A study of deliberate self-harm and its repetition among patients presenting to an emergency department

Case fatality of repeated suicidal acts among suicide attempters in rural China: a retrospective cohort study

Background

Individuals presenting to hospital due to suicide attempt are at high risk for repeated suicidal act, yet there are meager data on the extent to which repeated suicidal acts result in death.

Methods

This retrospective cohort study was based on a general hospital self-harm register system in a rural county in China. Identified individuals who attempted suicide were contacted and followed up for up to 8 years. Main outcomes over follow-up were: 1) suicide death, 2) nonlethal suicide attempt, and 3) suicidal acts including suicide death and nonlethal attempt. Incidence densities, correlates, and case fatality of repeated suicidal acts were estimated.

Findings

A total of 1086 individuals (two-thirds females, mean age 40.6 years) with a suicide attempt presenting to hospital (index attempt) were identified and followed up, with most of the index attempts by pesticide ingestion (79%). Over follow-up, there were 116 suicidal acts carried out by 108 individuals (69 females, 39 males), including 34 suicide deaths (21 females, 13 males), yielding a high case-fatality of 29.3%. During follow-up, suicide death rates were also high overall and in the first year of follow-up (846.7 and 1787.2 per 100,000 person years). Over follow-up, pesticide was the most common method (47/116) of repeated suicidal act and yielded a higher case-fatality than other methods (46.8% vs 17.4%, χ2 = 11.68, P < 0.001). The incidence densities of repeated suicidal acts and nonlethal attempts were low compared to rates reported in previous literature.

Interpretation

Incidence densities of repeated suicidal acts in a rural China cohort were low compared to previous studies. However, rates of suicide deaths over follow-up were high, a result driven by the high case-fatality of suicidal acts and attributable to the common use of pesticides. Reducing suicidal acts with pesticides is a key target for suicide prevention in rural China.

Funding

Beijing Municipal High Rank Public Health Researcher Training Program, Beijing Hospitals Authority Clinical Medicine Development of Special Funding Support, and Beijing Hospitals Authority's Ascent Plan.

Relationships between internalized stigma and depression and suicide risk among queer youth in the United States: a systematic review and meta-analysis

Background

Queer youth experience high rates of depression and suicidality. These disparities stem from stigma-based stressors, including internalized stigma (i.e., negative social views that minoritized individuals internalize about their own identity). Given the importance of this factor in understanding mental health disparities among queer youth, we completed a systematic review and meta-analysis examining the relationships between internalized stigma and outcomes of depression and suicide risk (i.e., suicidal ideation, non-suicidal self-injury, and suicidal behavior).

Methods

We followed the PRISMA standards. Six bibliographic databases were searched for studies in the United States from September 2008 to March 2022. Dual independent screening of search results was performed based on a priori inclusion criteria.

Results

A total of 22 studies were included for data extraction and review. Most studies examined general internalized homophobia, with few examining internalized biphobia or transphobia. Many studies examined depression as an outcome, few studies examined suicidal ideation or behavior, and no studies examined non-suicidal self-injury. Meta-analyses model results show the association between general internalized queer stigma and depressive symptoms ranged r = 0.19, 95% CI [0.14, 0.25] to r = 0.24, 95% CI [0.19, 0.29], the latter reflecting more uniform measures of depression. The association between internalized transphobia and depressive outcomes was small and positive (r = 0.21, 95% CI [-0.24, 0.67]). General internalized queer stigma and suicidal ideation had a very weak positive association (r = 0.07, 95% CI [-0.27, 0.41]) and an even smaller, weaker positive association with suicide attempt (r = 0.02, 95% CI [0.01, 0.03]).

Conclusion

Implications for clinical practice, policy, and future research are discussed.

Characteristics and patterns of individuals who have self-harmed: a retrospective descriptive study from Karachi, Pakistan

BACKGROUND

Self-Harm (SH) is a major global public health problem under-researched in Pakistan due to religious and legal implications. This study aims to identify the characteristics and patterns among patients with SH and factors associated with the intent to die.

