Sunday, December 24, 2017
Tuesday, December 19, 2017
Critical Thinking: A Vital Trait for Nurses
Critical Thinking: A Vital Trait for Nurses
by Srinidhi Lakhanigam, BSN, RN, CCRN, CMSRN | Dec 14, 2017 | Blog, Magazine, Minority and Community Health, Nursing Students | 0 Comments
One of the most commonly heard phrases right from day one of nursing school is “critical thinking.” The common consensus is that everyone has to develop sound critical thinking in order to be a safe and effective, registered nurse (RN). This necessity is magnified when it comes to critical care areas where one decision by the RN can change the patient’s outcome. Nursing has changed from a simple caregiving job to a complex and highly responsible profession. Hence, the role of nurses has changed from being task-oriented to a team-based, patient-centered approach with an emphasis on positive outcomes. Strong critical thinking skills will have the greatest impact on patient outcomes.
So, what is critical thinking and how do we develop this? A precise definition was proposed in a statement by Michael Scriven and Richard Paul at the Eighth Annual International Conference on Critical Thinking and Education Reform during the summer of 1987. “Critical thinking is the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action. In its exemplary form, it is based on universal intellectual values that transcend subject matter divisions: clarity, accuracy, precision, consistency, relevance, sound evidence, good reasons, depth, breadth, and fairness,” reads the document.
Simply put, critical thinking in nursing is a purposeful, logical process which results in powerful patient outcomes. “Critical thinking involves interpretation and analysis of the problem, reasoning to find a solution, applying, and finally evaluation of the outcomes,” according to a 2010 study published in the Journal of Nursing Education. This definition essentially covers the nursing process and reiterates that critical thinking builds upon a solid foundation of sound clinical knowledge. Critical thinking is the result of a combination of innate curiosity; a strong foundation of theoretical knowledge of human anatomy and physiology, disease processes, and normal and abnormal lab values; and an orientation for thinking on your feet. Combining this with a strong passion for patient care will produce positive patient outcomes. The critical thinking nurse has an open mind and draws heavily upon evidence-based research and past clinical experiences to solve patient problems.
How does one develop critical thinking skills? A good start is to develop an inquisitive mind, which leads to questioning, and a quest for knowledge and understanding of the complex nature of the human body and its functioning. A vital step in developing critical thinking for new nurses is to learn from those with a strong base of practical experience in the form of preceptors/colleagues. An open-minded nurse can learn valuable lessons from others’ critical thinking ability and will be able to practice for the good of their patients.
Critical thinking is self-guided and self-disciplined. Nursing interventions can be reasonably explained through evidence-based research studies and work experience. A strong sense of focus and discipline is also important for critical thinking to work. If thinking is unchecked, nurses can be easily misguided and deliver flawed patient care. A constant comparison of practice with best practices in the industry will help guide a nurse to think critically and improve care. This makes it easier to form habits which continue to have a positive impact on patients and colleagues. Every decision a critical thinking nurse makes affects not only the patient but also his or her families, coworkers, and self.
In summary, the take-home message for nurses is that critical thinking alone can’t ensure great patient care. A combination of open-mindedness, a solid foundational knowledge of disease processes, and continuous learning, coupled with a compassionate heart and great clinical preceptors, can ensure that every new nurse will be a critical thinker positively affecting outcomes at the bedside.
Saturday, December 16, 2017
Why Is Self-Harm Rising Among Teen Girls?
Why Is Self-Harm Rising Among Teen Girls?
Authors: News Author: Pauline Anderson; CME Author: Laurie Barclay, MD Faculty and Disclosures
Self-harm among children and adolescents carries a major public health burden and is highly associated with risk for suicide, anxiety disorders, and depression, as well as long-lasting psychological issues in childhood that often herald the onset of mental illnesses in adulthood.
The national suicide prevention strategy in the United Kingdom now targets lowering self-harm rates as a common forerunner of suicide. Such strategies require accurate population-level data regarding the frequency and course of self-harm among children and adolescents. The goals of this population-based cohort study were to evaluate temporal trends in sex- and age-specific incidence of self-harm among children and adolescents, as well as clinical management patterns and risk for cause-specific mortality after an index self-harm episode in early life.
Study Synopsis and Perspective
The incidence of self-harm among girls aged 13 to 16 years increased by 68% in the UK during a 4-year period, new research shows.
This apparent marked increase suggests an "urgent need to identify the causes of this phenomenon," the authors, led by Nav Kapur, MD, professor of psychiatry and population health, University of Manchester, United Kingdom, write.
The findings highlight the important role of primary care for early intervention, monitoring, and targeting of at-risk children and adolescents, said Dr Kapur.
"When a young person is in distress and presents with self-harm to services, that's a real marker; that's a real indication that we need to intervene," he told Medscape Medical News.
The investigators also found that primary care practices in more socially deprived areas are less likely to refer children and adolescents who self-harm to specialist mental health services, and that these teenagers are at higher risk of dying after an incident of self-harm compared with their peers without a self-harm history.
