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Ness, J., Hawton, K., Bergen, H., Waters, K., Kapur, N., Cooper, J., Steeg, S., Clarke, M. (2016). High volume repeaters of self-harm: Characteristics, patterns of emergency department attendance and subsequent deaths based on findings from the Multicentre Study of Self-harm in England. CRISIS, Oct 12:1-11. Link to the paper.

Self-harm is a behaviour which is often repeated and is associated with an increased risk of dying by suicide. In this study, we explored how common repeat attendance to the emergency department (ED) following self-harm was and the patterns of attendance amongst those who attended most frequently. Data collected as part of the Multicentre Study of Self-harm in England. High volume repetition was defined as ≥15 attendances to the ED following self-harm within four years. Every person with high volume repetition had an ED attendance timeline created. These timelines were then subjected to an executive sorting task and a hierarchical cluster analysis to try to identify similar groupings of patterns of presentations. We found that a very small number of people attending ED following self-harm did so frequently. Thus just 0.6% of patients fitted our high volume repeater definition, but they accounted10% of all the self-harm attendances to ED. Three types of attendance patterns were identified: 1. intermittent attendance with few clusters, 2. intermittent attendance with multiple clusters, 3. most frequent attendees. We also found that a greater proportion of those attending ED frequently subsequently died from external causes (e.g. accidental, suicide) compared to those who did not repeat self-harm frequently.
Conclusions: Individuals who frequently attend ED following self-harm represent a very small proportion of self-harm patients but account for a large number of all self-harm attendances. The need for early intervention is highlighted by the large clustered nature of attendances and the higher frequency of death from external causes. The research methods used in this study offer a new way of exploring very frequent repeat self-harm behaviour, which could have both clinical and research benefits.


Turnbull, P., Webb, R., Kapur, N., Clements, C., Bergen, H., Hawton, K., Ness, J., Waters, K., Townsend, E., Cooper, J. (2015). Variation by ethnic group in premature mortality risk following self-harm: a multicentre cohort study in England. BMC Psychiatry. Link to the paper.

People who self-harm are known to be at increased risk of dying early. There are differences in rates of self-harm and risk factors associated with self-harm for different ethnic groups, yet little is known about the influence of ethnicity on death after self-harm. We used data from the Multicentre Study of Self-harm in England, linked to a national mortality dataset, to investigate early death in South Asian and Black people, and compared them to early deaths in White people following a hospital presentation for self-harm. After adjusting for age, gender and area-level socioeconomic deprivation, we found that the risk of death by any cause was lower in South Asian and Black people after self-harm, than it was in White people after self-harm. Risk of dying by suicide after self-harm was much lower in Black people than in White people. We also found that many risk factors usually associated with dying early after self-harm, such as psychiatric treatment or concurrent alcohol misuse, were seen less often in South Asian and Black people than in White people. 
Conclusions: The risk of dying after a hospital presentation for self-harm is lower in South Asian and Black people than White people in the UK. South Asian and Black people also have fewer risk factors for premature death. This may truly reflect a lower risk of dying early after a hospital presentation for self-harm, but may also be a result of different help-seeking strategies employed by South Asian and Black people, who may be less likely that White people to attend hospital following self-harm. 


Kapur, N., Steeg S, Turnbull, P., Webb, R., Bergen, H., Hawton, K., Geulayov, G., Townsend, E., Ness, J., Waters, K., Cooper, J. (2015). Hospital management of suicidal behavious and subsequent mortality: a prospective cohort study. Lancet Psychiatry. Link to the paper.

