All-cause mortality after non-fatal self-poisoning: a cohort study

Suicide and mortality following self-harm in Culturally and Linguistically Diverse communities in Victoria, Australia: insights from a data linkage study

Background

While cultural backgrounds are well-documented to be relevant to intentional self-harm, little is known about how cultural and linguistically diverse (CALD) backgrounds affect mortality outcomes following self-harm.

Aim

This study aimed to compare the risk of all-cause mortality and suicide after intentional hospital admissions for self-harm among people from CALD (vs. non-CALD) backgrounds.

Method

Linked hospital and mortality data in Victoria, Australia, was used to assess suicide and all-cause death after hospital admissions for self-harm among patients aged 15+ years. All-cause death was identified by following up on 42,122 self-harm patients (hospitalized between 01 July 2007 and 30 June 2019) until death or 15 February 2021. Suicide death was evaluated in 16,928 self-harm inpatients (01 January 2013 and 31 December 2017) until death or 28 March 2018. Cox regression models were fitted to compare mortality outcomes in self-harm patients from CALD vs. non-CALD backgrounds.

Outcomes

During the follow-up periods, 3,716 of 42,122 (8.8%) participants died by any cause (by 15 February 2021), and 304 of 16,928 (1.8%) people died by suicide (by 28 March 2018). Compared to the non-CALD group, CALD intentional self-harm inpatients had a 20% lower risk of all-cause mortality (HR: 0.8, 95% CI: 0.7-0.9) and a 30% lower risk of suicide (HR: 0.7, 95% CI: 049-0.97). Specifically, being from North Africa/Middle East and Asian backgrounds lowered the all-cause mortality risk; however, the suicide risk in Asians was as high as in non-CALD people.

Conclusion

Overall, people from CALD backgrounds exhibited lower risks of all-cause mortality and suicide following hospital admission for self-harm compared to the non-CALD group. However, when comparing risks based on regions of birth, significant variations were observed. These findings underscore the importance of implementing culturally tailored background-specific suicide preventive actions. The study focussed on outcomes following hospital admission for self-harm and did not capture outcomes for cases of self-harm that did not result in hospital admission. This limits generalisability, as some CALD people might avoid accessing healthcare after self-harm due to cultural factors. Future research that not limited to hospital data is suggested to build on the results.

Repeat self-harm and mental health service use after self-harm in Culturally and Linguistically Diverse communities: Insights from a data linkage study in Victoria, Australia

PURPOSE

To examine the associations between Culturally and Linguistically Diverse backgrounds (vs non-Culturally and Linguistically Diverse) and in-hospital death due to self-harm, repeat self-harm and mental health service use after self-harm.

METHOD

A retrospective study of 42,127 self-harm hospital inpatients aged 15+ years in Victoria, Australia, from July 2008 to June 2019. Linked hospital and mental health service data were used to assess in-hospital death, repeat self-harm and mental health service use in the 12 months following index self-harm hospital admission. Logistic regression and zero-inflated negative binomial regression models were used to estimate associations between cultural background and outcomes.

RESULTS

Culturally and Linguistically Diverse people accounted for 13.3% of self-harm hospital inpatients. In-hospital death (0.8% of all patients) was negatively associated with Culturally and Linguistically Diverse background. Within 12 months, 12.9% of patients had self-harm readmission and 20.1% presented to emergency department with self-harm. Logistic regression components of zero-inflated negative binomial regression models showed no differences in the odds of (hospital-treated) self-harm reoccurrence between Culturally and Linguistically Diverse and non- Culturally and Linguistically Diverse self-harm inpatients. However, count components of models show that among those with repeat self-harm, Culturally and Linguistically Diverse people (e.g. born in Southern and Central Asia) made fewer additional hospital revisits than non-Culturally and Linguistically Diverse people. Clinical mental health service contacts following self-harm were made in 63.6% of patients, with Culturally and Linguistically Diverse people (Asian backgrounds 43.7%) less likely to make contact than the non-Culturally and Linguistically Diverse group (65.1%).

