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NATIONAL PARASUICIDE REGISTRY IRELAND

ANNUAL REPORT 2003

N A T I O N A L S U I C I D E R E S E A R C H F O U N D A T I O N

NATIONAL PARASUICIDE REGISTRY IRELANDANNUAL REPORT 2003


N A T I O N A L P A R A S U I C I D E R E G I S T R Y I R E L A N Di

Introduction and Executive Summary

This is the third annual report from the NationalParasuicide Registry. It is based on datacollected over the year 2003 on personspresenting to hospital with parasuicide(deliberate self harm). As in 2002, data werecollected from each health board region in theRepublic of Ireland. There was completecoverage of the Midland, Mid-Western, NorthEastern, North Western, South Eastern,Southern and Western Health Board regions andpartial coverage of the Eastern Regional HealthAuthority region. In total, data were collected forthe full calendar year from 39 acute hospitals.No data were collected from two general andone paediatric acute hospitals, all within theEastern Regional Health Authority in 2003. Datawere also collected from all 16 Irish prisons andplaces of detention. As of 2004, the NationalParasuicide Registry has secured approval tocollect data on deliberate self harm from allacute hospitals in the country.

Based on the near complete coverage of acutehospitals, we estimate that there wereapproximately 11,200 presentations due todeliberate self harm, involving approximately8,800 individuals in Ireland in 2003. In the AnnualReport 2002, we estimated that there were10,500 presentations to hospital due todeliberate self harm, involving approximately8,400 individuals in Ireland in 2002. The age-standardised rate of individuals presenting tohospital in the Republic of Ireland followingdeliberate self harm in 2003 was 209 per100,000. This represents a statisticallysignificant 3.6% increase on the rate of 202 per100,000 in 2002. All but one of the country’shealth boards experienced an increase in the

rate of individuals presenting to hospital as aconsequence of deliberate self harm, ranging inmagnitude from +1.9% in the Eastern RegionalHealth Authority to +13.4% in the North EasternHealth Board.

At a national level, the rate of deliberate selfharm in men increased significantly by 6.5%from 167 to 177 per 100,000. There was also amarginal increase in the rate of deliberate selfharm in women (+1.6%) from 237 to 241 per100,000. These changes have resulted in anarrowing of the difference between male andfemale rates of deliberate self harm. The femalerate was 36% higher than the male rate in 2003compared to 42% higher in 2002. The incidenceof deliberate self harm exhibited markedvariation by geographic area, with higher thanaverage rates among residents of the MidlandHealth Board and the Eastern Regional HealthAuthority and lower than average rates amongresidents of the North Western, Southern andWestern Health Boards. City rates of deliberateself harm generally exceeded those of thecounties. When county populations weredisaggregated to urban and rural districtpopulations, the incidence of deliberate selfharm was considerably higher in urban settings. Deliberate self harm was largely confined to theyounger age groups. Almost half of allpresentations (46.9%) were by people under 30years of age and 88.9% were by people agedless than 50 years. The peak rate for women in2003 (as in 2002) was in the 15-19 years agegroup, at 654 per 100,000, an increase of 5%from 2002. Thus, approximately one in every150 Irish adolescent girls was treated in hospitalin 2003 as a result of deliberate self harm.

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Among men, those in the 20-24 years age groupwere at highest risk, with a rate of 438 per100,000, which was 8% higher than in 2002. Itis a matter of concern that over the last threeyears we have not detected any evidence of adecrease or plateau in rates of deliberate selfharm in young Irish men and women.

Rates of deliberate self harm presentations tohospital by young people vary considerably fromyear to year at health board level. For example,in 2002, 15-19 year-old girls in the Mid-WesternHealth Board had a rate of 925 per 100,000,almost 50% higher than the national rate for thatage-gender sub-group. In 2003, the rate in 15-19year-old girls in the Mid-West region was 29%lower at 653 per 100,000, which was close tothe national average. By contrast, the incidenceof deliberate self harm in 15-19 year-old girls inthe Midland Health Board (502 per 100,000) was20% lower than the national average in 2002whereas in 2003 the rate increased by 82% to914 per 100,000. Similarly, there was a morethan two-fold (+109%) increase in the deliberateself harm rate among women in the 20-24 yearsage group in the North Western Health Boardregion between 2002 and 2003. While much ofthe year-to-year variation in the incidence ofhospital treated deliberate self harm in specificgender and age sub-groups will be due torandom statistical variation, this could notaccount for these observations.

This Annual Report again highlights that repeatpresentations to hospital due to deliberate selfharm represent a significant problem. In 2003,21.4% of all deliberate self harm presentationswere due to repeat acts. This was somewhat

higher than in 2002, when repeat acts accountedfor 19.3% of all deliberate self harmpresentations. The proportion of deliberate selfharm patients who made at least one repeatpresentation during the calendar year was13.8% in 2003, similar to the figure of 13.0% in2002. A small proportion (1.6%) of patientsmade at least five deliberate self harmpresentations to hospital in 2003. However,these patients accounted for one tenth (9.5%) ofall deliberate self harm presentations in thecountry. The equivalent figures for 2002 showedthat such multiple repeaters accounted for 1.4%of all deliberate self harm patients and 7.8% ofall presentations. Thus, there is some evidencethat repeated deliberate self harm is anincreasing problem in Ireland.

As in 2002, drug overdose was the commonestmethod of self harm, representing 78.5% of allacts registered in 2003. Half of all drug overdoseacts involved at least 25 tablets and mengenerally took more tablets in overdose actsthan women. At least 50 tablets were taken by21.5% of men as compared to 15.2% ofwomen. While it was common for several drugsto be taken in the same act, minor tranquillisers,paracetamol and anti-depressant drugs wereinvolved in 41%, 31% and 24% of deliberateoverdoses, respectively. Legislation restrictingthe sale of paracetamol-containing medicineswas enacted in October 2001. While therestrictions were phased in following theenactment of the legislation, we have shownthat paracetamol-containing medicines wereinvolved in the same proportion of intentionaldrug overdose acts in 2003 (31%) as in 2002(30%). However, further detailed analyses are

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required to assess the effects of the Irishlegislation on the use of paracetamol indeliberate overdose acts.

Self-cutting was the second commonestmethod of self harm, used as the main methodin almost one in five of all cases (18.0%). Cuttingwas significantly more common in men (23.0%)than in women (14.3%). With the exception ofthe UK, the finding that greater numbers of menpresent to hospital as a result of self-cutting is insharp contrast with the international literaturewhich reports a female preponderance amongpeople who cut themselves. Furtherinvestigation into these gender differences isrequired. Self-cutting was associated withincreased risk of repetition. One in five (19.3%)of individuals who presented as a result of self-cutting made a repeat presentation in 2003 ascompared to 12.7% of those who presented dueto an intentional drug overdose and 13.8% of alldeliberate self harm patients.

Method of self harm was also associated withthe next stage of care recommended followingtreatment in the accident and emergencydepartment. Half of all deliberate self harmcases resulted in admission to a ward of thetreating hospital, 12% were admitted forpsychiatric inpatient treatment from the accidentand emergency department, 7% refused to beadmitted, 3% left before next care could berecommended and 28% were dischargedfollowing emergency treatment. Thus, theaccident and emergency department was theonly treatment setting for 38% of all deliberateself harm patients. Referral for general hospitalinpatient care was most common following

cases of drug overdose and self-poisoning. Halfof the patients who used cutting as the mainmethod of self harm were discharged afterreceiving treatment in the accident andemergency department. As one would expect,the greater the potential lethality of the methodof self harm involved, the higher the proportionof cases admitted for psychiatric inpatient caredirectly from the accident and emergencydepartment. One-third of attempted hangingsand drownings, 19% of acts of self-cutting and8% of drug overdose cases were admitteddirectly for psychiatric inpatient care.

In 43% of all episodes of deliberate self harmregistered in 2003 there was evidence ofalcohol consumption. The proportion of patientswho used alcohol as part of their act wassignificantly higher in men (47%) than inwomen (39%). These levels are similar to thosereported for 2002 and continue to highlight thestrong association between alcoholconsumption and suicidal behaviour. Alcoholmay be one of the factors underlying the patternof presentation with deliberate self harm bytime of day and day of week. Presentationspeak in the hours around midnight and one-thirdof all presentations occur on Sundays andMondays. Given this pattern of hospitalpresentation, the frequent involvement ofalcohol and the finding that 38% of patients aretreated exclusively in the accident andemergency department, it is clear that we facea major challenge to ensure that all deliberateself harm patients receive a comprehensiveassessment of their needs and appropriatetreatment and referral.

