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Journal ArticleDOI

Self-harm in England: a tale of three cities. Multicentre study of self-harm.

TL;DR: Multicentre monitoring of self-harm in England has demonstrated similar overall patterns ofSelf- Harm in Oxford, Manchester and Leeds, with some differences reflecting local suicide rates.
Abstract: Background Self-harm is a major healthcare problem in the United Kingdom, but monitoring of hospital presentations has largely been done separately in single centres Multicentre monitoring of self-harm has been established as a result of the National Suicide Prevention Strategy for England
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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

Journal ArticleDOI
TL;DR: It seems that NSSI has to be understood as worldwide phenomenon, at least in Western cultures, as no differences were found in the prevalence and characteristics of self-injury and suicidal behaviors between adolescents from Germany and the USA.
Abstract: BackgroundThis study examined the prevalence of non-suicidal self-injury (NSSI), suicide attempts, suicide threats and suicidal ideation in a German school sample and compared the rates with a similar sample of adolescents from the midwestern USA by using cross-nationally validated assessment tools.MethodData were provided from 665 adolescents (mean age 14.8 years, s.d.=0.66, range 14–17 years) in a school setting. Students completed the Self-Harm Behavior Questionnaire (SHBQ), the Ottawa Self-Injury Inventory (OSI) and a German version of the Center for Epidemiological Studies–Depression Scale (CES-D).ResultsA quarter of the participants (25.6%) endorsed at least one act of NSSI in their life, and 9.5% of those students answered that they had hurt themselves repetitively (more than four times). Forty-three (6.5%) of the students reported a history of a suicide attempt. No statistically significant differences were observed between the German and US samples in terms of self-injury or suicidal behaviors.ConclusionsBy using the same validated assessment tools, no differences were found in the prevalence and characteristics of self-injury and suicidal behaviors between adolescents from Germany and the USA. Thus, it seems that NSSI has to be understood as worldwide phenomenon, at least in Western cultures.

311 citations


Additional excerpts

  • ...This conflation of suicidal and NSSI behaviors is particularly true within European countries, where the construct ‘deliberate self-harm’ (DSH) is used as an umbrella term for self-destructive behaviors regardless of suicidal intent (Hawton et al. 2007 ; Madge et al. 2008)....

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Journal ArticleDOI
TL;DR: Patients' history of NSSI (presence and frequency) was more strongly associated with history of suicide attempts than were patients' depressive symptoms, hopelessness, and symptoms of borderline personality disorder, and as stronglyassociated with suicide attempt history as current levels of suicidal ideation.
Abstract: Although attempted suicide and non-suicidal self-injury (NSSI) differ in several important ways, a significant number of individuals report histories of both behaviors. The current study further examined the relations between NSSI and attempted suicide among psychiatric inpatients. Self-report questionnaires were administered to 117 psychiatric inpatients at a general hospital (M=39.45 years old, S.D.=12.84 years, range=17-73 years). We found that presence and number of NSSI episodes were significantly related to presence and number of suicide attempts. Supporting the importance of NSSI assessment, patients' history of NSSI (presence and frequency) was more strongly associated with history of suicide attempts than were patients' depressive symptoms, hopelessness, and symptoms of borderline personality disorder, and as strongly associated with suicide attempt history as current levels of suicidal ideation. Finally, among patients with a history of suicide attempts, those with an NSSI history reported significantly greater lethal intent for their most severe attempt, and patients' number of prior NSSI episodes was positively correlated with the level of lethal intent associated with their most severe suicide attempt.

272 citations

Journal ArticleDOI
TL;DR: The ongoing controversy surrounding the proper role for this ubiquitous pain reliever is reviewed: its history, pathogenesis, clinical challenges in recognition and management, and current regulatory status are highlighted.

264 citations


Cites background from "Self-harm in England: a tale of thr..."

  • ...Two decades later, this had evolved so that paracetamol was understood, at least in the UK, as responsible for a rising number of deaths with extensive media publicity describing the problem.(30) Efforts to curb package size were encouraged by the Hawton group, based on surveys of overdose patients conducted in the 1990’s that suggested that impulsive behavior was responsible for most suicides: utilization of whatever was readily available in the home....

