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Background: People who present to the emergency department with self-harm and co-occurring substance use problems often have difficulty accessing effective care. Aims: To develop a brief psychosocial intervention for this population, which would be suitable for testing in a future randomized controlled trial. Methods: A modified Delphi method was used. A 34-item, 3-round, online Delphi survey was informed by a literature review and stakeholder telephone discussions ( n = 17). Two panels consisting of people with lived experience (PWLE: n = 15) and people with occupational experience (PWOE: n = 21) participated in the survey. The threshold for consensus was a pooled agreement rate across the two panels of 80% or more. Results: Expert consensus was achieved for 22 items. The new intervention consists of weekly follow-up phone calls for up to 1 month, delivered by Liaison Psychiatry practitioners, in which both self-harm and substance use problems are explored and addressed, and patients are supported in accessing community services. Limitations: Some stakeholder ideas regarding intervention components could not be included as survey options due to anticipated difficulties with implementation. Conclusions: The key elements of a brief psychosocial intervention for self-harm and co-occurring substance use problems have been agreed. Feasibility testing is currently underway.

Background: Travel distance to hospital emergency departments (EDs) may be a more influential factor in the spatial variation in hospital-presenting self-harm than for suicide deaths. Aims: We investigated the associations of travel distance to the nearest ED with self-harm hospital presentations and suicides in a large city in Taiwan. Method: Data for self-harm and suicide were extracted from Taiwan's National Suicide Surveillance System (2012-2016). Results: Adjusted analyses using Bayesian hierarchical models showed that a longer travel distance to the nearest hospital ED was associated with lower self-harm hospital presentation rates but not suicide rates. Limitations: This is an ecological study; the area-level associations could not be directly implied at the individual level. Conclusion: Living in remote neighborhoods could be a barrier to seeking medical help after self-harm, and this has implications for suicide, surveillance, prevention and intervention strategies.

Background : There is little information about characteristics and long-term outcomes of individuals who self-harm during a suicide cluster. Aims : To compare characteristics of individuals who self-harmed during a suicide cluster in South Wales (∼10 deaths between December 2007 and March 2008) with others who self-harmed prior to the cluster and to evaluate 10-year self-harm and mortality outcomes. Method : Using records from the hospital serving the catchment area of the suicide cluster, enhanced by national routinely collected linked data, we created the following two groups: individuals who self-harmed (a) during the suicide cluster and (b) 1 year before. We compared individuals' characteristics and performed logistic regression to compute odds ratios of 10-year self-harm and mortality outcomes. Results : Individuals who self-harmed during the cluster were less likely to be hospitalized or have a mental health history than those who self-harmed prior to the cluster. No significant group differences were found for 10-year self-harm outcomes, but all-cause mortality was higher for males. Limitations : Sample size was small, and data were lacking on psychological and social proximity to individuals who died during the suicide cluster. Conclusion : Our findings highlight the importance of long-term healthcare follow-up of those who self-harm during a suicide cluster, particularly males.

Background: Emergency departments are important points of intervention, to reduce the risk of further self-harm and suicide. A national programme to standardise the management of people presenting to the emergency department with self-harm and suicidal ideation (NCPSHI) was introduced in Ireland in 2014. The aim of this study was to evaluate the impact of the NCPSHI on patient outcomes and provision of care., Methods: Data on self-harm presentations were obtained from the National Self-Harm Registry Ireland from 2012 to 2017. The impacts of the NCPSHI on study outcomes (3-month self-harm repetition, biopsychosocial assessment provision, admission, post-discharge referral, and self-discharge) were examined at an individual and aggregate (hospital) level, using a before and after study design and interrupted time series analyses, respectively. The 15 hospitals that implemented the programme by January 2015 (of a total of 24 between 2015 and 2017) were included in the analyses., Results: There were 31,970 self-harm presentations during the study period. In hospitals with no service for self-harm (n = 4), risk of patients not being assessed reduced from 31.8 to 24.7% following the introduction of the NCPSHI. Mental health referral in this hospital group increased from 42.2 to 59.0% and medical admission decreased from 27.5 to 24.3%. Signs of a reduction in self-harm repetition were observed for this hospital group, from 35.1 to 30.4% among individuals with a history of self-harm, but statistical evidence was weak. In hospitals with a pre-existing liaison psychiatry service (n = 7), risk of self-discharge was lower post-NCPSHI (17.8% vs. 14.8%). In hospitals with liaison nurse(s) pre-NCPSHI (n = 4), medical admission reduced (27.5% vs. 24.3%) and there was an increase in self-harm repetition (from 5.2 to 7.8%. for those without a self-harm history)., Conclusion: The NCPSHI was associated with improvements in the provision of care across hospital groups, particularly those with no prior service for self-harm, highlighting the need to consider pre-existing context in implementation planning. Our evaluation emphasises the need for proper resourcing to support the implementation of clinical guidelines on the provision of care for people presenting to hospital with self-harm., (© 2023. The Author(s).)

Objective: Data from South Asia indicate that for 15%-20% of suicide attempts, pesticides are purchased from shops; otherwise, pesticides are obtained from an individual's house or nearby environment. We aimed to investigate the difference between individuals who directly purchase pesticides from shops for suicide attempts and suicide deaths versus those related to accessing the pesticides from an individual's house or nearby environment., Methods: We conducted two comparative studies in rural Sri Lanka: (1) non-fatal shop cases (n = 50) were survivors of self-poisoning with pesticides who ingested the pesticides after purchasing them from a shop; non-fatal domestic cases (n = 192) were survivors who accessed pesticides from their house or nearby environment. (2) fatal shop cases (n = 50) were individuals who died after ingesting pesticides they purchased for the act; fatal domestic cases (n = 102) were patients who died after ingesting pesticides they accessed at house or nearby environment. Logistic regression analysis was used to assess the characteristics which distinguished between the shop and domestic cases., Results: Data indicate that 20.7% and 32.9% of individuals who used pesticides for suicide attempts and suicide deaths had purchased them from shops, respectively. Being a non-farmer was the main distinguishing characteristic of shop cases: adjusted odds ratios (AOR) 8.9, 95% confidence intervals (CI) 3.2-24.4 for non-fatal shop cases, and AOR 4.0, 95% CI 1.5-10.6 for fatal shop cases. Non-fatal shop cases also had higher suicide intent (AOR 3.0, CI 1.0-8.9), and ingesting an insecticide (AOR 4.8, CI 1.8-1.0-8.9) than non-fatal domestic cases., Conclusion: A high suicide intent of individuals who purchase pesticides for the event explains the high proportion of such fatal cases. Such high suicide intent makes the prevention implications difficult to spell out for those individuals who purchase pesticides for self-poisoning. However, our findings are valuable for clinicians to assess pesticide poisoning cases in hospitals., (© 2023 John Wiley & Sons Ltd.)

Aims: Suicidal acts may cluster in time and space and lead to community concerns about further imitative suicidal episodes. Although suicide clusters have been researched in previous studies, less is known about the clustering of non-fatal suicidal behaviour (self-harm). Furthermore, most previous studies used crude temporal and spatial information, e.g., numbers aggregated by month and residence area, for cluster detection analysis. This study aimed to (i) identify space-time clusters of self-harm and suicide using daily incidence data and exact address and (ii) investigate the characteristics of cluster-related suicidal acts., Methods: Data on emergency department presentations for self-harm and suicide deaths in Taipei City and New Taipei City, Taiwan, were used in this study. In all-age and age-specific analyses, self-harm and suicide clusters were identified using space-time permutation scan statistics. A cut-off of 0.10 for the p value was used to identify possible clusters. Logistic regression was used to investigate the characteristics associated with cluster-related episodes., Results: A total of 5,291 self-harm episodes and 1,406 suicides in Taipei City (2004-2006) and 20,531 self-harm episodes and 2,329 suicides in New Taipei City (2012-2016) were included in the analysis. In the two cities, two self-harm clusters ( n [number of self-harm episodes or suicide deaths in the cluster] = 4 and 8 in Taipei City), four suicide clusters ( n  = 3 in Taipei City and n  = 4, 11 and 4 in New Taipei City) and two self-harm and suicide combined clusters ( n  = 4 in Taipei City and n  = 8 in New Taipei City) were identified. Space-time clusters of self-harm, suicide, and self-harm and suicide combined accounted for 0.05%, 0.59%, and 0.08% of the respective groups of suicidal acts. Cluster-related episodes of self-harm and suicide were more likely to be male (adjusted odds ratio [aOR] = 2.22, 95% confidence interval [CI] 1.26, 3.89) and young people aged 10-29 years (aOR = 2.72, 95% CI 1.43, 5.21) than their cluster-unrelated counterparts., Conclusions: Space-time clusters of self-harm, suicide, and self-harm and suicide combined accounted for a relatively small proportion of suicidal acts and were associated with some sex/age characteristics. Focusing on suicide deaths alone may underestimate the size of some clusters and/or lead to some clusters being overlooked. Future research could consider combining self-harm and suicide data and use social connection information to investigate possible clusters of suicidal acts.