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It is important that we consider these findingson the incidence and pattern of hospital treateddeliberate self harm in Ireland in the context offindings in other countries. Unfortunately as yet,no country has established a national, populationbased registry of deliberate self harm apart fromIreland. The best available data from outsideIreland is largely from urban centres in the UK.The rates of hospital treated self harm in oururban centres are broadly similar to thoseobserved in the UK.

This Report highlights the challenge deliberateself harm poses for our health system and oursociety as a whole. Deliberate self harm is amajor cause of suffering for individuals andfamilies that requires appropriate and targetedresponses from our health system. It is also apotent symptom or indicator of the mentalhealth of our population, the tip of an iceberg ofmental distress. Since an act of deliberate selfharm is an important predictor of repeated non-fatal and fatal suicidal behaviour, prevention ofrepetition should be prioritised in referralprocedures and treatment of those who haveengaged in deliberate self harm. We also needto better understand the fundamental family,social, cultural, economic, educational and otherdeterminants of poor mental health and suicidalbehaviour in our population. In Ireland the levelof discussion and openness on mental healthissues, including deliberate self harm andsuicide has increased in recent years. This is awelcome development. However, we need toensure that public discussion and mediacoverage of suicide and deliberate self harmremains measured, well informed and sensitiveto the needs and well being of psychologically

vulnerable and distressed individuals in oursociety. In particular, we need to continue towork as a society to create a culture andenvironment where people in psychologicaldistress feel able to seek help from family,friends and health professionals.

Ivan J PerryProfessor of Epidemiology and Public Health,University College, CorkDirector, National Parasuicide Registry, NationalSuicide Research Foundation, Cork

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Methodology

BACKGROUND

The National Parasuicide Registry is a nationalsystem of population monitoring for the occurrenceof deliberate self harm. It has been established, atthe request of the Department of Health andChildren, by the National Suicide ResearchFoundation.

The National Suicide Research Foundation wasfounded in January 1995 by the late Dr Michael JKelleher and currently operates under the MedicalDirectorship of Dr Margaret Kelleher, the ResearchDirectorship of Dr Ella Arensman and ProfessorIvan J Perry as Director of the National ParasuicideRegistry. The primary aims of the Foundation are todefine the true extent of the problem of suicidalbehaviour in Ireland, to identify and measure thefactors which induce and protect against suicidalbehaviour; and to develop strategies for theprevention of suicidal behaviour. The Foundation isrecognised by the European Regional Office of theWHO as the centre of excellence in suicidology inIreland and it is a member of the WHO EuropeanNetwork on Suicide Research and Prevention.

DEFINITION OF PARASUICIDE

The following definition of parasuicide, developedby the WHO/Euro Multicentre Study WorkingGroup, is used in the data collection system of theRegistry: ‘an act with non-fatal outcome in whichan individual deliberately initiates a non-habitualbehaviour, that without intervention from otherswill cause self harm, or deliberately ingests asubstance in excess of the prescribed or generallyrecognised therapeutic dosage, and which is aimedat realising changes that the person desires via theactual or expected physical consequences’. Thisdefinition includes acts involving varying levels ofsuicidal intent including definite suicide attemptsand acts where the individual had little or nointention of dying and where other motives such asloss of control, cry for help or self-punishment wereprimarily associated with the act of deliberate selfharm. Internationally, the term parasuicide is beingsuperseded by the term ‘deliberate self harm’. In

recognition of this, we use the term ‘deliberate selfharm’ in this Report.

INCLUSION CRITERIA

• All methods of self harm are included i.e., drugoverdoses, alcohol overdoses, lacerations,attempted drownings, attempted hangings,gunshot wounds, etc. where it is clear that theself harm was intentionally inflicted.

• All individuals who are alive on admission tohospital following a deliberate self harm act areincluded.

EXCLUSION CRITERIA

The following cases are NOT considered to bedeliberate self harm:• Accidental overdoses e.g., an individual who

takes additional medication in the case of illness,without any intention to self harm.

• Alcohol overdoses alone where the intention wasnot to self harm.

• Accidental overdoses of street drugs i.e., drugsused for recreational purposes, without theintention to self harm.

• Individuals who are dead on arrival at hospital asa result of suicide.

DATA RECORDING

All data are collected on pre-printed opticallyscannable forms. These forms are entered centrallyat the National Suicide Research Foundation usinghigh resolution optical character recognitionsoftware based on an integrated survey design anddata capture system.

DATA ITEMS

A minimal dataset has been developed todetermine the extent of deliberate self harm, thecircumstances relating to both the act and theindividual and to examine trends by area. While thedata items below will enable the system to avoidduplicate recording and to recognise repeat acts ofdeliberate self harm by the same individual, they

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ensure that it is impossible to identify an individualon the basis of the data recorded.

Entry numberEach of the registry forms is pre-printed with anentry number.

InitialsInitials of an individual deliberate self harm patientare recorded solely for the purposes of avoidingduplication and ensuring that repeat episodes arerecognised. Initials are recorded in an encodedformat so as to ensure that an individual cannot beidentified.

GenderMale or female gender is recorded when known.

Date of birthDate of birth is recorded in an encoded format tofurther protect the identity of the individual. As wellas being used to identify repeat deliberate selfharm presentations by the same individual, date ofbirth is used to calculate age. In the rare caseswhere the date of birth is not available, age isrecorded.

Area of residenceData collectors recode presentation addresses tothe appropriate Electoral Division and these areencoded numerically on the monitoring form.

Date and hour of attendance at hospital

Method(s) of self harmThe method(s) of self harm are recorded accordingto the 10th Revision of the WHO’s InternationalClassification of Diseases codes for intentionalinjury (X60-X84). The main methods are overdosesof drugs and medicaments (X60-X64), self-poisonings by alcohol (X65), poisonings whichinvolve the ingestion of chemicals, noxioussubstances, gases and vapours (X66-X69) and selfharm by hanging (X70), by drowning (X71) and bysharp object (X78). Some individuals may use acombination of methods e.g., overdose ofmedications and laceration of wrists. In this report,results generally relate to the ‘primary method’ ofself harm. In keeping with standardsrecommended by the WHO/Euro Study on SuicidalBehaviour, this is taken as the most lethal methodemployed.

Drugs takenWhere applicable, the name and quantity of thedrugs taken are recorded.

Medical card statusWhether the individual presenting has a medicalcard or not is recorded.

Seen byFor general hospital treated cases, this indicatesthe different disciplines involved in the initialtreatment of the presentation.

Recommended next careRecommended next care following treatment inthe hospital accident and emergency department isrecorded.

CONFIDENTIALITY

Confidentiality is strictly maintained. The NationalSuicide Research Foundation is registered with theData Protection Agency and complies with the IrishData Protection Act of 1988. Only anonymised dataare released in aggregate form in reports. Thenames and addresses of patients are not recorded.

ETHICAL APPROVAL

Ethical approval has been granted by the NationalResearch Ethics Committee of the Faculty of PublicHealth Medicine. The Registry has also receivedethical approval from the relevant ethicscommittees with responsibility for the individualhospitals and health boards.

REGISTRY COVERAGE

In 2003, deliberate self harm data were collectedfrom each health board region in the Republic ofIreland (pop: 3,978,862).

There was complete coverage of the MidlandHealth Board (pop: 230,296), which covers thewhole of the counties of Laois, Longford, Offaly andWestmeath. Deliberate self harm data werecollected from the Midland Regional Hospital atMullingar (formerly known as Longford/WestmeathGeneral Hospital), Midland Regional Hospital atPortlaoise (formerly known as Portlaoise GeneralHospital), Midland Regional Hospital at Tullamore(formerly known as Tullamore General Hospital), St

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Joseph's Hospital Longford and St Vincent'sHospital Athlone.

There was complete coverage of the Mid-WesternHealth Board (pop: 342,221), which covers thewhole of the counties of Clare, Limerick andTipperary North Riding. Deliberate self harm datawere collected from the Mid-Western RegionalHospital Limerick, Ennis General Hospital, NenaghGeneral Hospital and St John’s Hospital Limerick.

There was complete coverage of the North EasternHealth Board (pop: 350,050), which covers thewhole of the counties of Louth, Meath, Cavan andMonaghan. Deliberate self harm data werecollected from Cavan General Hospital, LouthCounty Hospital Dundalk, Monaghan GeneralHospital, Our Lady’s Hospital Navan and Our Ladyof Lourdes Hospital Drogheda.

