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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: The use of advance care planning and advance decisions for psychiatric care is growing. However, there is limited guidance on clinical management when a patient presents with suicidal behaviour and an advance decision and no systematic reviews of the extant literature., Objectives: To synthesise existing literature on the management of advance decisions and suicidal behaviour., Design: A systematic search of seven bibliographic databases was conducted to identify studies relating to advance decisions and suicidal behaviour. Studies on terminal illness or end-of-life care were excluded to focus on the use of advance decisions in the context of suicidal behaviour. A textual synthesis of data was conducted, and themes were identified by using an adapted thematic framework analysis approach., Results: Overall 634 articles were identified, of which 35 were retained for full text screening. Fifteen relevant articles were identified following screening. Those articles pertained to actual clinical cases or fictional scenarios. Clinical practice and rationale for management decisions varied. Five themes were identified: (1) tension between patient autonomy and protecting a vulnerable person, (2) appropriateness of advance decisions for suicidal behaviour, (3) uncertainty about the application of legislation, (4) the length of time needed to consider all the evidence versus rapid decision-making for treatment and (5) importance of seeking support and sharing decision-making., Conclusions: Advance decisions present particular challenges for clinicians when associated with suicidal behaviour. Recommendations for practice and supervision for clinicians may help to reduce the variation in clinical practice., Competing Interests: Competing interests: DG, KH and NK are members of the Department of Health’s (England) National Suicide Prevention Advisory Group. NK 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. KH and DG are NIHR Senior Investigators. KH is also supported by the Oxford Health NHS Foundation Trust and NK by the Greater Manchester Mental Health NHS Foundation Trust., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Observational studies are suited to examining links between the routine hospital management of self-harm and future suicide and all-cause mortality due to their large scale. However, care must be taken when attempting to infer causal associations in non-experimental settings., Methods: Data from the Multicentre Study of Self-Harm in England were used to examine associations between four types of hospital management (specialist psychosocial assessment, general hospital admission, psychiatric outpatient referral and psychiatric admission) following self-harm and risks of suicide and all-cause mortality in the subsequent 12 months. Missing data were handled by multiple imputation and propensity score (PS) methods were used to address observed differences between patients at baseline. Unadjusted, PS stratified and PS matched risk ratios (RRs) were calculated., Results: The PSs balanced the majority of baseline differences between treatment groups. Unadjusted RRs showed that all four treatment types were associated with either increased risks or no change in risks of suicide and all-cause mortality within a year. None of the four types of hospital management were associated with lowered risks of suicide or all-cause mortality following propensity score stratification (psychosocial assessment and medical admission) and propensity score matching (psychiatric outpatient referral and psychiatric admission), though there was no longer an increased risk among people admitted to a psychiatric bed. Individuals who self-cut were at an increased risk of death from any cause following psychosocial assessment and medical admission. Medical admission appeared to be associated with reduced risk of suicide in individuals already receiving outpatient or GP treatment for a psychiatric disorder., Conclusions: More intensive forms of hospital management following self-harm appeared to be appropriately allocated to individuals with highest risks of suicide and all-cause mortality. PS adjustment appeared to attenuate only some of the observed increased risks, suggesting that either differences between treatment groups remained, or that some treatments had little impact on reducing subsequent suicide or all-cause mortality risk. These findings are in contrast to some previous studies that have suggested psychosocial assessment by a mental health specialist reduces risk of repeat self-harm. Future observational self-harm studies should consider increasing the number of potential confounding variables collected., Competing Interests: D.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. All other authors declare no conflict of interest. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials, as detailed online in the guide for authors.