The study was published online October 18 in the BMJ.
Suicide Risk
Self-harm in young people is a major public health problem. Worldwide, it is the strongest risk factor for subsequent suicide. Suicide is the second most common cause of death after traffic incidents for those younger than 25 years.
Researchers used the UK-wide Clinical Practice Research Datalink, 1 of the world's largest databases of electronic primary care patient records.
The anonymized database contains more than 4.4 million active patient records from 674 general practices and is broadly representative of the national population in terms of age, sex, and ethnicity.
About 60% of practices participate in the Clinical Practice Research Datalink linkage scheme, which facilitates access to hospital statistics, national mortality data, and information on social deprivation from census figures.
The analysis comprised 3 phases.
In the first phase, researchers identified 16,912 children and adolescents aged 10 to 19 years who experienced at least 1 episode of self-harm for the period 2001 to 2014. Of the index episodes of self-harm, more than 80% were drug overdoses.
In the United Kingdom, self-harm is a "spectrum of behaviors" that captures self-poisoning as well as self-injury, including self-cutting, regardless of intent, said Dr Kapur. He added that it is difficult to distinguish suicide attempts from nonsuicidal episodes of self-harm.
In this new study, the incidence of self-harm among girls was about 3 times higher than among boys (37.4 per 10,000 compared with 12.3 per 10,000).
Depression diagnoses were recorded in more than a third of girls and more than a quarter of boys. Attention-deficit/hyperactivity disorder, autism spectrum disorders, conduct disorder, and schizophrenia spectrum disorders were more common in boys than girls. Eating disorders were more prevalent in girls.
Within 12 months of the index episode, repeat self-harm was more common (about 21.5%) in girls than boys.
Sex Differences
The researchers investigated 5 categories of deprivation. Among children and adolescents registered with healthcare practices in the most deprived areas, the annual incidence per 10,000 was higher than among those registered in practices in the least deprived areas (27.1 vs 19.6).
Among girls aged 13 to 16 years, the age-specific incidence rate per 10,000 jumped by 68% from 2011 to 2014, going from 45.9 (95% confidence interval [CI], 41.7-50.0) to 76.9 (95% CI, 70.7-83.2).
There were no noticeable increases in the incidence in self-harm over time among females in age groups other than those aged 13 to 16 years or among males of any age.
Dr Kapur cautioned that the study was based on databases that might miss some cases and that lack detail in the recording of self-harm.
Although the reasons behind the recent increase of self-harm among young teenage girls are not clear, the authors indicate it may be linked to common mental health problems in female youths, as well as biological factors such as puberty. The increase could simply be related to problems of identification. Youths might be more willing to talk about self-harm, parents more willing to disclose it, and physicians more likely to inquire about it, said Dr Kapur.
However, the sharp increase that is restricted to a specific age and sex suggests otherwise.
"If it was just an identification issue, we would expect to see it across all age groups, and we would expect to see it in boys as well as girls," said Dr Kapur.
Responsible Use of Social Media
He noted "converging evidence" from various sources, including recent surveys, that suggests that the rise is "real," and that self-harm rates "might actually be going up," said Dr Kapur.
On the assumption that the increase is real, Dr Kapur suggested some possible causes for such an increase.
Higher levels of stress could play a role, said Dr Kapur. Young girls might be experiencing the same level of stress as boys but are responding to it differently. Boys, for example, might drink alcohol, whereas girls might start cutting themselves.
Digital media might also contribute to the recent rise in self-harm among teenaged girls.
"Social media and the Internet can be helpful to some people, as well as harmful," said Dr Kapur. For example, some websites might connect kids to useful resources, whereas others might encourage self-harm or present it as a normal reaction to a stressful event.
"The solution there, I think, is about educating and training young people to use social media responsibly," said Dr Kapur.
In the second analytic phase, researchers assessed clinical management during the 12 months after self-harm. A total of 2395 persons (17.7%) were referred to mental health services in this time frame. Of those, 18.2% were girls and 16.5% were boys.
The study showed that children and adolescents from general practices that were located in the most deprived areas were 23% less likely to be referred compared with practices in the least deprived areas.
This, said Dr Kapur, is an example of the "so-called inverse care law," according to which people who have the most complex needs (more mental illness and economic adversity, for example) "paradoxically" have the least access to healthcare. This could be partly a result of geographical barriers to accessing care.
Not Just a Clinical Problem
Overall, 22.2% of patients were prescribed antidepressants in the year after the index self-harm episode. More girls were given these drugs than boys. Conversely, boys were more likely to be prescribed hypnotics, anxiolytics, and antipsychotics than girls.
In the third analytic phase, each person with an incident episode was matched by age, sex, and registered practice, with up to 20 comparison individuals for whom there was no record of self-harm.
The researchers compared mortality data from 8638 youth in the self-harm cohort with those of 170,274 unaffected children. There were 43 deaths in the former group and 176 in the latter cohort.