Background: Emotional dysregulation may be a risk factor for disordered eating and self-harm in young people, but few prospective studies have assessed these associations long-term, or considered potential mediators. We examined prospective relationships between childhood emotional dysregulation and disordered eating and self-harm in adolescence; and social cognition, emotional recognition, and being bullied as mediators., Methods: We analysed Avon Longitudinal Study of Parents and Children data on 3,453 males and 3,481 females. We examined associations between emotional dysregulation at 7 years and any disordered eating and any self-harm at 16 years with probit regression models. We also assessed whether social cognition (7 years), emotional recognition (8 years) and bullying victimisation (11 years) mediated these relationships., Results: Emotional dysregulation at age 7 years was associated with disordered eating [fully adjusted probit B (95% CI) = 0.082 (0.029, 0.134)] and self-harm [fully adjusted probit B (95% CI) = 0.093 (0.036, 0.150)] at age 16 years. There was no evidence of sex interactions or difference in effects between self-harm and disordered eating. Mediation models found social cognition was a key pathway to disordered eating (females 51.2%; males 27.0% of total effect) and self-harm (females 15.7%; males 10.8% of total effect). Bullying victimisation was an important pathway to disordered eating (females 17.1%; males 10.0% of total effect), but only to self-harm in females (15.7% of total effect). Indirect effects were stronger for disordered eating than self-harm., Conclusions: In males and females, emotional dysregulation in early childhood is associated with disordered eating and self-harm in adolescence and may be a useful target for prevention and treatment. Mediating pathways appeared to differ by sex and outcome, but social cognition was a key mediating pathway for both disordered eating and self-harm., (© 2022 The Authors. Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.)

Suicide is preventable, yet, in many settings, robust suicide prevention strategies have not been implemented. Although a commercial determinants of health lens is increasingly being applied to industries important to the field of suicide prevention, the interplay between the vested interests of commercial actors and suicide has received little attention. There is a need to shift attention to the causes of the causes, directing more focus to the ways that commercial determinants influence suicide and shape suicide prevention strategies. Such a shift in perspective, with an evidence base and precedents to draw upon, has transformative potential for research and policy agendas dedicated to understanding and addressing upstream modifiable determinants of suicide and self-harm. We propose a framework intended to help guide efforts to conceptualise, research, and address the commercial determinants of suicide and their inequitable distribution. We hope these ideas and lines of inquiry help to catalyse connections between disciplines and open further debate and discussion as to how to take such an agenda forward., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective: The COVID-19 pandemic has had a complex impact on risks of suicide and non-fatal self-harm worldwide with some evidence of increased risk in specific populations including women, young people, and people from ethnic minority backgrounds. This review aims to systematically address whether SARS-CoV-2 infection and/or COVID-19 disease confer elevated risk directly., Method: As part of a larger Living Systematic Review examining self-harm and suicide during the pandemic, automated daily searches using a broad list of keywords were performed on a comprehensive set of databases with data from relevant articles published between January 1, 2020 and July 18, 2021. Eligibility criteria for our present review included studies investigating suicide and/or self-harm in people infected with SARS-CoV-2 with or without manifestations of COVID-19 disease with a comparator group who did not have infection or disease. Suicidal and self-harm thoughts and behaviour (STBs) were outcomes of interest. Studies were excluded if they reported data for people who only had potential infection/disease without a confirmed exposure, clinical/molecular diagnosis or self-report of a positive SARS-CoV-2 test result. Studies of news reports, treatment studies, and ecological studies examining rates of both SARS-CoV-2 infections and suicide/self-harm rates across a region were also excluded., Results: We identified 12 studies examining STBs in nine distinct samples of people with SARS-CoV-2. These studies, which investigated STBs in the general population and in subpopulations, including healthcare workers, generally found positive associations between SARS-CoV-2 infection and/or COVID-19 disease and subsequent suicidal/self-harm thoughts and suicidal/self-harm behaviour., Conclusions: This review identified some evidence that infection with SARS-CoV-2 and/or COVID-19 disease may be associated with increased risks for suicidal and self-harm thoughts and behaviours but a causal link cannot be inferred. Further research with longer follow-up periods is required to confirm these findings and to establish whether these associations are causal.

Background: The first 4 weeks after initiation and cessation of opioid agonist treatment for opioid dependence are associated with an increased risk of all-cause mortality and overdose. We aimed to investigate whether the rate of self-harm and suicide among people who were prescribed opioid agonist treatment differs during initiation, cessation, and the remainder of time on and off treatment., Methods: We did a retrospective cohort study and used health-care records from UK Clinical Practice Research Datalink, linked to mortality and hospital admission data, for adults (age 18-75 years at cohort entry) who were prescribed opioid agonist treatment at least once in primary care in England between Jan 2, 1998, and Nov 30, 2018. We estimated rates and adjusted risk ratios (aRRs) of hospital admissions for self-harm and death by suicide, comparing time during and after treatment, as well as comparing stable periods of time on treatment with treatment initiation, cessation, and the remaining time off treatment., Findings: Between Jan 2, 1998, and Nov 30, 2018, 8070 patients (5594 [69·3%] men and 2476 [30·7%] women) received 17 004 episodes of opioid agonist treatment over 40 599 person-years. Patients were mostly of White ethnicity (7006 [86·8%] patients). 807 episodes of self-harm (1·99 per 100 person-years) and 46 suicides (0·11 per 100 person-years) occurred during the study period. The overall age-standardised and sex-standardised mortality ratio for suicide was 7·5 times (95% CI 5·5-10·0) higher in the study cohort than in the general population. Opioid agonist treatment was associated with a reduced risk of self-harm (aRR in periods off treatment 1·50 [95% CI 1·21-1·88]), but was not significantly associated with suicide risk (aRR in periods off treatment 1·21 [0·64-2·28]). Risk of self-harm (aRR 2·60 [95% CI 1·83-3·70]) and suicide (4·68 [1·63-13·42]) were both elevated in the first 4 weeks after stopping opioid agonist treatment compared with stable periods on treatment., Interpretation: Stable periods of opioid agonist treatment are associated with reduced risk of self-harm, emphasising the importance of improving retention of patients in treatment. The first month following cessation of opioid agonist treatment is a period of increased risk of suicide and self-harm, during which additional psychosocial support is required., Funding: Medical Research Council., Competing Interests: Declaration of interests LD reports investigator-initiated educational grant funding from Indivior, Mundipharma, Seqirus, and Reckitt Benckiser, outisde of the submitted work. MH reports speaker honoraria from MSD, Gillead, and Abbvie, outside of the submitted work. BW reports honoraria from and has been a member of an advisory board for Takeda, outside of the submitted work. DG is a member of England's National Suicide Prevention Strategy Advisory Group. PM was the chief investigator, and PP was a co-applicant, on a grant awarded to University of Bristol by Bristol and Weston Hospitals Charity (formerly known as Above & Beyond) focusing on suicide prevention for people presenting to the Emergency Department with self-harm and harmful substance use. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

