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Journal ArticleDOI

Repetition of deliberate self-harm and subsequent suicide risk: long-term follow-up study of 11 583 patients

01 Jul 2004-British Journal of Psychiatry (The Royal College of Psychiatrists)-Vol. 185, Iss: 1, pp 70-75
TL;DR: Repetition of DSH is associated with an increased risk of suicide in males and females and may be a better indicator of risk in females, especially young females.
Abstract: Background Repetition of deliberate self-harm (DSH) is a risk factor for suicide. Little information is available on the risk for specific groups of people who deliberately harm themselves repeatedly. Aims To investigate the long-term risk of suicide associated with repetition of DSH by gender, age and frequency of repetition. Method A mortality follow-up study to the year 2000 was conducted on 11 583 people who presented to the general hospital in Oxford between 1978 and 1997. Repetition of DSH was determined from reported episodes prior to the index episode and episodes presenting to the same hospital during the follow-up period. Deaths were identified through national registers. Results Thirty-nine per cent of patients repeated the DSH. They were at greater relative risk of suicide than the single-episode DSH group (2.24; 95% CI 1.77–2.84). The relative risk of suicide in the repeated DSH group compared with the single-episode DSH group was greater in females (3.5; 95% CI 1.3–2.4) than males (1.8; 95% CI 2.3–5.3) and was inversely related to age (up to 54 years). Suicide risk increased further with multiple repeat episodes of DSH in females. Conclusions Repetition of DSH is associated with an increased risk of suicide in males and females. Repetition may be a better indicator of risk in females, especially young females.

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Citations
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Journal ArticleDOI
TL;DR: A revised and refined version of the O'Carroll et al. (1996) nomenclature for suicidology is presented, with a focus on suicide-related ideations, communications, and behaviors, and it would be highly desirable that the set of definitions and the associated terminology be explicit and generalizable.
Abstract: A revised and refined version of the O'Carroll et al. (1996) nomenclature for suicidology is presented, with a focus on suicide-related ideations, communications, and behaviors. The hope is that this refinement will result in the development of operational definitions and field testing of this nomenclature in clinical and research settings. This revision would not have been possible without the international collaboration and dialogue addressing the nomenclature of suicidology since the O'Carroll et al. nomenclature appeared in 1996. Although it is doubtful that we will ever be able to construct universally unambiguous criteria to comprehensively characterize suicidal behaviors (and, overall, firmly establish the intention behind them), for scientific clarity it would be highly desirable that the set of definitions and the associated terminology be explicit and generalizable. De Leo, Burgis, Bertolote, Kerkhof, & Bille-Brahe, 2006, p. 5)

847 citations


Cites background from "Repetition of deliberate self-harm ..."

  • ...…better With a recent number of other nomenclatures to choose from (Brown, Jeglic,term for ISRB is deliberate self-harm (DSH), a term used by our colleagues, especially in Henriques, & Beck, 2006; De Leo et al., 2006; Hammad, Laughren, & Racoosin,Europe (Pattison & Kahan, 1983; Zahl & Hawton, 2004)....

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Journal ArticleDOI
28 Feb 2014-PLOS ONE
TL;DR: The incidence of repeat self-harm and suicide in this population has not changed in over 10 years and heterogeneity should be considered when evaluating interventions aimed at reducing non-fatal repeatSelf-harm.
Abstract: Background Non-fatal self-harm is one of the most frequent reasons for emergency hospital admission and the strongest risk factor for subsequent suicide. Repeat self-harm and suicide are key clinical outcomes of the hospital management of self-harm. We have undertaken a comprehensive review of the international literature on the incidence of fatal and non-fatal repeat self-harm and investigated factors influencing variation in these estimates as well as changes in the incidence of repeat self-harm and suicide over the last 30 years.

403 citations


Cites background from "Repetition of deliberate self-harm ..."

  • ...Patients who present to hospital for self-harm more than once have approximately double the risk of subsequent suicide compared to those presenting only once [5]....

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Journal ArticleDOI
TL;DR: Despite many findings of correlates, the data do not yet justify terming them risk factors, and longitudinal studies are needed.

377 citations

Journal ArticleDOI
TL;DR: Evidence of the relationship between alcohol use and suicide through a search of MedLine and PsychInfo electronic databases is reviewed and multiple genetically-related intermediate phenotypes might influence the relationshipBetween alcohol and suicide.
Abstract: Suicide is an escalating public health problem, and alcohol use has consistently been implicated in the precipitation of suicidal behavior. Alcohol abuse may lead to suicidality through disinhibition, impulsiveness and impaired judgment, but it may also be used as a means to ease the distress associated with committing an act of suicide. We reviewed evidence of the relationship between alcohol use and suicide through a search of MedLine and PsychInfo electronic databases. Multiple genetically-related intermediate phenotypes might influence the relationship between alcohol and suicide. Psychiatric disorders, including psychosis, mood disorders and anxiety disorders, as well as susceptibility to stress, might increase the risk of suicidal behavior, but may also have reciprocal influences with alcohol drinking patterns. Increased suicide risk may be heralded by social withdrawal, breakdown of social bonds, and social marginalization, which are common outcomes of untreated alcohol abuse and dependence. People with alcohol dependence or depression should be screened for other psychiatric symptoms and for suicidality. Programs for suicide prevention must take into account drinking habits and should reinforce healthy behavioral patterns.

