Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds
Correspondence: David Owens, Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, 15 Hyde Terrace, Leeds LS2 9LT, UK
Declaration of interest J.H.'s salary is paid by the mental health charity Leeds Mind from a research grant awarded by the UK National Lottery Charities Board.
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
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.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
From the primary studies and all their secondary references, we included in our review every research report that fulfilled four criteria. The studies we selected were written in English, were published after 1970, described patients recruited to a study after attending a general hospital as a result of an episode of non-fatal self-harm and reported the proportion that repeated self-harm fatally or not for any follow-up period of at least a year. Suicides in most primary studies included those that were definite (by verdict of a coroner or equivalent authority) or probable (open verdicts or equivalent judgement); definitions were too variable for us to discriminate further and we have included them all and used the above broad definition of suicide. Because our search strategy found only one small study from the Far East that met the above criteria, we excluded it; the final list consequently represents research from Europe, North America and Australasia.
We excluded studies where the sample was restricted to participants who were young or elderly or had a learning disability. We did not exclude primary studies whose subjects were selected according to some measure of severity, such as established multiple repetition of self-harm or attending for the first time. Instead, we combined all the data and then applied a quality scale (described below). The majority of the studies were observational in design. Where we used data from clinical trials we combined data from both treatment groups, because the Cochrane review of trials of self-harm management (Hawton et al, 2001) found no clear difference between outcomes for experimental interventions compared with treatment as usual. Where more than one published paper set out findings for the same sample, we extracted results from the most complete version.
Measuring the quality of the primary study findings
For each study reporting a 1-year rate of non-fatal repetition or suicide
we applied a ten-point quality scale based on features of the method and
analysis (Table 1).
|
Study size
We weighted the quality score in favour of larger studies because they
estimate outcome with the greatest precision. Clinical trials tend to score
low in these ratings because of small sample size. We previously found
(NHS Centre for Reviews and
Dissemination, 1998) that, for the studies reporting repetition of
non-fatal self-harm within 1 year, the median proportion repeating was 16%. A
follow-up study of 200 subjects (n=200) would generate a 95%
confidence interval of 11-21% (or 16±5%) around a sample estimate of
16% (Gardner et al,
1989). A more precise estimate can be derived from n=600:
13-19% (or 16±3%).
Because suicide is a rare outcome event, large sample sizes are needed for precise estimates. In the same way, we used the median from our previous review (3% suicide at 1-4 years of follow-up) to determine reasonably precise and achievable estimates: n=500 would generate a 95% confidence interval of 1.5-4.5% (or 3±1.5%); n=950 provides a more precise estimate of approximately 2-4% (or 3±1%).
Study sample
All hospitals discharge home a substantial proportion of patients attending
as a consequence of self-harm (Owens,
1990), which is as many as two-thirds from some accident and
emergency departments (Kapur et
al, 1998). Comprehensive studies of hospital contact
therefore identify subjects at accident and emergency or equivalent walk-in or
emergency departments at general or psychiatric hospitals. The next best
procedure is to ensure that all cases admitted as in-patients are included.
Weaker designs use convenience samples such as lists of weekday routine
referrals to the self-harm assessment service; there will be exclusion biases
but it is not clear what they might be. The most obvious biases of all occur
when studies confine their sample to mild or to severe cases, perhaps to
first-time or to multiple-repeat patients. We awarded up to four points for
sampling (see Table 1); the
final score is a cumulative one according to the absence of noticeable bias.
Clinical trials usually had numerous exclusions and tended to score low.
Ascertainment of outcome
We found that the studies determined subsequent suicides by one or more of
three methods: by inspection of local coroners' (or equivalent) records,
looking for the names of the study subjects; by efforts to determine the
whereabouts of each patient, for example using hospitals, general
practitioners and their records; and by checking names and other personal
details against national registration of deaths. The first of these methods is
weak missing those who move home, even by only a short distance, and
those who change their names. We awarded a point each for use of the two
better methods.