CONCLUSIONS

Culturally and Linguistically Diverse and non-Culturally and Linguistically Diverse people did not differ in the likelihood of hospital-treated repeat self-harm, but among those with self-harm repetition Culturally and Linguistically Diverse people had fewer recurrences than non-Culturally and Linguistically Diverse people and utilised mental health services less following self-harm admissions.

Meta-analysis of clinical risk factors for suicide among people presenting to emergency departments and general hospitals with suicidal thoughts and behaviours

BACKGROUND

Suicidal thoughts and behaviours (STB) are a common reason for presentation to emergency departments and general hospitals. A meta-analysis of the strength of clinical risk factors for subsequent suicide might aid understanding of suicidal behaviour and help suicide prevention.

METHODS

We conducted a meta-analysis of cohort and controlled studies on clinical risk factors and later suicide among people presenting to emergency departments and general hospitals with STB. Data were extracted from papers meeting inclusion criteria, published in Medline, PsycINFO, and Embase between 1 January 1960 and 10 October 2022 using papers located with the search terms ((suicide*).m_titl AND (emergency* OR accident and emergency OR casualty OR general hospital OR toxicology service).mp) or were indexed in PubMed and had titles located with the search terms (suicide* OR self-harm OR self-harm OR self-injury OR self-injury OR self-poisoning OR self-poisoning OR overdose OR para-suicide OR parasuicide [title/abstract]) AND (Emergency department OR emergency room OR Casualty OR general hospital OR toxicology OR accident and emergency [all fields]). Data about the association between clinical risk factors and suicide extracted from three or more studies were included in a random-effects meta-analysis of the odds of later death by suicide. The study was registered in PROSPERO and conducted according to MOOSE and PRISMA guidelines.

RESULTS

Seventy-five studies reported on 741,624 people, of which 19,649 died by suicide (2.65%). Male sex (odds ratio (OR) = 1.99) and age (OR = 2.01) were the most consistently reported risk factors. The strongest associations with subsequent death by suicide related to violent self-harm methods at the hospital presentation, including: unspecified violent method (OR = 4.97), any violent method (OR = 4.57) and the specific violent methods of drowning (OR = 4.32), hanging (OR = 4.26), and use of firearms (OR = 10.08). Patients categorised as higher risk using suicide prediction scales or any other method that combined risk factors had moderately increased odds of suicide (OR = 2.58). Younger age, Black and Hispanic ethnicity, overdose, a diagnosis of adjustment disorder, and the absence of any psychiatric diagnosis were protective against suicide.

CONCLUSIONS

Most risk factors for suicide among people who have presented with STB are not strongly associated with later suicide. The strongest risk factors relate to self-harm methods. In the absence of clear indicators of future suicide, all people presenting with suicidality warrant a thorough assessment of their needs, and further research is needed before we can meaningfully categorise people with STB according to suicide risk.

Psychotropic medication use before and after suicidal presentations to the emergency department: A longitudinal analysis

OBJECTIVE

The rates of annual emergency department (ED) visits in the United States for suicidal behaviour has nearly doubled over the last 10-15 years, with a decreased rate of hospitalizations, indicating the importance of intervention in the ED presentation. This paper describes the patterns of psychotropic use immediately before and after emergency department presentation to enhance understanding of interventions for increasing safety in these individuals.

METHODS

5070 adults seen in psychiatric consultation in two tertiary EDs with linkage to population-based administrative data to describe psychotropic prescriptions immediately before and after ED presentation.

RESULTS

55.9% of suicide attempts were by overdose, with 13.4% of suicide attempts occurring in the 18-21 age group. While no causal relationship can be inferred, half of those who presented to the ED with suicidal ideation or behaviour or non-suicidal self-injury were prescribed an antidepressant prior to ED presentation, with a spike in new prescriptions in the month immediately prior. 20% of those who presented to the ED with thoughts or behaviour received a new or different prescription for an antidepressant in the 1-month post-presentation. Prescribing of tricyclic antidepressants and opioids were decreased following ED presentation, however 21% of people still received opioids after a suicide attempt. Rates of antipsychotic prescriptions were increased.

CONCLUSION

Patients are seeking help in the one-month prior to emergency presentation. Clinicians must consider the risk in this period of heightened clinical distress, especially among those under age 21. It is important to consider the changes that can be made in the ED to impact safety.