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: The care received by people presenting to hospital following self-harm varies and it is unclear how different types of treatment affect risk of further self-harm., Method: Observational cohort data from the Manchester Self-Harm Project, UK, included 16 456 individuals presenting to an Emergency Department with self-harm between 2003 and 2011. Individuals were followed up for 12 months. We also used data from a smaller cohort of individuals presenting to 31 hospitals in England during a 3-month period in 2010/2011, followed up for 6 months. Propensity score (PS) methods were used to address observed confounding. Missing data were imputed using multiple imputation., Results: Following PS stratification, those who received a psychosocial assessment had a lower risk of repeat hospital attendance for self-harm than those who were not assessed [RR 0.87, 95% confidence interval (CI) 0.80-0.95]. The risk was reduced most among people less likely to be assessed. Following PS matching, we found no associations between risks of repeat self-harm and admission to a medical bed, referral to outpatient psychiatry or admission to a psychiatric bed. We did not find a relationship between psychosocial assessment and repeat self-harm in the 31 centre cohort., Conclusions: This study shows the potential value of using novel statistical techniques in large mental health datasets to estimate treatment effects. We found that specialist psychosocial assessment may reduce the risk of repeat self-harm. This type of routine care should be provided for all individuals who present to hospital after self-harm, regardless of perceived risk.

Background: Repetition of self-harm is common and is strongly associated with suicide. Despite this, there is limited research on high-volume repetition., Aim: To investigate individuals with high-volume repeat self-harm attendances to the emergency department (ED), including their patterns of attendance and mortality., Method: Data from the Multicentre Study of Self-Harm in England were used. High-volume repetition was defined as ⩾15 attendances within 4 years. An attendance timeline was constructed for each high-volume repeater (HVR) and the different patterns of attendance were explored using an executive sorting task and hierarchical cluster analysis., Results: A small proportion of self-harm patients are HVRs (0.6%) but they account for a large percentage of self-harm attendances (10%). In this study, the new methodological approach resulted in three types of attendance patterns. All of the HVRs had clusters of attendance and a greater proportion died from external causes compared with non-HVRs., Conclusion: The approach used in this study offers a new method for investigating this problem that could have both clinical and research benefits. The need for early intervention is highlighted by the large number of self-harm episodes per patient, the clustered nature of attendances, and the higher prevalence of death from external causes.

Background: Clinical guidelines have recommended psychosocial assessment of self-harm patients for years, yet estimates of its impact on the risk of repeat self-harm vary. Assessing the association of psychosocial assessment with risk of repeat self-harm is challenging due to the effects of confounding by indication., Methods: We analysed data from a cohort study of 15,113 patients presenting to the emergency departments of three UK hospitals to investigate the association of psychosocial assessment with risk of repeat hospital presentation for self-harm. Time of day of hospital presentation was used as an instrument for psychosocial assessment, attempting to control for confounding by indication., Results: Conventional regression analysis suggested psychosocial assessment was not associated with risk of repeat self-harm within 12 months (Risk Difference (RD) 0.00 95% confidence interval (95%CI) -0.01 to 0.02). In contrast, IV analysis suggested risk of repeat self-harm was reduced by 18% (RD -0.18, 95%CI -0.32 to -0.03) in those patients receiving a psychosocial assessment. However, the instrument of time of day did not remove all potential effects of confounding by indication, suggesting the IV effect estimate may be biased., Conclusions: We found that psychosocial assessments reduce risk of repeat self-harm. This is in-line with other non-randomised studies based on populations in which allocation to assessment was less subject to confounding by indication. However, as our instrument did not fully balance important confounders across time of day, the IV effect estimate should be interpreted with caution.