There was a highly publicised cluster of at least ten suicides in South Wales, United Kingdom, in 2007-2008. We carried out a qualitative descriptive study using cross-case thematic analysis to investigate the experiences and narratives of eight individuals who lived in the area where the cluster occurred and who survived an episode of near-fatal self-harm at the time of the cluster. Interviews were conducted from 01.01.2015 to 31.12.2015. All interviewees denied that the other deaths in the area had affected their own suicidal behaviour. However, in other sections of the interviews they spoke about the cluster contributing to difficulties they were experiencing at the time, including damage to social relationships, feelings of loss and being out of control. When asked about support, the interviewees emphasized the importance of counselling, which they would have found helpful but in most cases did not receive, even in the case of close contacts of individuals who had died. The findings suggest that effective prevention messaging must be subtle, since those affected may not be explicitly aware of or acknowledge the imitative aspects of their behaviour. This could be related to stigma attached to suicidal behaviour in a cluster context. Lessons for prevention include changing the message from asking if people 'have been affected by' the suicide deaths to emphasising the preventability of suicide, and directly reaching out to individuals rather than relying on people to come forward., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: A National Clinical Programme for the Management of Hospital-Presenting Self-Harm (NCP-SH) was introduced in Ireland in 2014. This involved the development of a model of care to standardise the management of self-harm in emergency departments, to be delivered by dedicated clinical nurse specialists. The core components of the programme were to: ensure an empathic and timely response, conduct a biopsychosocial assessment, involve family members in assessment and discharge planning, and provide a bridge to next care. The overall aim of the programme was to reduce the rate of repeat self-harm. This multistage study will evaluate the impact of the NCP-SH on hospital-presenting self-harm and to identify determinants influencing its implementation., Methods: Employing a sequential mixed methods design, the first stage will use data from the National Self-Harm Registry Ireland to examine the impact of the NCP-SH on self-harm repetition, along with other aspects of care, including provision of psychosocial assessments and changes in admissions and postdischarge referrals. A cost-effectiveness analysis will assess the cost per repeat self-harm attendance avoided as a result of the NCP-SH. The second stage will identify the influences of implementation fidelity-adherence to the programme's core components-using a combination of document analysis and semistructured interviews with staff of the programme, guided by the Consolidated Framework for Implementation Research., Ethics and Dissemination: This study has received full ethical approval and will run until August 2023. This study is novel in that it will identify important factors influencing successful implementation of complex programmes. It is expected that the findings will provide important learnings for the integration of mental health services in general hospital settings and will be disseminated via peer-review publications along with reports for clinicians and policy-makers., Competing Interests: Competing interests: AJ was the Clinical Lead for the National Clinical Programme for the Assessment and Management of Patients presenting to the Emergency Department following Self-Harm (from 1 February 2017 to 31 May 2021)., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There is widespread concern over the impact of public health measures, such as lockdowns, associated with COVID-19 on mental health, including suicide. High-quality evidence from low-income and middle-income countries, where the burden of suicide and self-harm is greatest, is scarce. We aimed to determine the effect of the pandemic on hospital presentations for self-poisoning., Methods: In this interrupted time-series analysis, we established a new self-poisoning register at the tertiary care Teaching Hospital Peradeniya in Sri Lanka, a lower-middle-income country. Using a standard extraction sheet, data were gathered for all patients admitted to the Toxicology Unit with self-poisoning between Jan 1, 2019, and Aug 31, 2020. Only patients classified by the treating clinician as having intentionally self-poisoned were included. Data on date of admission, age or date of birth, sex, and poisoning method were collected. No data on ethnicity were available. We used interrupted time-series analysis to calculate weekly hospital admissions for self-poisoning before (Jan 1, 2019-March 19, 2020) and during (March 20-Aug 31, 2020) the pandemic, overall and by age (age <25 years vs ≥25 years) and sex. Individuals with missing date of admission were excluded from the main analysis., Findings: Between Jan 1, 2019, and Aug 31, 2020, 1401 individuals (584 [41·7%] males, 761 [54·3%] females, and 56 [4·0%] of unknown sex) presented to the hospital with self-poisoning and had date of admission data. A 32% (95% CI 12-48) reduction in hospital presentations for self-poisoning in the pandemic period compared with pre-pandemic trends was observed (rate ratio 0·68, 95% CI 0·52-0·88; p=0·0032). We found no evidence that the impact of the pandemic differed by sex (rate ratio 0·64, 95% CI 0·44-0·94, for females vs 0·85, 0·57-1·26, for males; p interaction =0·43) or age (0·64, 0·44-0·93, for patients aged <25 years vs 0·81, 0·57-1·16, for patients aged ≥25 years; p interaction =0·077)., Interpretation: This is the first study from a lower-middle-income country to estimate the impact of the pandemic on self-harm (non-fatal) accounting for underlying trends. If the fall in hospital presentations during the pandemic reflects a reduction in the medical treatment of people who have self-poisoned, rather than a true fall in incidence, then public health messages should emphasise the importance of seeking help early., Funding: Elizabeth Blackwell Institute University of Bristol, Wellcome Trust, and Centre for Pesticide Suicide Prevention., Translations: For the Sinhalese and Tamil translations of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Over 90% of youth suicide deaths occur in low- and middle-income countries. Despite this relatively little is known about risk factors in this context., Aims: Investigate risk factors for deliberate self-harm (non-fatal) in young people in rural Sri Lanka., Methods: A prospective cohort study of 22,401 individuals aged 12-18 years with complete data on sex, student status, household asset score, household access to pesticides and household problematic alcohol use. Deliberate self-harm was measured prospectively by reviewing hospital records. Poisson regression estimated incidence rate ratios (IRRs) for the association of risk factors with deliberate self-harm., Results: Females were at higher risk of deliberate self-harm compared to males (IRR 2.05; 95%CI 1.75 - 2.40). Lower asset scores (low compared to high: IRR 1.46, 95%CI 1.12 - 2.00) and having left education (IRR 1.61 95%CI 1.31 - 1.98) were associated with higher risks of deliberate self-harm, with evidence that the effect of not being in school was more pronounced in males (IRR 1.94; 95%CI 1.40 - 2.70) than females. There was no evidence of an association between household pesticide access and deliberate self-harm risk, but problematic household alcohol use was associated with increased risk (IRR 1.23; 95%CI 1.04 - 1.45), with evidence that this was more pronounced in females than males (IRR for females 1.42; 95%CI 1.17 - 1.72). There was no evidence of deliberate self-harm risk being higher at times of school exam stress., Conclusion: Indicators of lower socioeconomic status, not being in school, and problematic alcohol use in households, were associated with increased deliberate self-harm risk in young people.

Background and Aims: Varenicline and nicotine replacement therapy (NRT) are the most commonly used medications to quit smoking. Given their widespread use, monitoring adverse risks remains important. This study aimed to estimate the neuropsychiatric and cardiovascular risks associated with varenicline and NRT as used in routine UK care., Design: Case-cross-over study., Setting: UK-based electronic primary care records in the Clinical Practice Research Datalink from 2006 to 2015 linked to hospital and mortality data sets., Participants: Adult smokers (n =282,429) observed during periods when exposed and not exposed to either varenicline or NRT., Measurements: Main outcomes included suicide, self-harm, myocardial infarction (MI), all-cause death and cause-specific death [MI, chronic obstructive pulmonary disease (COPD)]. In primary analyses, conditional logistic regression was used to compare the chance of varenicline or NRT exposure during the risk period (90 days prior to the event) with the chance of exposure during an earlier single reference period (91-180 days prior to the event) or multiple 90-day reference periods to increase statistical power., Findings: In the primary analyses, findings were inconclusive for the associations between varenicline and the main outcomes using a single reference period, while NRT was associated with MI [odds ratio (OR) = 1.40, 95% confidence interval (CI) = 1.18-1.67]. Using multiple reference periods, varenicline was associated with an increased risk of self-harm (OR = 1.32, 95% CI = 1.12-1.56) and suicide (OR = 3.56, 95% CI = 1.32-9.60) but a reduction in all-cause death (OR = 0.75, 95% CI = 0.61-0.93). NRT was associated with MI (OR = 1.54, 95% CI = 1.36-1.74), self-harm (OR = 1.30, 95% CI = 1.18-1.44) and deaths from MI (OR = 1.53, 95% CI = 1.11-2.10), COPD (OR = 1.33, 95% CI = 1.14-1.56) and all causes (OR = 1.28, 95% CI = 1.18-1.40) when using multiple reference periods., Conclusions: There appear to be positive associations between (1) nicotine replacement therapy (NRT) and myocardial infarction, death and risk of self-harm and (2) varenicline and increased risk of self-harm and suicide, as well as a negative association between varenicline and all-cause death. The associations may not be causal. They may reflect health changes at the time of smoking cessation (nicotine replacement therapy is prescribed for people with cardiac problems) or be associated with quit attempts (exposure to both medicines was associated with self-harm)., (© 2020 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Background: Empirical evidence supporting the distinction between suicide attempt (SA) and non-suicidal self-harm (NSSH) is lacking. Although NSSH is a risk factor for SA, we do not currently know whether these behaviours lie on a continuum of severity, or whether they are discrete outcomes with different aetiologies. We conducted this exploratory genetic epidemiology study to investigate this issue further., Methods: We explored the extent of genetic overlap between NSSH and SA in a large, richly-phenotyped cohort (the Avon Longitudinal Study of Parents and Children; N = 4959), utilising individual-level genetic and phenotypic data to conduct analyses of genome-wide complex traits and polygenic risk scores (PRS)., Results: The single nucleotide polymorphism heritability of NSSH was estimated to be 13% (SE 0.07) and that of SA to be 0% (SE 0.07). Of the traits investigated, NSSH was most strongly correlated with higher IQ (rG = 0.31, SE = 0.22), there was little evidence of high genetic correlation between NSSH and SA (rG = - 0.1, SE = 0.54), likely due to the low heritability estimate for SA. The PRS for depression differentiated between those with NSSH and SA in multinomial regression. The optimal PRS prediction model for SA (Nagelkerke R 2 0.022, p < 0.001) included ADHD, depression, income, anorexia and neuroticism and explained more variance than the optimal prediction model for NSSH (Nagelkerke R 2 0.010, p < 0.001) which included ADHD, alcohol consumption, autism spectrum conditions, depression, IQ, neuroticism and suicide attempt., Conclusions: Our findings suggest that SA does not have a large genetic component, and that although NSSH and SA are not discrete outcomes there appears to be little genetic overlap between the two. The relatively small sample size and resulting low heritability estimate for SA was a limitation of the study. Combined with low heritability estimates, this implies that family or population structures in SA GWASs may contribute to signals detected.