Meta-analysis of suicide rates among people discharged from non-psychiatric settings after presentation with suicidal thoughts or behaviours

OBJECTIVE

To quantify the suicide rate among people discharged from non-psychiatric settings after presentations with suicidal thoughts or behaviours.

METHOD

Meta-analysis of studies reporting suicide deaths among people with suicidal thoughts or behaviours after discharge from emergency departments or the medical or surgical wards of general hospitals.

RESULTS

A total of 115 studies reported 167 cohorts and 3747 suicide deaths among 248 005 patients during 1 263 727 person-years. The pooled suicide rate postdischarge was 483 suicide deaths per 100 000 person-years (95% confidence interval (CI) 445-520, prediction interval (PI) 200-770) with high between-sample heterogeneity (I²  = 92). The suicide rate was highest in the first year postdischarge (851 per 100 000 person-years) but remained elevated in the long term. Suicide rates were elevated among samples of men (716 per 100 000 person-years) and older people (799 per 100 000 person-years) but were lower in samples of younger people (107 per 100 000 person-years) and among studies published between 2010 and 2018 (329 per 100 000 person-years).

CONCLUSIONS

People with suicidal thoughts or behaviours who are discharged from non-psychiatric settings have highly elevated rates of suicide despite a clinically meaningful decline in these suicide rates in recent decades.

Long-term mortality and cause of death for patients treated in Intensive Care Units due to poisoning

BACKGROUND

Poisoned patients treated in the Intensive Care Unit are common, representing up to 6% of all ICU admissions. The in-hospital mortality is generally low but little is known about the long-term mortality in these patients. The aim of this study was to describe long-term mortality and cause of death in patients treated in the ICU for poisoning.

METHOD

A national observational study based on three registers: the National Patient Register, the Swedish Intensive Care Register and the Cause of Death Register. All patients ≥19 years admitted to a Swedish Intensive Care Unit between January 1, 2010 and December 31, 2011 with an ICD-10 code for poisoning were included.

RESULTS

A total of 6730 patients were included. The one-year mortality was 4.5% (n = 303), with an overweight of men among the deceased (59.1%, P = 0.002). Patients aged 19-39 years had a 48 times increased one-year mortality compared to the age-matched general population and 94% of these patients died from suicide and/or accident, of which 70% were from a new poisoning. The two-year mortality was 7.2%. Women have a slightly higher overall long-term survival over two years (P< 0.001).

CONCLUSION

The risk of premature death is markedly increased in younger patients one and two years after an ICU hospitalisation for non-fatal poisoning compared to the general population. A large majority die due to a new poisoning incident despite a previously known recent severe poisoning.

EDITORIAL COMMENT

Admission to ICU with poisoning, and particularly self-poisoning, may be associated with long-term mortaliity. In this study of 6730 patients admitted to a Swedish ICU for poisoning, the in-hospital mortality was low for that admission, but there is an increased risk of later mortality in young patients one and two years after hospital discharge.

Recurrence and mortality 1 year after hospital admission for non-fatal self-harm: a nationwide population-based study

AIMS

A large number of people present each day at hospitals for non-fatal deliberate self-harm (DSH). Examination of the short-term risk of non-fatal recurrence and mortality at the national level is of major importance for both individual medical decision-making and global organisation of care.

METHODS

Following the almost exhaustive linkage (96%) of two national registries in France covering 45 million inhabitants (i.e. 70% of the whole population), information about hospitalisation for DSH in 2008-2009 and vital status at 1 year was obtained. Individuals who died during the index hospital stay were excluded from analyses.