Children and adolescents who engaged in self-harm were more than 9 times more likely to die an "unnatural" death during the follow-up period than their unaffected peers (hazard ratio [HR], 9.35; 95% CI, 5.84-14.97 after adjusting for deprivation level).
They were 17 times more likely to die by suicide (adjusted HR, 17.48; 95% CI, 7.55-40.46).
"This is an important reminder that self-harm is a behavior that needs to be taken very seriously," said Dr Kapur. He added that it is clear that self-harm is "linked to suicide" and is not always merely an act of attention seeking.
In addition to assessing young patients for self-harm risk, clinicians should ensure these patients have access to good psychiatric treatments, including "talk therapies," said Dr Kapur.
He noted the importance of involving others in the community to help tackle the problem of self-harm among young people.
"This is not just a clinical responsibility; we need to be working with schools, families, and others."
Calling Attention
Commenting on the study for Medscape Medical News, R. Scott Benson, MD, a child and adolescent psychiatrist in Pensacola, Florida, who is a member of the practice guideline committee of the American Psychiatric Association, praised the authors for "calling attention to this problem."
However, the data showing a 68% rise in the incidence of self-harm in young teenaged girls are "a little bit inflammatory," said Dr Benson.
"You have to look at the relative incidence, which is still fairly low, although it's more than it used to be, and it's more than it should be."
The vast majority of teenagers "are doing just fine," said Dr Benson. He added that the group of teenagers who are having trouble is small, and a group in the middle are "kind of wobbling," noting: "It's in the group who are wobbling where we can really make a difference."
The study results "are pretty consistent with what our clinical experience has been," noted Dr Benson, who said he characterizes self-cutting and self-harm as "tension-discharge behaviors."
"It just tells me that someone is under enormous stress and tension and doesn't feel they're getting the kind of support they need," said Dr Benson.
"Our job is to identify those children who are experiencing all that stress and make sure they get care."
Dr Benson commented that the fact that the most deprived regions have the least access to mental health services might reflect a degree of family instability.
"If the kids are under more stress, their parents may also be suffering stress, and because of that stress, may be less able to come up with a plan for accessing services for their children."
Dr Kapur chaired the National Institute for Health and Care Excellence (NICE) self-harm guidelines, quality standard topic expert group; is current chair of the National Institute for Health and Care Excellence adult depression guidelines, treatment, and management committee; is a topic expert for National Institute for Health and Care Excellence suicide prevention guidelines; and is a member of the Department of Health Suicide Prevention Strategy Advisory Group. Dr Benson has disclosed no relevant financial relationships.
BMJ. Published online October 18, 2017.[1]
Study Highlights
Using the UK Clinical Practice Research Datalink including electronic health records from 674 general practices, investigators identified 16,912 patients aged 10 to 19 years who harmed themselves during 2001 to 2014.
The first phase of analysis evaluated temporal trends in sex- and age-specific annual incidence of self-harm.
Practice-level deprivation was assessed ecologically with the index of multiple deprivation.
The second phase of analysis studied the probability of mental health services referral and psychotropic drug prescribing as measures of clinical management.
To evaluate cause-specific mortality after self-harm, investigators matched 8638 patients who were linked to hospital episode statistics and Office for National Statistics mortality records with up to 20 unaffected children and adolescents (n=170,274), based on age, sex, and general practice.
The third phase of analysis estimated relative risks for all-cause mortality, unnatural death (including suicide and accidental death), and fatal acute alcohol or drug poisoning.
Stratified Cox proportional hazards models for the self-harm cohort compared with the matched unaffected comparison cohort allowed derivation of HRs.
Annual incidence of self-harm increased in girls (37.4 per 10,000) compared with boys (12.3 per 10,000).
Repeat self-harm within 12 months of the index episode was approximately 21.5% more common in girls than in boys.
Among girls aged 13 to 16 years, annual incidence of self-harm increased rapidly and substantially by 68% from 2011 to 2014, from 45.9 per 10,000 to 77.0 per 10,000.
Annual incidence of self-harm did not increase appreciably among younger girls or among boys.
Young patients at the most socially deprived practices had considerably higher incidences of self-harm (27.1 vs 19.6 per 10,000), but were 23% less likely to receive referrals within 12 months of the index self-harm episode.
During follow-up, risks for all-cause and cause-specific mortality were increased, and unnatural death was approximately 9 times more likely among young patients with self-harm.
Risks for suicide were especially elevated, with a deprivation-adjusted HR of 17.5 (95% CI, 7.6-40.5), as were risks for fatal acute alcohol or drug poisoning (HR, 34.3; 95% CI, 10.2-115.7).
On the basis of their findings, the investigators concluded that multiple public agencies should place urgent priorities on clarifying the mechanisms underlying the recent apparent increase in the incidence of self-harm among early- to midteenaged girls, and on coordinated initiatives to address inequalities in health services provision to distressed children and adolescents.