There was complete coverage of the NorthWestern Health Board (pop: 224,835), whichcovers the counties of Leitrim, Sligo and Donegal.Deliberate self harm data were collected fromLetterkenny General Hospital and Sligo GeneralHospital.

There was complete coverage of the South EasternHealth Board (pop: 431,679), which covers thewhole of the counties of Carlow, Kilkenny,Wexford, Waterford and the South Riding ofTipperary. Deliberate self harm data were collectedfrom Our Lady's Hospital Cashel, St Joseph'sHospital Clonmel, St Luke's Hospital Kilkenny,Waterford Regional Hospital and Wexford GeneralHospital.

There was complete coverage of the SouthernHealth Board (pop: 588,585), which covers thewhole of the counties of Cork and Kerry. Deliberateself harm data were collected from Cork UniversityHospital, Mercy University Hospital and SouthernInfirmary in Cork City and from Tralee, Bantry andMallow General Hospitals.

There was complete coverage of the WesternHealth Board (pop: 388,204), which covers thewhole of the counties of Galway, Mayo andRoscommon. Deliberate self harm data werecollected from University College Hospital Galway,Mayo General Hospital Castlebar, PortiunculaHospital Ballinasloe and Roscommon CountyHospital.

There was partial coverage of the Eastern RegionalHealth Authority (pop: 1,422,992), which covers thewhole of the counties of Dublin, Kildare andWicklow. Deliberate self harm data were collectedfor the full calendar year from the Adelaide andMeath Hospital including the National Children’sHospital, Beaumont Hospital, James ConnollyMemorial Hospital Blanchardstown, Naas GeneralHospital, St Columcille’s Hospital Loughlinstown, StMichael’s Hospital Dun-Laoghaire and TempleStreet Children’s University Hospital and anotherhospital whose ethics committee stipulated that itshould not be named in Registry reports. No datawere collected from the Mater MisericordiaeUniversity Hospital, Dublin, Our Lady’s Hospital forSick Children, Crumlin or St James’ Hospital,Dublin. Data collection is now underway in StJames’ Hospital.

Thus, in total, deliberate self harm data werecollected for the full calendar year from 39 acutehospitals (one of which included both an adult anda paediatric accident and emergency department).

Deliberate self harm data were also collected fromthe 16 Irish prisons and places of detention: ArbourHill Prison, Castlerea Prison, Cloverhill Prison, CorkPrison, Curragh Place of Detention, Dochas Centre,Fort Mitchel Place of Detention, Limerick Prison,Loughan House, Midlands Prison, Mountjoy Prison,Portlaoise Prison, Shelton Abbey, St Patrick’sInstitution, Training Unit and Wheatfield Prison.

EXTRAPOLATED DATA

As noted above there was partial coverage of thehospitals within the Eastern Regional HealthAuthority in 2003. We therefore had to extrapolatefrom these data in order to estimate numbers andrates of deliberate self harm for the Eastern Regionand the country as a whole.

There were three hospitals for which no data werecollected in 2003. We had information on thenumber of accident and emergency attendances ineach of these hospitals. Based on the ratio ofaccident and emergency attendances withdeliberate self harm to all accident and emergencyattendances from the other hospitals in the EasternRegional Health Authority, we estimated thenumber of attendances with deliberate self harm ineach of these three hospitals. The number ofindividuals who presented with deliberate self

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harm was estimated by applying the ratio ofpresentations to individuals derived from the datafrom the Eastern Region hospitals.

POPULATION DATA

As far as possible, the Central Statistics Officepopulation estimates for 2003 were utilised in thisAnnual Report. These estimates provide age-sex-specific population data nationally and by planningregion. Some planning regions correspond exactlywith health board regions. Where this was not thecase, the health board population was estimated asfollows: the planning region containing the highestproportion of the health board’s population wasidentified; the percentage change between thisplanning region’s population according to the censusin 2002 and the official estimates for 2003 wascalculated; this percentage change was applied tothe health board’s census 2002 population data. Forsmaller geographic units than health board regions,i.e. counties and urban/rural districts, census 2002population data were utilised.

CALCULATION OF RATES

Deliberate self harm rates were calculated basedon the number of persons resident in the relevantarea who engaged in deliberate self harmirrespective of whether they were treated in thatarea or elsewhere.

Crude and age-specific rates per 100,000population were calculated by dividing the numberof persons who engaged in deliberate self harm (n)by the relevant population figure (p) and multiplyingthe result by 100,000, i.e. (n / p) * 100,000.

European age-standardised rates (EASRs) are theincidence rates that would be observed if thepopulation under study had the same age-composition as a theoretical European population.Adjusting for the age-composition of the populationunder study ensures that differences observed bygender or by area are due to differences in theincidence of deliberate self harm rather thandifferences in the composition of the populations.EASRs were calculated as follows: For each five-year age group, the number of persons whoengaged in deliberate self harm was divided by thepopulation at risk and then multiplied by thenumber in the European standard population. TheEASR is the sum of these age-specific figures.

Crude, age-specific and EASRs of suicide werecalculated as described above.

In order to contrast patterns of deliberate self harmwith those of suicide, the latter was analysed overthe most recent five year period for which datawere available. These data comprised suicidesregistered by the Central Statistics Office in theyears 1999 to 2003. The longer time span wastaken because of the relative infrequency ofsuicide.

A NOTE ON SMALL NUMBERS

Calculated rates that are based on less than 20events are an inherently unreliable measure of theunderlying rate. In addition, suicide and deliberateself harm events should not be consideredindependent of one another, although theseassumptions are used in the calculation ofconfidence intervals, in the absence of any clearknowledge of the relationship between theseevents.

A NOTE ON CONFIDENCE INTERVALS

Confidence intervals provide us with a margin oferror within which underlying rates may bepresumed to fall on the basis of observed data.Confidence intervals assume that the event rate (n/ p) is small and that the events are independent ofone another. A 95% confidence interval for thenumber of events (n), is n +/- 2√n. For example, if25 admissions are observed in a specific region inone year, then the 95% confidence interval will be25 +/- 2√25 or 15 to 35. Thus, the 95% confidenceinterval around a rate ranges from (n - 2√n) / p to (n+ 2√n) / p, where p is the population at risk. If therate is expressed per 100,000 population, thenthese quantities must be multiplied by 100,000.

A 95% confidence interval may be calculated toestablish whether two rates differ statisticallysignificantly. The difference between the rates iscalculated. The 95% confidence interval for this ratedifference (rd) ranges from rd - 2√(n1 / p12 + n2 /p2

2) to rd + 2√(n1 / p1 2 + n2 / p22). If the rates were

expressed per 100,000 population, then 2√(n1 / p12

+ n2 / p22) must be multiplied by 100,000 before

being added to and subtracted from the ratedifference. If zero is outside of the range of the95% confidence interval, then the differencebetween the rates is statistically significant.

N A T I O N A L P A R A S U I C I D E R E G I S T R Y I R E L A N Dix

The following is the team of people who collectedthe data that formed the basis of this AnnualReport. Their efforts are greatly appreciated.

Midland Health BoardLaura Smith

Mid-Western Health BoardCatherine Murphy

North Eastern Health BoardBernadette ConnollySabrina Coyle

North Western Health BoardKathleen O’Donnell LetterkennySharon Kelly Sligo

South Eastern Health BoardBreda Brennan

Southern Health BoardUrsula Burke Cork CityBenita Sydes Bantry, Mallow and TraleeUna Walsh Cork City

Western Health BoardMary Nix

Eastern Regional Health AuthorityLiisa Aula East Coast Area BoardGrace Boon Northern Area BoardTim Mulvey Northern Area BoardCaroline McTurk South Western Area Board

We would like to acknowledge the assistance ofstaff from the Department of Health and Children,the National Suicide Review Group, the respectivehealth boards, and the individual hospitals whohave facilitated the process of data collection. Wewould also like to acknowledge the contribution ofofficers from the Central Statistics Office in thecompilation of data on suicides and the provision ofthe population data that were used in thecalculation of rates.

This Report has been compiled by Paul Corcoranand Rachel Farrow with supervision, support andinput from Ivan J Perry, Ella Arensman, HarryComber, Helen Keeley, Eileen Williamson and theData Registration Officers.

