© 2003 The Royal College of Psychiatrists
Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital
Centre for Suicide Research,University Department of Psychiatry, Warneford Hospital, Oxford
Centre for Statistics in Medicine, Institute of Health Sciences, Oxford, UK
Correspondence: Professor Keith Hawton, Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX, UK. E-mail: keith.hawton{at}psych.ox.ac.uk
Declaration of interest None. Funding is detailed in Acknowledgements.
 TOP ABSTRACT INTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Background Deliberate self-harm (DSH) is the strongest risk factor for future suicide. Up-to-date information on suicide.Up-to-date the extent of risk is lacking.
Aims To investigate the risk of suicide after DSH during a long follow-up period.
Method A mortality follow-up study to 2000 was conducted on 11 583 patients who presented to hospital after DSH between 1978 and 1997.Data were obtained from a general hospital DSH register in Oxford and the Office for National Statistics, and from equivalent mortality registers in Scotland and Northern Ireland.
Results Three hundred patients had died by suicide or probable suicide.The risk in the first year of follow-up was 0.7% (95% CI 0.6–0.9%), which was 66 (95% CI 52–82) times the annual risk of suicide in the general population.The risk after 5 years was 1.7%, at10 years 2.4% and at 15 years 3.0%.The risk was far higher in men than in women (hazard ratio 2.8,95% CI 2.2–3.6). In both genders it increased markedly with age at initial presentation.
Conclusions Following DSH there is a significant and persistent risk of suicide, which varies markedly between genders and age groups. Reduction in the risk of suicide following DSH must be a key element in national suicide prevention strategies.
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Suicide prevention is central to mental health policy in many countries (Taylor et al, 1997; Department of Health, 2002). The strongest predictor of suicide is previous deliberate self-harm (Sakinofsky, 2000), which is found in 40–60% of suicides (Hawton & Fagg, 1988; Rygnestad, 1988; Suokas & Lönnqvist, 1991; Nordentoft et al, 1993; Foster et al, 1997). The most reliable figure for risk of suicide after deliberate self-harm in the UK was based upon a sample of patients identified in the early 1970s (Hawton & Fagg, 1988): 1% had died by suicide within a year. There are no recent statistics on the extent of risk. The incidence of deliberate self-harm has increased in the UK in recent years (Hawton et al, 1997), with an estimated 170 000 general hospital presentations per year (Kapur et al, 1998). In addition, the gender and age distribution for suicidal behaviour has altered, with marked increases in both suicide and self-harm in young men and a reduction in the female:male ratio for deliberate self-harm (Hawton et al, 1997; Cantor, 2000). Little is known about how risk of suicide after self-harm varies with age, except that the risk increases with age in women (Hawton & Fagg, 1988; Nordström et al, 1995). Accurate and up-to-date detailed evidence on suicide risk after self-harm is important, especially in relation to targeting preventive efforts.
Using a long-term monitoring system for deliberate self-harm, we have investigated the short-term and longer-term risk of suicide following this behaviour. We have also examined the risk according to gender and age subgroups, and over time.
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
Study sample
The sample was identified by means of the Oxford Monitoring System for Attempted Suicide, through which data are collected on all deliberate self-harm presentations to the general hospital in Oxford. This database includes non-admitted patients as well as those admitted to hospital, and those not assessed by the general hospital psychiatric service as well as those who are assessed (Hawton et al, 1997). The completeness of the case identification has been verified (Sellar et al, 1990). The definition of deliberate self-harm includes intentional self-poisoning or self-injury, irrespective of motivation. The study sample consisted of all patients who presented during the 20-year period 1978–1997. Each patient's first episode during the study period was used as the index episode. The follow-up period was until the end of 2000.
Identification of suicides
Details of all individuals (name, gender and date of birth) who presented
during the study period were submitted to the Office for National Statistics
(ONS) for England and Wales. Tracing revealed whether these individuals were
alive or dead on 31 December 2000. It also provided information (including the
date) on those who had emigrated from England and Wales, moved to Ireland or
Scotland, or left the register for other reasons. Further tracing was done
through the Central Services Agency (Northern Ireland) and through the General
Register Office for Scotland. Copies of death certificates were obtained for
all those who had died. Deaths receiving a coroner's verdict of
‘suicide’ (ICD codes E950–E959;
World Health Organization,
1992) were combined with those given a verdict of
‘undetermined cause’ (E980–E989) or ‘accidental
poisoning’ (E850–E869) to create a ‘probable suicide’
group (henceforth referred to as ‘suicides’), because using
suicide verdicts alone underestimates overall mortality from suicide
(Charlton et al,
1992). Cases for which no information was available on whether the
person was alive or dead at any time during the follow-up period were excluded
from the study.