Background: Self-harm and eating disorders are often comorbid in clinical samples but their co-occurrence in the general population is unclear. Given that only a small proportion of individuals who self-harm or have disordered eating present to clinical services, and that both self-harm and eating disorders are associated with substantial morbidity and mortality, it is important to study these behaviours at a population level., Methods: We assessed the co-occurrence of self-harm and disordered eating behaviours in 3384 females and 2326 males from a UK population-based cohort: the Avon Longitudinal Study of Parents and Children (ALSPAC). Participants reported on their self-harm and disordered eating behaviours (fasting, purging, binge-eating and excessive exercise) in the last year via questionnaire at 16 and 24 years. At each age we assessed how many individuals who self-harm also reported disordered eating, and how many individuals with disordered eating also reported self-harm., Results: We found high comorbidity of self-harm and disordered eating. Almost two-thirds of 16-year-old females, and two-in-five 24-year old males who self-harmed also reported some form of disordered eating. Young people with disordered eating reported higher levels of self-harm at both ages compared to those without disordered eating., Limitations: We were not able to measure whether participants identified their disordered eating as a method of self-harm., Conclusions: Self-harm and disordered eating commonly co-occur in young people in the general population. It is important to screen for both sets of difficulties to provide appropriate treatment., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Purpose: The long-term consequences of parental emigration on offspring self-harm risk is unknown., Methods: We investigated the association between experiencing parental emigration in childhood with hospital presentations for self-poisoning in adulthood using a hospital case-control study. Cases were adult self-poisoning patients (≥18 year olds) admitted to the medical toxicology ward Teaching Hospital Peradeniya, Sri Lanka. Sex and age frequency matched controls were recruited from the outpatient department or nearby specialist clinics at the same hospital. Details of parental emigration were collected using a pre-piloted questionnaire. The relationship between parental emigration and self-poisoning in adulthood was estimated using logistic regression models., Results: 298 cases, and 500 hospital controls were interviewed for the study. We estimate that one in five adults experienced parental emmigration as children (95% CI 17% to 24%). We find limited evidence that children from households with emigrating parents were more likely to experience adverse childhood experiences than those with non-emigrating parents. We found no statistical evidence of an increased risk of self-poisoning in adulthood in individuals who experienced parental emigration (maternal or paternal) during childhood. There was no statistical evidence that the impact differed by the sex of the participant., Conclusion: Adults who experienced parental emigration as children were no more likely to self-poison than adults with non-emigrating parents. Further research using longitudinal data are needed to understand whether any adverse outcomes observed in 'left-behind' children are a consequence of parental emigration or due to factors associated but predate the emigration. Prospective data are also important to investigate whether there are any lasting effects on children who experience parental emigration., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Adverse childhood experiences (ACE) have been recognized as an important risk factor for suicidal behaviour among adults, but evidence from low and middle-income countries is lacking. This study explored associations between ACE and hospital admission due to non-fatal self-poisoning in Sri Lanka., Methods: This was a case-control study. Adults admitted to a tertiary care hospital for medical management of self-poisoning were included as cases, and age and sex matched controls were recruited from the outpatient department. ACE were measured using the World Health Organization's Childhood Adversity Scale. Logistic regression models adjusting for age, sex, ethnicity, and religion were used to quantify the association between ACE and self-poisoning., Results: The study included 235 cases and 451 controls. Cases were 2.5 times (95% CI 1.8, 3.6) more likely to report an ACE than controls and had higher ACE scores. Childhood physical abuse (OR 4.7, 95% CI 1.2, 19.0) and emotional abuse or neglect (OR 3.7, 95% CI 1.3, 10.1, and 3.7, 95% CI 2.3, 6.0 respectively), increased the risk of self-poisoning in adulthood, as did witnessing household violence (OR 2.2, 95% CI 1.4, 3.4), growing up in a household with a mentally ill or suicidal household member (OR 2.1, 95% CI 1.2, 3.4), and experiencing parental death/separation/divorce (OR 3.1, 95% CI 2.0, 4.9) as a child., Conclusions: Reducing exposures to ACEs should be a priority for prevention of suicide and self-harm in Sri Lanka. Innovative methods to increase support for children facing adversity should be explored., Competing Interests: The authors have declared that no competing interest exists.

Aims: Early puberty is associated with an increased risk of self-harm in adolescent females but results for males are inconsistent. This may be due to the use of subjective measures of pubertal timing, which may be biased. There is also limited evidence for the persistence of pubertal timing effects beyond adolescence, particularly in males. The primary aim of the current study was therefore to examine the association between pubertal timing and self-harm in both sexes during adolescence and young adulthood, using an objective measure of pubertal timing (age at peak height velocity; aPHV). A secondary aim was to examine whether this association differs for self-harm with v. without suicidal intent., Methods: The sample (n = 5369, 47% male) was drawn from the Avon Longitudinal Study of Parents and Children (ALSPAC), a prospective birth cohort study. Mixed-effects growth curve models were used to calculate aPHV. Lifetime history of self-harm was self-reported at age 16 and 21 years, and associated suicidal intent was examined at age 16 years. Associations were estimated using multivariable logistic regression adjusted for a range of confounders. Missing data were imputed using Multiple Imputation by Chained Equations., Results: Later aPHV was associated with a reduced risk of self-harm at 16 years in both sexes (females: adjusted per-year increase in aPHV OR 0.85; 95% CI 0.75-0.96; males: OR 0.72; 95% CI 0.59-0.88). Associations were similar for self-harm with and without suicidal intent. There was some evidence of an association by age 21 years in females (adjusted per-year increase in aPHV OR 0.91; 95% CI 0.80-1.04), although the findings did not reach conventional levels of significance. There was no evidence of an association by age 21 years in males (adjusted per-year increase in aPHV OR 0.99; 95% CI 0.74-1.31)., Conclusions: Earlier developing adolescents represent a group at increased risk of self-harm. This increased risk attenuates as adolescents transition into adulthood, particularly in males. Future research is needed to identify the modifiable mechanisms underlying the association between pubertal timing and self-harm risk in order to develop interventions to reduce self-harm in adolescence.

Background: The causal role of inflammatory markers on self-harm and suicidal risk has been studied using observational data, with conflicting results. Confounding and reverse causation can lead to bias, so we appraised question from a genetic perspective to protect against these biases. We measured associations between genetic liability for high levels of inflammatory markers Interleukin-6 (IL-6) and C-reactive protein (CRP) on self-harm, and conducted a secondary analysis restricted to self-harm with suicidal intent., Methods: We conducted two sample and multivariable Mendelian randomisation (MR) to assess the effects of IL-6 and CRP on self-harm utilising existing data and conducting new genome wide association studies to instrument IL-6 and CRP, and for the outcome of self-harm., Results: No single nucleotide polymorphisms (SNPs) reached genome-wide significance for self-harm, however 193 SNPs met suggestive significance levels (p < 5 × 10 -6 ). We found no evidence of an association between our instruments for IL-6 and self-harm in the two-sample MR, however we found an inverse association between instruments for CRP and self-harm, indicating that higher levels of circulating CRP may protect against self-harm (inverse variance weighted OR 0.92, 95%CI 0.84, 1.01, p = 0.08; MR Egger OR 0.86, 95% CI 0.74, 1.00, p = 0.05). The direct effect estimate for IL-6 was slightly smaller in the multivariable MR than in the two sample MR, while the CRP effect estimates were consistent with the two sample MR (OR 0.92, SE 1.05, p = 0.09)., Conclusions: Our findings are conflicting and indicate that IL-6 and CRP are not robust etiological markers of increased self-harm or suicide risk., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Previous studies of pubertal timing and self-harm are limited by subjective measures of pubertal timing or by the conflation of self-harm with suicide attempts and ideation. The current study investigates the association between an objective measure of pubertal timing - age at menarche - and self-harm with and without suicidal intent in adolescence and adulthood in females., Method: Birth cohort study based on 4042 females from the Avon Longitudinal Study of Parents and Children (ALSPAC). Age at menarche was assessed prospectively between ages 8 and 17 years. Lifetime history of self-harm was self-reported at ages 16 and 21 years. Associations between age at menarche and self-harm, both with and without suicidal intent, were examined using multivariable logistic regression., Results: Later age at menarche was associated with a lower risk of lifetime self-harm at age 16 years (OR per-year increase in age at menarche 0.87; 95% CI 0.80-0.95). Compared with normative timing, early menarche (<11.5 years) was associated with an increased risk of self-harm (OR 1.31, 95% CI 1.04-1.64) and later menarche (>13.8 years) with a reduced risk (OR 0.74, 95% CI 0.58-0.93). The pattern of association was similar at age 21 years (OR per-year increase in age at menarche 0.92, 95% CI 0.85-1.00). There was no strong evidence for a difference in associations with suicidal v. non-suicidal self-harm., Conclusions: Risk of self-harm is higher in females with early menarche onset. Future research is needed to establish whether this association is causal and to identify potential mechanisms.

There are concerns about high levels of mental ill-health amongst university students, but little is known about the mental health of students compared to non-students over time. Using data on young people (16-24) from three UK National Psychiatric Morbidity Surveys (2000, 2007, and 2014), we found no evidence that the overall prevalence of common mental disorder (CMD), suicide attempts, or non-suicidal self-harm (NSSH) differed between students and non-students, although there was an indication that CMDs rose markedly in female students between 2007 and 2014. A rise in NSSH is apparent in both students and non-students.

Background: People with substance use disorder (SUD) are at significantly greater risk of suicide compared with the general population. In recent years the number of suicides resulting from drug poisoning in England and Wales has increased. We sought to identify and evaluate the effect of interventions to prevent suicide or reduce self-harm among people with SUD., Methods: We conducted a systematic review of randomised controlled trials (RCTs) of interventions for people with SUD that included suicide or self-harm-related primary outcomes. We searched Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, PubMed, Embase and Web of Science from inception until 13th January 2019. Studies were assessed for bias using the Cochrane Risk of Bias 2 tool. A random effects meta-analysis of standardised mean differences (SMD) was conducted., Results: We identified six RCTs from four countries (Australia, Iran, the United States of America and the United Kingdom) comprising 468 participants in total. All but one study investigated psychosocial interventions. On average across studies there was weak evidence of a small positive effect of interventions on suicide or self-harm outcomes (d=-0.20, 95% CI=-0.39-0.00)., Limitations: Studies were heterogeneous in terms of population, intervention, controls and outcome. There were some concerns regarding bias for all trials. All trials were liable to type II error., Conclusions: Evidence is currently lacking regarding the effectiveness of interventions to prevent suicide and reduce self-harm amongst people with SUD., (Copyright © 2019. Published by Elsevier Inc.)