Acknowledgements

DELIBERATE SELF HARM IN THEREPUBLIC OF IRELAND


Deliberate Self Harm in theRepublic of Ireland

A N N U A L R E P O R T 2 0 0 3 3

DELIBERATE SELF HARM IN THE REPUBLIC OF IRELAND

I. Hospital Presentations

Over the period from 1 January to 31December 2003, the Registry recorded 9,839deliberate self harm presentations to hospitalthat were made by 7,825 individuals.Extrapolating to account for the partialcoverage of the Eastern Regional HealthAuthority indicates that there were 11,204deliberate self harm presentations by 8,805individuals in the country as a whole. Thesenumbers reflect increases of 4.6% and 6.3%on the number of individuals (8,421) andepisodes (10,537) estimated to have beentreated in 2002. The European age-standardised rate of individuals presenting tohospital in the Republic of Ireland followingdeliberate self harm in 2003 was 209 (95%Confidence Interval (CI): 204 to 214) per100,000. This was a 3.6% increase on theequivalent rate of 202 (95% CI: 197 to 206)per 100,000 in 2002. The rate difference was7 (95% CI: 1 to 14) per 100,000. This indicatesthat, adjusting for age, the rate of individualspresenting to hospital in Ireland followingdeliberate self harm was significantly higher in2003 than it was in 2002. The incidence ofdeliberate self harm in Ireland is examined indetail in Part II of the Report.

The numbers of deliberate self harm episodestreated in the Republic of Ireland by healthboard, age and sex are given in Appendix IE-1,below. Of the 9,839 recorded presentations in2003, 4,187 (42.6%) were made by 3,354 menand 5,651 (57.4%) were made by 4,470 women(gender was unknown in one case). Deliberateself harm episodes were generally confined tothe younger age groups. Almost half of allpresentations (46.9%) were by people under 30years of age and 88.9% were by people agedless than 50 years. In most age groups thenumber of acts by women exceeded thenumber by men. This was most pronounced inthe 10-19 year age group where there were 2.4times as many acts by women (499 by men and1,189 by women). A notable exception to thisfemale preponderance was in the 30-34 year agegroup where there were marginally moreepisodes by men than by women (641 by menand 630 by women).

Two-hundred and forty-eight (2.5%) of the 9,839episodes of deliberate self harm were byresidents of homeless hostels and people of nofixed abode, 184 (1.9%) by hospital inpatientsand 59 (0.6%) by prisoners.

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DELIBERATE SELF HARM BY HEALTH BOARD/AUTHORITY

Figure IE 1: The distribution of episodesbetween health boards and authorities in theRepublic of Ireland. The upper chart illustratesthe distribution arising from the Registry’s actualmonitoring of the hospitals. A full-year estimatefor the partially monitored Eastern RegionalHealth Authority is incorporated into the lowerchart.

Figure IE 2: Gender balance of deliberate selfharm episodes treated by health board/authority.

Despite partial coverage of the region in 2003,deliberate self harm presentations in the EasternRegional Health Authority accounted for 32.0%of all episodes recorded by the Registry.Extrapolating to a full-year estimate indicatedthat 40.2% of all deliberate self harmpresentations in the country were treated at ahospital within the Eastern Region. Adjusting forthis estimate, the proportion of cases treated bythe other health boards ranged from 4.1% in theNorth Western, to 5.9% in the Midland, 8.7% inthe Western, 9.1% in the North Eastern, 9.2% inthe Mid-Western, 10.9% in the South Easternand 11.8% in the Southern. Based on figuresacquired from either the relevant health board orauthority or the individual hospitals, deliberateself harm accounted for 0.95% of total

attendances to accident and emergencyservices in the country. This percentage ofattendances accounted for by deliberate selfharm varied by health board/authority from0.65% in the Midland, to 0.80% in the NorthWestern, 0.83% in the Western, 085 in theSouthern, 0.90% in the South Eastern, 0.99% inthe North Eastern and Mid-Western and 1.07%in the Eastern Region.

The gender balance of recorded episodes (at42.6% men to 57.4% women) varied by region(Figure IE 2). Female episodes alwaysoutnumbered male episodes. This was mostpronounced in the Southern and North WesternHealth Boards and least pronounced in the Mid-Western Health Board.

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EPISODES BY TIME OF OCCURRENCE

Variation by Month

Figure IE 3: Number of episodes by month ofoccurrence.

Table IE 2: Months with at least 15% more or fewer deliberate self harm presentationsthan expected by health board/authority.

Table IE 1: Number of episodes by month for men and women.

The monthly average number of episodes ofdeliberate self harm treated at the hospitalsmonitored for all of 2003 was 820. Accountingfor the number of days in each calendar month,the number of deliberate self harm presentationswas at least 5% from the number expected inthe months of January (+12.7%), July (-5.6%),November (+6.1%) and December (-9.5%). TheJanuary peak was evident for both genders(+9.4% for men, +15.2% for women) as was theDecember trough (-11.7% for men, -7.9% forwomen).

For each health board/authority region in thecountry, Table IE 2 indicates the months in whichthe number of deliberate self harm presentationswas at least 15% above or below the numberexpected. In four regions such an excess ofpresentations was observed in January whilefive regions experienced at least 15% fewerpresentations than expected in December.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec TotalMen 389 325 364 319 330 362 352 367 354 358 353 314 4187Women 553 416 498 456 478 455 437 462 459 491 504 442 5651Total 942 741 862 775 808 817 789 829 813 849 858* 756 9839* Gender was unknown for a case in November

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov DecMHB + - - + -MWHB + + + - + -NEHB - -NWHB + +SEHB + -SHB +WHB - + -ERHA + -


Variation by Day

Variation by Hour

Figure IE 5: Number of episodes by time ofattendance.

Figure IE 4: Number of episodes by weekday.

Table IE 3: Number of episodes by weekday for men and women.

There was a striking pattern in the number ofdeliberate self harm presentations seen over thecourse of the day. The numbers for both menand women gradually increased during the dayand peaked during the night and in the earlyhours of the morning. The number ofpresentations was high over the period from8pm to 4am. During this eight hour period,almost half (46.8%) of the total number ofpresentations were made. This contrasts withthe quietest eight hour period of the day, from5am to 1pm, which accounted for just 18.5% ofall presentations.

The number of deliberate self harmpresentations was highest on Mondays andSundays. There was a clear pattern over thecourse of the week. Numbers fell after Mondayto a low during midweek before rising again asSunday approached. This pattern of the numberof presentations by day of the week was morepronounced in women than in men.

Monday Tuesday Wed'day Thursday Friday Saturday Sunday TotalMen 653 573 600 581 534 570 676 4187

(15.6%) (13.7%) (14.3%) (13.9%) (12.8%) (13.6%) (16.1%) (100%)Women 955 739 727 733 743 778 974 5649

(16.9%) (13.1%) (12.9%) (13.0%) (13.2%) (13.8%) (17.2%) (100%)Total 1608 1312 1328* 1314 1277 1348 1650 9837*

(16.3%) (13.3%) (13.5%) (13.4%) (13.0%) (13.7%) (16.8%) (100%)* Gender was unknown for a case that presented on a Wednesday. There were two cases where the day of presentationwas unknown which are not included in the table.Note: On average, each day would be expected to account for 14.3% of presentations

A N N U A L R E P O R T 2 0 0 3 7

METHOD OF SELF HARM1

Overdose Alcohol Poisoning Hanging Drowning Cutting Other TotalMen 2682 24 115 141 130 965 130 4187

(64.1%) (0.6%) (2.7%) (3.4%) (3.1%) (23.0%) (3.1%) (100%)

Women 4510 18 79 69 81 808 86 5651(79.8%) (0.3%) (1.4%) (1.2%) (1.4%) (14.3%) (1.5%) (100%)

Total 7192 42 194 210 211 1774* 216 9839*(73.1%) (0.4%) (2.0%) (2.1%) (2.1%) (18.0%) (2.2%) (100%)

* Gender was unknown in one case of self-cutting.

It is not unusual for more than one method to be involved in an individual act of deliberate selfharm. Here, results relate to the ‘primary method’ of deliberate self harm. In keeping withstandards recommended by the WHO/Euro Study on Suicidal Behaviour, this is taken, in anyindividual case, as the most lethal method employed.