Background: Hopelessness is frequently observed in people who harm themselves and is an established risk factor for nonfatal self-harm repetition and suicide. Little is known about how the presence of hopelessness in addition to other risk factors affects subsequent risk., Method: Prospective cohort of 19,479 individuals presenting with self-harm to one of three English Emergency Departments between 1st January 2000 and 31st December 2010. Repeat self-harm and suicide deaths within twelve months of the first assessed episode were identified. Cox Proportional Hazards models were used to estimate Hazard Ratios (HRs) for risk factors with and without hopelessness., Results: A clinical impression of hopelessness was associated with increased risk of further self-harm (HR 1.35, 95% CI 1.16-1.58) and suicide (HR 2.56, CI 1.10-5.96) in the year following an index episode. For individuals who were living alone or homeless, unemployed, reported problems with housing, had received psychiatric treatment in the past, were currently receiving treatment or used alcohol during the self-harm episode, an exacerbation of an already elevated risk of repetition was observed amongst those who were assessed as hopeless. Where individuals presented with forensic problems, physical health problems or bereavement, an increase in risk was only observed for those who were also assessed as hopeless., Limitations: A clinical impression of hopelessness was assigned using a binary "yes"/"no" classification rather than a validated scale., Conclusions: Hopelessness intensifies the impact of several known risk factors for adverse outcomes following self-harm. These findings highlight the importance of identifying and therapeutically addressing this dynamic but potentially modifiable clinical risk factor during the psychosocial assessment and in subsequent care., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Objectives: Alcohol use and misuse are strongly associated with self-harm and increased risk of future self-harm and suicide. The UK general population prevalence of alcohol use, misuse and alcohol-attributable harm has been rising. We have investigated the prevalence of and trends in alcohol use and misuse in self-harm patients and their associations with repeat self-harm and subsequent death., Methods: We used patient data from the Multicentre Study of Self-Harm in England for 2000-2009 and UK mortality data for patients presenting from 2000 to 2007 who were followed up to the end of 2009., Results: Alcohol involvement in acts of self-harm (58.4%) and alcohol misuse (36.1%) were somewhat higher than found previously in self-harm patients. Alcohol involvement and misuse were most frequent in men, those aged 35-54 years and those from white ethnicities. The frequency of alcohol misuse increased between 2000 and 2009, especially in women. Repetition of self-harm was associated with alcohol involvement in self-harm and particularly with alcohol misuse. Risk of suicide was increased significantly in women misusing alcohol., Conclusions: Alcohol use and misuse in self-harm patients appears to have increased in recent years, particularly in women. The association of alcohol with greater risk of self-harm repetition and mortality highlights the need for clinicians to investigate alcohol use in self-harm patients. Ready availability of alcohol treatment staff in general hospitals could facilitate appropriate aftercare and the prevention of adverse outcomes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Self-poisoning and self-injury are associated with a high risk of suicide or death from any cause but the effect of routine aspects of hospital management on mortality risk is unknown., Methods: We did a prospective cohort study using data for adults who had self-harmed presenting to five emergency departments in the UK between 2000 and 2010. We assessed the relation between four aspects of management (psychosocial assessment, medical admission, psychiatric admission, referral for mental health follow-up) and death by suicide or any cause within 12 months of presentation., Findings: Of 38 415 individuals presenting with self-harm, 261 (0·7%) died by suicide and 832 (2·2%) died from any cause within 12 months. Most aspects of management were associated with a higher mortality risk in unadjusted analyses. Psychiatric admission was associated with the highest risks for both suicide (hazard ratio 2·35, 95% CI 1·59-3·45) and all-cause mortality (2·35, 2·04-2·72). After adjustment for baseline variables, the hazard ratios were generally smaller, particularly for psychiatric admission. There were significant interactions by sex, age, and history of self-harm., Interpretation: This was an observational study and so we cannot infer causation. However, our finding that clinical services seem to reserve the most intensive levels of treatment for patients at highest risk is reassuring. Aspects of routine management might be associated with a lower mortality risk but these effects vary by clinical subgroup., Funding: UK Department of Health., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: There has been little previous research on self-harm among people of Chinese origin living in the UK, although this population has grown substantially in recent years and China is now the largest source of international students at UK universities., Methods: We conducted a prospective cohort study using self-harm presentation data (1997-2011) collected