344 citations


Cites background from "Repetition of deliberate self-harm ..."

  • ...Repeated self-harm or attempted suicide are positively associated with a higher suicide risk [249]....

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Journal ArticleDOI
TL;DR: The first systematic review and meta-analysis of prospective studies of risk factors and risk assessment scales to predict suicide following self-harm found no scales have sufficient evidence to support their use and are unlikely to be of much practical use.
Abstract: Background People with a history of self-harm are at a far greater risk of suicide than the general population. However, the relationship between self-harm and suicide is complex. Aims To undertake the first systematic review and meta-analysis of prospective studies of risk factors and risk assessment scales to predict suicide following self-harm. Method We conducted a search for prospective cohort studies of populations who had self-harmed. For the review of risk scales we also included studies examining the risk of suicide in people under specialist mental healthcare, in order to broaden the scope of the review and increase the number of studies considered. Differences in predictive accuracy between populations were examined where applicable. Results Twelve studies on risk factors and 7 studies on risk scales were included. Four risk factors emerged from the meta-analysis, with robust effect sizes that showed little change when adjusted for important potential confounders. These included: previous episodes of self-harm (hazard ratio (HR) = 1.68, 95% CI 1.38–2.05, K = 4), suicidal intent (HR = 2.7, 95% CI 1.91–3.81, K = 3), physical health problems (HR = 1.99, 95% CI 1.16–3.43, K = 3) and male gender (HR = 2.05, 95% CI 1.70–2.46, K = 5). The included studies evaluated only three risk scales (Beck Hopelessness Scale (BHS), Suicide Intent Scale (SIS) and Scale for Suicide Ideation). Where meta-analyses were possible (BHS, SIS), the analysis was based on sparse data and a high heterogeneity was observed. The positive predictive values ranged from 1.3 to 16.7%. Conclusions The four risk factors that emerged, although of interest, are unlikely to be of much practical use because they are comparatively common in clinical populations. No scales have sufficient evidence to support their use. The use of these scales, or an over-reliance on the identification of risk factors in clinical practice, may provide false reassurance and is, therefore, potentially dangerous. Comprehensive psychosocial assessments of the risks and needs that are specific to the individual should be central to the management of people who have self-harmed.

341 citations

References
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Journal ArticleDOI
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.

1,024 citations

Book
01 Nov 2002
TL;DR: In this paper, Hawton and van Heeringen studied suicide in the Western world and found that suicidal ideation and behaviour is associated with depression and substance abuse, and the most common causes of suicide are depression and self-harm.
Abstract: About the Editors List of Contributors Preface Introduction (Keith Hawton and Kees van Heeringen) UNDERSTANDING SUICIDAL BEHAVIOUR Suicide in the Western World (Christopher H. Cantor) Suicide in Asia and the Far East (Andrew T.A. Cheng and Chau-Shoun Lee) Attempted Suicide: Patterns and Trends ( Ad J.F.M. Kerkhof) Biological Aspects of Suicidal Behaviour (Lil Traskman-Bendz and J.John Mann) The Psychology of Suicidal Behaviour (J. Mark G. Williams and Leslie R.. Pollock) Ethology and Suicidal Behaviour (Robert D. Goldney) Psychiatric Aspects of Suicidal Behaviour: Depression (Jouko K. Lonnqvist) Psychiatric Aspects of Suicidal Behaviour: Schizophrenia (Marc De Hert and Jozef Peuskens) Psychiatric Aspects of Suicidal Behaviour: Substance Abuse (George E. Murphy) Psychiatric Aspects of Suicidal Behaviour: Personality Disorders (Marsha M Linehan, Shireen L. Rizvi, Stacy Shaw Welch and Benjamin Page) Psychiatric Aspects of Suicidal Behaviour: Anxiety Disorders (Christer Allgulander) Sociology and Suicidal Behaviour (Unni Bille-Brahe) The Genetics of Suicidal Behaviour (Alec Roy, David Nielsen, Gunnar Rylander and Marco Sarchiapone) Pathways to Suicide: an Integrative Approach (Kees van Heeringen, Keith Hawton and J. Mark, G. Williams) SUICIDE AND ATTEMPTED SUICIDE IN SPECIFIC POPULATIONS AND CIRCUMSTANCES Suicidal Behaviour in Children: an Emphasis on Developmental Influences (Cynthia R. Pfeffer) Adolescent Suicidal Behaviour: a General Population Perspective (Erik Jan de Wilde) Adolescent Suicidal Behaviour: Psychiatric Populations (Alan Apter and Ornit Freudenstein) Suicidal Behaviour among the Elderly (Daniel Harwood and Robin Jacoby) Sexuality, Reproductive Cycle and Suicidal Behaviour (Jose Catalan) Suicidal Behaviour and the Labour Market (Stephen Platt and Keith Hawton) Physical Illness and Suicidal Behaviour (Issac Sakinofsky) Physical Illness and Suicidal Behaviour (Elsebeth Nylev Stenager and Egon Stenager) Ethical and Legal Issues (Antoon Leenaars and Colleagues) Suicide and Violence (Mathew K. Nock and Peter M. Marzuk) Suicide among Psychiatric Inpatients (Manfred Wolfersdorf) The Impact of Suicide on Relatives and Friends (Sheila E. Clark and Robert D. Goldney) THE TREATMENT OF SUICIDAL BEHAVIOUR Pharmacotherapy of Suicidal Ideation and Behaviour (Robbert J. Verkes and Philip J. Cowen) Psychotherapeutic Approaches to Suicidal Ideation and Behaviour (Heidi L. Heard) General Hospital Management of Suicide Attempters (Keith Hawton) Treatment Strategies for Adolescent Suicide Attempters (Philip Hazell) Treatment and Prevention of Suicidal Behaviour in the Elderly (Diego De Leo and Paolo Scocco) Multidisciplinary Approaches to the Management of Suicidal Behaviour (Kees van Heeringen) THE PREVENTION OF SUICIDE AND ATTEMPTED SUICIDE Prediction of Suicide and Attempted Suicide (Robert D. Goldney) General Population Strategies of Suicide Prevention (Rachel Jenkins and Bruce Singh) Prevention of Suicide in Psychiatric Patients (Lo...

