title: Clinical management following self-harm in a UK-wide primary care cohort.
abstract: BACKGROUND
  Little is known about the clinical management of patients in primary care following self-harm.
  
  
  METHODS
  A descriptive cohort study using data from 684 UK general practices that contributed to the Clinical Practice Research Datalink (CPRD) during 2001-2013. We identified 49,970 patients with a self-harm episode, 41,500 of whom had one complete year of follow-up.
  
  
  RESULTS
  Among those with complete follow-up, 26,065 (62.8%, 62.3-63.3) were prescribed psychotropic medication and 6318 (15.2%, 14.9-15.6) were referred to mental health services; 4105 (9.9%, CI 9.6-10.2) were medicated without an antecedent psychiatric diagnosis or referral, and 4,506 (10.9%, CI 10.6-11.2) had a diagnosis but were not subsequently medicated or referred. Patients registered at practices in the most deprived localities were 27.1% (CI 21.5-32.2) less likely to be referred than those in the least deprived. Despite a specifically flagged NICE 'Do not do' recommendation in 2011 against prescribing tricyclic antidepressants following self-harm because of their potentially lethal toxicity in overdose, 8.8% (CI 7.8-9.8) of individuals were issued a prescription in the subsequent year. The percentage prescribed Citalopram, an SSRI antidepressant with higher toxicity in overdose, fell sharply during 2012/2013 in the aftermath of a Medicines and Healthcare products Regulatory Agency (MHRA) safety alert issued in 2011.
  
  
  CONCLUSIONS
  A relatively small percentage of these vulnerable patients are referred to mental health services, and reduced likelihood of referral in more deprived localities reflects a marked health inequality. National clinical guidelines have not yet been effective in reducing rates of tricyclic antidepressant prescribing for this high-risk group.
authors.affiliation: Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, UK. Electronic address: matthew.carr@manchester.ac.uk.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Carr
authors.affiliation: Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, UK; NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, UK.
authors.forename: Darren M
authors.initials: DM
authors.lastname: Ashcroft
authors.affiliation: Centre for Health Informatics, Institute of Population Health, University of Manchester, UK; NIHR School for Primary Care Research, University of Manchester, UK.
authors.forename: Evangelos
authors.initials: E
authors.lastname: Kontopantelis
authors.affiliation: Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, UK.
authors.forename: David
authors.initials: D
authors.lastname: While
authors.affiliation: School of Psychological Sciences, University of Manchester, UK.
authors.forename: Yvonne
authors.initials: Y
authors.lastname: Awenat
authors.affiliation: Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, UK.
authors.forename: Jayne
authors.initials: J
authors.lastname: Cooper
authors.affiliation: Research Institute of Primary Care and Health Sciences, Keele University, UK.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Chew-Graham
authors.affiliation: Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, UK; Manchester Mental Health and Social Care Trust, UK.
authors.forename: Nav
authors.initials: N
authors.lastname: Kapur
authors.affiliation: Centre for Mental Health and Safety, Institute of Brain, Behaviour and Mental Health, University of Manchester, UK.
authors.forename: Roger T
authors.initials: RT
authors.lastname: Webb
mesh_terms: D000928:Antidepressive Agents / Q000627:therapeutic use*; D000929:Antidepressive Agents, Tricyclic / Q000008:administration & dosage / Q000009:adverse effects; D015283:Citalopram / Q000627:therapeutic use; D015331:Cohort Studies; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D008875:Middle Aged; D011203:Poverty; D011320:Primary Health Care; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D016728:Self-Injurious Behavior / Q000517:prevention & control*; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use; D006113:United Kingdom; D035862:Vulnerable Populations
chemical_list: D000928:Antidepressive Agents; D000929:Antidepressive Agents, Tricyclic; D015283:Citalopram; D017367:Selective Serotonin Reuptake Inhibitors
keywords: Diagnoses; Medication; Primary care; Referrals; Self-harm