from three hospitals in the City of Manchester, which has the largest Chinese population across all UK Local Authorities. Rate ratios between the Chinese and White groups were calculated using Poisson regression models. Chi-square tests (or Fisher's exact tests), logistic regression, and log-binomial regression were used to examine differences in characteristics and clinical management between groups., Results: Ethnicity was known in the study cohort for 23,297 (87%) amongst 26,894 individuals aged 15 years and above. A total number of 97/23,297 (0.4%) people of Chinese ethnic origin presented with self-harm over the study period and 20,419 (88%) were White people. Incidence of self-harm in the Chinese group (aged 16-64 years) was less than one fifth of that found in White people (0.6 versus 3.2 per 1000 person-years; rate ratio 0.18, 95% confidence interval 0.13-0.24), and was particularly low amongst men of Chinese origin. Individuals of Chinese origin who presented with self-harm were younger, more likely to be female and students, and more likely to self-injure and describe relationship problems as a precipitant than White people. They were less likely to have clinical risk factors such as drug/alcohol misuse and receiving psychiatric treatment, and were rated to have lower risk of self-harm repetition by treating clinicians., Conclusion: Future research needs to investigate whether the low incidence of self-harm presenting to hospitals amongst people of Chinese origin truly reflects a lower frequency of self-harm, or alternatively is due to markedly different post-episode help-seeking behaviours or student overrepresentation in this ethnic group. Relevant healthcare professionals need to be aware of the risk characteristics of people of Chinese origin who self-harm.

Introduction: Studies have shown wide variations in delivery of self-harm services but it is unclear how these relate to important outcomes such as self-harm repetition., Methods: Data were collected on self-harm presentations and hospital management from 31 hospitals in England. Key staff were interviewed about service provision for self-harm patients and responses were mapped to a 21-item service quality scale. Our main outcome was repeat hospital-presenting self-harm within six months., Results: 6347 individuals presented with 7599 episodes of self-harm during a three month period in 2010-2011. Re-attendance with self-harm within six months of index episode occurred in 21% (1308/6347) of individuals (range between hospitals 9-27%). We found little association between clinical management at hospital level (i.e. proportion of episodes receiving psychosocial assessment, medical or psychiatric admission, and referral to statutory or non-statutory services) and repetition rate. The median score on service quality scale was 14.5 (range between hospitals 10.5-19). There was no evidence of correlation between total service quality score and repetition of self-harm (Spearman׳s r=-0.06, p=0.73) or between individual service items and repetition., Limitations: We did not explore certain aspects of service provision e.g. quality of psychosocial assessments and length of admission. Hospital presentation for repeat self-harm may not be the most reliable measure of service quality., Conclusion: At aggregate level aspects of management and service structures did not appear to be associated with self-harm repetition rates. Future research should focus on better understanding the processes underlying the delivery of services at hospital level and their relationship to outcome., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Objectives: To assess alcohol-related premature death in people who self-harm compared to the general population, including variation by socioeconomic deprivation., Design: A retrospective longitudinal cohort analysis from the Multicentre Study of self-harm in England, 1 January 2000 to 31 December 2010, with cause-specific mortality follow-up through to 31 December 2012., Setting: Six emergency departments in Oxford, Manchester and Derby., Participants: All individuals aged 15 years or more who presented with self-harm (n = 39,014) to general hospital emergency departments, together with follow-up mortality information from the Data Linkage Service of the Health and Social Care Information Centre., Main Outcome Measures: STANDARDISED MORTALITY RATIOS (OBSERVED/EXPECTED NUMBER OF DEATHS: SMRs) and mean number of years of life lost (YLL) were estimated for alcohol-related mortality. Patients' characteristics and clinical management following self-harm were also examined., Results: After 7.5 years' (median) follow-up, 2695 individuals (6.9%) had died, significantly more males (9.5%) than females (5.0%), including 307 (11.4%) from alcohol-related causes. Alcohol-related death was more frequent than expected in both males (SMR 8.5, 95% CI 7.3 to 9.8) and females (11.6, 9.8 to 13.7), equating to 33.7 YLL (95% CI 32.4 to 35.0) in males and 38.1 YLL (36.6 to 39.6) in females. It was not associated with area-level socioeconomic deprivation. Alcohol-related death was associated with unemployed/sick/disabled status, alcohol use during self-harm, referral to drug/alcohol services and lack of psychosocial assessment following self-harm., Conclusions: Hospital-presenting self-harm patients should receive assessment following self-ham according to national guidance to enable early identification and treatment of alcohol problems.