Possible causes for this increase could include higher levels of stress and increased acceptability or even encouragement of self-harm by some social media.
Primary care plays an important role for early intervention and evaluation, monitoring, and targeting of young people who may not openly seek healthcare services for their self-harming behavior.
Given the scant evidence of consistent clinical management strategies for self-harm among children and adolescents, particularly in primary care settings, further development of appropriate interventions is needed.
The need to develop and implement effective interventions is especially crucial for girls in their early- to midteens, as this group had a 68% increase in self-harm incidence from 2011 to 2014.
Practices in the most deprived localities had the highest incidence of self-harm but the lowest likelihood of referral, illustrating the "inverse care law" in which quantity or quality of healthcare service provision is inversely associated with the level of healthcare need.
Increased mortality risks highlight the urgent need for effective interagency collaboration involving families, schools, and healthcare practices to improve safety for these distressed young people in the short term, and to help ensure their future mental health and well-being.
Given the particularly high relative risks for suicide and fatal acute alcohol or drug poisonings, interventions especially need to target prevention of these outcomes.
Study limitations include potential misclassification because of inaccurate code usage in primary care databases, possible lack of generalizability to the overall community, and underestimation of suicide in questionable cases.
Clinical Implications
From 2011 to 2015, the incidence of self-harm among girls aged 13 to 16 years increased by 68%, according to findings of a population-based cohort study.
Multiple public agencies should place urgent priorities on clarifying the mechanisms underlying this increase and on coordinated initiatives to address inequalities in provision of health services to distressed children and adolescents.
Implications for the Healthcare Team: Primary care plays an important role for early intervention and evaluation, monitoring, and targeting of young people who may not openly seek healthcare services for their self-harming behavior.
Authors: News Author: Pauline Anderson; CME Author: Laurie Barclay, MD Faculty and Disclosures
Self-harm among children and adolescents carries a major public health burden and is highly associated with risk for suicide, anxiety disorders, and depression, as well as long-lasting psychological issues in childhood that often herald the onset of mental illnesses in adulthood.
The national suicide prevention strategy in the United Kingdom now targets lowering self-harm rates as a common forerunner of suicide. Such strategies require accurate population-level data regarding the frequency and course of self-harm among children and adolescents. The goals of this population-based cohort study were to evaluate temporal trends in sex- and age-specific incidence of self-harm among children and adolescents, as well as clinical management patterns and risk for cause-specific mortality after an index self-harm episode in early life.
Study Synopsis and Perspective
The incidence of self-harm among girls aged 13 to 16 years increased by 68% in the UK during a 4-year period, new research shows.
This apparent marked increase suggests an "urgent need to identify the causes of this phenomenon," the authors, led by Nav Kapur, MD, professor of psychiatry and population health, University of Manchester, United Kingdom, write.
The findings highlight the important role of primary care for early intervention, monitoring, and targeting of at-risk children and adolescents, said Dr Kapur.
"When a young person is in distress and presents with self-harm to services, that's a real marker; that's a real indication that we need to intervene," he told Medscape Medical News.
The investigators also found that primary care practices in more socially deprived areas are less likely to refer children and adolescents who self-harm to specialist mental health services, and that these teenagers are at higher risk of dying after an incident of self-harm compared with their peers without a self-harm history.
The study was published online October 18 in the BMJ.
Suicide Risk
Self-harm in young people is a major public health problem. Worldwide, it is the strongest risk factor for subsequent suicide. Suicide is the second most common cause of death after traffic incidents for those younger than 25 years.
Researchers used the UK-wide Clinical Practice Research Datalink, 1 of the world's largest databases of electronic primary care patient records.
The anonymized database contains more than 4.4 million active patient records from 674 general practices and is broadly representative of the national population in terms of age, sex, and ethnicity.
About 60% of practices participate in the Clinical Practice Research Datalink linkage scheme, which facilitates access to hospital statistics, national mortality data, and information on social deprivation from census figures.
The analysis comprised 3 phases.
In the first phase, researchers identified 16,912 children and adolescents aged 10 to 19 years who experienced at least 1 episode of self-harm for the period 2001 to 2014. Of the index episodes of self-harm, more than 80% were drug overdoses.
In the United Kingdom, self-harm is a "spectrum of behaviors" that captures self-poisoning as well as self-injury, including self-cutting, regardless of intent, said Dr Kapur. He added that it is difficult to distinguish suicide attempts from nonsuicidal episodes of self-harm.
In this new study, the incidence of self-harm among girls was about 3 times higher than among boys (37.4 per 10,000 compared with 12.3 per 10,000).
Depression diagnoses were recorded in more than a third of girls and more than a quarter of boys. Attention-deficit/hyperactivity disorder, autism spectrum disorders, conduct disorder, and schizophrenia spectrum disorders were more common in boys than girls. Eating disorders were more prevalent in girls.
Within 12 months of the index episode, repeat self-harm was more common (about 21.5%) in girls than boys.