1

Almost three quarters (73.1%) of all deliberateself harm episodes involved an overdose ofmedication as the most lethal method of selfharm employed. Drug overdose was morecommonly used as a method of self harm bywomen than by men (64.1% of male episodesand 79.8% of female episodes). Whenconsideration was also given to overdose as asecondary method, its frequency increased to78.5% of all cases (70.2% of male episodes and84.6% of female episodes). While rare as a mainmethod of self harm, alcohol was involved in42.6% (4,195) of all cases. Alcohol wassignificantly more common in male deliberateself harm episodes (1,984, 47.4%) than infemale episodes (2,211, 39.1%). Cutting wasthe only other common method of self harm,used as the main method in almost one in fiveof all cases (1,774, 18.0%). Cutting wassignificantly more common in men (965, 23.0%)than in women (808, 14.3%).

Table IE 4: Number of episodes by most lethal method and gender.

Figure IE 6 : The overall distribution of the mostlethal method of self harm used in the country.


DRUGS USED IN OVERDOSE

The total number of tablets taken was known in5,676 (73.5%) of the 7,722 cases of drugoverdose. On average, 32 tablets were taken inthe episodes of deliberate self harm thatinvolved drug overdose. One quarter of drugoverdose acts involved less than 14 tablets, halfinvolved less than 24 tablets and three-quartersinvolved less than 40 tablets. The number oftablets taken varied by gender with men, onaverage, taking more (mean = 35) than women(mean = 30). Figure IE 7 illustrates the pattern inthe number of tablets taken in drug overdoseepisodes for both genders. Half (51.1%) of thefemale episodes and 45.7% of the maleepisodes of overdose involved 10-29 tablets. Atleast 50 tablets were taken by 21.5% of men ascompared to 15.2% of women.

Figure IE 8 illustrates the frequency with whichthe most common types of drugs were used in

overdose. 40.9% of all overdoses involved aminor tranquilliser and such a drug was usedmarginally more often by men than by women.A major tranquilliser was involved in 10.1% ofoverdoses. Half (50.2%) of all female overdoseacts and 39.5% of male acts involved ananalgesic drug. Paracetamol was the mostcommon analgesic drug taken, being involved insome form in 30.9% of drug overdose acts.Paracetamol was used significantly more oftenby women (34.5%) than by men (25.0%). One infour acts (24.0%) of deliberate overdoseinvolved an anti-depressant/mood stabiliser. Thegroup of anti-depressant drugs known asSelective Serotonin Reuptake Inhibitors (SSRIs)were present in 13.4% of overdose cases.‘Other prescribed drugs’ were taken in one infour (25.2%) of all overdoses which reflects thewide range of drugs taken deliberately in acts ofdrug overdose.

Figure IE 7: The pattern of the number oftablets taken in male and female acts of drugoverdose.

Note: Some drugs (eg compounds containingparacetamol and an opiate) are counted in twocategories. Figure IE 8: The variation in the type of drugsused in the Republic of Ireland.

A N N U A L R E P O R T 2 0 0 3 9

RECOMMENDED NEXT CARE

Of the 9,839 deliberate self harm presentationsrecorded in 2003, there were 298 cases (3.0%)where the individual left the accident andemergency department before a next carerecommendation could be made. In more thanhalf of these cases (155, 52.0%), it was knownthat the individual left before being treated.Following their treatment in the accident andemergency department, inpatient admission wasthe next stage of care recommended for 69.0%,irrespective of whether general or psychiatricadmission was intended and whether the patientrefused or not. Half of all deliberate self harmcases resulted in admission to a ward of thetreating hospital whereas 11.8% were admittedfor psychiatric inpatient treatment from theaccident and emergency department. Thispercentage is an underestimate of the percentageof all deliberate self harm cases admitted forpsychiatric inpatient care as some of thoseadmitted to a general hospital ward will besubsequently admitted as psychiatric inpatients2.In 7.2% of the deliberate self harm episodes, thepatient refused to allow him/herself to be admittedwhether for general or psychiatric care. More thana quarter of all cases were discharged followingtreatment in the accident and emergencydepartment3.

Next care recommendations varied significantly bygender. Women were more often admitted to award of the treating hospital (52.0% of womencompared to 47.1% of men). Admission topsychiatric inpatient care from the accident andemergency department followed male acts moreoften than female acts (14.0% of men comparedto 10.2% of women). Men were marginally morelikely to have either refused to be admitted (7.9%vs. 6.7%) or left the emergency room before arecommendation was made (3.7% vs. 2.5%). Thegreater frequency of general inpatient care inwomen may be related to their greater use of drugoverdose as a method of self harm. As can beseen from Table IE 5, recommended next carevaried according to the main method of self harm.General inpatient care was most commonfollowing cases of drug overdose and self-poisoning and least common after attemptedhanging, drowning and self-cutting. The latterfinding may be a reflection of the superficial natureof the injuries sustained in some cases ofattempted hanging, drowning and cutting. Ofthose cases where the patient used cutting as themain method of self harm, half (49.8%) weredischarged after receiving treatment in theaccident and emergency department. The greaterthe potential lethality of the method of self harm

Many patients who are admitted medically are given psychiatric review on the ward and may betransferred to the care of psychiatric services, once medically fit, or discharged for follow up asan outpatient.Patients discharged home/not admitted after accident and emergency treatment are usuallyreferred to their GP or given an outpatient department appointment.

2

3

Overdose Alcohol Poisoning Hanging Drowning Cutting Other Total(n=7183*) (n=42) (n=194) (n=210) (n=211) (n=1771*) (n=216) (n=9827*)

General admission 58.8% 54.8% 56.2% 25.7% 31.8% 20.6% 31.0% 49.9%

Psychiatric 8.0% 2.4% 17.0% 34.8% 31.3% 18.9% 34.7% 11.8%admission

Patient would not 7.2% 9.5% 6.2% 7.1% 7.6% 7.2% 9.3% 7.2%allow admission

Left before 2.9% 4.8% 2.6% 1.0% 4.7% 3.6% 2.3% 3.0%recommendation

Not admitted 23.1% 28.6% 18.0% 31.4% 24.6% 49.8% 22.7% 28.0%* This table does not include 12 cases that were transferred from the A&E of one hospital to the A&E of another.

Table IE 5: Recommended next care by method of deliberate self harm.


involved, the higher the proportion of casesadmitted for psychiatric inpatient care directly fromthe accident and emergency department.

Next care varied significantly by healthboard/authority. The proportion of deliberate selfharm patients who left before a recommendationwas made varied from 1.1% in the North WesternHealth Board to 4.9% in the Southern Health Board.Inpatient care (irrespective of type and whetherpatient refused) was recommended for half(49.7%) of the patients treated in the EasternRegional Health Authority. The proportion given thisrecommendation was higher in the other healthboards ranging from 62.6% in the Southern throughto 88.7% in the South Eastern. This pattern wasdue to general inpatient admission rates across thehealth boards. Only one in four patients treated in ahospital within the Eastern Region were admittedto a ward of the treating hospital whereas this

proportion ranged from 44.8% to 76.1% forpatients treated in the other health boards. As acorollary to this, almost half (46.9%) of the casestreated in a hospital within the Eastern RegionalHealth Authority were discharged followingemergency treatment compared to between 9.5%and 32.5% for patients treated in the other healthboards. Just 5.1% of patients treated in the NorthEastern Health Board were admitted for psychiatricinpatient care after treatment in the accident andemergency department whereas this ranged from8.1% to 15.1% in the other health boards. Asmentioned earlier, these percentagesunderestimate the percentage of all deliberate selfharm cases admitted for psychiatric inpatient careas some of those admitted to a general hospitalward will be subsequently admitted as psychiatricinpatients4. The extent to which this happens islikely to vary by health board.

Many patients who are admitted medically are given psychiatric review on the ward and may betransferred to the care of psychiatric services, once medically fit, or discharged for follow up asan outpatient.

4

Eastern Midland Mid- North North South Southern Western RepublicRegional Health Western Eastern Western Eastern Health Health of

Health Board Health Health Health Health Board Board IrelandAuthority Board Board Board Board(n=3142*) (n=658*) (n=1028*) (n=1025) (n=456) (n=1225) (n=1320*) (n=973) (n=9827*)

General 25.0% 58.4% 62.9% 76.1% 51.3% 74.4% 44.8% 59.0% 49.9%admission

Psychiatric 15.1% 13.4% 8.1% 5.1% 13.6% 10.0% 12.6% 11.8% 11.8%admission

Patient would not 9.6% 10.3% 5.6% 4.7% 10.1% 4.3% 5.2% 6.6% 7.2%allow admission

Left before 3.3% 1.2% 3.7% 2.3% 1.1% 1.9% 4.9% 3.1% 3.0%recommendation

Not admitted 46.9% 16.7% 19.6% 11.8% 23.9% 9.5% 32.5% 19.5% 28.0%

* This table does not include 12 cases that were transferred from the A&E of one hospital to the A&E of another.

