Summary of findings
This study provides new epidemiological evidence on the presentation of self-harm to general practice, comparing demographic subgroups using a large primary care database. Rates of gender-specific incidence and presentation were generally increasing over the duration of the study with consistently higher rates for females. Self-harm incidence and presentation rates decreased incrementally with age. Substantially higher rates were observed for females aged 15–24 years, and this group dominated the overall gender differences. We also found lower rates in England when compared against the other nations of the UK, and a gradient of increasing risk across deprivation quintiles (from least to greatest level of deprivation) with a notable increase in risk for the most deprived quintile. This suggests that the psychosocial determinants of self-harming behaviour cluster strongly in the poorest localities.
Comparison with existing evidence
The term ‘self-harm’ encompasses a range of methods with varying degrees of intent [
9]. Most of the evidence on self-harm and attempted suicide has arisen solely through data collected in hospital settings. There is a dearth of evidence in a primary care context in the UK and other countries. This lack of attention, and the limited instruction issued to GPs, is highlighted in recent NICE guidelines on the longer term management of self-harm [
5]. The guideline report includes a section that highlights the importance of primary care in managing the problem, but only three out of a total of 57 recommendations relate specifically to this healthcare tier.
We found self-harm rates to be generally increasing over our 13-year study period. This is consistent with findings from the previous decade (1990–1999), and represents a continuation of existing trends [
7]. A rise in both sexes reporting self-harm as a response to employment and financial problems has been reported in recent years [
23]. We found significantly higher rates for female patients and the younger age groups. Again, these findings are consistent with the evidence from secondary care settings [
1,
7]. Differences in method selection may play a key role with men tending to use more violent methods when engaging in suicidal behaviour, and are therefore more likely to die as a result [
24]. This may explain the higher rate of nonfatal self-harm observed in women. Men also more frequently express their psychological distress by alcohol misuse [
25] and aggression or violence towards others [
26].
When examining rates across the UK, we found lower rates in England compared to Northern Ireland, Scotland and Wales. These results mirror findings for completed suicide, where large disparities have been found between national rates [
8,
10]. Notably, it has been observed that rates in Scotland have increased markedly relative to those in England in recent decades [
27]. Employment and socio-economic status have been discussed as risk factors for self-harm in many studies [
7,
9,
10]. These factors, along with mental illness and alcohol misuse, could explain the heterogeneity in self-harm rates we observed across the UK nations [
28].
The need for closer relationships between primary and secondary healthcare practitioners, and between practices and community mental health teams, has also been emphasised [
29,
30]. In 2002, it was reported that the UK has one of the highest rates of self-harm in Europe, at 40 per 10,000 population [
31]. However, due to a lack of national databases for self-harm, reliable figures on the frequency of occurrence are not readily available. A multi-centre study of emergency department presentations of self-harm in three cities across England gave rates during 2000–2007 of 36, 46 and 44 per 10,000 population in Oxford, Manchester and Derby respectively [
7]. The corresponding gender-specific rates were 31, 37 and 37 for males and 41, 54 and 51 for females. Differences in reported rates of self-harm between primary and secondary care may result from the fact that only around half of patients visit their GP in the month following a presentation to a hospital [
32], and practices are only notified of an episode in approximately half of cases involving a mental health specialist [
33]. It is also likely that some patients only present to general practice settings and not hospital services.
Strengths and limitations
Our study’s main strength was the scale and scope of the CPRD, which enabled us to examine an outcome that is comparatively rare in the general population. A comprehensive self-harm database does not currently exist in the UK, but this is true of all other countries worldwide, except for the Republic of Ireland, which has established a national registry of hospital presentations [
34]. Multicentre monitoring of secondary care presentations has been undertaken, with the purpose of characterising the epidemiology of self-harm at a population level beyond reports from single centres [
1]. While these studies provide useful data, they report findings from just three cities and therefore do not provide a comprehensive national picture. Hospital Episodes Statistics (HES) linked to national mortality records have recently been used to examine self-harm in England [
35]. However, this dataset captures only the more medically serious cases that require admission. The general practices that contribute to the CPRD provide a broadly representative UK-wide sample with overall distributions of age and gender corresponding to those of the whole population. Because of this national representativeness, it is unlikely that any age or gender bias will have entered our analyses. Similar relative distributions have been observed in other studies [
7].
On an annual basis, we investigated incident episodes and the proportion of patients presenting to general practice on at least one occasion. This is a new definition for primary care in the context of a stable, non-transient, subset of the population. Thus, by placing practice registration restrictions, we ensured reliable comparisons between subgroups with an emphasis on temporal trends and relative risks. Internally standardised rate estimates have been used throughout. However, due to the nationally representative nature of the data, we found that crude and standardised estimates were almost identical.
Our study had several limitations. Firstly, comprehensive ascertainment of all self-harm episodes among this primary care patient cohort was reliant on patient disclosure of self-harming behaviour to their GPs, the consistency of clinical coding practice among GPs, and the completeness of notification of other cases by hospital emergency departments. Validation of self-harm case definition, by chart review of medical records, is not possible when using data from the CPRD. It is also possibile that increasing awareness of self-harm introduced a degree of surveillance bias into our analyses of temporal trends.
Secondly, it was necessary to restrict our analysis of incident episodes to the identification of first recorded events. As we did not have any means of ensuring that these were genuine first episodes, it is possible that some patients will have previously self-harmed, perhaps prior to their current practice registration. Finally, research has shown that self-harm may be more strongly related to individual socioeconomic factors than to geographical area characteristics [
36]. As this patient-level data was unavailable, it was a necessary limitation to use an ecological small area-level measure of deprivation as a proxy.