Fatal and non-fatal repetition of self-harm. Systematic review.
TL;DR: In this paper, a systematic review of published follow-up data from observational and experimental studies was conducted to estimate rates of fatal and non-fatal repetition of self-harm.
Abstract: Background Non-fatal self-harm frequently leads to non-fatal repetition and sometimes to suicide. We need to quantify these two outcomes of self-harm to help us to develop and test effective interventions.
Aims To estimate rates of fatal and non-fatal repetition of self-harm.
Method A systematic review of published follow-up data, from observational and experimental studies. Four electronic databases were searched and 90 studies met the inclusion criteria.
Results Eighty per cent of studies found were undertaken in Europe, over one-third in the UK. Median proportions for repetition 1 year later were: 16% non-fatal and 2% fatal; after more than 9 years, around 7% of patients had died by suicide. The UK studies found particularly low rates of subsequent suicide.
Conclusions After 1 year, non-fatal repetition rates are around 15%. The strong connection between self-harm and later suicide lies somewhere between 0.5% and 2% after 1 year and above 5% after 9 years. Suicide risk among self-harm patients is hundreds of times higher than in the general population.
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TL;DR: The ideation-to-action framework stipulates that the development of suicidal ideation and the progression from ideation to suicide attempts are distinct phenomena with distinct explanations and predictors.
Abstract: Suicidal behavior is a leading cause of death and disability worldwide. Fortunately, recent developments in suicide theory and research promise to meaningfully advance knowledge and prevention. One key development is the ideation-to-action framework, which stipulates that (a) the development of suicidal ideation and (b) the progression from ideation to suicide attempts are distinct phenomena with distinct explanations and predictors. A second key development is a growing body of research distinguishing factors that predict ideation from those that predict suicide attempts. For example, it is becoming clear that depression, hopelessness, most mental disorders, and even impulsivity predict ideation, but these factors struggle to distinguish those who have attempted suicide from those who have only considered suicide. Means restriction is also emerging as a highly effective way to block progression from ideation to attempt. A third key development is the proliferation of theories of suicide that are positioned within the ideation-to-action framework. These include the interpersonal theory, the integrated motivational-volitional model, and the three-step theory. These perspectives can and should inform the next generation of suicide research and prevention.
837 citations
TL;DR: Following DSH there is a significant and persistent risk of suicide, which varies markedly between genders and age groups, and reduction in the risk of Suicide must be a key element in national suicide prevention strategies.
Abstract: Background Deliberate self-harm (DSH) is the strongest risk factor for future suicide. Up-to-date information on the extent of risk is lacking. Aims To investigate the risk of suicide after DSH during a long follow-up period. Method A mortality follow-up study to 2000 was conducted on 11 583 patients who presented to hospital after DSH between 1978 and 1997. Data were obtained from a general hospital DSH register in Oxford and the Office for National Statistics, and from equivalent mortality registers in Scotland and Northern Ireland. Results Three hundred patients had died by suicide or probable suicide. The risk in the first year of follow-up was 0.7% (95% CI 0.6-0.9%), which was 66 (95% CI 52-82) times the annual risk of suicide in the general population. The risk after 5 years was 1.7%, at 10 years 2.4% and at 15 years 3.0%. The risk was far higher in men than in women (hazard ratio 2.8,95% CI 2.2-3.6). In both genders it increased markedly with age at initial presentation. Conclusions Following DSH there is a significant and persistent risk of suicide, which varies markedly between genders and age groups. Reduction in the risk of suicide following DSH must be a key element in national suicide prevention strategies.
687 citations
TL;DR: Deliberate self-harm is a widespread yet often hidden problem in adolescents, especially females, which shows both similarities and differences internationally.
Abstract: Background: Deliberate self-harm among young people is an important focus of policy and practice internationally. Nonetheless, there is little reliable comparative international information on its extent or characteristics. We have conducted a seven-country comparative community study of deliberate self-harm among young people. Method: Over 30,000 mainly 15- and 16-year-olds completed anonymous questionnaires at school in Australia, Belgium, England, Hungary, Ireland, the Netherlands and Norway. Study criteria were developed to identify episodes of self-harm; the prevalence of self-harm acts and thoughts, methods used, repetition, reasons given, premeditation, setting for the act, associations with alcohol and drugs, hospitalisation, and whether other people knew, were examined. Results: Self-harm was more than twice as common among females as males and, in four of the seven countries, at least one in ten females had harmed herself in the previous year. Additional young people had thought of harming themselves without doing so. More males and females in all countries except Hungary cut themselves than used any other method, most acts took place at home, and alcohol and illegal drugs were not usually involved. The most common reasons given were ‘to get relief from a terrible state of mind’ followed by ‘to die’, although there were differences between those cutting themselves and those taking overdoses. About half the young people decided to harm themselves in the hour before doing so, and many did not attend hospital or tell anyone else. Just over half those who had harmed themselves during the previous year reported more than one episode over their lifetime. Conclusions: Deliberate self-harm is a widespread yet often hidden problem in adolescents, especially females, which shows both similarities and differences internationally. Keywords: Adolescence, cross-cultural, self-harm, gender differences, motives.