Table IE 6: Recommended next care by health board/authority.

A N N U A L R E P O R T 2 0 0 3 11

Table IE 7: Number of individuals and number and percentage who repeated after their indexpresentation by main method of self harm.

REPETITION OF DELIBERATE SELF HARM

There were 7,738 individuals treated for 9,839deliberate self harm episodes in the 39 hospitalsthat were monitored by the Registry in 2003. Thisimplies that more than one in five (2,101, 21.4%)of all presentations in 2003 were due to repeatacts. This is significantly higher than in 2002,when repeat acts accounted for 19.3% of thedeliberate self harm presentations to the 35hospitals that were monitored for the full calendaryear by the Registry. Of the 7,738 deliberate selfharm patients, 1,065 (13.8%) made at least onerepeat attempt during the calendar year whichpresented to hospital. In 2002, the repetition rate

was 13.0%. At least five deliberate self harmpresentations were made by 126 individuals.While these repeaters accounted for just 1.6% ofall deliberate self harm patients, the 937presentations they made represented one tenth(9.5%) of the 9,839 deliberate self harmpresentations recorded by the Registry. Theequivalent figures for 2002 showed that suchmultiple repeaters accounted for 1.4% of alldeliberate self harm patients and 7.8% of allpresentations. Thus, from several perspectives,there is evidence that repeated deliberate selfharm is an increasing problem in Ireland.

Overdose Alcohol Poisoning Hanging Drowning Cutting Other Total(n=7183*) (n=42) (n=194) (n=210) (n=211) (n=1771*) (n=216) (n=9827*)

Number of 5868 30 145 166 165 1195 169 7738individuals treated

Number who 743 4 16 33 18 231 20 1065repeated

Percentage who 12.7% 13.3% 11.0% 19.9% 10.9% 19.3% 11.8% 13.8%repeated

Eastern Midland Mid- North North South Southern Western RepublicRegional Health Western Eastern Western Eastern Health Health of

Health Board Health Health Health Health Board Board IrelandAuthority* Board Board Board Board

Men 1076 234 361 330 149 417 467 320 3304Women 1397 310 424 473 216 555 666 429 4433Total 2473 544 785 803 365 972 1134** 749 7738**

Men 146 27 63 52 24 70 47 60 464Women 215 28 70 73 31 67 67 59 601Total 361 55 133 125 55 137 114 119 1065

Men 13.6% 11.5% 17.5% 15.8% 16.1% 16.8% 10.1% 18.8% 14.0%Women 15.4% 9.0% 16.5% 15.4% 14.4% 12.1% 10.1% 13.8% 13.6%Total 14.6% 10.1% 16.9% 15.6% 15.1% 14.1% 10.1% 15.9% 13.8%* The Eastern Regional Health Authority figures will slighty underestimate the repetition rate as some repeat presentationswill have been made to the two major acute hospitals in the health authority that were not monitored by the Registry in 2003.** There was one individual in the Southern Health Board whose gender was unknown.

Number of individuals treated

Percentage who repeated

Number who repeated

Table IE 8: Number of individuals and number and percentage who repeated by gender and healthboard/authority5.

The sum of the health board figures exceeds the total number of individuals treated in thecountry because individuals who made multiple presentations were counted once in each regionwhere they were treated but only once for the country as a whole.

5

SUICIDE

METHOD OF SUICIDE


The rate of repetition varied highly significantlyaccording to the main method of self harm involvedin act (Table IE 7). Cutting was associated with anincreased level of repetition. Almost one in five ofthose who used it as the main method of self harmat the time of their index act made at least onesubsequent deliberate self harm presentation in2003.

The rate of repetition was similar in men(464/3,304, 14.0%) and women (601/4,433,13.6%). Table IE 8 details the number ofindividuals treated in each health board/authorityand the number and percentage of individualswho presented to hospital with a repeat act. Thelevel of repetition varied significantly by healthboard/authority. 10.1% of the deliberate selfharm patients treated in the Midland andSouthern Health Boards repeated within thecalendar year which was a significantly lowerrepetition rate than in the country as a wholewhereas the repetition rate in the Mid-WesternHealth Board (16.9%) was significantly higherthan the national rate. In the other health boards,between 14.1% and 15.9% of the deliberateself harm patients repeated.

Over the five year period 1999-2003, 2,213suicides were registered in the Republic ofIreland. Men and women accounted for 1,791(80.9%) and 422 (19.1%) of these deaths,respectively. This yields a male/female suicideratio of 4.2 to one. The average number ofsuicide deaths registered per year was 358 formen and 84 for women. Based on theextrapolated deliberate self harm figures for thecountry, annually, there are approximately 13episodes of deliberate self harm for every deathby suicide amongst men and approximately 76episodes of deliberate self harm for every deathby suicide amongst women.

The method employed in acts of suicidecontrasted with those used in episodes ofdeliberate self harm. The more lethal methodsof hanging and drowning were more dominant,especially for men. Three-quarters of malesuicides involved either hanging (57.0%) ordrowning (17.3%). No other method of suicidewas common among men. Hanging (29.6%),drowning (28.0%) and drug overdose (28.4%)were equally common as methods of femalesuicide. These methods accounted for 86.0% ofall female suicide deaths.

Figure IE 9: The method of suicide for men andwomen.

A N N U A L R E P O R T 2 0 0 3 13

II. Incidence Rates

Over the period from 1 January to 31 December2003, the Registry recorded 9,839 deliberateself harm presentations to hospital that weremade by 7,738 individuals. Excluding residentsof the Eastern Region, the crude and Europeanage-standardised rates of hospital-treateddeliberate self harm in 2003 for the ‘rest ofIreland’ were 206 (95% confidence interval: 201to 212) and 199 (95% CI: 194 to 205) per100,000, respectively. Extrapolating to accountfor the partial coverage of the Eastern RegionalHealth Authority indicated that there were11,204 deliberate self harm presentations by8,805 individuals in the country as a whole.Based on these data, the Irish person-basedcrude and age-standardised rates of deliberateself harm were 221 (95% CI: 217 to 226) and209 (95% CI: 204 to 214) per 100,000,respectively. The age-standardised rates reflectincreases in the incidence of hospital-treateddeliberate self harm when compared with theequivalent rates for 2002. The increase wasstatistically significant for the ‘rest of Ireland’and for Ireland as a whole (incorporating theextrapolated data for the Eastern Region) whenboth genders were combined.

VARIATION BY GENDER AND AGE

The person-based age-standardised rate ofdeliberate self harm for men and women was177 (95% CI: 171–184) and 241 (95% CI:234–248) per 100,000, respectively. As shownin Table IE 9, this represents a statisticallysignificant increase in the male rate since 2002whereas the female rate showed only amarginal increase. The female rate of deliberateself harm in 2003 was significantly higher(+36%) than the male rate. This was a reductionon the 42% gender difference observed in 2002which is a consequence of the significant rise inmale deliberate self harm. Population figures,the number and rate of persons treated inhospital following deliberate self harm in 2003

and the annual rate of suicide (based on suicidedeaths registered by the Central StatisticsOffice in the five years 1999-2003) are given inAppendix IE-2 by age and gender for personsresiding in the Republic of Ireland.

There was a striking pattern in the incidence ofdeliberate self harm when examined by age.The rates were highest among the young. At654 per 100,000 and up 5% since 2002, thepeak rate for women was among 15-19 year-olds. This rate implies that approximately one inevery 150 girls in this age group presented tohospital in 2003 as a consequence of deliberateself harm. The peak rate for men was 438 per100,000 among 20-24 year-olds, which is anincrease of 8% since 2002. However, the mostnotable change in an age-sex specific rate wasfor 35-44 year-old men. This group had a rate of282 per 100,000 in 2003, 19% higher than therate of 238 per 100,000 observed in 2002. Theincidence of deliberate self harm graduallydecreased with increasing age in men. This wasthe case to a lesser extent in women as theirrate remained relatively stable, at just over 300per 100,000, across the 25 to 49 year age range.After the age of 65 years, the deliberate selfharm rate in men and women was relatively low.

Figure IE 10: Person-based rate of deliberateself harm in the Republic of Ireland by age andgender.