METHOD

This retrospective descriptive study where SH cases presented to private tertiary care teaching hospital in Karachi, Pakistan, from January 2013 to December 2017 were extracted from HIMS records. Details related to demography, history, associated factors, access to methods used, and intent to die were collected on a structured proforma and analysed using STATA version 14.  RESULTS: A total of 350 cases were analysed. More than half of the reported cases were in the age group 20-39 years. Though only one-fourth of the SH cases had a past psychiatric history, it was found to be significantly (P-value < 0.05) associated with intent to die. Notably, 81% of the cases do not have a history of SH. Drug overdose (61.6%) and insecticides (36.6%) were the two most common methods used. Depression was identified in nearly half of the cases. The most common reason for attempting SH was inter-personal relationship issues (54.3%).

CONCLUSION

This paper provides recent data on the characteristics and patterns associated with the intent to die of individuals who have self-harmed. In most cases of SH, past psychiatric history was not evident. Current psychiatric diagnosis and young adults were favoured in this study. The data from this study has limited representation for all demographic representation of SH cases from Pakistan as being from a single private hospital. There is a need for further research on SH in Pakistan.

Investigating the relationship between childhood sexual abuse, self-harm repetition and suicidal intent: mixed-methods study

BACKGROUND

Research into the association between childhood sexual abuse (CSA) and self-harm repetition is limited.

AIMS

We aimed to examine the association between self-harm repetition, mental health conditions, suicidal intent and CSA experiences among people who frequently self-harm.

METHOD

A mixed-methods study was conducted including consecutive patients aged ≥18 years, with five or more self-harm presentations, in three Irish hospitals. Information was extracted from psychiatric records and patients were invited to participate in a semi-structured interview. Data was collected and analysed with a mixed-methods, convergent parallel design. In tandem, the association between CSA and self-harm repetition, suicidal intent and mental health conditions was examined with logistic regression models and independent sample t-test, with psychiatric records data. Thematic analysis was conducted with interview data, to explore CSA experiences and self-harm repetition.

RESULTS

Between March 2016 and July 2019, information was obtained on 188 consecutive participants, with 36 participants completing an interview. CSA was recorded in 42% of the total sample and 72.2% of those interviewed. CSA was positively associated with self-harm repetition (odds ratio 6.26, 95% CI 3.94-9.94, P = 0.00). Three themes emerged when exploring participants' CSA experiences: CSA as a precipitating factor for self-harm, secrecy of CSA accentuating shame, and loss experiences linked to CSA and self-harm.

CONCLUSIONS

CSA was frequently reported among people who frequently self-harm, and associated with self-harm repetition. Identification of patients at risk of repetition is key for suicide prevention. This is an at-risk group with particular characteristics that must be considered; comprehensive patient histories can help inform and tailor treatment pathways.

Prevalence and risk factors for repetition of non-fatal self-harm in Hong Kong, 2002-2016: A population-based cohort study

Background

A history of self-harm is strongly associated with future self-harm attempts. Large-scale Asian cohort studies examining risk factors for repeated self-harm are lacking. This paper reports on annual prevalence, cumulative risk, annual risk of non-fatal self-harm repetition, and risk factors among Hong Kong patients with a history of self-harm.

Methods

The Hong Kong Clinical Data Analysis and Reporting System (CDARS) provided all accident & emergency department and inpatient self-harm records between Jan 1, 2002 and Dec 31, 2016. Demographic and clinical characteristics were extracted. Annual prevalence, over-time cumulative and annual risks of non-fatal self-harm repetition were estimated, and the adjusted hazard ratios (HR; plus 95% CIs) of putative risk factors associated with repetition were estimated using Wei-Lin-Weissfeld (WLW) generalization of the Cox model for recurrent event analysis.

