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

Bergen, Helen A.; Hawton, Keith; Kapur, Navneet; Cooper, Jayne; Steeg, Sarah; Ness, Jennifer; Waters, Keith

doi:10.1017/s0033291711001747

Cited by 54 publications

(50 citation statements)

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“…The Multicentre Study of Self-harm in England, conducted in the cities of Derby, Manchester, and Oxford, reported on the shared characteristics and similarity of risk factors for suicide and accidental death after self-harm. 41 It is therefore noteworthy that, in our study, risk of accidental death was also greatly elevated in the self-harm cohort. …”

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confidence: 42%

“…Our proportional hazards assumption testing 35 revealed that such data pooling may yield invalid estimates averaged across the whole duration of follow-up if the degree of risk elevation is substantially greater during the first year. Few investigations have reported relative risk restricted to the first follow-up year; 2 Taiwanese studies (1 conducted in Nantou County 41 and the other in Taipei City 11 ) found age-and sex-adjusted elevations of risk by 100-fold or more. The Multicentre Study of Self-harm in England, conducted in the cities of Derby, Manchester, and Oxford, reported on the shared characteristics and similarity of risk factors for suicide and accidental death after self-harm.…”

Section: Comparison With Existing Evidencementioning

confidence: 99%

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Premature Death Among Primary Care Patients With a History of Self-Harm

et al. 2017

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PURPOSE Self-harm is a public health problem that requires a better understanding of mortality risk. We undertook a study to examine premature mortality in a nationally representative cohort of primary care patients who had harmed themselves. During 2001During -2013, a total of 385 general practices in England contributed data to the Clinical Practice Research Datalink with linkage to Office for National Statistics mortality records. We identified 30,017 persons aged 15 to 64 years with a recorded episode of self-harm. We estimated the relative risks of all-cause and cause-specific natural and unnatural mortality using a comparison cohort of 600,258 individuals matched on age, sex, and general practice. METHODS RESULTSWe found an elevated risk of dying prematurely from any cause among the self-harm cohort, especially in the first year of follow-up (adjusted hazard ratio for that year, 3.6; 95% CI, 3.1-4.2). In particular, suicide risk was especially high during the first year (adjusted hazard ratio, 54.4; 95% CI, 34.3-86.3); although it declined sharply, it remained much higher than that in the comparison cohort. Large elevations of risk throughout the follow-up period were also observed for accidental, alcohol-related, and drug poisoning deaths. At 10 years of follow-up, cumulative incidence values were 6.5% (95% CI, 6.0%-7.1%) for allcause mortality and 1.3% (95% CI, 1.2%-1.5%) for suicide.CONCLUSIONS Primary care patients who have harmed themselves are at greatly increased risk of dying prematurely by natural and unnatural causes, and especially within a year of a first episode. These individuals visit clinicians at a relatively high frequency, which presents a clear opportunity for preventive action. Primary care patients with myriad comorbidities, including self-harming behavior, mental disorder, addictions, and physical illnesses, will require concerted, multipronged, multidisciplinary collaborative care approaches. Ann Fam Med 2017;15:246-254. https://doi.org/10.1370/afm.2054. INTRODUCTIONS elf-harm is a major public health problem. Deprived populations have a higher incidence of self-harm, 1 and national incidence rates have risen in the wake of the economic downturn and subsequent austerity era.2 A greatly reduced life expectancy and an elevated risk of early death have been reported among people who seek care at hospitals after self-harm in Australia, 3 (Self-Harm: Longer-Term Management, 2011), and was Chair of the NICE Self-harm, Quality Standard Topic Expert Group (2013) For the study reported here, we used electronic health data linked to national mortality records to investigate the risk of dying prematurely after selfharm in a large primary care cohort in England. By examining deaths from both unnatural and natural causes, our intention was to highlight the potential clinical and public health benefits of addressing the physical health as well as the psychosocial needs of these patients. We currently know very little about long-term mortality risk in this population because researcher...

