Healthcare presentations with self-harm and the association with COVID-19: an e-cohort whole-population-based study using individual-level linked routine electronic health records in Wales, UK, 2016 - March 2021

Abstract

Background Multi-setting population-based studies on healthcare service presentations with self-harm covering the first 12 months of the COVID-19 pandemic are yet to be published. Aims Ascertain changes across settings in healthcare service presentations with self-harm during Waves 1 and 2 of the COVID-19 pandemic. Method E-cohort study using individual-level linked routine healthcare data from Wales, UK, 2016-March 2021. We measured weekly proportion of self-harm contacts and people who self-harmed in contact with general practice (GP), emergency department (ED) and hospital admissions. We modelled weekly trends using linear regression and generalised estimated equations, quantifying time differences using difference-in-difference (DiD). Results We included 3,552,210 Welsh residents aged ≥10 years. Counts of self-harm presentations across settings was at a minimum at the start of stay-at-home restrictions during both waves and recovered compared to previous years in 3-5 months. Those who self-harmed in April 2020 were more likely to be seen in GP compared to other settings and previous years - mean rate of OR=1.2, although actual numbers fell. The proportion of self-harm ED contacts admitted to hospital dropped from June 2020 (1.9 [1.5-2.3] pp/month). Self-harm and COVID-19 infection had a bidirectional effect - self-harm history had OR=1.4 [1.2-1.6] and incidence had DiD=1.1 [0.8-1.4]. Conclusions Those that self-harmed and sought help during the COVID-19 pandemic potentially encountered stringent criteria for hospitalisation, particularly in Wave 2, while in Wave 1 they preferentially presented to GP. Reductions in contacts likely resulted in unmet healthcare needs which may later emerge placing further burden on individuals and healthcare services.

The impact of the COVID-19 pandemic on presentations to health services following self-harm: systematic review

“…Four studies used healthcare records in the UK to compare expected versus observed primary and secondary care–recorded episodes of self-harm, and found reductions of between 26 and 44%. 6,7,30,32 Another study based in Sri Lanka found a 32% reduction in hospital presentations for self-poisoning compared with pre-pandemic numbers. However, these estimates included months no later than August 2020.…”

“…All six studies rated as high-moderate quality (including one preprint) found decreases in frequency of presentations during the early months of the pandemic, with reductions of between 17 and 56% reported. 6,7, [29][30][31][32] These studies were of primary and secondary care settings combined (four studies), emergency department presentations among ages 18-25 years (one study) and self-poisoning presentations to hospital (one study). Four studies used healthcare records in the UK to compare expected versus observed primary and secondary care-recorded episodes of self-harm, and found reductions of between 26 and 44%.…”

“…Among the four studies including months from 2021 in their observation period (up to May 2021), three were rated as high-moderate quality. Among these, two studies of primary and secondary care-recorded self-harm reported longer-term reductions of between 8 and 30%, respectively, 30,32 and another study of emergency department presentations by young people aged 12-25 years found no overall change. 29 Studies including follow-up months beyond 2020 were limited to those originating from high-income countries.…”

SARS-CoV-2 Infection and the Risk of Suicidal and Self-Harm Thoughts and Behaviour: A Systematic Review

“…For example, a study of clinical presentations for self-harm in Wales, posted as a preprint after the timeframe of our review, showed an association between SARS-CoV-2 infection and self-harm. 28 Specifically, a prior history of a self-harm presentation appeared to increase the risk of SARS-CoV-2 infection; in contrast, infection was not associated with subsequent self-harm. 28 Emerging evidence suggests that SARS-CoV-2 infection may have a bidirectional relationship with psychiatric illness with each being a risk factor for occurrence of the other.…”

“… 28 Specifically, a prior history of a self-harm presentation appeared to increase the risk of SARS-CoV-2 infection; in contrast, infection was not associated with subsequent self-harm. 28 Emerging evidence suggests that SARS-CoV-2 infection may have a bidirectional relationship with psychiatric illness with each being a risk factor for occurrence of the other. 29 Therefore, it may be that at least some of the observed associations in our review, specifically those that did not control for the presence of mental disorders, may be confounded since people with psychiatric illnesses are at higher risk for both SARS-CoV-2 infection and STBs.…”