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. We followed up 38,145 people admitted to hospital following self-harm between 2000 and 2010 to investigate the association between the treatments patients receive in hospital (psychosocial assessment, medical admission, psychiatric admission, referral for mental health follow-up) and their subsequent risk of death. We found that most aspects of management were associated with increased mortality risk, and psychiatric admission or mental health follow-up were associated with the highest risk of death. This finding suggests that hospitals might be reserving the most intensive treatments for the patients at greatest need. There were significant interactions by subgroup, suggesting that the association between management and outcome was not the same for all people. In particular, admission to an inpatient psychiatric ward might reduce 12 month all-cause mortality in some high risk groups (men, adults older than 65 years, and those with a history of self-harm). 
Conclusions:The findings of this study show how high the risk of suicide and other premature death can be for patients who attend A&E after self-harm. The risk is elevated further for people requiring the most intensive forms of clinical management, such as referral to outpatient mental health services and psychiatric hospital admission. Reassuringly, these findings indicate clinicians are appropriately allocating treatment. When we take into account some of the differences between patients, admission to inpatient psychiatry appears to have benefits in terms of reducing suicide and other early death in some subgroups. 


Hawton, K., Bergen, H., Cooper, J., Turnbull, P., Waters, K., Ness, J. & Kapur, N. (2015) Suicide following self-harm: findings from the Multicentre Study of self-harm in England, 2000-2012. Journal of Affective Disorders 175, 147-51. Link to the paper.

Self-harm is a key risk factor for suicide and it is important to have up-to-date information on the extent of this risk. We followed up 40,346 self-harm patients identified in the three centres of the Multicentre Study of Self-harm in England between 2000 and 2010. By the end of 2012, 2704 individuals had died. Nearly one in five of the deaths were by suicide (including open verdicts), which occurred in 1.6% of patients (2.6% of males and 0.9% of females). Overall, 0.5% of individuals died by suicide in the first year (including 0.82% of males and 0.27% of females), during which time the risk was 49 times greater than the risk of suicide in the general population. Risk of suicide increased with age. While self-poisoning had been the most frequent method of self-harm, hanging was the most common method of subsequent suicide, particularly in males. The number of suicides was probably a considerable underestimate as there were also a large number of deaths recorded as accidents, the majority of which were poisonings (these often involving psychotropic drugs).
Conclusions: The findings underline the importance of suicide prevention initiatives focused on the self-harm population, especially during the initial months following an episode of self-harm. Estimates of using suicide and open verdicts may underestimate the true risk of suicide following self-harm and inclusion of accidental poisonings may be warranted in future risk estimates. 


Owens, D, Kelley, R., Munyombwe, T., Bergen, H., Hawton, K., Cooper, J., Ness, J., Waters, K., West, R. & Kapur N. (2015). Switching methods of self-harm at repeat episodes: Findings from a multicentre cohort study. Journal of Affective Disorders 180, 44-51. Link to the paper.

It is recognised that people who self-harm more than once may switch from one method of self-harm to another. In this study we aimed to find out the frequency, pattern, determinants and characteristics of changes in methods of self-harm in individuals presenting to general hospitals. We used information on over 33,000 consecutive self-harm episodes identified in six general hospitals in Manchester, Derby and Oxford between 2003 and 2007. Over an average of 30 months of follow-up, 23% of people repeated self-harm and one-third of them switched method, often with a very short time interval between episodes, and especially where the person was male, younger, or had self-harmed previously. Self-poisoning was far less likely than other methods to be followed by switching of method. 
Conclusions: When self-harm is repeated the method used often changes, but the nature of the change may be relatively unpredictable, except that this less often occurs following self-poisoning. Clinicians should therefore avoid potentially misleading assumptions about risks or needs of patients based simply on the method of harm. 


Bergen, H., Hawton, K., Webb, R., Cooper, J., Steeg, S., Haigh, M., Ness, J., Waters, K. & Kapur N. (2014). Alcohol-related mortality following self-harm: a multicentre cohort study. JRSM Open, 5(8), 2054270414533326. Link to the paper.