We have assessed the methodological quality of randomized controlled trials (RCTs) of interventions to prevent self-harm repetition and suicide. Trials were identified in two systematic reviews of RCTs of psychosocial treatments following a recent (within six months) episode of self-harm indexed in any of five electronic databases (CCDANCTR-Studies and References, CENTRAL, Medline, Embase, and PsycINFO) between 1 January, 1998 and 29 April, 2015. A total of 66 trials were included, 55 in adults and 11 in children and adolescents. While evidence for efficacy of some approaches has grown, there were few trials from low-to-middle income countries, little information on interventions for males, information on the control condition was often limited, data on suicides were often not reported, and, while trials have increased in size in recent years, most have included too few participants to detect clinically significant results. There are major limitations in many trials of interventions for individuals who self-harm. Improved methodology, especially with regard to study size, provision of details of control therapy, and evaluation of key outcomes, would enhance the evidence base for clinicians and service users.

Aims: To investigate the spatial distribution of self-harm incidence rates, their socioeconomic correlates and sex/age differences using data on self-harm presentations to emergency departments from The Manchester Self-Harm Project (2003-2013)., Methods: Smoothed standardised incidence ratios for index self-harm episodes (n = 14 771) and their associations with area-level socioeconomic factors across 258 small areas (median population size = 1470) in the City of Manchester municipality were estimated using Bayesian hierarchical models., Results: Higher numbers and rates of self-harm were found in the north, east and far southern zones of the city, in contrast to below average rates in the city centre and the inner city zone to the south of the centre. Males and females aged 10-24, 25-44 and 45-64 years showed similar geographical patterning of self-harm. In contrast, there was no clear pattern in the group aged 65 years and older. Fully adjusted analyses showed a positive association of self-harm rates with the percentage of the unemployed population, households privately renting, population with limiting long-term illness and lone-parent households, and a negative association with the percentage of ethnicity other than White British and travel distance to the nearest hospital emergency department. The area-level characteristics investigated explained a large proportion (four-fifths) of the variability in area self-harm rates. Most associations were restricted to those aged under 65 years and some associations (e.g. with unemployment) were present only in the youngest age group., Conclusions: The findings have implications for allocating prevention and intervention resources targeted at high-risk groups in high incidence areas. Targets for area-based interventions might include tackling the causes and consequences of joblessness, better treatment of long-term illness and consideration of the accessibility of health services.

Background: Adverse childhood experiences (ACEs) such as physical and emotional abuse are strongly associated with self-harm, but mechanisms underlying this relationship are unclear. Inflammation has been linked to both the experience of ACEs and self-harm or suicide in prior research. This is the first study to examine whether inflammatory markers mediate the association between exposure to ACEs and self-harm., Methods: Participants were 4,308 young people from the Avon Longitudinal Study of Parents and Children (ALSPAC), a population-based birth cohort in the United Kingdom. A structural equation modelling approach was used to fit a mediation model with the number of ACEs experienced between ages 0 and 9 years old (yo), levels of the inflammatory markers interleukin-6 and C-reactive protein measured at 9.5 yo, and self-harm reported at 16 yo., Results: The mean number of ACEs young people experienced was 1.41 (SE 0.03). Higher ACE scores were associated with an increased risk of self-harm at 16 yo (direct effect relative risk (RR) per additional ACE 1.11, 95% CI 1.05, 1.18, p < 0.001). We did not find evidence of an indirect effect of ACEs on self-harm via inflammation (RR 1.00, 95% CI 1.00, 1.01, p = 0.38)., Conclusions: Young people who have been exposed to ACEs are a group at high risk of self-harm. The association between ACEs and self-harm does not appear to be mediated by an inflammatory process in childhood, as indexed by peripheral levels of circulating inflammatory markers measured in childhood. Further research is needed to identify alternative psychological and biological mechanisms underlying this relationship., (© 2019 The Authors. Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health.)

Background: Evidence from high income countries (HICs) suggests that individuals who present to hospital after self-harm are an important target for suicide prevention, but evidence from low and middle-income countries (LMICs) is lacking. We aimed to investigate the risk of repeat self-harm and suicide, and factors associated with these outcomes, in a large cohort of patients presenting to hospital with self-harm in rural Sri Lanka., Methods: In this cohort study, hospital presentations for self-harm at 13 hospitals in a rural area of North Central Province (population 224 000), Sri Lanka, were followed up with a self-harm surveillance system, established as part of a community randomised trial, and based on data from all hospitals, coroners, and police stations in the study area. We estimated the risk of repeat non-fatal and fatal self-harm and risk factors for repetition with Kaplan-Meier methods and Cox proportional hazard models. Sociodemographic (age, sex, and socioeconomic position) and clinical (past self-harm and method of self-harm) characteristics investigated were drawn from a household survey in the study area and data recorded at the time of index hospital presentation. We included all individuals who had complete data for all variables in the study in our primary analysis., Outcomes: Between July 29, 2011, and May 12, 2016, we detected 3073 episodes of self-harm (fatal and non-fatal) in our surveillance system, of which 2532 (82·3%) were linked back to an individual in the baseline survey. After exclusion of 145 ineligible episodes, we analysed 2259 index episodes of self-harm. By use of survival models, the estimated risk of repeat self-harm (12 months: 3· 1%, 95% CI 2·4-3·9; 24 months: 5·2%, 4·3-6·4) and suicide (12 months: 0·6%, 0·4-1·1; 24 months: 0·8%, 0·5-1·3) in our study was considerably lower than that in HICs. A higher risk of repeat self-harm was observed in men than in women (fatal and non-fatal; hazard ratio 2·0, 95% CI 1·3-3·2; p=0·0021), in individuals aged 56 years and older compared with those aged 10-25 years (fatal; 16·1, 4·3-59·9; p=0·0027), and those who used methods other than poisoning in their index presentation (fatal and non-fatal; 3·9, 2·0-7·6; p=0·00027). We found no evidence of increased risk of repeat self-harm or suicide in those with a history of self-harm before the index episode., Interpretation: Although people who self-harm are an important high-risk group, focusing suicide prevention efforts on those who self-harm might be somewhat less important in LMICs compared with HICs given the low risk of repeat self-harm and subsequent suicide death. Strategies that focus on other risk factors for suicide might be more effective in reducing suicide deaths in LMICs in south Asia. A better understanding of the low incidence of repeat self-harm is also needed, as this could contribute to prevention strategies in nations with a higher incidence of repetition and subsequent suicide death., Funding: Wellcome Trust., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: The number of people presenting to hospital emergency departments after self-harming has increased in England. However, most people who self-harm do not present to hospitals, so whether this rise reflects an increase in the prevalence of self-harm in the community is unknown. Also unknown is whether the prevalence of non-suicidal self-harm (NSSH) or suicidal self-harm, or both, has increased. We aimed to establish temporal trends in the prevalence of NSSH in England., Methods: We analysed data from participants in the 2000 (n=7243), 2007 (n=6444), and 2014 (n=6477) Adult Psychiatric Morbidity Surveys of the general population, selecting those aged 16-74 years and living in England. We used weighted data and controlled for complex survey design. We generated temporal trends in lifetime prevalence and methods of, and motivations for, NSSH, and consequent service contact. We used multiple variable logistic regression analyses to investigate factors associated with service contact., Findings: The prevalence of self-reported lifetime NSSH increased from 2·4% (95% CI 2·0-2·8) in 2000, to 6·4% (5·8-7·2) in 2014. Increases in prevalence were noted in both sexes and across age groups-most notably in women and girls aged 16-24 years, in whom prevalence increased from 6·5% (4·2-10·0) in 2000, to 19·7% (15·7-24·5) in 2014. The proportion of the population reporting NSSH to relieve unpleasant feelings of anger, tension, anxiety, or depression increased from 1·4% (95% CI 1·0-2·0) to 4·0% (3·2-5·0) in men and boys, and from 2·1% (1·6-2·7) to 6·8% (6·0-7·8) in women and girls, between 2000 and 2014. In 2014, 59·4% (95% CI 54·7-63·9) of participants who had engaged in NSSH reported no consequent medical or psychological service contact, compared with 51·2% (42·2-60·0) in 2000 and 51·8% (47·3-56·4) in 2007. Male participants and those aged 16-34 years were less likely to have contact with health services than were female participants and older people., Interpretation: The prevalence of NSSH has increased in England, but resultant service contact remains low. In 2014, about one in five female 16-24-year-olds reported NSSH. There are potential lifelong implications of NSSH, such as an increased frequency of suicide, especially if the behaviours are adopted as a long-term coping strategy. Self-harm needs to be discussed with young people without normalising it. Young people should be offered help by primary care, educational, and other services to find safer ways to deal with emotional stress., Funding: NHS Digital, English Department of Health and Social Care, and the National Institute for Health Research., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Previous research suggests that there is an association between domestic violence (DV) and self-harm (SH). Yet, the prevalence and clinical significance of DV among individuals presenting acutely to hospital with SH in the UK is unknown., Objective: To measure the prevalence and correlates of DV among patients presenting to hospital with SH., Methods: We conducted a cross-sectional study using registry data in order to describe the prevalence of DV within a UK population of people presenting to the emergency department (ED) with SH (n=1142)., Results: 11.1% (95% CI 9.4% to 13.1%) of the sample reported DV. Those reporting DV were more likely to be female and separated from a partner. DV was associated with self-poisoning and with previous occurrence of SH., Conclusion: Our findings suggest that DV victimisation is more prevalent among those presenting to ED with self-harm than among the general population of ED attenders, and that the presence of DV may signify increased risk among those presenting to ED with SH., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Risk scales are used widely for assessing individuals presenting to Emergency Departments (EDs) following self-harm. There is growing evidence that risk scales have limited clinical utility in identifying episodes at highest risk of repeat self-harm. However, their cost-effectiveness in terms of treatment allocation and subsequent repeat self-harm is unknown. We aimed to examine the cost-effectiveness of five risk scales (SAD PERSONS Scale, Modified SAD PERSONS Scale, ReACT Self-Harm Rule, Manchester Self-Harm Rule, Barratt Impulsivity Scale) and single item clinician and patient ratings of risk., Method: Quality-Adjusted Life Years were estimated for each episode. The five risk scales and the patient rating were compared to the clinician rating. Incremental cost-effectiveness ratios (ICERs) were estimated for each scale, using a range of ICER thresholds. Sensitivity analysis explored different model assumptions., Results: The formal scales were less cost-effective than the clinician and patient ratings across a range of ICER thresholds (£0-£30,000). The five scales were also less cost-effective than the clinician rating in most alternative scenario analyses. However, the clinician rating would be likely to result in unnecessary treatment costs for over half of patients identified as high risk., Limitations: Our primary model depended on the assumption that high-intensity care reduced patients' risk of further self-harm., Conclusion: The use of formal assessment tools for managing self-harm presentations to EDs did not appear to be cost-effective. While the judgement of a mental health clinician was found to be slightly more cost-effective, it still resulted in incorrect allocation of costs and missed treatment opportunities., (Copyright © 2019. Published by Elsevier B.V.)