Non-fatal repetition is more difficult to determine because of inadequate collection of data in most hospitals. We awarded half a point each for four steps taken to maximise identification of all the repeat episodes: use of a catchment area for the inclusion of subjects; interview follow-up of subjects; checks in general practice records; and checking of accident and emergency records.
Analysis of data
Many studies wrongly estimated the proportion repeating by recruiting
subjects over a long period and following them up to a single end-point,
failing to correct for the difference between subjects in the time-period
denominator. Where a study used a uniform follow-up period for
example, everyone followed up for exactly 1 year from the date of inclusion
we awarded a point. Studies that used survival analysis scored a
further point.
Combining the studies into a summary
The studies emerging from the literature search included single group
cohorts, cohort analytical studies and clinical trials. This body of research
is too heterogeneous for meta-analysis
(Egger et al, 1998).
Instead, we have placed the findings in rank order and we report their medians
together with their interquartile range (25th-75th centiles).
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The main results of our analysis, grouped by duration of follow-up, are shown in Fig. 1. The median proportion repeating non-fatal self-harm is 16% at 1 year and 23% in studies lasting longer than 4 years. For subsequent suicide, the increment in the median after a longer follow-up is relatively much more from less than 2% at 1 year up to nearly four times greater in the studies lasting over 9 years.
|
Subgroup analyses
For repetition at 1 year and suicide at 1 year we rank-ordered the studies
according to date of publication and compared the findings of the more recent
and older halves (Figs 2a and
3a). Medians were largely
unaffected by the split but there was a wider dispersion of values among the
studies in the past 10 years.
|
|
The high proportion of studies from the UK led us to examine the 1-year findings according to whether studies were UK-based or from elsewhere (Figs 2b and 3b). For repetition, UK studies showed the same median values as the rest of the literature but were more narrowly grouped around that median. For the 1-year suicide rate, both the UK and other studies showed tight bunching but UK studies had a median nearly five times lower than that of the rest of the literature (MannWhitney W=54.5, P<0.001).
The comparisons of 1-year findings based on the quality scores of the primary studies are shown in Figs 2c and 3c. For repetition and then for suicide we placed the studies in rank order according to quality score and then compared the better findings (those above the whole-group median score) with those below the median. For repetition, the values for the better-quality findings bunch tightly around 15% (a similar median to the one we found for all 37 studies); for the poorer-quality findings, the values are more dispersed around a higher median (21%). Examining suicide, we find a similar pattern: the higher-quality findings are tightly grouped around a median (1.8%) identical to that of the whole group of 26 studies, and the poorer-quality findings are far more widely dispersed around a slightly higher median.
Figure 4 shows a larger proportion of high-quality findings among the reports of non-fatal repetition than among the reports of subsequent suicide. We might have predicted this disparity because we were aware of few large studies that could estimate suicide with precision.
|
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
We were struck by the relative absence of studies from the USA, in line with the few American studies about intervention following self-harm (Hawton et al, 2001). Publication bias seems an unlikely explanation; our search terms used standard procedures, and three of the four bibliographical databases that we used are American and thereby likely to bias in favour of American studies. Clinical epidemiological study of self-harm is uncommon in the USA, despite the huge scale of self-harm there (Vastag, 2001).
Summary of quantitative findings
Summing up our findings, it seems that a reasonable estimate of non-fatal
repetition is 15-16% at 1 year with a slow rise to 20-25% over the following
few years. In this review we have not been able to determine the 1-year
repetition rate of an inception cohort (first-time self-harm cases). For
suicide following self-harm we cannot settle on a simple finding. The median
1-year suicide rate for the better half of all the studies reviewed was four
times higher than the median rate for all UK studies
(Fig. 3), which might point to
real differences in outcome according to location or to deficits in either the
UK or non-UK literature.
Why were suicide findings inconsistent?