Sex Differences
The researchers investigated 5 categories of deprivation. Among children and adolescents registered with healthcare practices in the most deprived areas, the annual incidence per 10,000 was higher than among those registered in practices in the least deprived areas (27.1 vs 19.6).
Among girls aged 13 to 16 years, the age-specific incidence rate per 10,000 jumped by 68% from 2011 to 2014, going from 45.9 (95% confidence interval [CI], 41.7-50.0) to 76.9 (95% CI, 70.7-83.2).
There were no noticeable increases in the incidence in self-harm over time among females in age groups other than those aged 13 to 16 years or among males of any age.
Dr Kapur cautioned that the study was based on databases that might miss some cases and that lack detail in the recording of self-harm.
Although the reasons behind the recent increase of self-harm among young teenage girls are not clear, the authors indicate it may be linked to common mental health problems in female youths, as well as biological factors such as puberty. The increase could simply be related to problems of identification. Youths might be more willing to talk about self-harm, parents more willing to disclose it, and physicians more likely to inquire about it, said Dr Kapur.
However, the sharp increase that is restricted to a specific age and sex suggests otherwise.
"If it was just an identification issue, we would expect to see it across all age groups, and we would expect to see it in boys as well as girls," said Dr Kapur.
Responsible Use of Social Media
He noted "converging evidence" from various sources, including recent surveys, that suggests that the rise is "real," and that self-harm rates "might actually be going up," said Dr Kapur.
On the assumption that the increase is real, Dr Kapur suggested some possible causes for such an increase.
Higher levels of stress could play a role, said Dr Kapur. Young girls might be experiencing the same level of stress as boys but are responding to it differently. Boys, for example, might drink alcohol, whereas girls might start cutting themselves.
Digital media might also contribute to the recent rise in self-harm among teenaged girls.
"Social media and the Internet can be helpful to some people, as well as harmful," said Dr Kapur. For example, some websites might connect kids to useful resources, whereas others might encourage self-harm or present it as a normal reaction to a stressful event.
"The solution there, I think, is about educating and training young people to use social media responsibly," said Dr Kapur.
In the second analytic phase, researchers assessed clinical management during the 12 months after self-harm. A total of 2395 persons (17.7%) were referred to mental health services in this time frame. Of those, 18.2% were girls and 16.5% were boys.
The study showed that children and adolescents from general practices that were located in the most deprived areas were 23% less likely to be referred compared with practices in the least deprived areas.
This, said Dr Kapur, is an example of the "so-called inverse care law," according to which people who have the most complex needs (more mental illness and economic adversity, for example) "paradoxically" have the least access to healthcare. This could be partly a result of geographical barriers to accessing care.
Not Just a Clinical Problem
Overall, 22.2% of patients were prescribed antidepressants in the year after the index self-harm episode. More girls were given these drugs than boys. Conversely, boys were more likely to be prescribed hypnotics, anxiolytics, and antipsychotics than girls.
In the third analytic phase, each person with an incident episode was matched by age, sex, and registered practice, with up to 20 comparison individuals for whom there was no record of self-harm.
The researchers compared mortality data from 8638 youth in the self-harm cohort with those of 170,274 unaffected children. There were 43 deaths in the former group and 176 in the latter cohort.
Children and adolescents who engaged in self-harm were more than 9 times more likely to die an "unnatural" death during the follow-up period than their unaffected peers (hazard ratio [HR], 9.35; 95% CI, 5.84-14.97 after adjusting for deprivation level).
They were 17 times more likely to die by suicide (adjusted HR, 17.48; 95% CI, 7.55-40.46).
"This is an important reminder that self-harm is a behavior that needs to be taken very seriously," said Dr Kapur. He added that it is clear that self-harm is "linked to suicide" and is not always merely an act of attention seeking.
In addition to assessing young patients for self-harm risk, clinicians should ensure these patients have access to good psychiatric treatments, including "talk therapies," said Dr Kapur.
He noted the importance of involving others in the community to help tackle the problem of self-harm among young people.
"This is not just a clinical responsibility; we need to be working with schools, families, and others."
Calling Attention
Commenting on the study for Medscape Medical News, R. Scott Benson, MD, a child and adolescent psychiatrist in Pensacola, Florida, who is a member of the practice guideline committee of the American Psychiatric Association, praised the authors for "calling attention to this problem."
However, the data showing a 68% rise in the incidence of self-harm in young teenaged girls are "a little bit inflammatory," said Dr Benson.
"You have to look at the relative incidence, which is still fairly low, although it's more than it used to be, and it's more than it should be."
The vast majority of teenagers "are doing just fine," said Dr Benson. He added that the group of teenagers who are having trouble is small, and a group in the middle are "kind of wobbling," noting: "It's in the group who are wobbling where we can really make a difference."
The study results "are pretty consistent with what our clinical experience has been," noted Dr Benson, who said he characterizes self-cutting and self-harm as "tension-discharge behaviors."
"It just tells me that someone is under enormous stress and tension and doesn't feel they're getting the kind of support they need," said Dr Benson.
