Rohan Borschmann, PhD1,2,3,4, Jesse T. Young, MPH2,5,6, Stuart A. Kinner, PhD1,2,7,8,9
 
1 Centre for Adolescent Health, Murdoch Children’s Research Institute; Royal Children’s Hospital, 50 Flemington Road, Parkville VIC 3052, Melbourne, AUSTRALIA
2 Centre for Mental Health, Melbourne School of Population and Global Health; University of Melbourne, AUSTRALIA
3 Health Services and Population Research Department; Institute of Psychiatry, Psychology & Neuroscience; King’s College London, UK
4 Department of Psychiatry; University of Melbourne, AUSTRALIA
5 Centre for Health Services Research, School of Population and Global Health, The University of Western Australia, Perth, WA, 6009, AUSTRALIA
6 National Drug Research Institute, Curtin University, Perth, WA, 6008, AUSTRALIA
7 Mater Research Institute-UQ; University of Queensland, AUSTRALIA
8 School of Public Health and Preventive Medicine; Monash University, Melbourne, AUSTRALIA
9 Griffith Criminology Institute; Griffith University, AUSTRALIA
 
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It is well-established that rates of both suicide and self-harm are elevated in incarcerated populations. Rates of suicide following release from prison are also elevated but, until recently, little was known about the epidemiology of self-harm in people released from prison. We set out to address this notable gap in the literature by analysing cohort data from the Passports study (1), a randomised controlled trial of a service brokerage intervention for adults within six weeks of expected release from one of seven prisons in Queensland, Australia. The aims of our program of research were to:
 
1)      determine the incidence of, identify risk factors for, and characterise ambulance attendances and emergency department (ED) presentations resulting from self-harm (i.e. ‘medically-verified self-harm’); and
2)      examine the level of agreement between self-reported self-harm history and self-harm in historical medical records, and to investigate the association between self-harm history and medically-verified self-harm in adults after release from prison.
 
We conducted baseline surveys with 1325 adults between 2008 and 2010. Baseline data were linked prospectively with state-wide correctional, ambulance, emergency department, hospital, and death records. We investigated associations between baseline demographic, criminal justice and mental health-related factors, and subsequent ambulance attendances and emergency department presentations resulting from self-harm.
 
During the follow-up period (approximately 2-4 years per participant), there were 120 (3.9%) ambulance attendances (2) and 165 (4.4%) emergency department presentations (3) resulting from self-harm. Factors associated with ambulance and ED utilisation resulting from self-harm were: identifying as Indigenous, having previously been hospitalised for psychiatric treatment, having been identified by prison staff as being at risk of self-harm whilst incarcerated, and having had a prior ambulance attendance or emergency department presentation due to self-harm.
 
The level of agreement between self-reported and medically-verified history of self-harm was poor, with just 37% of participants with a history of medically verified self-harm disclosing this at baseline. Adults with a medically-verified history of self-harm were at increased risk of self-harm after release from prison compared to people without a history of self-harm in their medical records. The risk of self-harm for those who did not disclose self-harm but had medical records confirming previous self-harm (i.e. the ‘false negative’ group) was higher than for those who did disclose self-harm but had no medical records to confirm this (i.e. the ‘unconfirmed positive’ group). A total of 24 participants (19.5% of those who had a medically-verified self-harm episode during follow-up) were in the ‘false negative’ group, highlighting the magnitude of the missed opportunity to intervene if administrative data were not available.
 
Based on our findings, we conclude that ambulance and ED utilisation resulting from self-harm after release from prison are common and represent an opportunity for tertiary self-harm and suicide intervention in this population. The transition from prison to the community is challenging, particularly for those with a history of mental disorder; mental health support during and after release may reduce the risk of adverse outcomes, including self-harm. Finally, a self-reported history of self-harm should not be considered a sensitive indicator of prior self-harm resulting in acute care contact, or of future self-harm risk in adults released from prison. To identify those who should be targeted for preventive strategies, data from multiple sources should be used whenever possible.
 
 
 
References
 
1.            Kinner SA, Lennox N, Williams GM, Carroll M, Quinn B, Boyle FM, et al. Randomised controlled trial of a service brokerage intervention for ex-prisoners in Australia. Contemporary Clinical Trials. 2013;36(1):198-206.
2.            Borschmann R, Young J, Moran P, Carroll M, Heffernan E, Spittal M, et al. Ambulance attendances resulting from self-harm in adults following release from prison: findings from a prospective data linkage study. Social Psychiatry and Psychiatric Epidemiology. 2017;(in press).
3.            Borschmann R, Thomas E, Moran P, Carroll M, Heffernan E, Spittal MJ, et al. Self-harm following release from prison: A prospective data linkage study. Australian and New Zealand Journal of Psychiatry. 2016;51(3):DOI: 10.1177/0004867416640090.
3.          Borschmann, R, Young, J, Moran, P, Spittal, MJ, Snow, K, Mok, K, Kinner, SA. (2016). The accuracy and predictive value of incarcerated adults’ accounts of their self-harm histories: findings from an Australian data linkage study. CMAJ Open (http://cmajopen.ca/content/5/3/E694.full).

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