Quality scores in the suicide studies were generally low, with a median
quality score for all 26 studies of only 2.5 out of 10 (interquartile range
2-5). Scores for the 9 UK studies were not noticeably different from those of
the 17 non-UK studies: UK study median quality score=2 (2-5.5) and non-UK
median=3 (1-5), a difference without statistical significance
(MannWhitney W=212, P=0.6).
We checked whether health service differences between the UK and elsewhere might have led the UK studies to concentrate on accident and emergency departments, thereby biasing their samples towards those less severe episodes that result in discharge from accident and emergency. In 2 out of 9 UK studies and 4 out of 17 studies from other countries, the researchers followed up all the patients who attended, not just the admitted patients. Similarly, we found the same median scores for sampling (out of a maximum of four) in UK and non-UK studies: zero for each group, with the same upper quartiles of 3.5. We therefore found no evidence of a group difference based on differential attention to patients attending hospital and leaving without in-patient admission.
Consequences of the inconsistent findings about suicide
Although our review might suggest that suicide following self-harm has a
substantially lower incidence in the UK than elsewhere, the cumulative
findings about suicide after self-harm are too flimsy to rely on. We need to
understand the links between non-fatal self-harm and suicide if we are to plan
clinical services and intervention research properly. The best current UK
estimate of hospital attendance due to self-harm is around 400 per 100 000
(Hawton et al, 1997);
0.5% incidence of suicide in the next year after self-harm (our median
estimate for UK studies) accounts for 2 per 100 000 population, which is
one-fifth of the England and Wales suicide rate of 10 per 100 000. If the same
calculation is applied to our 1.8% median estimate from the better-quality
studies, then around two-thirds of suicides (7 per 100 000) might be preceded
by non-fatal self-harm in the preceding year.
Whichever estimate is the closer to the truth, it is plain that national suicide prevention strategies ought to be based on up-to-date research into non-fatal self-harm. High-quality follow-up studies of self-harm will help to keep those strategies relevant to clinical needs. The studies that ought to be undertaken will be large, following up well over 1000 self-harm patients, and they will be based on all patients attending hospital, regardless of whether or not they were admitted from accident and emergency. Determining the outcome of those who are treated only in primary care will be feasible only when there is an increase in data-sharing in primary care. Repetition will be ascertained from accident and emergency or other hospital contact records, rather than from ward, special unit or discharge data. Suicides will be determined by the use of national records of the registration of deaths. The study data will be analysed using the statistical techniques of survival analysis.
Suicide is a rare event occurring in 1 in 10 000 people a year, and bringing about a reduction in the population's suicide rates is a difficult challenge. Recent non-fatal self-harm indicates a large increase in individual risk it is probably the major risk factor but the incidence among these people rises to around 1 %. Unfortunately, all our clinical methods for predicting suicide among our patients have a very poor positive predictive value at this low level of incidence (Geddes, 1999). Only a population strategy (Rose, 1992) is likely to achieve a reduction in the suicidal potential after self-harm through application of an intervention aimed at all self-harm patients. But current evidence tells us that the few clinical trials of intervention after self-harm are characterised by inadequate power, unrepresentative samples and unsuitable data analysis (Hawton et al, 1998). The second research need is therefore for the first-ever large, well-designed clinical trial of brief intervention after non-fatal self-harm.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