RESULTS

Over 2 years, 136,451 individuals were hospitalised in medicine or surgery for DSH. The sample comprised 62.8% women, median age 38 in both genders, with two peaks at 16 and 44 years in women, and one peak at 37 years in men. The method used for DSH was drug overdose in 82.1% of cases. Admission to an intensive care unit occurred in 12.9%. Following index hospitalisation, 71.3% returned home and 23.7% were transferred to a psychiatric inpatient care unit. DSH recurrence during the following year occurred in 12.4% of the sample, within the first 6 months in 75.2%, and only once in 74.6%. At 1 year, 2.6% of the sample had died. The overall standardised mortality ratio was 7.5 but reached more than 20 in young adults. The causes were natural causes (35.7%), suicide (34.4%), unspecified cause (17.5%) and accident (12.4%). Most (62.9%) deaths by suicide occurred within the first 6 months following index DSH. Violent means (i.e. not drug overdose) were used in 70% of suicide cases. Concordance between means used for index DSH and for suicide was low (30% overall), except for drug overdose. Main suicide risk factors were older age, being male, use of a violent means at index DSH, index admission to an intensive care unit, a transfer to another medical department or to a psychiatric inpatient unit, and recurrence of DSH. However, these factors had low positive predictive values individually (below 2%).

CONCLUSIONS

Non-fatal DSH represent frequent events with a significant risk of short-term recurrence and death from various causes. The first 6 months following hospital discharge appear to be a critical period. Specific short-term aftercare programs targeting all people with a DSH episode have to be developed, along other suicide prevention strategies.

[Suicide mortality in Colombia and México: Trends and impact between 2000 and 2013]

INTRODUCTION

Suicides are one of the main public health issues globally. Objective: To analyze the trends and impact of suicide mortality in Colombia and México between 2000 and 2013, nationally, by sex and age groups. Materials and methods: Mortality vital statistics from the Colombian Departamento Administrativo Nacional de Estadística and the Mexican Instituto Nacional de Estadística y Geografía were used. We conducted a descriptive and cross sectional study for which we calculated standardized mortality rates and years of life lost in people between 0 and 100 years of age. Results: In Colombia, the suicide mortality rate decreased between 2000 and 2013 for both sexes (28% for men and 38% for women); an opposite trend was observed in México (with an increase of 34% for males and 67% for females). In 2013, the years of life lost in Colombia were 0,32 among men and 0,15 among women, with a decreasing trend since 2000, whereas in México a level of 0,42 was observed in men and 0,2 in women, with an increasing trend since 2000. The age groups where suicides had a bigger impact were those of men 15 to 49 years of age in both countries, while suicides were more uniformly distributed among women between 15 and 84 years of age.

CONCLUSION

 Suicide mortality increased gradually in México, whereas in Colombia an opposite trend was observed. Suicides can be prevented, so it is fundamental to implement public health policies focused on timely identification, comprehensive prevention strategies and the study of associated risk factors.

Routine biological tests in self-poisoning patients: results from an observational prospective multicenter study

CONTEXT

Routine biological tests are frequently ordered in self-poisoning patients, but their clinical relevance is poorly studied.

MATERIALS AND METHODS

This is a prospective multicentric observational study conducted in the emergency departments and intensive care units of 5 university and nonuniversity French hospitals. Adult self-poisoning patients without severely altered vital status on admission were prospectively included.

RESULTS

Routine biological test (serum electrolytes and creatinine, liver enzymes, bilirubin, blood cell count, prothrombin time) ordering and results were analyzed. A total of 1027 patients were enrolled (age, 40.2 ± 14 years; women, 61.5%); no patient died during the hospital stay. Benzodiazepine was suspected in more than 70% of cases; 65% (range, 48%-80%) of patients had at least 1 routine biological test performed. At least 1 abnormal test was registered in 23% of these patients. Three factors were associated with abnormal test results: age older than 40 years, male sex, and poisoning with a drug known to alter routine tests (ie, acetaminophen, NSAIDs, metformine, lithium). Depending on these factors, abnormal results ranged from 14% to 48%. Unexpected severe life-threatening conditions were recorded in 6 patients. Only 3 patients were referred to the intensive care unit solely because of abnormal test results.

CONCLUSION

Routine biological tests are commonly prescribed in nonsevere self-poisoning patients. Abnormal results are frequent but their relevance at bedside remains limited.

