrast, in older men, reductions in suicide by gassing were accompanied by only a slight increase in overdose suicides as well as reductions in rates of suicide using all other methods. The modest rise in overdose fatalities in older men occurred despite the fact that they were more often prescribed barbiturates and tricyclic antidepressants than younger men. CONCLUSIONS: Accessibility to and the lethality of particular methods of suicide may have profound effects on overall suicide rates. Such effects appear to depend upon the popularity of the method and the extent to which alternative methods that are acceptable to the individual are available. Social and psychological interpretations of fluctuations in suicide rates should only be made after assessing the possible contribution to these of changes in method availability and lethality.

Adolescent↗
PubMed2000

Are recent increases in deliberate self-harm associated with changes in socio-economic conditions? An ecological analysis of patterns of deliberate self-harm in bristol 1972-3 and 1995-6.

BACKGROUND: The incidence of deliberate self-harm (DSH) in Britain has increased markedly over the last 30 years. Reasons for this rise are not clear. We have investigated whether changes in the social and economic environment underlie any of the recent increase in DSH incidence. METHODS: An ecological analysis was used to assess associations between changes in census-based measures of the social and economic environment--the Townsend Deprivation Index and a three-factor social fragmentation index--and changes in age- and sex-specific hospital attendance rates for DSH for the 28 wards of the city of Bristol between 1972-3 and 1995-6. RESULTS: There were significant cross-sectional associations between the Townsend Index and rates of DSH in both males and females in both time periods. Increases in Townsend Index were also associated with increases in DSH. This association was statistically significant at the 5% level in 25-34 year-old females. Associations with the social fragmentation index were weak, although our index was based on rather limited data. CONCLUSIONS: This analysis suggests that changes in levels of socio-economic deprivation may influence area-specific patterns of DSH and such changes may have contributed to recent rises in DSH.

Adolescent↗
PubMed2000

Youth suicide trends in Australian metropolitan and non-metropolitan areas, 1988-1997.

OBJECTIVE: The objective of this study was to examine trends in suicide among 15-34-year-olds living in Australian metropolitan and non-metropolitan areas between 1988 and 1997. METHOD: Suicide and population data were obtained from the Australian Bureau of Statistics. We calculated overall and method-specific suicide rates for 15-24 and 25-34-year-old males and females separately, according to area of residence defined as non-metropolitan (< or = 20,000 people) or metropolitan. RESULTS: Between 1988 and 1997 suicide rates in 15-24-year-old non-metropolitan males were consistently 50% higher than metropolitan 15-24-year-olds. In 1995-1997, for example, the rates were: 38.2 versus 25.1 per 100,000 respectively (p < 0.0001). The reverse pattern was seen in 25-34-year-old females with higher rates in metropolitan areas (7.5 per 100,000) compared with non-metropolitan areas (6.1 per 100,000, p = 0.21) in 1995-1997. There were no significant differences according to area of residence in 25-34-year-old males or 15-24-year-old females. Over the years studied we found no clear evidence that suicide rates increased to a greater extent in rural than urban areas. Rates of hanging suicide have approximately doubled in both sexes and age groups in both settings over this time. Despite an approximate halving in firearm suicide, rates remain 3-fold higher among nonmetropolitan residents. CONCLUSION: Non-metropolitan males aged 15-24 years have disproportionately higher rates of suicide than their metropolitan counterparts. Reasons for this require further investigation. Hanging is now the most favoured method of non-metropolitan suicide replacing firearms from 10 years ago. Although legislation may reduce method-specific suicide the potential for method-substitution means that overall rates may not fall. More comprehensive interventions are therefore required.

Adolescent↗
PubMed2000

How great a burden does early discharge to hospital-at-home impose on carers? A randomized controlled trial.

OBJECTIVE: to assess the effects of an early discharge hospital-at-home scheme on self-reported carer strain and quality of life. DESIGN: a randomized controlled trial SETTING: Bristol, UK. SUBJECTS: 133 carers of patients receiving either early discharge from hospital to hospital-at-home (n = 93) care or usual hospital care and discharge (n = 40). OUTCOME MEASURES: modified 12-item Carer Strain Index, COOP-WONCA charts and EuroQol EQ-5D at 4 weeks and 3 months post-randomization. RESULTS: the mean age of carers was 65 years; 56% were women. There were no marked differences between the groups in any of the outcomes used at either 4-week or 3-month follow-up. CONCLUSION: there was no evidence of increased self-reported burden imposed on carers of patients discharged early from hospital. Decisions on the implementation of hospital-at-home schemes should be influenced by considerations of cost and effectiveness rather than effects on carers. The effects on carers may, however, differ for other forms of home-based care.

Aged↗
PubMed2000

Comparison of trends in method-specific suicide rates in Australia and England & Wales, 1968-97.

OBJECTIVE: To compare secular trends in method-specific suicide rates among young people in Australia and England & Wales between 1968 and 1997. METHODS: Australian data were obtained from the Australian Bureau of Statistics, and for England & Wales from the Office for National Statistics. Overall and method-specific suicide rates for 15-34 year old males and females were calculated using ICD codes E950-9 and E980-9 except E988.8. RESULTS: In both settings, suicide rates have almost doubled in young males over the past 30 years (from 16.8 to 32.9 per 100,000 in Australia and from 10.1 to 19.0 in England & Wales). Overall rates have changed little in young females. In both sexes and in both settings there have been substantial increases in suicide by hanging (5-7 fold increase in Australia and four-fold increase in England & Wales). There have also been smaller increases in gassing in the 1980s and '90s. In females, the impact of these increases on overall rates has been offset by a decline in drug overdose, the most common method in females. CONCLUSIONS: Rates of male suicide have increased substantially in both settings in recent years, and hanging has become an increasingly common method of suicide. The similarity in observed trends in both settings supports the view that such changes may have common causes. Research should focus on understanding why hanging has increased in popularity and what measures may be taken to diminish it.