Figure IE 11: Person-based rate of deliberate self harm by residents of Irish health boards by age andgender.

(a) Midland Health Board (b) Mid-Western Health Board

(c) North Eastern Health Board (d) North Western Health Board

(e) South Eastern Health Board (f) Southern Health Board

A N N U A L R E P O R T 2 0 0 3 15

Figure IE 11: Person-based rate of deliberate self harm by residents of Irish health boards by age andgender.

Figure IE 11 shows the pattern of the incidence ofdeliberate self harm by age and gender for theresidents of each health board/authority, separately.The pattern was broadly similar to that at nationallevel. The deliberate self harm rate was highestamong the young. The peak female rate was in 15-19 year-olds in all but the North Western HealthBoard where the peak rate was in 20-24 year-olds.The deliberate self harm rate in women aged 15-19years in the Midland Health Board was especiallyhigh at 914 per 100,000. The secondary peak inmiddle-aged women was evident in several healthboard regions. The peak male rate, while lesspronounced, was in the 20-24 year age group in allbut the Western Health Board.

There were a number of significant changes in age-sex-specific deliberate self harm rates between2002 and 2003. Girls aged 15-19 years in theMidland Health Board had a deliberate self harmrate of 914 per 100,000 in 2003, 82% higher thantheir rate of 502 per 100,000 in 2002. The samepopulation in the Mid-Western Health Boardexperienced a 29% decrease in their deliberate selfharm rate, from 925 to 653 per 100,000. There wasa doubling (+109%) of the deliberate self harm ratefor 20-24 year-old women of the North WesternHealth Board (324 to 677 per 100,000). Male 35-44year-old residents of the Eastern Regionexperienced a 43% increase in their deliberate selfharm rate from 235 to 336 per 100,000 whereasthere was a 28% fall in the 25-29 year-old femalerate in the Region (376 to 271 per 100,000).

Deliberate self harm was rare in 10-14 year-olds,particularly for boys. Respectively, the male andfemale rates were 9 and 5 times higher in 15-19 year-olds. Thus, the incidence of deliberate self harmincreases rapidly over a short age range. This isillustrated in greater detail in Figure IE 12. It can beseen that deliberate self harm was rare in those aged12 years and younger. In 13-20 year olds, the femalerate of deliberate self harm was significantly higherthan the male rate. The increases in the female rate inearly teenage years were particularly striking. For eachage from 15 through 20 years, the female rate ofdeliberate self harm was greater than 600 per100,000 with the peak at 723 per 100,000 for 17 year-olds. Thus, one in every 140 17 year-old girls in Irelandpresented to hospital in 2003 having deliberately selfharmed.

In order to compare the age pattern of deliberateself harm with that of suicide, the annual age-specific rate of suicide (based on data registered bythe Central Statistics Office in 1999-2003) isillustrated in Figure IE 13. The clearest differencerelates to the male preponderance in suicide acrossall ages but particularly among 20-29 year-olds. Themale suicide rate peaked at 32 per 100,000 in 25-29year-olds. For 30-64 year-olds, the male suicide ratefluctuated between 19 and 25 per 100,000. Inelderly men, the rate of suicide gradually decreasedwith increasing age although to a lesser extent thanthe decrease with increasing age that wasobserved for male deliberate self harm. The agepattern of female suicide did not show any greatsimilarity to that for deliberate self harm.

(g) Western Health Board (h) Eastern Regional Health Authority


Figure IE 12: Person-based rate of deliberateself harm in the Republic of Ireland by singleyear of age for 10-24 year-olds.

Figure IE 14: Person-based European age-standardised rate (EASR) of deliberate self harmin the Republic of Ireland by healthboard/authority of residence and gender.

Figure IE 13: Annual rate of suicide in theRepublic of Ireland by age and gender (based ondata registered by the Central Statistics Office in1999-2003).

VARIATION BY AREA

Rates by health board/authority

For each gender, the incidence of deliberate selfharm in residents of the Midland Health Board andEastern Regional Health Authority wassignificantly higher than the national male andfemale rates of 177 and 241 per 100,000,respectively. The 12% higher male rate in the Mid-Western Health Board was almost statisticallysignificant. Male and female residents of theNorth Western, Southern and Western HealthBoards had significantly lower deliberate self harmrates than men and women in the country as awhole.

In each health board/authority, the female rate ofdeliberate self harm was significantly higher thanthe male rate. The margin was least marked, at+24%, for Mid-Western Health Board residents.For Midland, North Western, South Eastern,Western and Eastern Regional HealthBoard/Authority residents, the female rate washigher by 30-41%, which was similar to thedifference in the country as a whole. The greatestgender difference was for residents of theSouthern and North Eastern Health Boards forwhom the female rate was 46% and 51% higherthan the male rate, respectively.

There were a number of notable changes in theincidence of deliberate self harm between 2003and 2002. Most regions experienced an increase inmale and female rates. Men in the Eastern Regionexperienced a significant increase of 12%. The43% jump in the rate of deliberate self harm in 35-44 year-old men in the East, noted earlier,contributed most to the increase in that region. The17% and 11% increases in the rate of deliberateself harm in women residing in the Midland andSouthern Health Boards, respectively, were almoststatistically significant. The former was due in largepart to the 82% higher rate in teenage girls aged15-19 years. While not statistically significant, thefemale rate in the North Eastern and North WesternHealth Boards increased by 10-11%. In contrast,there was a 10% drop in the female rate ofdeliberate self harm in the Mid-Western HealthBoard which was largely due to the 29% decreasein the rate for 15-19 year-old girls.

A N N U A L R E P O R T 2 0 0 3 17

MEN WOMEN

Midland 205.8 (+/-27) 28 (+/-27.8) +16.0 289.6 (+/-32) 48.4 (+/-33) +20.1

Mid-Western 199 (+/-22) 22 (+/-23) +12.1 246 (+/-24) 5 (+/-25) +1.9

North Eastern 174 (+/-20) -3 (+/-21) -1.8 262 (+/-25) 21 (+/-26) +8.8

North Western 138 (+/-22) -39 (+/-23) -22.0 194 (+/-26) -47 (+/-27) -19.4

South Eastern 180 (+/-18) 3 (+/-21) +1.7 251 (+/-22) 10 (+/-25) +4.0

Southern 148.9 (+/-15) -29 (+/-15) -16.1 217.7 (+/-17) -24 (+/-17) -9.8

Western 138 (+/-17) -39 (+/-18) -22.2 187.7 (+/-20) -54 (+/-21) -22.2

Eastern Region**** 197 (+/-11) 20 (+/-13) +11.0 257 (+/-12) 16 (+/-14) +6.5

Ireland**** 177.4 (+/-6) 241.2 (+/-7)

Health board/ Rate 95% Rate 95% % Rate 95% Rate 95% %Authority CI* difference** CI*** difference CI* difference** CI*** difference

* 95% Confidence Interval for the health board/authority deliberate self harm rate** Rate difference = Health board/authority rate – national rate (177 and 241 per 100,000 for men and women, respectively)*** 95% Confidence Interval for deliberate self harm rate difference**** Deliberate self harm rate based on/incorporating the extrapolated Eastern Regional Health Authority data.

Table IE 10: Person-based European age-standardised rate (EASR) of deliberate self harm in theRepublic of Ireland by health board/authority of residence and gender with comparison to the nationalrate

MEN WOMEN

Midland 206 196 10 (+/-38) +4.9 290 248 42 (+/-44) +16.9

Mid-Western 199 189 10 (+/-31) +5.2 245.8 271.5 -26 (+/-36) -9.5

North Eastern 174 169 5 (+/-29) +2.8 262 238 24 (+/-34) +10.2

North Western 138 138 0 (+/-31) +0.3 194 175 19 (+/-36) +10.9

South Eastern 180 171 9 (+/-26) +5.2 251 238 13 (+/-31) +5.5

Southern 149 138 11 (+/-20) +8.2 217.7 195.4 22 (+/-24) +11.4

Western 138 139 -1 (+/-24) -1.0 188 177 11 (+/-28) +6.1

Eastern Region** 197 176 21 (+/-16) +11.7 257 270 -13 (+/-18) -4.8

Ireland** 177.4 166.6 11 (+/-9) +6.5 241 237 4 (+/-10) +1.6

Health board/ 2003 2002 Rate 95% % 2003 2002 Rate 95% %Authority Rate Rate difference CI* difference Rate Rate difference CI* difference

* 95% Confidence Interval for deliberate self harm rate difference** Deliberate self harm rate based on/incorporating the extrapolated Eastern Regional Health Authority data.