APPENDIX STUDIES REVIEWED |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Adam, K. S., Valentine, J., Scarr, G., et al (1983) Follow-up of attempted suicide in Christchurch. Australian and New Zealand Journal of Psychiatry, 17, 18-25.[Medline]
Allard, R., Marshall, M. & Plante, M. C. (1992) Intensive follow-up does not decrease the risk of repeat suicide attempts. Suicide and Life-Threatening Behavior, 22, 303-314.[Medline]
Allgulander, C. & Fisher, L. D. (1990) Clinical predictors of completed suicide and repeated self-poisoning in 8895 self-poisoning patients. European Archives of Psychiatry and Neurological Sciences, 239, 270-276.[Medline]
Aoun, S. (1999) Deliberate self-harm in rural Western Australia: results of an intervention study. Australian and New Zealand Journal of Mental Health Nursing, 8, 65-73.[CrossRef][Medline]
Arensman, E., Kerkhof, A. J., Hengeveld, M. W., et al (1995) Medically treated suicide attempts: a four year monitoring study of the epidemiology in The Netherlands. Journal of Epidemiology and Community Health, 49, 285-289.[Abstract]
Bancroft, J. & Marsack, P. (1977) The repetitiveness of self-poisoning and self-injury. British Journal of Psychiatry, 131, 394-399.[Abstract]
Batt, A., Eudier, F., Le Vaou, P., et al (1998) Repetition of parasuicide: risk factors in general hospital referred patients. Journal of Mental Health, 7, 285-297.[CrossRef]
Bille-Brahe, U. & Jessen, G. (1994) Repeated suicidal behavior: a two-year follow-up. Crisis, 15, 77-82.[Medline]
Bocchetta, A., Ardau, R., Burrai, C., et al (1998) Suicidal behaviour on and off lithium prophylaxis in a group of patients with prior suicide attempts. Journal of Clinical Psychopharmacology, 18, 384-389.[CrossRef][Medline]
Boyes, A. P. (1994) Repetition of overdose: a retrospective 5-year study. Journal of Advanced Nursing, 20, 462-468.[Medline]
Braftos, O. (1971) Attempted suicide. A comparative study of patients who have attempted suicide and psychiatric patients in general. Acta Psychiatrica Scandinavica, 47, 38-56.
Buglass, D. & McCulloch, J. W. (1970) Further suicidal behaviour: the development and validation of predictive scales. British Journal of Psychiatry, 116, 483-491.[Medline]
Buglass, D. & Horton, J. (1974) The repetition of parasuicide: a comparison of three cohorts. British Journal of Psychiatry, 125, 168-174.[Medline]
Carter, G. L., Whyte, I. M., Ball, K., et al (1999) Repetition of deliberate self-poisoning in an Australian hospital-treated population. Medical Journal of Australia, 170, 307-311.[Medline]
Crawford, M. J. & Wessely, S. (1998) Does
initial management affect the rate of repetition of deliberate self-harm?
Cohort study. BMJ, 317,
985-990.
Cullberg, J., Wasserman, D. & Stefansson, C. G. (1988) Who commits suicide after a suicide attempt? An 8 to 10 year follow up in a suburban catchment area. Acta Psychiatrica Scandinavica, 77, 598-603.[Medline]
Curran, S., Fitzgerald, M. & Greene, V.
(1999) Psychopathology 8 years post parasuicide.
Crisis, 20,
115-121.[Medline]
Cusick, T. E., Chang, F. C., Woodson, T. L., et al (1999) Is resuscitation after traumatic suicide attempt a futile effort? A five-year review at a Level 1 trauma centre. American Surgeon, 65, 643-647.[CrossRef][Medline]
De Moore, G. M. & Robertson, A. R. (1996) Suicide in the 18 years after deliberate self-harm. A prospective study. British Journal of Psychiatry, 169, 489-494.[Abstract]
Ekeberg, O., Ellingsen, O. & Jacobsen, D. (1991) Suicide and other causes of death in a five-year follow-up of patients treated for self-poisoning in Oslo. Acta Psychiatrica Scandinavica, 83, 432-437.[Medline]
Ekeberg, O., Ellingsen, O. & Jacobsen, D. (1994) Mortality and causes of death in a 10-year follow-up of patients treated for self-poisonings in Oslo. Suicide and Life-Threatening Behavior, 24, 398-405.[Medline]
Gardner, R., Hanka, R., O'Brien, V. C., et al (1977) Psychological and social evaluation in cases of deliberate self-poisoning admitted to a general hospital. BMJ, ii, 1567-1570.