Adolescent↗
PubMed2000

The effects of dietary supplementation on growth and adult mortality: a re-analysis and follow-up of a pre-war study.

The aim of this study was to re-analyse a diet supplementation study conducted in the 1930s and investigate the effects of food supplementation on children's growth and later adult mortality. A non-randomised controlled trial was carried out in eight of the sixteen centres participating in the Carnegie Survey of Diet and Health in pre-war Britain (1937-39). Food supplements were given for 12 months either at school or as food parcels sent to the family home. 545 children aged 2-14 received food supplements and 494 children of a similar age acted as their controls. The children came from 465 families. The increase in childhood height and its components-leg length and trunk length-over 12 months follow-up were measured. Mortality from all causes over 60 years follow-up to 1998 was also assessed. There were important differences between fed and control children at baseline. Supplemented children came from larger families with poorer diets and most were examined, on average, 12 days later than control children. After adjustment for baseline imbalances those receiving supplements increased in height by 3.7 mm (95% CI 1.9-5.5) more than the controls. After adjustment, most of the difference in growth appeared to arise as a result of increases in leg length. After adjustment for confounding factors measured in childhood, no significant effect of childhood food supplements on adult mortality was seen. The age-adjusted hazard ratio for all cause mortality was higher in the supplemented compared to control subjects: 1.13 95% CI (0.77-1.64). We found that provision of childhood food supplements led to increased growth amongst supplemented children. The increases in height in this study were mainly as a result of increases in leg length and are similar to those found in a more recent randomised trial in South Wales. Whilst other analyses suggest that childhood height is important in predicting adult mortality patterns, we found no significant effect of childhood food supplements on adult mortality patterns in this study, although the study lacked statistical power to detect small but, nevertheless, important differences in mortality. Larger randomised trials with long term follow-up would be required to investigate the impact of childhood food supplementation on adult health.

Adolescent↗
PubMed2000

How accurately are height, weight and leg length reported by the elderly, and how closely are they related to measurements recorded in childhood?

BACKGROUND: This paper examines (1) the accuracy of self-reported height, leg length and weight in a group of subjects aged 56-78; (2) whether recent measurement of height and weight influences the accuracy of self-reporting and (3) associations between childhood and adult height, leg length and BMI measured in old age. METHODS: All 3182 surviving members of the Boyd Orr cohort were sent postal questionnaires in 1997-1998 and a sub-sample (294) was also clinically examined. RESULTS: Self-reported height was overestimated and body mass index (BMI), based on reported height and weight, underestimated. The mean difference between self-report and measured values were for height: 2.1 cm in males and 1.7 cm in females; for BMI the difference was -1.3 kg/m(2) in males and -1.2 kg/m(2) in females. Shorter individuals and older subjects tended to over-report their height more than others. The overweight under-reported their weight to a greater extent. Recent measurement appeared to decrease over-reporting of height but not weight. Correlations between self-report and measured height and BMI were generally over 0.90, but weaker for leg length (r = 0.70 in males and 0.71 in females). Adult height and leg length were quite closely related to their relative values in childhood (correlation coefficients ranged from 0.66 to 0.84), but associations between adult and childhood BMI were weak (r = 0.19 in males and 0.21 in females). CONCLUSIONS: Self-reported measures of height and weight may be used in studies of the elderly although systematic reporting errors may bias effect estimates. As overweight individuals tend to under-report and the short and underweight tend to over-report, studies investigating associations of disease with height and weight using self-reported measures will underestimate effects. The weak associations between childhood and adult BMI indicate that associations between childhood adiposity and adult cardiovascular disease found in this cohort may reflect the specific effect of childhood overweight, rather than its persistence into adulthood. This suggests that avoidance of adiposity may be as important in childhood as in adulthood.

Aged↗
PubMed2000

Use of paracetamol (acetaminophen) for suicide and nonfatal poisoning: worldwide patterns of use and misuse.

Paracetamol (acetaminophen) is one of the most frequently used drugs in intentional overdoses. We have investigated associations between its availability and its use for overdose and suicide around the world by means of a postal questionnaire and literature review. Countries that limit the quantity of paracetamol available in a single purchase generally report lower rates of paracetamol-related morbidity and mortality. National policy decisions regarding restrictions on its availability need to weigh the inconvenience caused to the many who use the drug safely against those of the few in whom overdose may be fatal. We recommend restricting the quantity of drug available as a single purchase as the most pragmatic means of reducing paracetamol-related suicide and liver failure.

Acetaminophen↗
PubMed1999

Childhood socioeconomic position and adult cardiovascular mortality: the Boyd Orr Cohort.

The relation between childhood socioeconomic position and adult cardiovascular mortality is examined in 3,750 individuals whose families took part in the Carnegie survey of family diet and health in England and Scotland between 1937 and 1939. The trend in coronary heart disease mortality across social position groups was not statistically significant at conventional levels (p = 0.12), while a strong linear trend was seen for stroke mortality (p = 0.01). Adjustment for the Townsend deprivation index of area of residence during adult life did not materially alter these findings, indicating that the effects of socioeconomic influences upon particular cardiovascular diseases differ according to the age at which they are experienced.

Age of Onset↗