Table IE 11: Person-based European age-standardised rate (EASR) of deliberate self harm in theRepublic of Ireland in 2003 and 2002 by health board/authority of residence and gender

Limerick CityWestmeath

LongfordTipperary North

Waterford CityCork City

LouthMonaghan

WexfordOffaly

CarlowTipperary South

CavanGalway County

KerryMeathLaoisClare

Galway CityKilkennyDonegal

LeitrimCork County

Limerick CountySligo

Waterford CountyRoscommon

Mayo


RATES BY COUNTY6

Figure IE 15a: Person-based European age-standardised rate (EASR) of deliberate self harmin the Republic of Ireland by county/city ofresidence for men.

Figure IE 15b: Person-based European age-standardised rate (EASR) of deliberate self harmin the Republic of Ireland by county/city ofresidence for women.

The partial coverage of the Eastern Regional Health Authority meant that reliable deliberate selfharm rates could not be calculated for the constituent counties and city boroughs.

6

Limerick CityCork City

Galway CityLouth

CarlowWestmeath

Tipperary NorthWaterford City

Tipperary SouthOffalyLaois

LongfordKilkennyWexford

CavanSligo

MeathRoscommon

KerryDonegal

Limerick CountyClare

Galway CountyMonaghan

MayoCork County

Waterford CountyLeitrim

A N N U A L R E P O R T 2 0 0 3 19

There was widespread variation in male andfemale deliberate self harm rates when examinedby county/city of residence. The male rate variedfrom 74 per 100,000 for Leitrim to 481 per100,000 for Limerick city. The lowest and highestfemale rates were recorded for Mayo andLimerick city residents at 146 and 344 per100,000, respectively. There were some notablechanges in deliberate self harm rates atcounty/city level between 2002 and 2003. Formen, there was a statistically significant rise from216 to 293 per 100,000 in Cork city. This 36%jump resulted in Cork city having the secondhighest rate behind Limerick city which itselfexperienced a 12% increase in its male rate. Whilenot statistically significant, the male rate ofdeliberate self harm increased by 48% and 42% inCarlow and Tipperary North, respectively.

There was greater volatility in the femaledeliberate self harm rate between 2002 and 2003.Leitrim had the lowest female deliberate self harmrate in 2002 at 97 per 100,000. In 2003, the femalerate was 200 per 100,000 (+107%) although thiswas still below the national rate. Longford’sfemale deliberate self harm rate increased by 56%from 213 per 100,000 which was close to thenational rate to 333 per 100,000, which gave thecounty the third highest rate in 2003. It should benoted that both these counties have lowpopulations and therefore large fluctuations aremore likely to be observed from year to year.Another Midland county, Laois, had a low femalerate of deliberate self harm in 2002 (141 per100,000) but this increased by 62% to 229 per100,000 which was close to the national rate in2003. Galway county, Kerry and Meath alsoexperienced increases from low to averagefemale rates. There was a 39% increase, from 169to 236 per 100,000, in Galway, a 28% increase,from 182 to 233 per 100,000, in Kerry and a 28%increase, from 179 to 230 per 100,000, in Meath.Women in Monaghan exhibited a more significantincrease in their deliberate self harm rate. Theirrate of 199 per 100,000 in 2002 increased by 53%to 305 per 100,000 in 2003 which resulted in amove from below to above the national rate.

With the exception of women in Galway city,above average deliberate self harm rates wererecorded for male and female residents of thecities of Cork (+65% for men, +27% for women),Galway (+52% for men, -8% for women),Limerick (+171% for men, +43% for women) andWaterford (+23% for men, +35% for women). Formen, the rates for the residents of thecorresponding counties were far lower. This wasthe case to a lesser extent for women as femaleresidents of Galway county had a marginallyhigher rate than their counterparts in Galway city.However, in general, this indicates that deliberateself harm is particularly common in large urbansettings in Ireland, most notably in Limerick city.

Generally at county/city level, the femaledeliberate self harm rate exceeded the male rateby a margin similar to that for the country as awhole (+36%). The cities of Limerick, Galway and,to a lesser extent, Cork, were notable exceptions.In Cork city, the female rate (306 per 100,000) wasjust 4% higher than the male rate (293 per100,000). Women in Galway city had an 18%lower rate than the men (221 vs 270 per 100,000).For Limerick city residents in 2002, the maledeliberate self harm rate marginally exceeded thefemale rate. This was due to the men having a ratethat was 157% higher than the national averagecompared to a 77% higher rate for Limerick citywomen. The 12% increase in the male rate andthe 28% decrease in the female rate led to awidening of the gender difference in 2003 suchthat the female rate (344 per 100,000) was 28%lower than the male rate (481 per 100,000).Compared to the national rate in 2003, Limerickcity men had a 171% higher rate while Limerickcity women had a 43% higher rate.

There was some indication that low rates ofdeliberate self harm were associated with thecounties in the province of Connacht. For men andwomen, the seven counties with the lowestdeliberate self harm rates included three of thefive Connacht counties (Galway, Mayo andLeitrim) for men and four of the five Connachtcounties (Leitrim, Sligo, Roscommon and Mayo)for women.


URBAN AND RURAL DISTRICT COMPARISONBY HEALTH BOARD

Figure IE 16 illustrates the deliberate self harmrate for residents of urban districts and ruraldistricts by health board region. For each region,the incidence of deliberate self harm wassignificantly higher in the urban districtpopulation. Respectively, the rate was 66%,118%, 126%, 128%, 129%, 139% and 248%higher in the urban district populations of theWestern, North Western, Southern, Mid-Western, Midland, South Eastern and NorthEastern Health Boards.

Having seen that rates of deliberate self harm inthe larger urban centres generally exceed thoseobserved in rural areas, it is now clear thatdeliberate self harm is an urban problem in abroader sense due to the high rates that werealso recorded for the Irish population living insmaller urban centres/districts throughout thecountry.

Figure IE 16: Person-based European age-standardised rate (EASR) of deliberate self harmfor urban and rural district residents in theRepublic of Ireland by health board

A N N U A L R E P O R T 2 0 0 3 21

APP

END

IX IE

-1: H

OSP

ITA

L-TR

EATE

D E

PISO

DES

OF

DEL

IBER

ATE

SELF

HA

RM IN

TH

E RE

PUB

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OF

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AN

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onal

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este

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B

oard

Nor

thW

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ealth

B

oard

Sout

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ealth

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rd

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tern

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lth

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rd

Repu

blic

of

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00

00

00

00

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5-9y

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02

0

10-1

4yrs

2260

410

211

520

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115

524

512

4416

2

15-1

9yrs

150

307

3980

5696

3911

118

5742

131

6712

644

119

455

1027

20-2

4yrs

267

250

6460

9198

6470

3757

108

9810

513

578

9581

486

3

25-2

9yrs

163

184

3654

5971

7576

2533

8186

8690

5564

580

658

30-3

4yrs

191

193

5553

8767

4582

3126

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7784

5737

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630

35-3

9yrs

152

211

1639

6775

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2230

8081

5062

6572

514

636

40-4

4yrs

138

195

3228

5048

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4576

4557

412

548

45-4

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9818

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2629

2540

5617

1433

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246

7

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4211

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719

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307

1121

2820

6025

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55-5

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3754

812

1517

108

65

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1520

1614

117

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2331

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39

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26

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1017

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APP

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1571

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1561

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1462

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1478

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1165

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1048

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1018

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6608

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5314

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6050

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3735

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5225

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2325

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12.9

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3825

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7720

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17.7

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2001

654

5024

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2(+

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)

Per

sons

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% C

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Rat

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* D

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the

ext

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who

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t kn

own

are

not

incl

uded

in th

is ta

ble.

** A

nnua

l rat

e ba

sed

on s

uici

de d

eath

s re

gist

ered

by

the

Cen

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Sta

tistic

s O

ffic

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the

five

year

s 19

99-2

003

***

95%

Con

fiden

ce In

terv

al**

** T

he to

tal r

ates

are

Eur

opea

n ag

e-st

anda

rdis

ed ra

tes

per 1

00,0

00

The offices of theNational Suicide Research Foundation

are at1 Perrott AvenueCollege RoadCorkIreland.

Tel.: +353 21 4277499Fax: +353 21 4277545E-mail: [email protected]

ISSN 1649-4326

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