We assessed alcohol-related premature death in people who self-harm compared to the general population, including differences in risk according to socioeconomic status. We studied 39,014 individuals aged 15 years or more who presented to emergency departments in Oxford, Manchester or Derby following self-harm between 2000 and 2010 and identified deaths up to the end of 2012. After an average (median) of 7.5 years' follow-up, 2695 individuals (6.9%) had died, including significantly more males (9.5%) than females (5.0%). Overall, 307 (11.4%) individuals had died from alcohol-related causes. Alcohol-related death was far more frequent than expected in both males and females. Taking account of the age when deaths occurred, deaths from alcohol-related causes occurred some 34 years earlier than would have been expected in male patients and some 38 years earlier in female patients. This was unrelated to the level of socioeconomic deprivation in the areas where individuals lived. 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: Alcohol-related deaths contribute substantially to premature deaths in self-harm patients. During the assessment of patients following self-harm there should be a particular focus on possible alcohol misuse to enable early detection and treatment of alcohol problems. This requires easy access to alcohol misuse services. It could contribute to prevention of premature death from alcohol-related causes.


Steeg, S., & Kapur, N. (2011). How do methods used in previous episodes of non-fatal self-harm relate to eventual suicide? Journal of Affective Disorders, 136, 526-533. Link to the paper.

Methods used at an index episode of non-fatal self-harm may predict risk of future suicide. In this study we investigated suicide risk associated with most recent non-fatal method, and whether or not change in method was important. Increased risks of suicide by injury were found for individuals who used self-cutting, hanging/ asphyxiation, carbon monoxide/other gas, traffic-related and other self-injury at the last episode of self-harm (1.8 to 5-fold risks compared to poisoning). One-third who died by suicide used the same method for their last self-harm and for suicide, including 41% who self-poisoned.
Conclusions: Individuals using dangerous methods of self-harm, such as hanging and inhalation of car exhaust or other gas, should receive particularly intensive follow-up after a non-fatal attempt. There appears to be no pattern in change of method in the last two episodes of self-harm which leads to increased risk of suicide. Other factors need to be considered, as well as last method non-fatal self-harm, when suicide risk is assessed in the emergency department. 

See also: Evid Based Mental Health


Bergen, H., Hawton, K., Kapur, N., Cooper, J., Steeg, S., Ness, J., & Waters, K. (2011). Shared characteristics of suicides and other unnatural deaths following non-fatal self-harm? A multicentre study of risk factors. Psychological Medicine. Link to the paper.

In this study we compared the risk of death by suicide and by accidental cause in individuals who had previously presented to Emergency Departments with self-harm during 2000 to 2007. Individuals were followed up to the end of 2009 using national death registers to identifydeaths and ascertain the cause. There were many risks common to both types of death, such as being male, of older age and having a history of psychiatric treatment. Individuals who died by suicide were more likely to have previously self-harmed, particularly using violent methods or self-cutting rather than poisoning, and to have mental health problems. Individuals dying by accidental narcotic poisoning (or non-narcotic poisoning) were likely to have had recreational/ illicit drug (or alcohol) problems at their last episode of non-fatal self-harm.
Conclusions: Individuals who died by suicide and by accidents have many things in common, such as unemployment or disability, life problems, alcohol or drug use and mental illness. These difficulties may lead to a variety of self-destructive behaviour. Differences seem to be partly related to the criteria coroners use in reaching verdicts. Drug or alcohol use may make an accidental verdict more likely than a suicide verdict. 

See also Evid Based Mental Health 2012;15:101


Bergen, H., Hawton, K., Waters, K., Cooper, J. & Kapur, N. (2010).Psychosocial assessment and repetition of self-harm: The significance of single and multiple repeat episode analyses. Journal of Affective Disorders 123, 95-101. Link to the paper.

Self-harm is a common reason for presentation to the Emergency Department. An important question is whether psychosocial assessment following self-harm affects further repetition of self-harm. In this study we found that psychosocial assessment reduced the risk of a single repeat episode by 51% in individuals without a history of psychiatric treatment, and by 26% in individuals with a history of psychiatric treatment. For recurrent repetition of up to 5 episodes, psychosocial assessment decreased risk of a further episode by 13%. Appropriate statistical models which take account of multiple episodes by the same person are needed to accurately assess risk in recurrent repetition.
Conclusions: Psychosocial assessment is beneficial in reducing repeated self-harm in people both with and without a history of psychiatric care. Our finding supports the recommendation from the National Institute for Clinical Excellence that all individuals presenting to the emergency department with self-harm should receive a psychosocial assessment.