Suicide After Nonfatal Self-Harm

Background: Nonfatal self-harm is the strongest predictor of suicide, with some of the risk factors for subsequent suicide after nonfatal self-harm being similar to those for suicide in general. However, we do not have sufficient information regarding the medical care provided to nonfatal self-harm episodes preceding suicide. Aims: Our study sought to explore hospital care and predictive characteristics of the risk of suicide after nonfatal self-harm. Method: Individuals with history of nonfatal self-harm who died by suicide were compared with those who had a nonfatal self-harm episode but did not later die by suicide. Cases were identified by cross-linking data collected through a self-harm monitoring project, 2000–2007, and comprehensive local data on suicides for the same period. Results: Dying by suicide after nonfatal self-harm was more common for male subjects than for female subjects (OR = 3.3, 95% CI = 1.7–6.6). Self-injury as the method of nonfatal self-harm was associated with higher risk of subsequent suicide than was self-poisoning (OR = 2.0, 95% CI = 1.04–3.9). More urgent care at the emergency department (OR = 2.7, 95% CI = 1.1–6.3) and admission to hospital (OR = 2.0, 95% CI = 1.0–4.0) at the index episode were related to a heightened risk of suicide. Conclusion: The findings of our study could help services to form assessment and aftercare policies.

MIDSHIPS: multicentre intervention designed for self-harm using interpersonal problem-solving: protocol for a randomised controlled feasibility study

BACKGROUND

Around 150,000 people each year attend hospitals in England due to self-harm, many of them more than once. Over 5,000 people die by suicide each year in the UK, a quarter of them having attended hospital in the previous year because of self-harm. Self-harm is a major identifiable risk factor for suicide. People receive variable care at hospital; many are not assessed for their psychological needs and little psychological therapy is offered. Despite its frequent occurrence, we have no clear research evidence about how to reduce the repetition of self-harm. Some people who have self-harmed show less active ways of solving problems, and brief problem-solving therapies are considered the most promising psychological treatments.

METHODS/DESIGN

This is a pragmatic, individually randomised, controlled, feasibility study comparing interpersonal problem-solving therapy plus treatment-as-usual with treatment-as-usual alone, for adults attending a general hospital following self-harm. A total of 60 participants will be randomised equally between the treatment arms, which will be balanced with respect to the type of most recent self-harm event, number of previous self-harm events, gender and age. Feasibility objectives are as follows: a) To establish and field test procedures for implementing the problem-solving intervention; b) To determine the feasibility and best method of participant recruitment and follow up; c) To assess therapeutic delivery; d) To assess the feasibility of obtaining the definitive trial's primary and secondary outcomes; e) To assess the perceived burden and acceptability of obtaining the trial's self-reported outcome data; f) To inform the sample size calculation for the definitive trial.

DISCUSSION

The results of this feasibility study will be used to determine the appropriateness of proceeding to a definitive trial and will allow us to design an achievable trial of interpersonal problem-solving therapy for adults who self-harm.

TRIAL REGISTRATION

Current Controlled Trials (ISRCTN54036115).

Serious suicidal behaviors: socio-demographic and clinical features in a multinational, multicenter sample

BACKGROUND

Declared suicidal intent and physical danger are both considered important components in defining suicidal behaviors (SB).

AIMS

1) To investigate characteristics of serious suicidal behaviors (SSB), defined by either suicidal intent or lethality; 2) To determine any difference in terms of socio-demographic, clinical and/or service usage variables between SSB and non-serious suicidal behaviors (NSSB).

METHODS

A total of 2631 contacts for SB were registered in the context of the MONSUE (Monitoring Suicidal Behavior in Europe) study project. Demographic and clinical information were registered. ICD-10 was used for classifying data about psychiatric diagnoses, methods used for SB and injuries reported. Clear intentionality, high-case fatality methods and serious injuries all defined SSB (n = 1169; 44.4%)

RESULTS

SSB were more often preceded by a contact with an inpatient (either psychiatric or somatic) rather than an outpatient service. Among those having a previous history of SB, SSB subjects had fewer contacts with health services before the previous attempt. The strongest predictors for SSB appeared to be older age and not professing a religion.

CONCLUSION

Many of the known factors contributing to the risk of completed suicide were also present for SSB. Our findings on service usage by suicide attempters show which aspects of mental health services should be strengthened in order to improve suicide prevention.