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confidence: 42%

Section: Comparison With Existing Evidencementioning

confidence: 99%

Premature Death Among Primary Care Patients With a History of Self-Harm

et al. 2017

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“…A study in Nottingham, England that followed up for 16 years a thousand people who had self-poisoned showed a higher suicide rate among those who had also cut themselves at the same episode (Owens et al, 2005). Multicentre monitoring of thirty thousand people who had self-harmed in three English cities found greater than doubling of suicide risk in people who had combined self-poisoning and self-injury compared with those who had selfpoisoned only (Bergen et al, 2012b). Monitoring in Oxford has examined the relation between Suicide Intent Scale (SIS) scores and method of non-fatal self-harm, showing high median SIS scores among patients whose attendance at hospital was due to combined self-poisoning and self-injury higher median scores than found in those who had self-poisoned only or self-injured only .…”

Section: Combined Methods Of Self-harm and Fatal And Non-fatal Repetimentioning

confidence: 99%

“…The present study is not large enough to have examined rare lethal events and they have been amalgamated here with a range of non-cutting injuries, many of which are not physically severe. Whether self-cutting is a risk for later suicide is not wholly clear in the literature, although there are recent UK studies that point to such a risk (Cooper et al, 2005;Bergen et al, 2012a;Bergen et al, 2012b). Inconsistent findings concerning suicide after self-cutting may well be tied up with sampling differences (Bergen et al, 2012a), with some follow-up cohorts based on hospital-admitted rather than ED cases, with cutting much less likely than is poisoning, or injuries other than cutting, to have led to admission (Christiansen and Jensen, 2007;Runeson et al, 2010).…”

Section: Self-injury and Suicidementioning

confidence: 99%

“…Monitoring studies in the UK and in Ireland (Lilley et al, 2008;Perry et al, 2012) have found high non-fatal repetition rates among those attending because of combined poisoning and injury, and two studies have pointed to a high long-term risk of suicide (Owens et al, 2005;Bergen et al 2012b). Non-fatal repetition has been observed too to have an association with suicide (Zahl and Hawton, 2004;Haw et al, 2007;Bergen et al, 2012a).…”

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confidence: 99%

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Combination of self-harm methods and fatal and non-fatal repetition: A cohort study

Birtwistle

Kelley

House

et al. 2017

Journal of Affective Disorders

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Self-harm, Traumatic Brain Injury, and Suicide—Reply

Madsen

Nordentoft

Benros

2018

JAMA

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In participants with high depressive symptoms or taking antidepressants, the absolute rate of dementia was 1.91 (95% CI, 1.62-2.20) per 100 person-years compared with 1.21 (95% CI, 1.11-1.31) per 100 person-years in participants without depression (absolute rate difference, 0.70 [95% CI, 0.55-0.86] per 100 person-years).Depression could affect the relationship between cardiovascular health and dementia in 2 ways. It could represent a confounding factor, so that failure to control for depression may lead to a biased association of cardiovascular health level with dementia. Depression could also serve as a modification factor, exerting a synergistic effect with poor cardiovascular health on dementia risk. However, we did not find evidence that depressive symptomatology or antidepressant use either confounded or modified that relationship. The multivariate association between the number of metrics at optimal level and dementia was virtually unchanged after further controlling for history of treated depression, high depressive symptomatology, and antidepressant use at baseline (hazard ratio for 1 additional metric, 0.91; 95% CI, 0.84-0.97; P = .006). Findings were similar with the cardiovascular health score (hazard ratio for 1 point, 0.93; 95% CI, 0.89-0.97; P < .001). Similarly, when we included repeated measures of depressive symptomatology and antidepressant use during follow-up in the models, the results were unchanged. In addition, no significant interaction between cardiovascular health level exposures and either high depressive symptomatology or antidepressant use at baseline was found (P ≥ .59). Hence, the multivariate hazard ratio for dementia for each additional metric at optimal level was 0.91 (95% CI, 0.84-0.98) in participants without depressive symptoms or treatment (n = 5521) and 0.92 (95% CI, 0.79-1.08) in those with high depressive symptomatology or treatment use (n = 1105).In summary, depression did not confound nor modify the reported relationship between cardiovascular health level and dementia risk, although analyses may be underpowered to detect an interaction with depressive symptoms in this cohort. Nonetheless, given the strength of the associations between depression and both poorer cardiovascular health and dementia, strategies to detect and treat psychosocial risk factors in addition to poor cardiovascular health for the prevention of dementia deserve further evaluation.

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

Cited by 54 publications

References 44 publications

Premature Death Among Primary Care Patients With a History of Self-Harm

Premature Death Among Primary Care Patients With a History of Self-Harm

Combination of self-harm methods and fatal and non-fatal repetition: A cohort study

Self-harm, Traumatic Brain Injury, and Suicide—Reply

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