"Our job is to identify those children who are experiencing all that stress and make sure they get care."
Dr Benson commented that the fact that the most deprived regions have the least access to mental health services might reflect a degree of family instability.
"If the kids are under more stress, their parents may also be suffering stress, and because of that stress, may be less able to come up with a plan for accessing services for their children."
Dr Kapur chaired the National Institute for Health and Care Excellence (NICE) self-harm guidelines, quality standard topic expert group; is current chair of the National Institute for Health and Care Excellence adult depression guidelines, treatment, and management committee; is a topic expert for National Institute for Health and Care Excellence suicide prevention guidelines; and is a member of the Department of Health Suicide Prevention Strategy Advisory Group. Dr Benson has disclosed no relevant financial relationships.
BMJ. Published online October 18, 2017.[1]
Study Highlights
Using the UK Clinical Practice Research Datalink including electronic health records from 674 general practices, investigators identified 16,912 patients aged 10 to 19 years who harmed themselves during 2001 to 2014.
The first phase of analysis evaluated temporal trends in sex- and age-specific annual incidence of self-harm.
Practice-level deprivation was assessed ecologically with the index of multiple deprivation.
The second phase of analysis studied the probability of mental health services referral and psychotropic drug prescribing as measures of clinical management.
To evaluate cause-specific mortality after self-harm, investigators matched 8638 patients who were linked to hospital episode statistics and Office for National Statistics mortality records with up to 20 unaffected children and adolescents (n=170,274), based on age, sex, and general practice.
The third phase of analysis estimated relative risks for all-cause mortality, unnatural death (including suicide and accidental death), and fatal acute alcohol or drug poisoning.
Stratified Cox proportional hazards models for the self-harm cohort compared with the matched unaffected comparison cohort allowed derivation of HRs.
Annual incidence of self-harm increased in girls (37.4 per 10,000) compared with boys (12.3 per 10,000).
Repeat self-harm within 12 months of the index episode was approximately 21.5% more common in girls than in boys.
Among girls aged 13 to 16 years, annual incidence of self-harm increased rapidly and substantially by 68% from 2011 to 2014, from 45.9 per 10,000 to 77.0 per 10,000.
Annual incidence of self-harm did not increase appreciably among younger girls or among boys.
Young patients at the most socially deprived practices had considerably higher incidences of self-harm (27.1 vs 19.6 per 10,000), but were 23% less likely to receive referrals within 12 months of the index self-harm episode.
During follow-up, risks for all-cause and cause-specific mortality were increased, and unnatural death was approximately 9 times more likely among young patients with self-harm.
Risks for suicide were especially elevated, with a deprivation-adjusted HR of 17.5 (95% CI, 7.6-40.5), as were risks for fatal acute alcohol or drug poisoning (HR, 34.3; 95% CI, 10.2-115.7).
On the basis of their findings, the investigators concluded that multiple public agencies should place urgent priorities on clarifying the mechanisms underlying the recent apparent increase in the incidence of self-harm among early- to midteenaged girls, and on coordinated initiatives to address inequalities in health services provision to distressed children and adolescents.
Possible causes for this increase could include higher levels of stress and increased acceptability or even encouragement of self-harm by some social media.
Primary care plays an important role for early intervention and evaluation, monitoring, and targeting of young people who may not openly seek healthcare services for their self-harming behavior.
Given the scant evidence of consistent clinical management strategies for self-harm among children and adolescents, particularly in primary care settings, further development of appropriate interventions is needed.
The need to develop and implement effective interventions is especially crucial for girls in their early- to midteens, as this group had a 68% increase in self-harm incidence from 2011 to 2014.
Practices in the most deprived localities had the highest incidence of self-harm but the lowest likelihood of referral, illustrating the "inverse care law" in which quantity or quality of healthcare service provision is inversely associated with the level of healthcare need.
Increased mortality risks highlight the urgent need for effective interagency collaboration involving families, schools, and healthcare practices to improve safety for these distressed young people in the short term, and to help ensure their future mental health and well-being.
Given the particularly high relative risks for suicide and fatal acute alcohol or drug poisonings, interventions especially need to target prevention of these outcomes.
Study limitations include potential misclassification because of inaccurate code usage in primary care databases, possible lack of generalizability to the overall community, and underestimation of suicide in questionable cases.
Clinical Implications
From 2011 to 2015, the incidence of self-harm among girls aged 13 to 16 years increased by 68%, according to findings of a population-based cohort study.
Multiple public agencies should place urgent priorities on clarifying the mechanisms underlying this increase and on coordinated initiatives to address inequalities in provision of health services to distressed children and adolescents.
Implications for the Healthcare Team: Primary care plays an important role for early intervention and evaluation, monitoring, and targeting of young people who may not openly seek healthcare services for their self-harming behavior.