682 citations
TL;DR: Lithium is an effective treatment for reducing the risk of suicide in people with mood disorders and may exert its antisuicidal effects by reducing relapse of mood disorder.
Abstract: Objective To assess whether lithium has a specific preventive effect for suicide and self harm in people with unipolar and bipolar mood disorders. Design Systematic review and meta-analysis. Data sources Medline, Embase, CINAHL, PsycINFO, CENTRAL, web based clinical trial registries, major textbooks, authors of important papers and other experts in the discipline, and websites of pharmaceutical companies that manufacture lithium or the comparator drugs (up to January 2013). Inclusion criteria Randomised controlled trials comparing lithium with placebo or active drugs in long term treatment for mood disorders. Review methods Two reviewers assessed studies for inclusion and risk of bias and extracted data. The main outcomes were the number of people who completed suicide, engaged in deliberate self harm, and died from any cause. Results 48 randomised controlled trials (6674 participants, 15 comparisons) were included. Lithium was more effective than placebo in reducing the number of suicides (odds ratio 0.13, 95% confidence interval 0.03 to 0.66) and deaths from any cause (0.38, 0.15 to 0.95). No clear benefits were observed for lithium compared with placebo in preventing deliberate self harm (0.60, 0.27 to 1.32). In unipolar depression, lithium was associated with a reduced risk of suicide (0.36, 0.13 to 0.98) and also the number of total deaths (0.13, 0.02 to 0.76) compared with placebo. When lithium was compared with each active individual treatment a statistically significant difference was found only with carbamazepine for deliberate self harm. Lithium tended to be generally better than the other active comparators, with small statistical variation between the results. Conclusions Lithium is an effective treatment for reducing the risk of suicide in people with mood disorders. Lithium may exert its antisuicidal effects by reducing relapse of mood disorder, but additional mechanisms should also be considered because there is some evidence that lithium decreases aggression and possibly impulsivity, which might be another mechanism mediating the antisuicidal effect.
643 citations
TL;DR: The results highlight the importance in a suicide prevention strategy of early intervention after an episode of self-harm, and the importance of attention to physical illness, alcohol problems, and living circumstances, in treating female patients.
Abstract: OBJECTIVE: The purposes of this study were to estimate suicide rates up to 4 years after a deliberate self-harm episode, to investigate time-period effects on the suicide rate over the follow-up period, and to examine potential sociodemographic and clinical predictors of suicide within this cohort. METHOD: This prospective cohort study included 7,968 deliberate self-harm attendees at the emergency departments of four hospital trusts in the neighboring cities of Manchester and Salford, in northwest England, between September 1, 1997, and August 31, 2001. Suicide rates and standardized mortality ratios (SMRs) for the cohort were calculated. Potential risk factors were investigated by using Cox’s proportional hazards models. RESULTS: Sixty suicides occurred in the cohort during the follow-up period. An approximately 30-fold increase in risk of suicide, compared with the general population, was observed for the whole cohort. The SMR was substantially higher for female patients than for male patients. Suicide ...
603 citations
References
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TL;DR: Subjects who received dialectical behavior therapy had fewer incidences of parasuicide and less medically severe parasuicides, were more likely to stay in individual therapy, and had fewer inpatient psychiatric days.
Abstract: A randomized clinical trial was conducted to evaluate the effectiveness of a cognitive-behavioral therapy, ie, dialectical behavior therapy, for the treatment of chronically parasuicidal women who met criteria for borderline personality disorder. The treatment lasted 1 year, with assessment every 4 months. The control condition was "treatment as usual" in the community. At most assessment points and during the entire year, the subjects who received dialectical behavior therapy had fewer incidences of parasuicide and less medically severe parasuicides, were more likely to stay in individual therapy, and had fewer inpatient psychiatric days. There were no between-group differences on measures of depression, hopelessness, suicide ideation, or reasons for living although scores on all four measures decreased throughout the year.
1,979 citations
Book•
01 Jan 1992
TL;DR: This chapter discusses the relation of risk to exposure, prevention for individuals and the 'high-risk' strategy, and the population strategy of prevention.