The association between suicidal ideation and increased mortality from natural causes

BACKGROUND

Despite strong evidence for increased suicide mortality among individuals experiencing thoughts of suicide, the effect of suicidal ideation on increased natural mortality has not been evaluated. The present study aimed to assess whether there is excess mortality from all natural causes or from specific natural causes that is attributable to suicidal ideation. Adjustments were made for a range of demographic, mental health and physical health measures to examine evidence for specific mechanisms of the relationship.

METHOD

A community-based Australian cohort of 861 older adults was followed for up to 17 years. Vital status and cause of death were ascertained from a national death registry.

RESULTS

After adjusting for demographics, physical health and mental health, presence of suicidal ideation was associated with a 23% increase in the risk of mortality from natural causes (p=0.034). The increased mortality was largely attributable to heart disease deaths (hazard ratio=1.43, p=0.041).

LIMITATIONS

There was a limited number of deaths from respiratory disease or stroke, and modest rates of suicidal ideation in the cohort. Assessment of suicidal ideation was brief, while adjustment for mental health symptoms relied on non-diagnostic measures.

CONCLUSIONS

Although the relationship between suicidal ideation and mortality from natural causes was partly explained by physical and mental health status, thoughts of suicide independently accounted for an increased risk of mortality. Further research should examine whether this relationship is mediated by poorer health behaviours among individuals experiencing thoughts of suicide.

Deliberate self-harm before psychiatric admission and risk of suicide: survival in a Danish national cohort

PURPOSE

Psychiatric illness and deliberate self-harm (DSH) are major risk factors of suicide. In largely 15% of psychiatric admissions in Denmark, the patient had an episode of DSH within the last year before admission. This study examined the survival and predictors of suicide in a suicidal high-risk cohort consisting of hospitalized psychiatric patients with recent DSH.

METHODS

This national prospective register-based study examined all hospitalized psychiatric patients who self-harmed within a year before admission. All admitted patients, in the time period 1998-2006, were followed and survival analyses techniques were used to identify predictors of suicide.

RESULTS

The study population consisted of 17,257 patients; 520 (3%) died by suicide during follow-up; 50% of the suicides occurred within a year from the index admission. A rate of 1,645 suicides per 100,000 person-years in the first year after psychiatric admission was found. Adjusted analyses showed that a higher degree of education, having DSH within a month before psychiatric admission and contact with a private psychiatrist increased the risk of suicide.

CONCLUSIONS

Psychiatric hospitalized patients with recent DSH revealed high suicide rates, even during hospitalization. When discharging psychiatric patients with recent DSH careful arrangement of follow-up treatment in the outpatient setting is recommendable.

Premature death after self-harm: a multicentre cohort study

BACKGROUND

People who self-harm have an increased risk of premature death. The aim of this study was to investigate cause-specific premature death in individuals who self-harm, including associations with socioeconomic deprivation.

METHODS

We undertook a cohort study of patients of all ages presenting to emergency departments in Oxford, Manchester, and Derby, UK, after self-poisoning or self-injury between Jan 1, 2000, and Dec 31, 2007. Postcodes of individuals' place of residence were linked to the Index of Multiple Deprivation 2007 in England. Mortality information was supplied by the Medical Research Information Service of the National Health Service. Patients were followed up to the end of 2009. We calculated age-standardised mortality ratios (SMRs) and years of life lost (YLL), and we tested for associations with socioeconomic deprivation.

FINDINGS

30 950 individuals presented with self-harm and were followed up for a median of 6·0 years (IQR 3·9-7·9). 1832 (6·1%) patients died before the end of follow-up. Death was more likely in patients than in the general population (SMR 3·6, 95% CI 3·5-3·8), and occurred more in males (4·1, 3·8-4·3) than females (3·2, 2·9-3·4). Deaths due to natural causes were 2-7·5 times more frequent than was expected. For individuals who died of any cause, mean YLL was 31·4 years (95% CI 30·5-32·2) for male patients and 30·7 years (29·5-31·9) for female patients. Mean YLL for natural-cause deaths was 25·9 years (25·7-26·0) for male patients and 25·5 years (25·2-25·8) for female patients, and for external-cause deaths was 40·2 years (40·0-40·3) and 40·0 years (39·7-40·5), respectively. Disease of the circulatory (13·1% in males; 13·0% in females) and digestive (11·7% in males; 17·8% in females) systems were major contributors to YLL from natural causes. All-cause mortality increased with each quartile of socioeconomic deprivation in male patients (χ(2) trend 39·6; p<0·0001), female patients (13·9; p=0·0002), and both sexes combined (55·4; p<0·0001). Socioeconomic deprivation was related to mortality in both sexes combined from natural causes (51·0; p<0·0001) but not from external causes (0·30; p=0·58). Alcohol problems were associated with death from digestive-system disease, drug misuse with mental and behavioural disorders, and physical health problems with circulatory-system disease.