Gardner, R., Hanka, R., Roberts, S. J., et al (1982) Psychological and social evaluation in cases of deliberate self-poisoning seen in an accident department. BMJ, 284, 491-493.[Medline]
Garzotto, N., Siani, R., Tansella, C. Z., et al (1976) Cross-validation of a predictive scale for subsequent suicidal behaviour in an Italian sample. British Journal of Psychiatry, 128, 137-140.[Abstract]
Gharagozlou, H. & Hadjmohammadi, M. (1977) Report on a three-year follow-up of 100 cases of suicidal attempts in Shiraz, Iran. International Journal of Social Psychiatry, 23, 209-210.[Medline]
Gibbons, J. S., Butler, J., Urwin, P., et al (1978) Evaluation of a social work service for self-poisoning patients. British Journal of Psychiatry, 133, 111-118.[Abstract]
Gilbody, S., House, A. & Owens, D. (1997) The early repetition of deliberate self harm. Journal of the Royal College of Physicians of London, 31, 171-172.[Medline]
Greer, S. & Bagley, C. (1971) Effect of psychiatric intervention in attempted suicide: a controlled study. BMJ, i, 310-312.
Hall, D. J., O'Brien, F., Stark, C., et al (1998) Thirteen-year follow-up of deliberate self-harm, using linked data. British Journal of Psychiatry, 172, 239-242.[Abstract]
Hansen, W. & Wang, A. G. (1984) Suicide attempts in a Danish region. Social Psychiatry, 19, 197-201.[Medline]
Hassanyeh, F., O'Brien, G., Holton, A. R., et al (1989) Repeat self-harm: an 18-month follow-up. Acta Psychiatrica Scandinavica, 79, 265-267.[Medline]
Hawton, K., Bancroft, J., Catalan, J., et al (1981) Domiciliary and outpatient treatment of self-poisoning patients by medical and non-medical staff. Psychological Medicine, 11, 169-177.[Medline]
Hawton, K., McKeown, S., Day, A., et al (1987) Evaluation of out-patient counselling compared with general practitioner care following overdoses. Psychological Medicine, 17, 751-761.[Medline]
Hawton, K. & Fagg, J. (1988) Suicide, and other causes of death, following attempted suicide. British Journal of Psychiatry, 152, 359-366.[Abstract]
Hawton, K., Fagg, J. & McKeown, S. P. (1989) Alcoholism, alcohol and attempted suicide. Alcohol and Alcoholism, 24, 3-9.[Medline]
Hawton, K., Fagg, J., Simkin, S., et al (1997) Trends in deliberate self-harm in Oxford, 1985-1995. Implications for clinical services and the prevention of suicide. British Journal of Psychiatry, 171, 556-560.[Abstract]
Hjelmeland, H. (1996) Repetition of parasuicide: a predictive study. Suicide and Life-Threatening Behavior, 26, 395-404.[Medline]
Hjelmeland, H., Stiles, T. C., Bille-Brahe, U., et al (1998) Parasuicide: the value of suicidal intent and various motives as predictors of future suicidal behaviour. Archives of Suicide Research, 4, 209-225.[CrossRef]
Johnsson, F. E., Ojehagen, A. & Traskman-Bendz, L. (1996) A 5-year follow-up study of suicide attempts. Acta Psychiatrica Scandinavica, 93, 151-157.[Medline]
Kaplan, K. J. & Harrow, M. (1999) Psychosis and functioning as risk factors for later suicidal activity among schizophrenia and schizoaffective patients: a disease-based interactive model. Suicide and Life-Threatening Behavior, 29, 10-24.[Medline]
Kennedy, P., Rogers, B., Speer, S., et al (1999) Spinal cord injuries and attempted suicide: a retrospective review. Spinal Cord, 37, 847-852.[CrossRef][Medline]
Leon, A. C., Keller, M. B., Warshaw, M. G., et al
(1999) Prospective study of fluoxetine treatment and suicidal
behaviour in affectively ill subjects. American Journal of
Psychiatry, 156,
195-201.