Background: Suicidal thoughts and non-suicidal self-harm are common in adolescents and are strongly associated with suicide attempts. We aimed to identify predictors of future suicide attempts in these high-risk groups., Methods: Participants were from the Avon Longitudinal Study of Parents and Children, a population-based birth cohort study in the UK. The sample included 456 adolescents who reported suicidal thoughts and 569 who reported non-suicidal self-harm at 16 years of age. Logistic regression analyses were used to explore associations between a wide range of prospectively recorded risk factors and future suicide attempts, assessed at the age of 21 years., Findings: 38 (12%) of 310 participants with suicidal thoughts and 46 (12%) of 380 participants who had engaged in non-suicidal self-harm reported having attempted suicide for the first time by the follow-up at 21 years of age. Among participants with suicidal thoughts, the strongest predictors of transition to attempts were non-suicidal self-harm (odds ratio [OR] 2·78, 95% CI 1·35-5·74; p=0·0059), cannabis use (2·61, 1·11-6·14; p=0·029), other illicit drug use (2·47, 1·02-5·96; p=0·045), exposure to self-harm (family 2·03, 0·93-4·44, p=0·076; friend 1·85, 0·93-3·69, p=0·081), and higher levels of the personality type intellect/openness (1·62, 1·06-2·46; p=0·025). Among participants with non-suicidal self-harm at baseline, the strongest predictors were cannabis use (OR 2·14, 95% CI 1·04-4·41; p=0·038), other illicit drug use (2·17, 1·10-4·27; p=0·025), sleep problems (waking in the night 1·91, 0·95-3·84, p=0·069; insufficient sleep 1·97, 1·02-3·81, p=0·043), and lower levels of the personality type extraversion (0·71, 0·49-1·03; p=0·068)., Interpretation: Most adolescents who think about suicide or engage in non-suicidal self-harm will not make an attempt on their life. Many commonly cited risk factors were not associated with transition to suicide attempt among these high-risk groups. Our findings suggest that asking about substance use, non-suicidal self-harm, sleep, personality traits, and exposure to self-harm could inform risk assessments, and might help clinicians to identify which adolescents are at greatest risk of attempting suicide in the future., Funding: American Foundation for Suicide Prevention, National Institute for Health Research Biomedical Research Centre at the University Hospitals Bristol National Health Service Foundation Trust, and the University of Bristol., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Bipolar and other psychiatric disorders are associated with considerably increased risk of suicidal behaviour, which may include self-poisoning with medication used to treat the disorder. Therefore, choice of medication for treatment should include consideration of toxicity, especially for patients at risk. The aim of this study was to estimate the relative toxicity of specific drugs within two drug categories, antipsychotics and mood stabilizers, using large-scale databases to provide evidence that could assist clinicians in making decisions about prescribing, especially for patients at risk of suicidal behaviour., Method: Two indices were used to assess relative toxicity of mood stabilisers and antipsychotics: case fatality (the ratio between rates of fatal and non-fatal self-poisoning) and fatal toxicity (the ratio between rates of fatal self-poisoning and prescription). Mood stabilisers assessed included lithium [reference], sodium valproate, carbamazepine, and lamotrigine, while antipsychotics included chlorpromazine [reference], clozapine, olanzapine, quetiapine and risperidone. Fatal self-poisoning (suicide) data were provided by the Office for National Statistics (ONS), non-fatal self-poisoning data by the Multicentre Study of Self-harm in England, and information on prescriptions by the Clinical Practice Research Datalink. The primary analysis focussed on deaths due to a single drug. Cases where the drug of interest was listed as the likely primary toxic agent in multiple drug overdoses were also analysed. The study period was 2005-2012., Results: There appeared to be little difference in toxicity between the mood stabilisers, except that based on case fatality where multiple drug poisonings were considered, carbamazepine was over twice as likely to result in death relative to lithium (OR 2.37 95% CI 1.16-4.85). Of the antipsychotics, clozapine was approximately18 times more likely to result in death when taken in overdose than chlorpromazine (single drug case fatality: OR 18.53 95% CI 8.69-39.52). Otherwise, only risperidone differed from chlorpromazine, being less toxic (OR 0.06 95% CI 0.01-0.47)., Conclusions: There was little difference in toxicity of the individual mood stabilisers. Clozapine was far more toxic than the other antipsychotics. The findings are relevant to prescribing policy, especially for patients at particular risk of suicidal behaviour.

Background: The rise in Internet use adds a new dimension to suicide prevention. We investigated suicide/self-harm (S/Sh)-related Internet use among patients presenting to hospital with self-harm., Method: We asked 1,198 adult and 315 child and adolescent patients presenting to hospital following self-harm in a city in South West England about Internet use associated with their hospital presentation. Associations between Internet use and sociodemographic and clinical characteristics were investigated using multivariable logistic regression models. Focus groups with clinicians explored the acceptability and utility of asking about Internet use., Results: The prevalence of S/Sh-related Internet use was 8.4% (95% CI: 6.8-10.1%) among adult hospital presentations and 26.0% (95% CI = 21.3-31.2%) among children's hospital presentations. In both samples, S/Sh-related Internet use was associated with higher levels of suicidal intent. Mostly, clinicians found it acceptable to ask about Internet use during psychosocial assessments and believed this could inform perceptions of risk and decision-making., Limitations: It is unclear whether the findings in this study are applicable to the general self-harm patient population because only those who had psychosocial assessments were included., Conclusion: S/Sh-related Internet use is likely to become increasingly relevant as the Internet-native generation matures. Furthermore, Internet use may be a proxy marker for intent.

Background: Randomized controlled trials (RCTs) are the mainstay of evaluations of the efficacy of psychosocial interventions. In a recent Cochrane systematic review we analysed the efficacy of cognitive behavioural-based psychotherapies compared to treatment as usual (TAU) in adults who self-harm. In this study we examine the content and reporting quality of TAU in these trials and their relationship to outcomes., Methods: Five electronic databases (CCDANCTR-Studies and References, CENTRAL, MEDLINE, EMBASE, and PsycINFO) were searched for RCTs, indexed between 1 January 1998 and 30 April 2015, of cognitive-behavioural interventions compared to TAU for adults following a recent (within six months) episode of self-harm. Comparisons were made between outcomes for trials which included different categories of TAU, which were grouped as: multidisciplinary treatment, psychotherapy only, pharmacotherapy only, treatment by primary care physician, minimal contact, or unclear., Results: 18 trials involving 2433 participants were included. The content and reporting quality of TAU varied considerably between trials. The apparent effectiveness of cognitive behavioural psychotherapy varied according to TAU reporting quality and content. Specifically, effects in favour of cognitive-behavioural psychotherapy were strongest in trials in which TAU content was not clearly described (Odds Ratio: 0.29, 95% Confidence Interval 0.15-0.62; three trials) compared to those in which TAU comprised multidisciplinary treatment (Odds Ratio: 0.79, 95% CI 0.63 to 0.97; 12 trials)., Limitations: The included trials had high risk of bias with respect to participant and clinical personnel blinding, and unclear risk of bias for selective outcome reporting., Conclusions: TAU content and quality represents an important source of heterogeneity between trials of psychotherapeutic interventions for prevention of self-harm. Before clinical trials begin, researchers should plan to carefully describe both aspects of TAU to improve the overall quality of investigations., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Despite accelerating interest in the impact of the internet on suicidal behaviour, empirical work has not captured detailed narratives from those who engaged in suicide-related internet use. This study explored the suicide-related online behaviour of two contrasting samples of distressed users, focusing on their purpose, methods and the main content viewed. In-depth interviews were conducted in the UK between 2014-2016 with i) young people in the community; and ii) self-harm patients presenting to hospital emergency departments. Data were analysed using methods of constant comparison. Suicide-related internet use varied according to the severity of suicidal feelings. In the young people sample, where severity was lower, use was characterised by disorganised browsing without clear purpose. A range of content was 'stumbled upon' including information about suicide methods. They also pursued opportunities to interact with others and explore online help. Self-harm patients were a higher severity group with a history of suicidal behaviour. Their use was purposeful and strategic, focused around 'researching' suicide methods to maximise effectiveness. They made specific choices about content viewed; many consulting factual content in preference to user generated accounts, while help content and communication was avoided. Findings indicate further action is necessary to improve online safety. Also, novel online help approaches are needed to engage individuals experiencing suicidal crisis. Awareness of the nature of suicide-related internet use and how this may reflect the status of an individual's suicidal thinking could be beneficial to clinicians to promote safety and indicate risk., Competing Interests: The authors have declared that no competing interests exist.