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Journal ArticleDOI
TL;DR: Self-cutting as a method of self-harm in children and adolescents conveys greater risk of suicide (and repetition) than self-poisoning although different methods are usually used for suicide.
Abstract: Background: Self-harm (intentional self-poisoning and self-injury) in children and adolescents is often repeated and is associated with increased risk of future suicide. We have investigated factors associated with these outcomes. Method: We used data collected in the Multicentre Study of Self-harm in England on all self-harm hospital presentations by individuals aged 10-18 years between 2000 and 2007, and national death information on these individuals to the end of 2010. Cox hazard proportional models were used to identify independent and multivariable predictors of repetition of self-harm and of suicide. Results: Repetition of self-harm occurred in 27.3% of individuals (N = 3920) who presented between 2000 and 2005 and were followed up until 2007. Multivariate analysis showed that repetition was associated with age, self-cutting, and previous self-harm and psychiatric treatment. Of 51 deaths in individuals who presented between 2000 and 2007 and were followed up to 2010 (N = 5133) half (49.0%) were suicides. The method used was usually different to that used for self-harm. Multivariate analysis showed that suicide was associated with male gender [Hazard ratio (HR) = 2.4, 95% CI 1.2-4.8], self-cutting (HR = 2.1, 95% CI 1.1-3.7) and prior psychiatric treatment at initial presentation (HR = 4.2, 95% CI 1.7-10.5). It was also associated with self-cutting and history of psychiatric treatment at the last episode before death, and history of previous self harm. Conclusions: Self-cutting as a method of self-harm in children and adolescents conveys greater risk of suicide (and repetition) than self-poisoning although different methods are usually used for suicide. The findings underline the need for psychosocial assessment in all cases. Language: en

264 citations


Cites background or methods from "Self-harm in England: a tale of thr..."

  • ...For further details see (Hawton et al., 2007) and (Bergen et al., 2010)....

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  • ...30per1,000,000 inmalesand females, respectively, in England and Wales in 2010), but official suicide figures considerably underestimate the likely true rate of suicide in adolescents (Gosney & Hawton, 2007)....

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  • ...We have investigated repetition of self-harm and suicide following self-harm in a large sample of children and adolescents who presented to hospitals in the Multicentre Study of Self-harm in England because of intentional self-poisoning or self-injury....

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  • ...Importantly, the way we obtained mortality information through national flagging means that we should have identified all deaths that occurred in England, Wales and Scotland....

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  • ...…longitudinal studybasedondata collected through theMulticentre Study of Self-harm in England (Bergen, Hawton, Waters, Cooper, & Kapur, 2010; Hawton et al., 2007) to investigate both risk of repetition of self-harm and of suicide following self-harm in children and adolescents, and the…...

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References
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Journal ArticleDOI
TL;DR: A stress-diathesis model is proposed in which the risk for suicidal acts is determined not merely by a psychiatric illness but also by a diathesis, reflected in tendencies to experience more suicidal ideation and to be more impulsive and, therefore, more likely to act on suicidal feelings.
Abstract: OBJECTIVE: Risk factors for suicide attempts have rarely been studied comprehensively in more than one psychiatric disorder, preventing estimation of the relative importance and the generalizability of different putative risk factors across psychiatric diagnoses. The authors conducted a study of suicide attempts in patients with mood disorders, psychoses, and other diagnoses. Their goal was to determine the generalizability and relative importance of risk factors for suicidal acts across diagnostic boundaries and to develop a hypothetical, explanatory, and predictive model of suicidal behavior that can subsequently be tested in a prospective study. METHOD: Following admission to a university psychiatric hospital, 347 consecutive patients who were 14–72 years old (51% were male and 68% were Caucasian) were recruited for study. Structured clinical interviews generated axis I and axis II diagnoses. Lifetime suicidal acts, traits of aggression and impulsivity, objective and subjective severity of acute psycho...

1,629 citations


"Self-harm in England: a tale of thr..." refers background in this paper

  • ...Alcohol may influence both the occurrence of self-harm, through contributing to interpersonal and other problems and an individual’s reactions to them, and impulsivity and aggression, both of which are important factors in suicidal behaviour [26]....

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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

Journal ArticleDOI
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

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


"Self-harm in England: a tale of thr..." refers background in this paper

  • ...Self-harm patients have a greatly elevated risk of subsequent suicide [7, 21, 36] and at least half of all individuals who die by suicide have a history of self-harm [1, 11, 19], with a quarter having episodes in the year before death....

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