Liberman, R. P. & Eckman, T. (1981) Behaviour therapy vs insight-oriented therapy for repeated suicide attempters. Archives of General Psychiatry, 38, 1126-1130.[Abstract]
Linehan, M. M., Armstrong, H. E., Suarez, A., et al (1991) Cognitivebehavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.[Abstract]
Lonnqvist, J. & Karha, E. (1984) Suicide attempts in Helsinki. Psychiatria Fennica, 15, 135-145.
Lonnqvist, J., Niskanen, P., Achte, K. A., et al (1975) Self-poisoning with follow-up considerations. Suicide, 5, 39-46.[Medline]
Lonnqvist, J. & Ostamo, A. (1991) Suicide following the first suicide attempt: a five year follow-up using a survival analysis. Psychiatria Fennica, 22, 171-179.
McEvedy, C. J. (1997) Trends in self-poisoning: admissions to a central London hospital, 1991-1994. Journal of the Royal Society of Medicine, 90, 496-498.[Abstract]
McFarland, B. H. & Beavers, D. J. (1986) Psychiatric consultation following attempted suicide. Journal of the American Osteopathic Association, 86, 743-750.[Medline]
McLeavey, B. C., Daly, R. J., Ludgate, J. W., et al (1994) Interpersonal problem-solving skills training in the treatment of self-poisoning patients. Suicide and Life-Threatening Behavior, 24, 382-394.[Medline]
Moller, H. (1989) Efficacy of different strategies of aftercare for patients who have attempted suicide. Journal of the Royal Society of Medicine, 82, 643-647.[Medline]
Morgan, H. G., Barton, J., Pottle, S., et al (1976) Deliberate self-harm: a follow-up study of 279 patients. British Journal of Psychiatry, 128, 361-368.[Abstract]
Morgan, H. G., Jones, E. M. & Owen, J. H. (1993) Secondary prevention of non-fatal deliberate self-harm: the Green Card Study. British Journal of Psychiatry, 163, 111-112.[Abstract]
Muller-Oerlinghausen, B., Muser-Causemann, B. & Volk, J. (1992) Suicides and parasuicides in a high-risk patient group on and off lithium long-term medication. Journal of Affective Disorders, 25, 261-270.[CrossRef][Medline]
Nielsen, B., Wang, A. G. & Bille-Brahe, U. (1990) Attempted suicide in Denmark (IV). A five-year follow-up. Acta Psychiatrica Scandinavica, 81, 250-254.[Medline]
Nordentoft, M., Breum, L., Munck, L. K., et al (1993) High mortality by natural and unnatural causes: a 10 year follow up study of patients admitted to a poisoning treatment centre after suicide attempts. BMJ, 306, 1637-1641.[Medline]
Nordstrom, P., Samuelsson, M. & Asberg, M. (1995) Survival analysis of suicide risk after attempted suicide. Acta Psychiatrica Scandinavica, 91, 336-340.[Medline]
Ojehagen, A., Regnell, G. & Traskman-Bendz, L. (1991) Deliberate self-poisoning: repeaters and nonrepeaters admitted to an intensive care unit. Acta Psychiatrica Scandinavica, 84, 266-271.[Medline]
Ojehagen, A., Danielsson, M. & Traskman-Bendz, L. (1992) Deliberate self-poisoning: treatment follow-up of repeaters and nonrepeaters. Acta Psychiatrica Scandinavica, 85, 370-375.[Medline]
Owens, D., Dennis, M., Jones, S., et al (1991) Self-poisoning patients discharged from accident and emergency: risk factors and outcome. Journal of the Royal College of Physicians of London, 25, 218-222.[Medline]
Paerregaard, G. (1975) Suicide among attempted suicides: a 10-year follow-up. Suicide, 5, 140-144.[Medline]
Pallis, D. J., Gibbons, J. S. & Pierce, D. W. (1984) Estimating suicide risk among attempted suicides. II. Efficiency of predictive scales after the attempt. British Journal of Psychiatry, 144, 139-148.[Abstract]
Palsson, S. P., Jonsdottir, G. & Petursson, H. (1996) The mortality risk of psychiatric emergency patients. A follow-up study. Nordic Journal of Psychiatry, 50, 207-216.