Friday, December 1, 2017
Enriched Music Therapy Benefits Stroke Patients Long Term
Enriched Music Therapy Benefits Stroke Patients Long Term
Daniel M. Keller, PhD
November 03, 2016
HYDERABAD, INDIA — An enriched intervention approach using music therapy encompassing movement, cognitive focus, psychological well-being, and social interaction benefits stroke patients in the long term, a study shows.
Stroke often leads to depressed mood, social isolation, and diminished feelings of well-being, the researchers point out, and mental distress can impair motor recovery and increase the risk for future stroke.
Addressing the mental, social, and physical domains at the same time, their integrative approach differs from traditional ones that provide separate, isolated occupational, physical, and speech therapies and psychological, social work, and physiatry services.
Preeti Raghavan, MD, from Rusk Rehabilitation at the New York University School of Medicine in New York City, said music is a "universal language," and this sort of enriched intervention approach is appropriate for all types of ethnic communities and may be especially beneficial in areas with limited resources.
She presented her findings here at the World Stroke Congress (WSC) 2016.
Biological Underpinnings
Animal experiments have shown that environments enhanced with sensory stimuli facilitate post-stroke recovery by promoting neurogenesis and neuronal survival, the authors note. Brain-derived neurotrophic factor can enhance learning when training is intensive, and oxytocin promotes social bonding, is neuroprotective, reduces infarct size and inflammation, and enhances neuroplasticity.
Studies in humans have shown two-way signaling between the auditory and motor cortices that underlies beat perception. Rhythms promote efficient recruitment of motor units, leading to improved motor outcomes.
For the Music Upper Limb Therapy–Integrated (MULT-I) preliminary feasibility study, Dr Raghavan recruited patients with chronic hemiparesis from a stroke that occurred at least 6 months earlier. They had to be able to open and close the hand partially on the affected side, with an upper limb score of no greater than 60 on the Fugl-Meyer Scale, meaning there was still room for improvement. Participants could not have a major disability, as indicated by a modified Rankin Scale score greater than 4.
Patients (five groups of three) participated in biweekly 45-minute sessions for 6 weeks. They did not have to have any prior musical training. One occupational therapist and two music therapists provided a 1:1 therapist-to-patient ratio.
Each session consisted of an initial 5 minutes of stretching, 35 minutes of music making, and 5 minutes of discussion. Each person chose a percussive instrument. The only requirement was that patients had to be able to hold an object with which to hit the instrument or to shake the instrument (such as maracas).
Therapists videotaped the group interactive music sessions, reviewed them, and adjusted subsequent interventions based on those observations.
Disability was reduced and well-being improved after the MULT-I program, and these improvements persisted. Modified Rankin Scale measures went from 2.4 before the program to 2.0 afterward (P = .03) and to 1.5 one year later (P = .04 vs before). World Health Organization well-being scores improved from 14 before the program to 18 afterward (P = .03) and the same one year later.
Dr Raghavan said that in the discussion period, even after just the first session, participants commented that they felt function "coming back to what I used to be doing" and "I see that the rhythm is there; it's going to my brain, telling me how to maneuver it."
The experiences in the music sessions carried over into daily life. Participants described benefits going beyond the music-making sessions, such as dancing again, taking the subway, using the affected arm in cooking, dressing, or rising from a chair.
Music Benefits Multiple Domains
Dr Raghavan explained the multiple benefits of music. In the physical domain, it promotes movement, she said, especially repetitive movements by coupling auditory and motor mechanisms. It also distracts attention from the physical efforts required. In the mental domain, music benefits mood and cognitive recovery while eliciting strong behavioral responses, and it integrates cognitive, emotional, and sensorimotor brain functions. Finally, interactive group music benefits patients' social functioning by promoting spontaneous interaction and facilitating development of relationships. Music is also a means of verbal and nonverbal communication.
She said that some of the lessons learned are that "music therapy can provide an enriched environment, it could be relatively low cost, it could be compatible with existing values in different parts of the world, it could address social isolation…and attention." The enriched environment program also has observable results in terms of reduced motor impairment and improved well-being.
Session chair Patrik Michel, MD, head of the stroke center at Lausanne University Hospital in Switzerland, commented to Medscape Medical News that Dr Raghavan presented convincing evidence "that several factors, in particular subjective well-being, were actually improved through this kind of therapy" using professionals to lead an enriched group music program.
He said that usually in rehabilitation, any different kind of enriched therapy activating previously unsolicited brain regions will usually lead to an improvement in patients' function. "This is just tapping into a domain where we have underused the brain that is going beyond traditional motor rehabilitation, traditional speech rehabilitation but just using new auditory, emotional, and musical clues to improve function," he said.
Professor Michel said it will be important to figure out the best amount of music therapy to provide and the best form of music therapy. In this study, the patients were active participants in the sessions, compared with the more traditional music therapy in which patients passively listen to music.
There was no commercial funding for the study. Dr Raghavan and Professor Michel have disclosed no relevant financial relationships.
World Stroke Congress (WSC) 2016. Presented October 28, 2016.