Background: Evidence to guide clinical management of self-harm is sparse, trials have recruited selected samples, and psychological treatments that are suggested in guidelines may not be available in routine practice., Aims: To examine how the management that patients receive in hospital relates to subsequent outcome., Methods: We identified episodes of self-harm presenting to three UK centres (Derby, Manchester, Oxford) over a 10 year period (2000 to 2009). We used established data collection systems to investigate the relationship between four aspects of management (psychosocial assessment, medical admission, psychiatric admission, referral for specialist mental health follow up) and repetition of self-harm within 12 months, adjusted for differences in baseline demographic and clinical characteristics., Results: 35,938 individuals presented with self-harm during the study period. In two of the three centres, receiving a psychosocial assessment was associated with a 40% lower risk of repetition, Hazard Ratios (95% CIs): Centre A 0.99 (0.90-1.09); Centre B 0.59 (0.48-0.74); Centre C 0.59 (0.52-0.68). There was little indication that the apparent protective effects were mediated through referral and follow up arrangements. The association between psychosocial assessment and a reduced risk of repetition appeared to be least evident in those from the most deprived areas., Conclusion: These findings add to the growing body of evidence that thorough assessment is central to the management of self-harm, but further work is needed to elucidate the possible mechanisms and explore the effects in different clinical subgroups.

Background: Little information is available to inform clinical assessments on risk of self-harm repetition in ethnic minority groups., Methods: In a prospective cohort study, using data collected from six hospitals in England for self-harm presentations occurring between 2000 and 2007, we investigated risk factors for repeat self-harm in South Asian and Black people in comparison to Whites., Results: During the study period, 751 South Asian, 468 Black and 15,705 White people presented with self-harm in the study centres. Repeat self-harm occurred in 4379 individuals, which included 229 suicides (with eight of these fatalities being in the ethnic minority groups). The risk ratios for repetition in the South Asian and Black groups compared to the White group were 0.6, 95% CI 0.5-0.7 and 0.7, 95% CI 0.5-0.8, respectively. Risk factors for repetition were similar across all three groups, although excess risk versus Whites was seen in Black people presenting with mental health symptoms, and South Asian people reporting alcohol use and not having a partner. Additional modelling of repeat self-harm count data showed that alcohol misuse was especially strongly linked with multiple repetitions in both BME groups., Limitations: Ethnicity was not recorded in a third of cases which may introduce selection bias. Differences may exist due to cultural diversity within the broad ethnic groups., Conclusion: Known social and psychological features that infer risk were present in South Asian and Black people who repeated self-harm. Clinical assessment in these ethnic groups should ensure recognition and treatment of mental illness and alcohol misuse., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Background: Self-harm (intentional self-poisoning and self-injury) in children and adolescents is often repeated and is associated with increased risk of future suicide. We have investigated factors associated with these outcomes., Method: We used data collected in the Multicentre Study of Self-harm in England on all self-harm hospital presentations by individuals aged 10-18 years between 2000 and 2007, and national death information on these individuals to the end of 2010. Cox hazard proportional models were used to identify independent and multivariable predictors of repetition of self-harm and of suicide., Results: Repetition of self-harm occurred in 27.3% of individuals (N = 3920) who presented between 2000 and 2005 and were followed up until 2007. Multivariate analysis showed that repetition was associated with age, self-cutting, and previous self-harm and psychiatric treatment. Of 51 deaths in individuals who presented between 2000 and 2007 and were followed up to 2010 (N = 5133) half (49.0%) were suicides. The method used was usually different to that used for self-harm. Multivariate analysis showed that suicide was associated with male gender [Hazard ratio (HR) = 2.4, 95% CI 1.2-4.8], self-cutting (HR = 2.1, 95% CI 1.1-3.7) and prior psychiatric treatment at initial presentation (HR = 4.2, 95% CI 1.7-10.5). It was also associated with self-cutting and history of psychiatric treatment at the last episode before death, and history of previous self harm., Conclusions: Self-cutting as a method of self-harm in children and adolescents conveys greater risk of suicide (and repetition) than self-poisoning although different methods are usually used for suicide. The findings underline the need for psychosocial assessment in all cases., (© 2012 The Authors. Journal of Child Psychology and Psychiatry © 2012 Association for Child and Adolescent Mental Health.)