INTERPRETATION

Physical health and life expectancy are severely compromised in individuals who self-harm compared with the general population. In the management of self-harm, clinicians assessing patients' psychosocial problems should also consider their physical needs.

FUNDING

Department of Health Policy Research Programme.

Shared characteristics of suicides and other unnatural deaths following non-fatal self-harm? A multicentre study of risk factors

BACKGROUND

Mortality, including suicide and accidents, is elevated in self-harm populations. Although risk factors for suicide following self-harm are often investigated, rarely have those for accidents been studied. Our aim was to compare risk factors for suicide and accidents.

METHOD

A prospective cohort (n=30 202) from the Multicentre Study of Self-harm in England, 2000-2007, was followed up to 2010 using national death registers. Risk factors for suicide (intentional self-harm and undetermined intent) and accidents (narcotic poisoning, non-narcotic poisoning, and non-poisoning) following the last hospital presentation for self-harm were estimated using Cox models.

RESULTS

During follow-up, 1833 individuals died, 378 (20.6%) by suicide and 242 (13.2%) by accidents. Independent predictors of both suicide and accidents were: male gender, age 35 years (except accidental narcotic poisoning) and psychiatric treatment (except accidental narcotic poisoning). Factors differentiating suicide from accident risk were previous self-harm, last method of self-harm (twofold increased risks for cutting and violent self-injury versus self-poisoning) and mental health problems. A risk factor specific to accidental narcotic poisoning was recreational/illicit drug problems, and a risk factor specific to accidental non-narcotic poisoning and non-poisoning accidents was alcohol involvement with self-harm.

CONCLUSIONS

The similarity of risk factors for suicide and accidents indicates common experiences of socio-economic disadvantage, life problems and psychopathology resulting in a variety of self-destructive behaviour. Of factors associated with the accidental death groups, those for non-narcotic poisoning and other accidents were most similar to suicide; differences seemed to be related to criteria coroners use in reaching verdicts. Our findings support the idea of a continuum of premature death.

Changes in rates, methods and characteristics of suicide attempters over a 15-year period: comparison between Stockholm, Sweden, and Würzburg, Germany

PURPOSE

To investigate age and sex-specific changes in rates, methods used and characteristics of suicide attempters receiving medical care, over a 15-year period in two European WHO catchment areas (Stockholm, Sweden; and Würzburg, Germany).

METHODS

The data for this study were obtained from the WHO/EURO Multicentre Study on Suicidal Behaviour for the period 1989-2003. Sex-specific, person-based suicide attempt rates were calculated for each year separately for the age groups 15-24 and 25 or above. The Chi-square test for trend was applied to estimate changes in proportions of socio-demographic and socio-economic variables.

RESULTS

Significantly, increasing trends in suicide attempt rates occurred in young females, and in males and females aged 25 or above in Würzburg. On the contrary, men 25 years and above showed a significant decrease in suicide attempt rates in Stockholm. Young females in Würzburg tended to use less violent methods for their attempts whereas in Stockholm young females were increasingly inclined to attempt suicide using violent methods. In Stockholm, young female suicide attempters tended to be more often economically inactive, particularly due to an increasing proportion of students. Young females in Würzburg were often less well educated, as were their young male counterparts. This contrasted with trends in the education of men and women of 25 or above in Stockholm.

CONCLUSIONS

The results of this study suggest temporal changes in trends, methods used and in the social profile of suicide attempters.