Objective: To examine the hypothesis that autism spectrum disorders (ASD) diagnosis and traits in childhood are associated with suicidal thoughts, plans and self-harm at 16 years, and that any observed associations are explained by depression at 12 years., Method: We examined associations between ASD diagnosis and 4 dichotomized ASD traits (social communication, pragmatic language, repetitive behavior, and sociability) with suicidal and nonsuicidal self-harm, suicidal thoughts, and suicidal plans at age 16 years in 5,031 members of the United Kingdom-based birth cohort study the Avon Longitudinal Study of Parents and Children. We assessed whether any associations were explained by depressive symptoms in early adolescence measured by the Short Moods and Feelings Questionnaire at 12 years., Results: Children with impaired social communication had a higher risk of self-harm with suicidal intent (relative risk [RR] = 2.14, 95% CI = 1.28-3.58), suicidal thoughts (RR = 1.42, 95% CI = 1.06-1.91), and suicidal plans (RR = 1.95, 95% CI = 1.09-3.47) by age 16 years as compared to those without. There was no evidence for an association between ASD diagnosis and outcomes, although these analyses were imprecise because of small numbers. There was also no evidence of an association between other autism traits and the outcomes. Approximately 32% of the total estimated association between social communication impairment and self-harm was explained by depressive symptoms at 12 years., Conclusion: Social communication impairments are an important autistic trait in relation to suicidality. Early identification and management of depression may be a preventative mechanism, and future research identifying other potentially modifiable mechanisms may lead to interventions against suicidal behavior in this high-risk group., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Risk scales are used widely in the management of patients presenting to hospital following self-harm. However, there is evidence that their diagnostic accuracy in predicting repeat self-harm is limited. Their predictive accuracy in population settings, and in identifying those at highest risk of suicide is not known., Method: We compared the predictive accuracy of the Manchester Self-Harm Rule (MSHR), ReACT Self-Harm Rule (ReACT), SAD PERSONS Scale (SPS) and Modified SAD PERSONS Scale (MSPS) in an unselected sample of patients attending hospital following self-harm. Data on 4000 episodes of self-harm presenting to Emergency Departments (ED) between 2010 and 2012 were obtained from four established monitoring systems in England. Episodes were assigned a risk category for each scale and followed up for 6 months., Results: The episode-based repeat rate was 28% (1133/4000) and the incidence of suicide was 0.5% (18/3962). The MSHR and ReACT performed with high sensitivity (98% and 94% respectively) and low specificity (15% and 23%). The SPS and the MSPS performed with relatively low sensitivity (24-29% and 9-12% respectively) and high specificity (76-77% and 90%). The area under the curve was 71% for both MSHR and ReACT, 51% for SPS and 49% for MSPS. Differences in predictive accuracy by subgroup were small. The scales were less accurate at predicting suicide than repeat self-harm., Conclusions: The scales failed to accurately predict repeat self-harm and suicide. The findings support existing clinical guidance not to use risk classification scales alone to determine treatment or predict future risk.

Background: In South Asia, up to 20% of people ingesting pesticides for self-poisoning purchase the pesticide from a shop with the sole intention of self-harm. Individuals who are intoxicated with alcohol and/or non-farmers represent 72% of such high-risk individuals. We aimed to test the feasibility and acceptability of vendor-based restrictions on pesticide sales for such high-risk individuals., Methods: We conducted a pilot study in 14 (rural = 7, urban = 7) pesticide shops in Anuradhapura District of Sri Lanka. A two-hour training program was delivered to 28 pesticide vendors; the aim of the training was to help vendors recognize and respond to customers at high risk of pesticide self-poisoning. Knowledge and attitudes of vendors towards preventing access to pesticides for self-poisoning at baseline and in a three month follow-up was evaluated by questionnaire. Vendors were interviewed to explore the practice skills taught in the training and their assessment of the program., Results: The scores of knowledge and attitudes of the vendors significantly increased by 23% (95% CI 15%-32%, p < 0.001) and by 16% (95% CI 9%-23%, p < 0.001) respectively in the follow-up. Fifteen (60%) vendors reported refusing sell pesticides to a high-risk person (non-farmer or intoxicated person) in the follow-up compared to three (12%) at baseline. Vendors reported that they were aware from community feedback that they had prevented at least seven suicide attempts. On four identified occasions, vendors in urban shops had been unable to recognize the self-harming intention of customers who then ingested the pesticide. Only 2 (8%) vendors were dissatisfied with the training and 23 (92%) said they would recommend it to other vendors., Conclusions: Our study suggests that vendor-based sales restriction in regions with high rates of self-poisoning has the potential to reduce access to pesticides for self-poisoning. A large-scale study of the effectiveness and sustainability of this approach is needed.

Purpose: Socioeconomic deprivation is associated with increased rates of self-harm but its association with levels of clinical care has not previously been explored. The aim of the current study was to investigate socioeconomic differences in the clinical management of people who self-harm., Methods: Cross-sectional analysis of 3607 people presenting to a large inner-city hospital following self-harm., Results: People living in the least deprived quintile were more likely to receive a psychosocial assessment (most vs. least deprived: 63.51 vs. 70.14%). This effect persisted in our fully adjusted model (OR 1.45, CI 1.15-1.82, p = 0.002). Mediation analysis suggested this association was in large part explained by higher rates of self-discharge in people presenting from areas of higher deprivation., Conclusions: Compared to those from more deprived areas, people from less deprived areas are more likely to receive a psychosocial assessment when presenting to hospital following self-harm. The occurrence of higher rates of self-discharge from emergency departments among those from more deprived areas may explain the association.

Objectives: To evaluate the impact of an expansion of liaison psychiatry services (LPS) on patient management, outcomes and treatment costs for emergency department (ED) attendances for self-harm., Design: Retrospective before and after cohort study using routinely collected Self-Harm Surveillance Register data., Setting: A large hospital in South West England., Subjects: Patients attending the ED for self-harm., Interventions: Extension of the LPS' working hours from 9:00 to 17:00, Monday to Friday to 8:00 to 22:00, 7 days a week, following a £250 000 annual investment MAIN OUTCOME MEASURES: Number and characteristics of ED attendances for self-harm. The before and after cohorts were compared in terms of key process measures, including proportion of patients receiving a psychosocial assessment, average length of hospital stay, waiting times for assessment, proportion of patients who self-discharged without an assessment, levels of repeat self-harm attendances and mean cost per patient attendance., Results: 298 patients attended ED for self-harm on 373 occasions between January and March 2014, and 318 patients attended on 381 occasions between January and March 2015. The proportion of ED attendances where patients received a psychosocial assessment increased from 57% to 68% (p=0.003), median waiting time decreased by 3 hours and 14 min (p=0.017), and the proportion of episodes where patients self-discharged without a psychosocial assessment decreased from 20% to 13% (p=0.022). The mean cost per patient attendance was marginally lower after the intervention (-£84; 95% CI -£254 to £77)., Conclusions: The extended LPS seems to have had a favourable effect on the management and outcomes of self-harm patients. The cost of extending the LPS' working hours might be partially offset by more efficient assessment and discharge. The impact of the extended LPS on the care of hospitalised patients with mental health problems other than self-harm requires further evaluation., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background Scales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking. Aims To evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months. Method A multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy. Results In total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% ( n = 145). Sensitivity ranged from 1% (95% CI 0-5) for the SAD PERSONS scale, to 97% (95% CI 93-99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2-47) for the Modified SAD PERSONS Scale to 47% (95% CI 41-53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50-0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69-0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk ( P <0.001). Conclusions Risk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm., Competing Interests: Declaration of interestD.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the NICE guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for depression. R.O.C. was a member of the NICE guideline development group for the longer-term management of self-harm and is a member of the Scottish Government's suicide prevention implementation and monitoring group., (© The Royal College of Psychiatrists 2017.)

Self-harm is common in young people, and can have profound effects on parents and other family members. We conducted narrative interviews with 41 parents and other family members of 38 young people, aged up to 25, who had self-harmed. Most of the participants were parents but included one sibling and one spouse. This article reports experiences of the parent participants. A cross-case thematic analysis showed that most participants were bewildered by self-harm. The disruption to their worldview brought about by self-harm prompted many to undergo a process of "sense-making"-by ruminative introspection, looking for information, and building a new way of seeing-to understand and come to terms with self-harm. Most participants appeared to have been successful in making sense of self-harm, though not without considerable effort and emotional struggle. Our findings provide grounds for a deeper socio-cultural understanding of the impact of self-harm on parents., (© The Author(s) 2015.)