Background: People who self-harm have an increased risk of premature death. The aim of this study was to investigate cause-specific premature death in individuals who self-harm, including associations with socioeconomic deprivation., Methods: We undertook a cohort study of patients of all ages presenting to emergency departments in Oxford, Manchester, and Derby, UK, after self-poisoning or self-injury between Jan 1, 2000, and Dec 31, 2007. Postcodes of individuals' place of residence were linked to the Index of Multiple Deprivation 2007 in England. Mortality information was supplied by the Medical Research Information Service of the National Health Service. Patients were followed up to the end of 2009. We calculated age-standardised mortality ratios (SMRs) and years of life lost (YLL), and we tested for associations with socioeconomic deprivation., Findings: 30 950 individuals presented with self-harm and were followed up for a median of 6·0 years (IQR 3·9-7·9). 1832 (6·1%) patients died before the end of follow-up. Death was more likely in patients than in the general population (SMR 3·6, 95% CI 3·5-3·8), and occurred more in males (4·1, 3·8-4·3) than females (3·2, 2·9-3·4). Deaths due to natural causes were 2-7·5 times more frequent than was expected. For individuals who died of any cause, mean YLL was 31·4 years (95% CI 30·5-32·2) for male patients and 30·7 years (29·5-31·9) for female patients. Mean YLL for natural-cause deaths was 25·9 years (25·7-26·0) for male patients and 25·5 years (25·2-25·8) for female patients, and for external-cause deaths was 40·2 years (40·0-40·3) and 40·0 years (39·7-40·5), respectively. Disease of the circulatory (13·1% in males; 13·0% in females) and digestive (11·7% in males; 17·8% in females) systems were major contributors to YLL from natural causes. All-cause mortality increased with each quartile of socioeconomic deprivation in male patients (χ(2) trend 39·6; p<0·0001), female patients (13·9; p=0·0002), and both sexes combined (55·4; p<0·0001). Socioeconomic deprivation was related to mortality in both sexes combined from natural causes (51·0; p<0·0001) but not from external causes (0·30; p=0·58). Alcohol problems were associated with death from digestive-system disease, drug misuse with mental and behavioural disorders, and physical health problems with circulatory-system disease., Interpretation: Physical health and life expectancy are severely compromised in individuals who self-harm compared with the general population. In the management of self-harm, clinicians assessing patients' psychosocial problems should also consider their physical needs., Funding: Department of Health Policy Research Programme., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

We examined epidemiology and characteristics of self-harm in adolescents and impact of national guidance on management. Data were collected in six hospitals in three centres between 2000 and 2007 in the Multicentre Study of Self-harm in England. Of 5,205 individuals (7,150 episodes of self-harm), three-quarters were female. The female:male ratio in 10-14 year-olds was 5.0 and 2.7 in 15-18 year-olds. Rates of self-harm varied somewhat between the centres. In females they averaged 302 per 100,000 (95 % CI 269-335) in 10-14 year-olds and 1,423 (95 % CI 1,346-1,501) in 15-18 year-olds, and were 67 (95 % CI 52-82) and 466 (95 % CI 422-510), respectively, in males. Self-poisoning was the most common method, involving paracetamol in 58.2 % of episodes. Presentations, especially those involving alcohol, peaked at night. Repetition of self-harm was frequent (53.3 % had a history of prior self-harm and 17.7 % repeated within a year). Relationship problems were the predominant difficulties associated with self-harm. Specialist assessment occurred in 57 % of episodes. Self-harm in children and adolescents in England is common, especially in older adolescents, and paracetamol overdose is the predominant method. National guidance on provision of psychosocial assessment in all cases of self-harm requires further implementation.