Pederson, A. M., Awad, G. A. & Kindler, A. R. (1973) Epidemiological differences between white and nonwhite suicide attempters. American Journal of Psychiatry, 130, 1071-1076.[Medline]
Pierce, D. W. (1981) The predictive validation of a suicide intent scale: a five year follow-up. British Journal of Psychiatry, 139, 391-396.[Abstract]
Pierce, D. W. (1984) Suicidal intent and repeated self-harm. Psychological Medicine, 14, 655-659.[Medline]
Rodger, C. R. & Scott, A. I. (1995) Frequent deliberate self-harm: repetition, suicide and cost after three or more years. Scottish Medical Journal, 40, 10-12.[Medline]
Rosen, D. H. (1970) The serious suicide attempt: epidemiological and follow-up study of 886 patients. American Journal of Psychiatry, 127, 764-770.[Medline]
Rosenman, S. J. (1983) Subsequent deaths after attempted suicide by drug overdose in the western region of Adelaide, 1976. Medical Journal of Australia, 2, 496-499.[Medline]
Ruchholtz, S., Pajonk, F. G., Waydhas, C., et al (1999) Long-term results and quality of life after parasuicidal multiple blunt trauma. Critical Care Medicine, 27, 522-530.[Medline]
Rygnestad, T. K. (1982) Prospective study of social and psychiatric aspects in self-poisoned patients. Acta Psychiatrica Scandinavica, 66, 139-153.[Medline]
Rygnestad, T. K. (1988) A prospective 5-year follow-up study of self-poisoned patients. Acta Psychiatrica Scandinavica, 77, 328-331.[Medline]
Sakinofsky, I., Roberts, R. S., Brown, Y., et al (1990) Problem resolution and repetition of parasuicide. A prospective study. British Journal of Psychiatry, 156, 395-399.[Abstract]
Salander Renberg, E. E. (1999) Parasuicide in a northern Swedish county 1989-1995 and its relation to suicide. Archives of Suicide Research, 5, 97-112.[CrossRef]
Salkovskis, P. M., Atha, C. & Storer, D. (1990) Cognitivebehavioural problem solving in the treatment of patients who repeatedly attempt suicide. A controlled trial. British Journal of Psychiatry, 157, 871-876.[Abstract]
Schmidtke, A., Bille-Brahe, U., DeLeo, D., et al (1996) Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989-1992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatrica Scandinavica, 93, 327-338.[Medline]
Siani, R., Garzotto, N., Tansella, C. Z., et al (1979) Predictive scales for parasuicide repetition. Further results. Acta Psychiatrica Scandinavica, 59, 17-23.[Medline]
Steer, R. A., Beck, A. T., Garrison, B., et al (1988) Eventual suicide in interrupted and uninterrupted attempters: a challenge to the cry-for-help hypothesis. Suicide and Life-Threatening Behavior, 18, 119-128.[Medline]
Stocks, R. & Scott, A. I. F. (1991) What happens to patients who frequently harm themselves? A retrospective one-year outcome study. British Journal of Psychiatry, 158, 375-378.[Abstract]
Sundqvist-Stensman, U. (1988) Suicides among persons treated for self-poisoning at an ICU. Opuscula Medica, 33, 71-76.
Suokas, J. & Lonnqvist, J. (1991) Outcome of attempted suicide and psychiatric consultation: risk factors and suicide mortality during a five-year follow-up. Acta Psychiatrica Scandinavica, 84, 545-549.[Medline]
Taylor, S. (1998) Training and supervision of deliberate self-harm assessments. Psychiatric Bulletin, 22, 510-512.