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Daniel M. Keller, PhD
November 03, 2016
HYDERABAD, INDIA — An enriched intervention approach using music therapy encompassing movement, cognitive focus, psychological well-being, and social interaction benefits stroke patients in the long term, a study shows.
Stroke often leads to depressed mood, social isolation, and diminished feelings of well-being, the researchers point out, and mental distress can impair motor recovery and increase the risk for future stroke.
Addressing the mental, social, and physical domains at the same time, their integrative approach differs from traditional ones that provide separate, isolated occupational, physical, and speech therapies and psychological, social work, and physiatry services.
Preeti Raghavan, MD, from Rusk Rehabilitation at the New York University School of Medicine in New York City, said music is a "universal language," and this sort of enriched intervention approach is appropriate for all types of ethnic communities and may be especially beneficial in areas with limited resources.
She presented her findings here at the World Stroke Congress (WSC) 2016.
Biological Underpinnings
Animal experiments have shown that environments enhanced with sensory stimuli facilitate post-stroke recovery by promoting neurogenesis and neuronal survival, the authors note. Brain-derived neurotrophic factor can enhance learning when training is intensive, and oxytocin promotes social bonding, is neuroprotective, reduces infarct size and inflammation, and enhances neuroplasticity.
Studies in humans have shown two-way signaling between the auditory and motor cortices that underlies beat perception. Rhythms promote efficient recruitment of motor units, leading to improved motor outcomes.
For the Music Upper Limb Therapy–Integrated (MULT-I) preliminary feasibility study, Dr Raghavan recruited patients with chronic hemiparesis from a stroke that occurred at least 6 months earlier. They had to be able to open and close the hand partially on the affected side, with an upper limb score of no greater than 60 on the Fugl-Meyer Scale, meaning there was still room for improvement. Participants could not have a major disability, as indicated by a modified Rankin Scale score greater than 4.
Patients (five groups of three) participated in biweekly 45-minute sessions for 6 weeks. They did not have to have any prior musical training. One occupational therapist and two music therapists provided a 1:1 therapist-to-patient ratio.
Each session consisted of an initial 5 minutes of stretching, 35 minutes of music making, and 5 minutes of discussion. Each person chose a percussive instrument. The only requirement was that patients had to be able to hold an object with which to hit the instrument or to shake the instrument (such as maracas).
Therapists videotaped the group interactive music sessions, reviewed them, and adjusted subsequent interventions based on those observations.
Disability was reduced and well-being improved after the MULT-I program, and these improvements persisted. Modified Rankin Scale measures went from 2.4 before the program to 2.0 afterward (P = .03) and to 1.5 one year later (P = .04 vs before). World Health Organization well-being scores improved from 14 before the program to 18 afterward (P = .03) and the same one year later.
Dr Raghavan said that in the discussion period, even after just the first session, participants commented that they felt function "coming back to what I used to be doing" and "I see that the rhythm is there; it's going to my brain, telling me how to maneuver it."
The experiences in the music sessions carried over into daily life. Participants described benefits going beyond the music-making sessions, such as dancing again, taking the subway, using the affected arm in cooking, dressing, or rising from a chair.
Music Benefits Multiple Domains
Dr Raghavan explained the multiple benefits of music. In the physical domain, it promotes movement, she said, especially repetitive movements by coupling auditory and motor mechanisms. It also distracts attention from the physical efforts required. In the mental domain, music benefits mood and cognitive recovery while eliciting strong behavioral responses, and it integrates cognitive, emotional, and sensorimotor brain functions. Finally, interactive group music benefits patients' social functioning by promoting spontaneous interaction and facilitating development of relationships. Music is also a means of verbal and nonverbal communication.
She said that some of the lessons learned are that "music therapy can provide an enriched environment, it could be relatively low cost, it could be compatible with existing values in different parts of the world, it could address social isolation…and attention." The enriched environment program also has observable results in terms of reduced motor impairment and improved well-being.
Session chair Patrik Michel, MD, head of the stroke center at Lausanne University Hospital in Switzerland, commented to Medscape Medical News that Dr Raghavan presented convincing evidence "that several factors, in particular subjective well-being, were actually improved through this kind of therapy" using professionals to lead an enriched group music program.
He said that usually in rehabilitation, any different kind of enriched therapy activating previously unsolicited brain regions will usually lead to an improvement in patients' function. "This is just tapping into a domain where we have underused the brain that is going beyond traditional motor rehabilitation, traditional speech rehabilitation but just using new auditory, emotional, and musical clues to improve function," he said.
Professor Michel said it will be important to figure out the best amount of music therapy to provide and the best form of music therapy. In this study, the patients were active participants in the sessions, compared with the more traditional music therapy in which patients passively listen to music.
There was no commercial funding for the study. Dr Raghavan and Professor Michel have disclosed no relevant financial relationships.
World Stroke Congress (WSC) 2016. Presented October 28, 2016.
For more Medscape Neurology news, join us on Facebook and Twitter
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