Objective: Self-harm is closely related to completed suicide, especially in older age. As empirical research of self-harm in older age is scarce, with no studies confined to first-ever episodes in older age, we examined the clinical characteristics and the risk of repetition in first-ever self-harm in older age., Method: The Manchester Self-Harm (MaSH) project, a prospective cohort study, gathered data from September 1, 1997, through August 31, 2007, for individuals presenting with self-harm at emergency departments of 3 large hospitals in North West England. The characteristics of older patients (aged ≥ 55 years) who presented with a first-ever episode of self-harm are described and compared to those of middle-aged patients (35-54 years) presenting with a first-ever episode of self-harm. Following each episode, the MaSH form, a standard assessment form developed for the MaSH project, was completed by a clinician. Potential risk factors for repetition were examined by Cox regression analyses., Results: A total of 374 older patients and 1,937 middle-aged patients presented with a first-ever episode of self-harm. The circumstances at the time of self-harm suggested higher suicidal intent in older age. In comparison with middle-aged patients, the rate of repetition in older-aged patients was lower (15.4% versus 11.8%, respectively; hazard ratio for older age = 0.65; 95% CI, 0.45-0.93; P = .019), although repetition was more often fatal among the older group (3.3% versus 13.6%, respectively; P = .009). The most important predictor of repetition in older age, ie, physical health problems, had no predictive value in middle-aged patients, whereas psychiatric characteristics had little impact on the risk of repetition in old age., Conclusions: High suicidal intent and different predictors of repetition in first-ever self-harm in older age highlight the need for age-specific interventions beyond the scope of psychiatric care alone., (© Copyright 2011 Physicians Postgraduate Press, Inc.)

The objectives of this study were to identify 1) the proportion of self-harm episodes that resulted in assessment by a specialist self-harm team and offers, attendance, and completion of brief therapy and 2) the factors associated with these treatment options. A prospective cohort study of 717 hospital presentations of self-harm was conducted. Rates of assessment, offers and completion of therapy ranged from 50% to 60%. Of those offered therapy, 73% attended one or more sessions. Attendance was associated with depressive psychopathology and existing treatment in primary care. These results may reflect some of the challenges of engaging this patient group. We found that receipt of treatment was determined by patient factors. Future studies might also examine the role of service-related or clinician factors.

We analyzed retrospectively 1191 cases of bone graft harvesting of the iliac crest which had been performed at our hospital between 1982 and 1991. There was an operative revision rate of 2.8%. For further study, we analyzed the clinical reports of all autograft (iliac crest) donors in a representative year (1991) and re-examined all those who still had symptoms. A total of 104 grafts were taken from 97 patients. Of these, 18 developed postoperative complications (19.6%), such as hematoma, which could usually be treated with local procedures such as aspiration. The rate of hematoma tended to be lower in those patients who had received a local coagulant, but this was not significant. Of the patients 55% still had problems 1 year after operation at the time of re-examination, but in most cases they were minor, for example, local irritation or discomfort. Serious problems developed in those patients who had a palpable defect of the iliac crest. We advise using local coagulants to decrease the rate of postoperative complications, although we cannot statistically prove the effect. When large grafts are harvested, the iliac crest should be reconstructed for better long-term results.