785 citations

Journal ArticleDOI
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


"Repetition of deliberate self-harm ..." refers background or methods in this paper

  • ...Through this system information is collected about each individual who presents to the general hospital in Oxford with an episode of DSH (Hawton et al, 1997; Hawton et al, 2003)....

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  • ...In a previous report of this long-term follow-up study of a large sample of DSH patients we showed that risk of suicide following DSH was greater in males than in females and that it increased with age (Hawton et al, 2003)....

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  • ...It is based on a consistent approach to the monitoring of DSH (Hawton & Fagg, 1992; Hawton et al, 1997, 2003)....

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  • ...Analyses reported elsewhere showed no difference between the untraced and traced in terms of age, gender or method of DSH (Hawton et al, 2003)....

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  • ...…with repetition by gender, age and number of repeats Although male DSH patients have a greater overall risk of suicide than female patients (Hawton et al, 2003), the relative risk in 74 CLINICAL IMPLICATIONS & Repetition of deliberate self-harm increases the risk of suicide over both the…...

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Journal ArticleDOI
TL;DR: The number of deaths in a large series of suicide attempters followed up after their attempts was 3.3 times greater than expected and factors identified at the time of the attempts which were associated with suicide risk included being male, advancing age, psychiatric disorder, long-term use of hypnotics, poor physical health, and repeat attempts.
Abstract: The number of deaths in a large series of suicide attempters followed up after their attempts was 3.3 times greater than expected. Suicide or probable suicide occurred in 2.8% by the end of the eighth year of follow-up, the rate of suicidal deaths being 26.9 times the expected rate. The highest risk of suicide was during the first 3 years, especially in the first 6 months, following an attempt. Factors identified at the time of the attempts which were associated with suicide risk included: being male, advancing age (females only), psychiatric disorder (especially schizophrenia), long-term use of hypnotics, poor physical health, and repeat attempts. Recent disruption of a relationship with a partner and major rows rarely preceded the attempts of those who later killed themselves. Factors predicting long-term risk of suicide also predicted short-term risk. There were more than double the expected number of deaths from natural causes, the excess being greatest in females. Markedly high death rates were found for endocrine, circulatory and respiratory diseases, and accidents.

446 citations


"Repetition of deliberate self-harm ..." refers background in this paper

  • ...Repetition increases the risk of further DSH (Wilkinson & Smeeton, 1987; Owens et al, 1994) and eventual suicide (Hawton & Fagg, 1988; Tejedor et al, 1999)....

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  • ...The results confirm that repetition of DSH is associated with increased risk of eventual suicide (Hawton & Fagg, 1988; Tejedor et al, 1999; Owens et al, 2002)....

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Journal ArticleDOI
TL;DR: Specific issues are: should plots go up or down, how far in time to extend the plot, showing the extent of follow-up, displaying statistical uncertainty by including SEs or CIS, and exercising caution when interpreting the shape of plots and the time-pattern of treatment difference.

439 citations


"Repetition of deliberate self-harm ..." refers background in this paper

  • ...The Kaplan–Meier curves shown in this paper are truncated at 15 years of followup time because numbers in some subgroups had fallen by then to 520% of the original sample (Pocock et al, 2002)....

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