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The Royal College of Psychiatrists Improving the lives of people with mental illness

Kaleidoscope February 2018

BJPsych February 2018

The ‘iceberg model’ has fatal self-harm (suicide) as the highly visible tip overlaying the more frequent non-fatal self-harm seen by clinical services, which lies atop of an even larger base never contacting services. Although accepted in principle, few data have shown the relative sizes of these three groups, hampering potential preventative and educative programmes. A new paper in Lancet Psychiatry explored this in young people using national mortality and hospital monitoring self-harm data, and a schools’ survey. The data are harrowing: 171 adolescents (aged 12–17) died by suicide in England between 2011 and 2013; for each of these deaths there were about 370 hospital presentations with self-harm, and 3900 adolescents self-harming but unseen in the community. Ratios of non-fatal/fatal self-harm varied between genders – the former far higher in females, with males accounting for 70% of suicides. Hanging or asphyxiation were the most common cause of death, self-poisoning the most common hospital presentation and self-cutting the most common form of self-harm in the community. These figures are difficult to ignore, suicide is the leading cause of adolescent death in the UK. Every year an estimated 200,000 young people self-harm in England and are not seen; this suggests that out-reach of our services must be developed and the authors propose schools-based programmes as a key target.

#MeToo is leading us through a necessary cultural shift. The other day Formula 1 announced it will no longer have “grid girls” from next season; well that only took thirty years from Play Your Cards Right’s “Dolly dealers” – our children will look back with the same bewilderment we feel when we see old footage of people smoking on planes. A challenging but moving editorial in the New England Journal of Medicine argues that unacceptable behaviour is an issue beyond politicians and film directors to occur also in healthcare. A second paper reviewed in Kaleidoscope takes a related difficult topic: despite accounting for the majority of undergraduate science and healthcare degrees at University, women remain grossly under-represented at the most senior professional levels. The authors went to multiple university lectures and found that when women:men student ratios were equal, women were two and a half times less likely to ask a question than men; it got even worse if a man asked the first question. It argues that women are literally less visible, and something needs to change. Difficult but important conversations for us all. We’ve recently recorded a highly stimulating podcast at the College with some leading women in medicine and neuroscience, and will be publishing that with the Mental Health Foundation next month; watch out too for a forthcoming editorial in the BJPsych on the topic.


  1. Despite pharmacodynamic logic and early animal model success, the first randomised controlled trial of cannabidiol in psychosis failed to show any benefit over placebo.

    Answer: False; the data look promising.

  2. Analysis of behaviour following calls for gun control changes and public health warnings after the ‘Sandy Hook’ school shootings showed it was followed by an increase in gun sales.

    Answer: True, sadly.

  3. Data on unwanted sexual approaches towards female doctors from male colleagues show these to occur at a similar rate to those in society more generally.

    Answer: True, sadly.



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