Abstract: Part 1 The Objectives of Preventive Medicine: The scope for prevention. Why seek to prevent?: the economic and humanitarian arguments. Priorities: a matter of choice Part 2 What needs to be prevented?: Sick individuals: a continuum of disease severity case definitions. A continuum of risk: the prevention paradox mass and individual measures. A unified approach Part 3 The Relation of Risk to Exposure: The dose-effect relationship. The limitations of research methods. Small but widespread risks: a public health disaster? Part 4 Prevention for Individuals and the "High-risk" Strategy Prevention and clinical care The high-risk strategy. Identifying risk-screening. Strengths and weaknesses of the high-risk strategy Part 5 Individuals and Populations: Individual variation: genetic, social and behavioural determinants of diversity. Variation between populations. Sick and healthy populations Part 6 Some Implications of Population change: Effects of the population average on the occurrence of deviance examples from mental health. Health implications for the population as a whole: cardiovascular disease body weight birth weight early development and adult health Down's Syndrome alcohol osteoporosis and fractures occupational and environmental health other fields of application. Safety Part 7 The Population Strategy of Prevention: Principles: the sociological, moral and medical arguments scope proximal and underlying causes. Strengths. Limitations and problems 8. In Search of Health: How do populations change?: the alcohol example. Scientific justification for change. Social engineering versus individual freedom. Freedom of choice. Role of governments. Who takes the decisions? The largest threat to public health: war. Social and economic deprivation. Responsibility for health.
1,886 citations
TL;DR: A Medline search identified 566 articles published in 1995 and indexed with the medical subject heading (MeSH) term “meta-analysis” and randomly selected 100 articles, finding about half were based on observational studies, mainly cohort and case-control studies of medical interventions or aetiological associations.
Abstract: In previous articles we have focused on the potentials, principles, and pitfalls of meta-analysis of randomised controlled trials.1 2 3 4 5 Meta-analysis of observational data is, however, also becoming common. In a Medline search we identified 566 articles (excluding those published as letters) published in 1995 and indexed with the medical subject heading (MeSH) term “meta-analysis.” We randomly selected 100 of these articles and examined them further. Sixty articles reported on actual meta-analyses, and 40 were methodological papers, editorials, and traditional reviews (1). Among the meta-analyses, about half were based on observational studies, mainly cohort and case-control studies of medical interventions or aetiological associations.
View this table:
Characteristics of 100 articles randomly selected from articles published in 1995 and indexed in Medline with keyword “meta-analysis”
The randomised controlled trial is the principal research design in the evaluation of medical interventions. However, aetiological hypotheses—for example, those relating common exposures to the occurrence of disease—cannot generally be tested in randomised experiments. Does breathing other people's tobacco smoke cause lung cancer, drinking coffee cause coronary heart disease, and eating a diet rich in saturated fat cause breast cancer? Studies of such “menaces of daily life”6 use observational designs or examine the presumed biological mechanisms in the laboratory. In these situations the risks involved are generally small, but once a large proportion of the population is exposed, the potential public health implications of these associations—if they are causal—can be striking.
Analyses of observational data also have a role in medical effectiveness research.7 The evidence available from clinical trials will rarely answer all the important questions. Most trials are conducted to establish efficacy and safety of a single agent in a specific clinical situation. Owing to the limited size of such trials, less common adverse effects of drugs may only be detected in case-control …
976 citations
TL;DR: The National Service Framework for Mental Health (NSF—MH) is a strategic blueprint for services for adults of working age for the next 10 years.
Abstract: The National Service Framework for Mental Health (NSF—MH) is a strategic blueprint for services for adults of working age for the next 10 years. It is both mandatory, in being a clear statement of what services must seek to achieve in relation to the given standards and performance indicators, and
791 citations
TL;DR: Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989–1992 and the WHO/EURO Multicentre Study on Parasuicide results.
Abstract: The World Health Organization/EURO Multicentre Project on Parasuicide is part of the action to implement target 12 of the WHO programme, "Health for All by the Year 2000', for the European region. Sixteen centres in 13 European countries are participating in the monitoring aspect of the project, in which trends in the epidemiology of suicide attempts are assessed. The highest average male age-standardized rate of suicide attempts was found for Helsinki, Finland (314/100,000), and the lowest rate (45/100,000) was for Guipuzcoa, Spain, representing a sevenfold difference. The highest average female age-standardized rate was found for Cergy-Pontoise, France (462/100,000), and the lowest (69/100,000) again for Guipuzcoa, Spain. With only one exception (Helsinki), the person-based suicide attempt rates were higher among women than among men. In the majority of centres, the highest person-based rates were found in the younger age groups. The rates among people aged 55 years or over were generally the lowest. For the majority of the centres, the rates for individuals aged 15 years or over decreased between 1989 and 1992. The methods used were primarily "soft' (poisoning) or cutting. More than 50% of the suicide attempters made more than one attempt, and nearly 20% of the second attempts were made within 12 months after the first attempt. Compared with the general population, suicide attempters more often belong to the social categories associated with social destabilization and poverty.
723 citations