Tejedor, M. C., Diaz, A., Castillon, J. J., et al (1999) Attempted suicide: repetition and survival findings of a follow-up study. Acta Psychiatrica Scandinavica, 100, 205-211.[Medline]
Thies-Flechtner, K., Muller-Oerlinghausen, B., Seibert, W., et al (1996) Effect of prophylactic treatment on suicide risk in patients with major affective disorders data from a randomized prospective trial. Pharmacopsychiatry, 29, 103-107.[Medline]
Torhorst, A., Moller, H. J., Kurz, A., et al (1988) Comparing a 3-month and a 12-month outpatient aftercare program for parasuicide repeaters. In Current Issues of Suicidology (eds H. J. Moller, A. Schmidtke & R. Welz), pp. 419-424. Berlin: Springer-Verlag.
Van der Sande, R., Van Rooijen, L., Buskens, E., et al (1997) Intensive in-patient and community intervention versus routine care after attempted suicide. A randomised controlled intervention study. British Journal of Psychiatry, 171, 35-41.[Abstract]
Van Heeringen, C., Jannes, S., Buylaert, W., et al (1995) The management of non-compliance with referral to out-patient after-care among attempted suicide patients: a controlled intervention study. Psychological Medicine, 25, 963-970.[Medline]
Verkes, R. J., Van der Mast, R. C., Hengeveld, M. W., et
al (1998) Reduction by paroxetine of suicidal behavior
in patients with repeated suicide attempts but not major depression.
American Journal of Psychiatry,
155,
543-547.
Wilkinson, G. & Smeeton, N. (1987) The repetition of parasuicide in Edinburgh 1980-1981. Social Psychiatry, 22, 14-19.[Medline]
Department of Health (1999) A National Service Framework for Mental Health. London: Department of Health.
Egger, M., Schneider, M. & Davey-Smith, G.
(1998) Spurious precision? Meta-analysis of observational
studies. BMJ, 316,
140-144.
Gardner, M. J., Gardner, S. B. & Winter, P. D. (1989) Confidence Interval Analysis (computer program). London: BMJ.
Geddes, J. (1999) Suicide and homicide by
people with mental illness. BMJ,
318,
1225-1226.
Gunnell, D. & Frankel, S. (1994) Prevention
of suicide: aspirations and evidence. BMJ,
308,
1227-1233.
Hawton, K., Fagg, J., Simkin, S., et al (1997) Trends in deliberate self-harm in Oxford, 1985-1995. Implications for clinical services and the prevention of suicide. British Journal of Psychiatry, 171, 556-560.[Abstract]
Hawton, K., Arensman, E., Townsend, E., et al
(1998) Deliberate self-harm: systematic review of the
efficacy of psychosocial and pharmacological treatments in preventing
repetition. BMJ, 317,
441-447.
Hawton, K., Townsend, E., Arensman, E., et al (2001) Psychosocial and pharmacological treatments for deliberate self harm. The Cochrane Library, issue 2. Oxford: Update Software.
Kapur, N., House, A., Creed, F., et al
(1998) Management of deliberate self poisoning in adults in
four teaching hospitals: descriptive study. BMJ,
316,
831-832.
NHS Centre for Reviews and Dissemination (1998) Deliberate self-harm. Effective Health Care, 4, December.
Owens, D. (1990) Self-harm patients not admitted to hospital. Journal of the Royal College of Physicians of London, 24, 281-283.[Medline]
Owens, D. & House, A. (1994) General hospital services for deliberate self-harm. Journal of the Royal College of Physicians of London, 28, 370-371.[Medline]
Rose, G. (1992) The Strategy of Preventive Medicine. Oxford: Oxford University Press.
Secretary of State for Health (1999) Saving Lives. Our Healthier Nation. London: Stationery Office.
Vastag, B. (2001) Suicide prevention plan calls
for physicians' help. Journal of the American Medical
Association, 285,
2701-2703.
Received for publication November 13, 2001. Revision received March 12, 2002. Accepted for publication March 19, 2002.
Related articles in BJP: