Suicide following presentation to hospital for non-fatal self-harm in the Multicentre Study of Self-harm: a long-term follow-up study


Suicide following presentation to hospital for non-fatal self-harm in the Multicentre Study of Self-harm: a long-term follow-up study


Summary

Background

Self-harm is the strongest risk factor for subsequent suicide, but risk may vary.
We compared the risk of suicide following hospital presentation for self-harm according
to patient characteristics, method of self-harm, and variations in area-level socioeconomic
deprivation, and estimated the incidence of suicide by time after hospital attendance.

Methods

In this ongoing Multicentre Study of Self-harm in England, the study population consists
of individuals aged at least 15 years who had attended the emergency department of
five general hospitals in Oxford, Manchester, and Derby after non-fatal self-harm
between Jan 1, 2000, and Dec 31, 2013. Information on method of self-harm was obtained
through systematic monitoring in hospitals. Level of socioeconomic deprivation was
based on the Index of Multiple Deprivation (IMD) characterising the area where patients
lived, grouping them according to IMD quintiles. Mortality follow-up was up to Dec
31, 2015, resulting in up to 16 years of follow-up. We calculated incidence of suicide
since first hospital presentation by follow-up period and estimated the association
between individual factors (age, gender, method of self-harm, IMD, and number of non-fatal
self-harm presentations to hospital) and suicide using mixed-effect models.

Findings

Between Jan 1, 2000, and Dec 31, 2013, there were 92 177 presentations to the study
hospitals by 51 108 individuals. 1325 patients involved in 1563 self-harm episodes
were excluded from the study because they had missing information on gender, age,
or mortality. The resulting study sample consisted of 90 614 hospital presentations
by 49 783 individuals. By the end of follow-up on Dec 31, 2015, 703 patients had died
by suicide. The overall incidence of suicide was 163·1 (95% CI 151·5–175·6) per 100 000
person-years, and 260·0 (237·4–284·8) per 100 000 person-years in men and 94·6 (83·3–107·4)
per 100 000 person-years in women. The incidence of suicide was highest in the year
following discharge from hospital (511·1 [451·7–578·2] per 100 000 person-years),
particularly in the first month (1787·1 [1423·0–2244·4] per 100 000 person-years).
Based on all presentations to hospital, men were three times more likely than women
to die by suicide after self-harm (OR 3·36 [95% CI 2·77–4·08], p<0·0001). Age was positively related to suicide risk in both genders, with a 3% increase in risk for every one-year increase in age at hospital presentation (OR 1·03 [1·03–1·04], p<0·0001). Relative to hospital presentations after self-poisoning alone, presentations involving both self-injury and self-poisoning were associated with higher suicide risk (adjusted OR 2·06 [95% CI 1·42–2·99], p<0·0001], as were presentations after self-injury alone (adjusted OR 1·36 [1·09–1·70], p=0·007). Similarly, relative to self-harm by self-poisoning alone, attempted hanging or asphyxiation (adjusted OR 2·70 [1·53–4·78], p=0·001) and traffic-related acts of self-injury (adjusted OR 2·99 [1·17–7·65], p=0·022) were associated with greater risk of suicide. Self-cutting combined with self-poisoning was also associated with increased suicide risk (adjusted OR 1·36, [1·08–1·71], p=0·01). Compared with those patients living in the most deprived areas, those who lived in the least deprived areas (first national IMD quintile) had a greater risk of dying by suicide (adjusted OR 1·76 [1·32–2·34], p<0·0001) after adjusting for gender, age, previous self-harm, and psychiatric treatment, as did those living in the second least deprived areas (adjusted OR 1·64 [1·20–2·25], p=0·002).

Interpretation

Patients attending hospital for self-harm are at high risk of suicide, especially
immediately after hospital attendance. Certain patient characteristics and methods
of self-harm, together with living in areas of low socioeconomic deprivation, can
increase patients’ subsequent suicide risk. However, while specific risk factors can
be usefully integrated into the assessment process, individual factors have poor utility
in predicting suicide, so the needs and risks of all patients should be assessed to
develop appropriate aftercare plan, including early follow-up.

Funding

UK Department of Health and Social Care.

To read this article in full you will need to make a payment

References

  1. 1.
    • Hawton K
    • Bergen H
    • Casey D
    • et al.

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

    Soc Psychiatry Psychiatr Epidemiol. 2007; 42: 513-521

  2. 2.
    • National Institute for Health and Care Excellence

    Self-harm in over 8s: long-term management.

  3. 3.
    • Carroll R
    • Metcalfe C
    • Gunnell D

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

    PLoS One. 2014; 9e89944

  4. 4.
    • Foster T
    • Gillespie K
    • McClelland R

    Mental disorders and suicide in Northern Ireland.

    Br J Psychiatry. 1997; 170: 447-452

  5. 5.
    • Gairin I
    • House A
    • Owens D

    Attendance at the accident and emergency department in the year before suicide: retrospective study.

    Br J Psychiatry. 2003; 183: 28-33

  6. 6.
    • Runeson B
    • Haglund A
    • Lichtenstein P
    • Tidemalm D

    Suicide risk after nonfatal self-harm: a national cohort study, 2000–2008.

    J Clin Psychiatry. 2016; 77: 240-246

  7. 7.
    • Fedyszyn IE
    • Erlangsen A
    • Hjorthøj C
    • Madsen T
    • Nordentoft M

    Repeated suicide attempts and suicide among individuals with a first emergency department contact for attempted suicide: a prospective, nationwide, Danish register-based study.

    J Clin Psychiatry. 2016; 77: 832-840

  8. 8.
    • Kuo CJ
    • Gunnell D
    • Chen CC
    • Yip PS
    • Chen YY

    Suicide and non-suicide mortality after self-harm in Taipei City, Taiwan.

    Br J Psychiatry. 2012; 200: 405-411

  9. 9.
    • Bergen H
    • Hawton K
    • Waters K
    • et al.

    How do methods of recent non-fatal self-harm relate to eventual suicide?.

    J Affect Disord. 2012; 136: 526-533

  10. 10.
    • Olfson M
    • Wall M
    • Wang S
    • Crystal S
    • Gerhard T
    • Blanco C

    Suicide following deliberate self-harm.

    Am J Psychiatry. 2017; 174: 765-774

  11. 11.
    • Hawton K
    • Bergen H
    • Cooper J
    • et al.

    Suicide following self-harm: findings from the Multicentre Study of Self-harm in England, 2000–2012.

    J Affect Disord. 2015; 175: 147-151

  12. 12.
    • Mitchell RJ
    • Cameron CM

    Self-harm hospitalised morbidity and mortality risk using a matched population-based cohort design.

    Aust N Z J Psychiatry. 2018; 52: 262-270

  13. 13.
    • Zahl D
    • Hawton K

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

    Br J Psychiatry. 2004; 185: 70-75

  14. 14.
    • Da Cruz D
    • Pearson A
    • Saini P
    • et al.

    Emergency department contact prior to suicide in mental health patients.

    Emerg Med J. 2011; 28: 467-471

  15. 15.
    • Owens D
    • Kelley R
    • Munyombwe T
    • et al.

    Switching methods of self-harm at repeat episodes: findings from a multicentre cohort study.

    J Affect Disord. 2015; 180: 44-51

  16. 16.
    • Cairns JM
    • Graham E
    • Bambra C

    Area-level socioeconomic disadvantage and suicidal behaviour in europe: a systematic review.

    Soc Sci Med. 2017; 192: 102-111

  17. 17.
    • Hawton K
    • Harriss L
    • Hall S
    • Simkin S
    • Bale E
    • Bond A

    Deliberate self-harm in Oxford, 1990–2000: a time of change in patient characteristics.

    Psychol Med. 2003; 33: 987-996

  18. 18.
    • Ministry of Housing
    • Communities & Local Government

    National Statistics: English indices of deprivation 2015.

  19. 19.
    • Office for National Statistics

    Suicides in the United Kingdom, 2013 registrations.

  20. 20.
    • Runeson B
    • Tidemalm D
    • Dahlin M
    • Lichtenstein P
    • Långström N

    Method of attempted suicide as predictor of subsequent successful suicide: national long term cohort study.

    BMJ. 2010; 341c3222

  21. 21.
    • Office for National Statistics

    Dataset: suicides in the UK.

  22. 22.
    • Office for National Statistics

    Dataset: estimates of the population for the UK, England and Wales, Scotland and Northern Ireland.

  23. 23.
    • Huber CG
    • Schneeberger AR
    • Kowalinski E
    • et al.

    Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study.

    Lancet Psychiatry. 2016; 3: 842-849

  24. 24.
    • Rudd MD
    • Berman AL
    • Joiner Jr, TE
    • et al.

    Warning signs for suicide: theory, research, and clinical applications.

    Suicide Life Threat Behav. 2006; 36: 255-262

  25. 25.
    • Chen VC
    • Tan HK
    • Chen CY
    • et al.

    Mortality and suicide after self-harm: community cohort study in Taiwan.

    Br J Psychiatry. 2011; 198: 31-36

  26. 26.
    • Haw C
    • Casey D
    • Holmes J
    • Hawton K

    Suicidal intent and method of self-harm: a large-scale study of self-harm patients presenting to a general hospital.

    Suicide Life Threat Behav. 2015; 45: 732-746

  27. 27.
    • Kapur N
    • Murphy E
    • Cooper J
    • et al.

    Psychosocial assessment following self-harm: results from the multi-centre monitoring of self-harm project.

    J Affect Disord. 2008; 106: 285-293

  28. 28.
    • Carroll R
    • Knipe D
    • Moran P
    • Gunnell D

    Socioeconomic deprivation and the clinical management of self-harm: a small area analysis.

    Soc Psychiatry Psychiatr Epidemiol. 2017; 52: 1475-1481

  29. 29.
    • Martin JL
    • McLean G
    • Park J
    • et al.

    Impact of socioeconomic deprivation on rate and cause of death in severe mental illness.

    BMC Psychiatry. 2014; 14: 261

  30. 30.
    • Townsend E
    • Ness J
    • Waters K
    • et al.

    Self-harm and life problems: findings from the Multicentre Study of Self-harm in England.

    Soc Psychiatry Psychiatr Epidemiol. 2016; 51: 183-192

  31. 31.
    • Hawton K
    • Harriss L
    • Hodder K
    • Simkin S
    • Gunnell D

    The influence of the economic and social environment on deliberate self-harm and suicide: an ecological and person-based study.

    Psychol Med. 2001; 31: 827-836

  32. 32.
    • Neeleman J
    • Wessely S

    Ethnic minority suicide: a small area geographical study in south London.

    Psychol Med. 1999; 29: 429-436

  33. 33.
    • The Lancet Psychiatry

    Smorgasbord or Smaug’s hoard?.

    Lancet Psychiatry. 2019; 6: 631

  34. 34.
    • National Institute for Health and Care Excellence

    Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care.

    British Psychological Society,
    Leicester (UK)2004 ()

  35. 35.
    • Vuagnat A
    • Jollant F
    • Abbar M
    • Hawton K
    • Quantin C

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

    Epidemiol Psychiatr Sci. 2019; ()

  36. 36.
    • Stanley B
    • Brown GK
    • Brenner LA
    • et al.

    Comparison of the safety planning intervention with follow-up vs usual care of suicidal patients treated in the emergency department.

    JAMA Psychiatry. 2018; 75: 894-900

Article Info

Publication History

Published: November 06, 2019

Identification

DOI: https://doi.org/10.1016/S2215-0366(19)30402-X

Copyright

© 2019 Elsevier Ltd. All rights reserved.

ScienceDirect

Access this article on ScienceDirect

Linked Articles

No Comment

Leave a reply

Your email address will not be published. Required fields are marked *