Purpose: Self-harm patient management varies markedly between hospitals, with fourfold differences in the proportion of patients who are admitted to a medical or psychiatric inpatient bed. The current study aimed to investigate whether differences in admission practices are associated with patient outcomes (repeat self-harm) while accounting for differences in patient case mix., Methods: Data came from the National Self-Harm Registry Ireland. A prospective cohort of 43,595 self-harm patients presenting to hospital between 2007 and 2012 were included. As well as conventional regression analysis, instrumental variable (IV) methods utilising between hospital differences in rates of hospital admission were used in an attempt to gain unbiased estimates of the association of admission with risk of repeat self-harm., Results: The proportion of self-harm patients admitted to a medical bed varied from 10 to 74 % between hospitals. Conventional regression and IV analysis suggested medical admission was not associated with risk of repeat self-harm. Psychiatric inpatient admission was associated with an increased risk of repeat self-harm in both conventional and IV analyses. This increased risk persisted in analyses stratified by gender and when restricted to self-poisoning patients only., Conclusions: No strong evidence was found to suggest medical admission reduces the risk of repeat self-harm. Models of health service provision that encourage prompt mental health assessment in the emergency department and avoid unnecessary medical admission of self-harm patients appear warranted. Psychiatric inpatient admission may be associated with a heightened risk of repeat self-harm in some patients, but these findings could be biased by residual confounding and require replication., Competing Interests: Conflicts of Interest: None declared.

Background: Self-harm (intentional acts of non-fatal self-poisoning or self-injury) is common, particularly in young adults aged 15-35 years, often repeated, and strongly associated with suicide. Effective aftercare of individuals who self-harm is therefore important. We have undertaken a Cochrane systematic review and meta-analysis of the effectiveness of psychosocial interventions for self-harm in adults., Methods: We searched five electronic databases (CCDANCTR-Studies and References, CENTRAL, MEDLINE, Embase, and PsycINFO) between Jan 1, 1998, and April 29, 2015, for randomised controlled trials of psychosocial interventions for adults after a recent (within 6 months) episode of self-harm. Most interventions were assessed in single trials. We report results for interventions for which at least three randomised controlled trials comparing interventions with treatment as usual have been published and hence might contribute to clinical guidance. The primary outcome was repetition of self-harm at the conclusion of treatment and at 6, 12, and 24 months' follow-up analysed, when available, with the intention-to-treat method; if this was not possible, we analysed with all available case data., Findings: We identified 29 non-overlapping randomised controlled trials with three independent trials of the same intervention. Cognitive-behavioural-based psychotherapy (CBT; comprising cognitive-behavioural and problem-solving therapy) was associated with fewer participants repeating self-harm at 6 months' (odds ratio 0·54, 95% CI 0·34-0·85; 12 trials; n=1317) and at 12 months' follow-up (0·80, 0·65-0·98; ten trials; n=2232). There were also significant improvements in the secondary outcomes of depression, hopelessness, suicidal ideation, and problem solving. Patients receiving dialectical behaviour therapy (in three trials) were not less likely to repeat self-harm compared with those provided with treatment as usual at 6 months (odds ratio [OR] 0·59, 95% CI 0·16-2·15; n=267, three trials) or at 12 months (0·36, 0·05-2·47; n=172, two trials). However, the secondary endpoint of frequency of self-harm was associated with a significant reduction with use of dialectical behaviour therapy (mean difference -18·82, 95% CI -36·68 to -0·95). Four trials each of case management (OR 0·78, 95% CI 0·47-1·30; n=1608) and sending regular postcards (OR 0·87, 95% CI 0·62-1·23; n=3277) did not reduce repetition of self-harm., Interpretation: CBT seems to be effective in patients after self-harm. Dialectical behaviour therapy did not reduce the proportion of patients repeating self-harm but did reduce the frequency of self-harm. However, aside from CBT, there were few trials of other promising interventions, precluding firm conclusions as to their effectiveness., Funding: National Institute for Health Research., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Self-harm (SH; intentional self-poisoning or self-injury) is common, often repeated, and associated with suicide. This is an update of a broader Cochrane review first published in 1998, previously updated in 1999, and now split into three separate reviews. This review focuses on psychosocial interventions in adults who engage in self-harm., Objectives: To assess the effects of specific psychosocial treatments versus treatment as usual, enhanced usual care or other forms of psychological therapy, in adults following SH., Search Methods: The Cochrane Depression, Anxiety and Neurosis Group (CCDAN) trials coordinator searched the CCDAN Clinical Trials Register (to 29 April 2015). This register includes relevant randomised controlled trials (RCTs) from: the Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date)., Selection Criteria: We included RCTs comparing psychosocial treatments with treatment as usual (TAU), enhanced usual care (EUC) or alternative treatments in adults with a recent (within six months) episode of SH resulting in presentation to clinical services., Data Collection and Analysis: We used Cochrane's standard methodological procedures., Main Results: We included 55 trials, with a total of 17,699 participants. Eighteen trials investigated cognitive-behavioural-based psychotherapy (CBT-based psychotherapy; comprising cognitive-behavioural, problem-solving therapy or both). Nine investigated interventions for multiple repetition of SH/probable personality disorder, comprising emotion-regulation group-based psychotherapy, mentalisation, and dialectical behaviour therapy (DBT). Four investigated case management, and 11 examined remote contact interventions (postcards, emergency cards, telephone contact). Most other interventions were evaluated in only single small trials of moderate to very low quality.There was a significant treatment effect for CBT-based psychotherapy compared to TAU at final follow-up in terms of fewer participants repeating SH (odds ratio (OR) 0.70, 95% confidence interval (CI) 0.55 to 0.88; number of studies k = 17; N = 2665; GRADE: low quality evidence), but with no reduction in frequency of SH (mean difference (MD) -0.21, 95% CI -0.68 to 0.26; k = 6; N = 594; GRADE: low quality).For interventions typically delivered to individuals with a history of multiple episodes of SH/probable personality disorder, group-based emotion-regulation psychotherapy and mentalisation were associated with significantly reduced repetition when compared to TAU: group-based emotion-regulation psychotherapy (OR 0.34, 95% CI 0.13 to 0.88; k = 2; N = 83; GRADE: low quality), mentalisation (OR 0.35, 95% CI 0.17 to 0.73; k = 1; N = 134; GRADE: moderate quality). Compared with TAU, dialectical behaviour therapy (DBT) showed a significant reduction in frequency of SH at final follow-up (MD -18.82, 95% CI -36.68 to -0.95; k = 3; N = 292; GRADE: low quality) but not in the proportion of individuals repeating SH (OR 0.57, 95% CI 0.21 to 1.59, k = 3; N = 247; GRADE: low quality). Compared with an alternative form of psychological therapy, DBT-oriented therapy was also associated with a significant treatment effect for repetition of SH at final follow-up (OR 0.05, 95% CI 0.00 to 0.49; k = 1; N = 24; GRADE: low quality). However, neither DBT vs 'treatment by expert' (OR 1.18, 95% CI 0.35 to 3.95; k = 1; N = 97; GRADE: very low quality) nor prolonged exposure DBT vs standard exposure DBT (OR 0.67, 95% CI 0.08 to 5.68; k = 1; N =18; GRADE: low quality) were associated with a significant reduction in repetition of SH.Case management was not associated with a significant reduction in repetition of SH at post intervention compared to either TAU or enhanced usual care (OR 0.78, 95% CI 0.47 to 1.30; k = 4; N = 1608; GRADE: moderate quality). Continuity of care by the same therapist vs a different therapist was also not associated with a significant treatment effect for repetition (OR 0.28, 95% CI 0.07 to 1.10; k = 1; N = 136; GRADE: very low quality). None of the following remote contact interventions were associated with fewer participants repeating SH compared with TAU: adherence enhancement (OR 0.57, 95% CI 0.32 to 1.02; k = 1; N = 391; GRADE: low quality), mixed multimodal interventions (comprising psychological therapy and remote contact-based interventions) (OR 0.98, 95% CI 0.68 to 1.43; k = 1 study; N = 684; GRADE: low quality), including a culturally adapted form of this intervention (OR 0.83, 95% CI 0.44 to 1.55; k = 1; N = 167; GRADE: low quality), postcards (OR 0.87, 95% CI 0.62 to 1.23; k = 4; N = 3277; GRADE: very low quality), emergency cards (OR 0.82, 95% CI 0.31 to 2.14; k = 2; N = 1039; GRADE: low quality), general practitioner's letter (OR 1.15, 95% CI 0.93 to 1.44; k = 1; N = 1932; GRADE: moderate quality), telephone contact (OR 0.74, 95% CI 0.42 to 1.32; k = 3; N = 840; GRADE: very low quality), and mobile telephone-based psychological therapy (OR not estimable due to zero cell counts; GRADE: low quality).None of the following mixed interventions were associated with reduced repetition of SH compared to either alternative forms of psychological therapy: interpersonal problem-solving skills training, behaviour therapy, home-based problem-solving therapy, long-term psychotherapy; or to TAU: provision of information and support, treatment for alcohol misuse, intensive inpatient and community treatment, general hospital admission, or intensive outpatient treatment.We had only limited evidence on whether the intervention had different effects in men and women. Data on adverse effects, other than planned outcomes relating to suicidal behaviour, were not reported., Authors' Conclusions: CBT-based psychological therapy can result in fewer individuals repeating SH; however, the quality of this evidence, assessed using GRADE criteria, ranged between moderate and low. Dialectical behaviour therapy for people with multiple episodes of SH/probable personality disorder may lead to a reduction in frequency of SH, but this finding is based on low quality evidence. Case management and remote contact interventions did not appear to have any benefits in terms of reducing repetition of SH. Other therapeutic approaches were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to these interventions is inconclusive.