Findings

There were 127,801 self-harm episodes by 99,116 individuals. Annual prevalence of repeated self-harm, of all self-harms, ranged from 7•36% to 28•71% during the study period. Risk of self-harm repetition within one year of the index event was 14•25% (95% CI, 14•04%-14•46%). People with four or more previous self-harm episodes carried the highest risk of self-harm repetition (adjusted HR 4•81 [95% CI 4•46-5•18]). Significant risk factors for non-fatal self-harm repetition included male gender (1•08 [1•05-1•11]), older age (65+ years) (1•07 [1•01-1•13]), social welfare for payment (1•30 [1•27-1•34]), psychiatric admission (1•60 [1•50-1•72]), self-injury only (1•19 [1•15-1•23]), self-injury combined with self-poisoning (1•38 [1•24-1•53]), depression and bipolar disorders (1•09 [1•04-1•14]), personality disorders (1•18 [1•06-1•32]), substance misuse (1•31 [1•27-1•36]), and asthma (1•18 [1•02-1•36]).

Interpretation

Hong Kong self-harm patients with non-fatal self-harm events should be supported by effective, timely and ongoing aftercare plans based on their risk profiles, to reduce risk of self-harm reoccurrence.

Funding

Research Grants Council, General Research Funding: 17611619.

Recurrence of suicidal thoughts and behaviors during one year of follow-up: An exploratory study

Suicidal thoughts and behaviors (STB) include suicidal ideation (SI), suicide attempt (SA) and completed suicide. We aimed to identify recurrence predictors of any type of STB, and separately for SA and SI, and to analyze the time until event. A 108-subject cohort presenting at Emergencies with STB was followed during one year. Recurrence risk factors were investigated by multiple Cox survival regressions. Within one year, 31.5%, 23.1% and 9.3% patients recurred with any STB, SA, and SI respectively. Most recurrences (~70%) occurred within the first 6 months. Seeking emergency psychiatric assistance for problems other than STB during follow-up was a common predictor for recurrence of any STB, and SA and SI specifically. Previous SA history and contact with psychiatry outpatient units during follow-up predicted both STB in general and SA in particular. A specific predictor for SA was hospitalization at index, while SI recurrence was associated to SI at index. These results highlight the importance of early intervention and multidisciplinary follow-up considering concurrent psychosocial or adaptive problems. A careful exploration at Emergencies is needed to target potential predictors.

Evidence-Based Suicide Prevention: Collective Impact of Engagement with Community Stakeholders

Purpose: In response to the rising suicide trend in Hong Kong, the Centre for Suicide Research and Prevention ("CSRP") was established in 2002, with the aim to capitalize on the collective impact of research-support practices to prevent suicides.Method: The CSRP has since become an international knowledge hub that applies a public health approach and innovative strategies to address suicide-related problems at multiple levels.Results: The CSRP actively engages in research, teaching, and knowledge exchange with community stakeholders. These effort are associated with Hong Kong's more than 30% reduction in suicide rates between 2003 and 2016.Discussion: The rationale for and examples of the CSRP's practices in face of the suicide prevention challenges lay ahead were also discussed.Conclusion: The outcomes of these practices, which hold great potential for suicide prevention worldwide, have contributed to important academic debates in the field of suicidology.

Mental disorders as risk factors for suicidal behavior in young people: A meta-analysis and systematic review of longitudinal studies

BACKGROUND

Suicide is the second leading cause of death for young people.

OBJECTIVE

To assess mental disorders as risk factors for suicidal behaviour among adolescents and young adults including population-based longitudinal studies.

METHOD

We conducted a systematic literature review. Bibliographic searches undertaken in five international databases and grey literature sources until January 2017 yielded a total of 26,883 potential papers. 1701 full-text articles were assessed for eligibility of which 1677 were excluded because they did not meet our eligibility criteria. Separate meta-analyses were conducted for each outcome (suicide death and suicide attempts). Odds ratio (OR) and 95% confidence intervals (95%CI) and beta coefficients and standard errors were calculated.

RESULTS

24 studies were finally included involving 25,354 participants (12-26 years). The presence of any mental disorder was associated with higher risk of suicide death (OR = 10.83, 95%CI = 4.69-25.00) and suicide attempt (OR = 3.56; 95%CI 2.24-5.67). When considering suicidal attempt as the outcome, only affective disorders (OR = 1.54; 95%CI = 1.21-1.96) were significant. Finally, the results revealed that psychiatric comorbidity was a primary risk factor for suicide attempts.

LIMITATIONS

Data were obtained from studies with heterogeneous diagnostic assessments of mental disorders. Nine case-control studies were included and some data were collected in students, not in general population.

CONCLUSIONS

Mental disorders and comorbidity are strong predictors of suicide behaviour in young people. Detection and management of the affective disorders as well as their psychiatric comorbidity could be a crucial strategy to prevent suicidality in this age group.

Nonsuicidal Self-Injury Among a Representative Sample of US Adolescents, 2015

OBJECTIVES

To provide prevalence estimates of adolescent nonsuicidal self-injury (NSSI) based on large, representative, nonclinical samples of high-school students, and to explore gender differences in health risks associated with NSSI.

METHODS

We used 2015 Centers for Disease Control and Prevention Youth Risk Behavior Surveillance System data to estimate the prevalence of self-injury and variables potentially associated with self-injury for high-school-age boys (n = 32 150) and girls (n = 32 521) in 11 US states. We used logistic regression analysis to consider associations between NSSI and other health risks.

RESULTS

Rates of boys reporting purposefully hurting themselves without wanting to die over the past 12 months ranged from 6.4% (Delaware) to 14.8% (Nevada). Rates for girls varied from 17.7% (Delaware) to 30.8% (Idaho). Rates declined with age and varied by race and ethnicity. Depression; suicidal thoughts, plans, and attempts; sexual minority status; being electronically bullied; smoking; and substance use were associated with NSSI. There were minor differences in associations between NSSI and health risk variables by gender.

CONCLUSIONS

Nonclinical populations of adolescents are at high risk for self-injury. Nonsuicidal self-injury was higher among girls than among boys, but patterns of association with other health risks were similar.

Surviving moment to moment: The experience of living in a state of ambivalence for those with recurrent suicide attempts

OBJECTIVE

This qualitative study aimed to capture the experience of living in the ambivalent space between life and death for adults with recurrent suicide attempts (RSA). It sought to expand upon an earlier study that explored the processes involved in transitioning away from RSA among adults, which revealed that occupying this ambivalent space is a crucial part of this process.

DESIGN

Interpretive phenomenological analysis (IPA) was used. This methodology was designed to explore the lived experiences and meaning making and enabled interpretation of the multidimensional subjective experiences of RSA participants.

METHODS

In-depth semi-structured interviews were conducted with eight adult women with a history of RSA who had participated in a therapeutic intervention at the research site (Skills for Safer Living: A Psychosocial/Psychoeducational Intervention for People with Recurrent Suicide Attempts [SfSL/PISA]). The six stages of IPA were followed to analyse the interview data.

RESULTS

Analysis revealed the superordinate theme, 'surviving moment to moment', which refers to a precarious state of making decisions about one's life and destiny on a moment-to-moment basis without clear commitment to either life or death. Two subordinate themes were identified: 'deciding not to die in the moment' when the participants were more invested in dying than living and 'deciding to live in the moment' when they were more invested in living than dying.

CONCLUSION

The study illuminated the complex process of making decisions about ones' destiny on a moment-to-moment basis. It revealed the torment experienced when occupying this state, while paradoxically, also revealing how indecision about life and death provided a lifeline opportunity for those with RSA. Clinicians who recognize the subtle distinctions associated with this in-between state can tailor their interventions accordingly.

PRACTITIONER POINTS

Surviving moment to moment is characterized by a state of emotional flux and uncertainty about one's destiny, where the person has not fully committed to either life or death. Within this state, there are two interlinked subprocesses, whereby the person is leaning more towards death or life. A critical feature in working with this client group is to recognize their ambiguity and the fragility and temporality of their decisions about their destiny. The practitioner has an opportunity to be a catalyst in the momentum towards life by demonstrating understanding of this survival struggle and tailoring intervention to fit with the nuanced processes within this state.

Suicide and deliberate self-harm in Afghanistan

BACKGROUND

Suicide and deliberate self-harm (DSH) are major public health problems globally. There is limited information on suicide and DSH from Afghanistan.

AIMS

To review available literature on suicide and DSH in Afghanistan.

METHODS

Using online resources and literature on suicidal behavior (suicide, DSH and suicidal ideation) was searched.

RESULTS

There were only seven published studies identified on suicidal behavior in Afghanistan. Six of these have been published since 2003 and majority has focused on suicidal behavior in women.

CONCLUSIONS

Both DSH and suicide are underreported and understudied subjects in Afghanistan. There is need for more research in this area.

A Pilot Study on the Efficacy of Volunteer Mentorship for Young Adults With Self-Harm Behaviors Using a Quasi-Experimental Design

BACKGROUND

Studies have shown that postdischarge care for self-harm patients is effective in reducing repeated suicidal behaviors. Little is known about whether volunteer support can help reduce self-harm repetition and improve psychosocial well-being.

AIM

This study investigated the efficacy of volunteer support in preventing repetition of self-harm.

METHOD

This study used a quasi-experimental design by assigning self-harm patients admitted to the emergency departments to an intervention group with volunteer support and treatment as usual (TAU) for 9 months and to a control group of TAU. Outcome measures include repetition of self-harm, suicidal ideation, hopelessness, and level of depressive and anxiety symptoms.

RESULTS

A total of 74 cases were recruited (38 participants; 36 controls). There were no significant differences in age, gender, and clinical condition between the two groups at the baseline. The intervention group showed significant improvements in hopelessness and depressive symptoms. However, the number of cases of suicide ideation and of repetition of self-harm episodes was similar for both groups at the postintervention period.

CONCLUSION

Postdischarge care provided by volunteers showed significant improvement in hopelessness and depression. Volunteers have been commonly involved in suicide prevention services. Further research using rigorous methods is recommended for improving service quality in the long term.

Coping Card Usage can Further Reduce Suicide Reattempt in Suicide Attempter Case Management Within 3-Month Intervention

This randomized controlled trial was designed to evaluate the effectiveness of using crisis coping cards (n = 32) in the case management of suicide prevention compared with case management without the use of coping cards (n = 32) over a 3-month intervention period. The generalized estimating equation was used to examine the interaction effect between treatments and time on suicide risk, depression, anxiety, and hopelessness. Results indicated that subsequent suicidal behaviors, severity of suicide risk, depression, anxiety, and hopelessness were reduced more in the coping card intervention group compared to the case management only group. Moreover, for the survival curves of time to suicide reattempt, the coping card group showed a significantly longer time to reattempt than the case management only group at 2-month and 3-month intervention periods.

Young people who self-harm: a prospective 1-year follow-up study

PURPOSE

To explore repetition, service provision and service engagement following presentation of young people to emergency services with self-harm.

METHODS

969 patients who presented to accident and emergency services after self-harm were followed up prospectively for a period of 1 year. Data on rates, method, clinical history, initial service provision, engagement and repetition (defined as re-presenting to emergency services with further self-harm) were gathered from comprehensive electronic records.

RESULTS

Young people were less likely to repeat self-harm compared to those aged 25 and above. A psychiatric history and a history of childhood trauma were significant predictors of repetition. Young people were more likely to receive self-help as their initial service provision, and less likely to receive acute psychiatric care or a hospital admission. There were no differences in engagement with services between young people and those aged 25 and above.

CONCLUSION

Younger individuals may be less vulnerable to repetition, and are less likely to represent to services with repeated self-harm. All young people who present with self-harm should be screened for mental illness and asked about childhood trauma. Whilst young people are less likely to be referred to psychiatric services, they do attend when referred. This may indicate missed opportunity for intervention.

Non-fatal repetition of self-harm in Taipei City, Taiwan: cohort study

BACKGROUND

Repeat self-harm is an important risk factor for suicide. Few studies have explored risk factors for non-fatal repeat self-harm in Asia.

AIMS

To investigate the risk of non-fatal repeat self-harm in a large cohort of patients presenting to hospital in Taipei City, Taiwan.

METHOD

Prospective cohort study of 7601 patients with self-harm presenting to emergency departments (January 2004-December 2006). Survival analysis was used to examine the rates, timing and factors associated with repeat self-harm.

RESULTS

In total 778 (10.2%) patients presented to hospital with one or more further episodes of self-harm. The cumulative risk of non-fatal repetition within 1 year of a self-harm episode was 9.3% (95% CI 8.7-10.1). The median time to repetition within 1 year was 105 days. Females had a higher incidence of repeat self-harm than males (adjusted hazard ratio 1.25, 95% CI 1.05-1.48) but males had shorter median time to repetition (107 v. 80 days). Other independent risk factors for repeat self-harm within 1 year of an index episode were: young age, self-harm by medicine overdose and increasing number of repeat episodes of self-harm.

CONCLUSIONS

The risk of non-fatal repeat self-harm in Taipei City is lower than that seen in the West. Risk factors for repeat non-fatal self-harm differ from those for fatal self-harm. The first 3 months after self-harm is a crucial period for intervention.

Risk factors of suicide mortality among multiple attempters: A national registry study in Taiwan

BACKGROUND/PURPOSE

Little is known about the risk factors of suicide mortality among multiple attempters. This study aims to investigate the predictors of suicidal mortality in a prospective cohort of attempters in Taiwan, focusing on the time interval and suicide method change between the last two nonfatal attempts.

METHODS

The representative data retrieved from the National Suicide Surveillance System (NSSS) was linked with National Mortality Database to identify the causes of death in multiple attempters during 2006-2008. Cox-proportional hazard models were applied to calculate the hazard ratios for the predictors of suicide.

RESULTS

Among the 55,560 attempters, 6485 (11.7%) had survived attempts ranging from one to 11 times; 861 (1.5%) eventually died by suicide. Multiple attempters were characterized by female (OR = 1.56, p < 0.0001), nonrecipient of national aftercare service (OR = 1.62, p < 0.0001), and current contact with mental health services (OR = 3.17, p < 0.0001). Most multiple attempters who survived from hanging (68.1%) and gas poisoning (61.9%) chose the same method in the following fatal episode. Predictors of suicidal death were identified as male, older age (≥ 45 years), shorter interval and not maintaining methods of low lethality in the last two nonfatal attempts. Receipt of nationwide aftercare was associated with lower risk of suicide but the effect was insignificant.

CONCLUSION

The time interval of the last two nonfatal attempts and alteration in the lethality of suicide method were significant factors for completed suicide. Risk assessment involving these two factors may be necessary for multiple attempters in different clinical settings. Effective strategies for suicide prevention emphasizing this high risk population should be developed in the future.

General hospital-treated self-poisoning in England and Australia: comparison of presentation rates, clinical characteristics and aftercare based on sentinel unit data

OBJECTIVE

Hospital-treated deliberate self-poisoning (DSP) is common and the existing national monitoring systems are often deficient. Clinical Practice Guidelines (UK and Australia) recommend universal psychosocial assessment within the general hospital as standard care. We compared presentation rates, patient characteristics, psychosocial assessment and aftercare in UK and Australia.

METHODS

We used a cross sectional design, for a ten year study of all DSP presentations identified through sentinel units in Oxford, UK (n=3042) and Newcastle, Australia (n=3492).

RESULTS

Oxford had higher presentation rates for females (standardised rate ratio 2.4: CI 99% 1.9, 3.2) and males (SRR 2.5: CI 99% 1.7, 3.5). Female to male ratio was 1.6:1, 70% presented after-hours, 95% were admitted to a general hospital and co-ingestion of alcohol occurred in a substantial minority (Oxford 24%, Newcastle 32%). Paracetamol, minor tranquilisers and antidepressants were the commonest drug groups ingested, although the overall pattern differed. Psychosocial assessment rates were high (Oxford 80%, Newcastle 93%). Discharge referral for psychiatric inpatient admission (Oxford 8%, Newcastle 28%), discharge to home (Oxford 80%, Newcastle 70%) and absconding (Oxford 11%, Newcastle 2%) differed between the two units.

CONCLUSIONS

Oxford has higher age-standardised rates of DSP than Newcastle, although many other characteristics of patients are similar. Services can provide a high level of assessment as recommended in clinical guidelines. There is some variation in after-care. Sentinel service monitoring routine care of DSP patients can provide valuable comparisons between countries.

An observational study of the impact of service use on suicidality among adults with mental disorders

Background

It is unclear whether treatment of mental disorders reduces the probability that a) people without suicidal ideation will begin to contemplate suicide, or b) people who have thought about killing themselves (but have not attempted suicide) will go on to make an attempt.

Methods

Mental disorders, service use for emotional or substance use problems, and suicidality were assessed using the World Mental Health version of the Composite International Diagnostic Interview. Discrete-time survival analysis was used to establish the temporal priority of mental health service use and suicide-related outcomes among the 5,862 participants in the Collaborative Psychiatric Epidemiological Surveys who reported a mental disorder.

Results

Use of specialty mental health services, but not other types of services for emotional or substance use problems, was associated with an increased risk of future suicide ideation (OR = 1.27, CI = 1.01–1.60). However, respondents with a history of suicidal ideation were less likely to report a subsequent suicide attempt if they had received any type of service for emotional or substance use problems (OR = 0.62, CI = 0.46–0.83), regardless of the type of service received (i.e., it did not matter whether the service received was mental health care, general medical care, or non-health care related).

Conclusions

Among persons with frank DSM disorders and suicidal ideation, the receipt of treatment is associated with a lower rate of subsequent suicide attempts, compared with those who never received treatment, regardless of treatment provider type. Follow-up studies are a logical next step to our observational investigation.

Risk factors of suicide attempts by poisoning: review

Introduction: Suicide, a complex and universal human phenomenon, is a major public health problem. This study reviewed the literature about the major risk factors associated with suicide attempts by poisoning. Methods: An integrative review of the literature was performed in databases (LILACS, PubMed and MEDLINE) to search for studies published between 2003 and 2013, using the following keywords: suicide, attempted; poisoning; risk factors. Inclusion criteria were: original study with abstract, sample of adults, and attempted suicide by poisoning in at least 50% of the study population. Results: Two hundred and nineteen studies were retrieved and read by two independent examiners, and 22 were included in the study. The main risk factors for suicide attempts by poisoning were female sex, age 15-40 years, single status, little education, unemployment, drug or alcohol abuse or addiction, psychiatric disorder and psychiatric treatment using antidepressants. Conclusion: Further prospective studies should be conducted to confirm these risk factors or identify others, and their findings should contribute to planning measures to prevent suicide attempts.

Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis

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.

Methods and Findings

Medline, EMBASE, PsycINFO, Google Scholar, article reference lists and personal paper collections of the authors were searched for studies describing rates of fatal and non-fatal self-harm amongst people who presented to health care services for deliberate self-harm. Heterogeneity in pooled estimates of repeat self-harm incidence was investigated using stratified meta-analysis and meta-regression. The search identified 177 relevant papers. The risk of suicide in the 12 months after an index attempt was 1.6% (CI 1.2–2.4) and 3.9% (CI 3.2–4.8) after 5 years. The estimated 1 year rate of non-fatal repeat self-harm was 16.3% (CI 15.1–17.7). This proportion was considerably lower in Asian countries (10.0%, CI 7.3–13.6%) and varies between studies identifying repeat episodes using hospital admission data (13.7%, CI 12.3–15.3) and studies using patient report (21.9%, CI 14.3–32.2). There was no evidence that the incidence of repeat self-harm was lower in more recent (post 2000) studies compared to those from the 1980s and 1990s.

Conclusions

One in 25 patients presenting to hospital for self-harm will kill themselves in the next 5 years. The incidence of repeat self-harm and suicide in this population has not changed in over 10 years. Different methods of identifying repeat episodes of self-harm produce varying estimates of incidence and this heterogeneity should be considered when evaluating interventions aimed at reducing non-fatal repeat self-harm.

Risk factors for repetition of self-harm: a systematic review of prospective hospital-based studies

BACKGROUND

Self-harm entails high costs to individuals and society in terms of suicide risk, morbidity and healthcare expenditure. Repetition of self-harm confers yet higher risk of suicide and risk assessment of self-harm patients forms a key component of the health care management of self-harm patients. To date, there has been no systematic review published which synthesises the extensive evidence on risk factors for repetition.

OBJECTIVE

This review is intended to identify risk factors for prospective repetition of self-harm after an index self-harm presentation, irrespective of suicidal intent.

DATA SOURCES

PubMed, PsychInfo and Scirus were used to search for relevant publications. We included cohort studies which examining factors associated with prospective repetition among those presenting with self-harm to emergency departments. Journal articles, abstracts, letters and theses in any language published up to June 2012 were considered. Studies were quality-assessed and synthesised in narrative form.

RESULTS

A total of 129 studies, including 329,001 participants, met our inclusion criteria. Some factors were studied extensively and were found to have a consistent association with repetition. These included previous self-harm, personality disorder, hopelessness, history of psychiatric treatment, schizophrenia, alcohol abuse/dependence, drug abuse/dependence, and living alone. However, the sensitivity values of these measures varied greatly across studies. Psychological risk factors and protective factors have been relatively under-researched but show emerging associations with repetition. Composite risk scales tended to have high sensitivity but poor specificity.

CONCLUSIONS

Many risk factors for repetition of self-harm match risk factors for initiation of self-harm, but the most consistent evidence for increased risk of repetition comes from long-standing psychosocial vulnerabilities, rather than characteristics of an index episode. The current review will enhance prediction of self-harm and assist in the efficient allocation of intervention resources.

Reinventing intention: 'self-harm' and the 'cry for help' in postwar Britain

PURPOSE OF REVIEW

To sketch out how contemporary Anglophone literature on self-damaging behaviour negotiates serious conceptual difficulties around intention, and to demonstrate (in the British context) how the large-scale emergence of this type of behaviour is made possible by new forms of psychological provision at district general hospitals.

RECENT FINDINGS

In the past decade, there has been increasing public awareness of 'self-harm'. Despite the view that 'self-harm' has always existed, the British roots of the current 'epidemic' can be traced to changes in the organization of mental healthcare in the postwar period. These changes make possible new understandings of the story behind physical injuries, and allow these readings to be aggregated and projected onto a national, epidemic scale.

SUMMARY

The increasing provision of psychiatric expertise in general hospitals makes possible new interpretations of self-injury - as psychosocial communication, or affect self-regulation - and creates the phenomenon of 'self-harm' as we understand it today.

The incidence and repetition of hospital-treated deliberate self harm: findings from the world's first national registry

BACKGROUND

Suicide is a significant public health issue with almost one million people dying by suicide each year worldwide. Deliberate self harm (DSH) is the single most important risk factor for suicide yet few countries have reliable data on DSH. We developed a national DSH registry in the Republic of Ireland to establish the incidence of hospital-treated DSH at national level and the spectrum and pattern of presentations with DSH and repetition.

METHODS AND FINDINGS

Between 2003 and 2009, the Irish National Registry of Deliberate Self Harm collected data on DSH presentations to all 40 hospital emergency departments in the country. Data were collected by trained data registration officers using standard methods of case ascertainment and definition. The Registry recorded 75,119 DSH presentations involving 48,206 individuals. The total incidence rate fell from 209 (95% CI: 205-213) per 100,000 in 2003 to 184 (95% CI: 180-189) per 100,000 in 2006 and increased again to 209 (95% CI: 204-213) per 100,000 in 2009. The most notable annual changes were successive 10% increases in the male rate in 2008 and 2009. There was significant variation by age with peak rates in women in the 15-19 year age group (620 (95% CI: 605-636) per 100,000), and in men in the 20-24 age group (427 (95% CI: 416-439) per 100,000). Repetition rates varied significantly by age, method of self harm and number of previous episodes.

CONCLUSIONS

Population-based data on hospital-treated DSH represent an important index of the burden of mental illness and suicide risk in the community. The increased DSH rate in Irish men in 2008 and 2009 coincided with the advent of the economic recession in Ireland. The findings underline the need for developing effective interventions to reduce DSH repetition rates as a key priority for health systems.