Estimation of risk of suicide
Risk of suicide was calculated in terms of the number of persons entering a
study period for whom outcome was known at the end of that period. Each
person's first presentation within the study period was used in the
calculation of risk over time. The risk of suicide within 1 year of deliberate
self-harm was compared with general population rates of suicide in England and
Wales. This comparison was restricted to suicides and deaths due to
undetermined cause. Numbers of suicides and general population statistics
categorised by gender and age groups for 1978, 1988 and 1998 were averaged and
then applied to the study sample to compute expected numbers of deaths. The
relative risk in the study sample was calculated as a ratio of actual
v. expected numbers of deaths.
Statistical analyses
All patients traced by the ONS for any length of time from their first
presentation were entered into a survival analysis. Kaplan–Meier curves
were plotted and log rank tests used to test for differences in suicide risk
between genders, age groups (10–24 years, 25–34 years, 35–54
years, 55 years and over) and 5-year index periods (1978–1982,
1983–1987, 1988–1992, 1993–1997). Risks of suicide at
different time periods were estimated from this analysis, including 95%
confidence intervals. Cox's regression models were fitted, assuming
proportional hazards, to estimate risk over time and according to gender and
age at index episode. Kaplan–Meier curves are shown in this paper
truncated at 15 years of follow-up time, as numbers in some subgroups had by
then fallen to less than 20% of the original sample
(Pocock et al, 2002).
Analyses were carried out using the Statistical Package for the Social
Sciences version 10.0 (SPSS,
2000) and STATA version 7.0
(StataCorp, 2001).
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
The original sample included 12 666 patients. Because of lack of information on the patients' date of birth, 151 cases were not submitted to the ONS. Of the 12 515 cases submitted, the outcome in 929 cases could not be determined owing to incomplete or inaccurate information on name or date of birth, and 3 had unclassifiable information on date of death or underlying cause. Therefore a total of 11 583 cases for which information was available on the patient's mortality or survival were included in the investigation.
The majority of people in the sample were women and in the younger age
groups (Table 1). Most
self-harm episodes involved self-poisoning. The untraced patients did not
differ significantly from the traced patients in terms of either gender or
age. Somewhat fewer of the untraced patients had self-poisoned (84.3%
v. 89.4%) and more had self-injured (11.7% v. 7.6%;
2=23.85, d.f.=2, P<0.001). For those who were
traced the follow-up time ranged from 1 day to 23 years, with a median of 10.8
years.
|
View this table: [in a new window] | Table 1 Age, gender and method of deliberate self-harm at first presentation in the group of patients for whom survival information was available |
Deaths
A total of 1187 (10.2%) persons had died by the end of 2000. Three hundred
(2.6%) had died by suicide according to our definition. A suicide verdict was
recorded for 177 (59.0% of these), an open verdict for 82 (27.3%) and an
accidental poisoning verdict for 41 (13.7%). The most frequent method of
suicide was self-poisoning, with little difference between the genders in the
distribution of this and other methods of suicide
(Table 2). The majority,
however, had used a method different from that used in the index episode of
self-harm, with hanging and gas (usually car exhaust) being the most
frequent.
|
View this table: [in a new window] | Table 2 Methods of suicide |
Effects of gender and age
The overall risk of suicide within a year of deliberate self-harm
(Table 3) was 0.7% (95% CI
0.6%–0.9%). It was far higher in males (1.1%) than in females (0.5%).
The figures for suicides at 5 years and 10 years indicate continuing risk.
After 15 years, 3.0% had died by suicide, including 4.8% of men and 1.8% of
women. Survival analysis (Fig.
1) shows that the risk of suicide was markedly greater in males
than in females throughout the follow-up period (log rank
2=80.47, d.f.=1, P<0.0001). This remained
significant after adjusting for age (log rank 2=76.53,
P<0.0001). A Cox model showed that over the 15-year follow-up
period the hazard ratio for males relative to females was 2.8 (95% CI
2.2–3.6). Figure 1 also
shows that the risk of suicide in both genders was highest during the period
immediately following self-harm.
|
View this table: [in a new window] | Table 3 Risk of suicide (based on Kaplan—Meier estimates) after 1 year, 5 years, 10 years and 15 years of follow-up, and hazard ratios for the total follow-up period |
 View larger version (10K): [in a new window] [as a PowerPoint slide] |
Fig. 1 Cumulative percentages of suicides over the 15-year follow-up period.
|
In both genders there was a marked escalation in risk of suicide with
increasing age at the time of the initial self-harm episode
(Table 3). Survival analyses
(Figs 2,
3) show that the age
differential in risk persisted throughout the follow-up period and was
statistically significant for both men (log rank 2=26.53,
P<0.0001) and women (log rank 2=51.73,
P<0.0001). The increased risk with age was particularly marked in
women aged 55 years and over. There was no significant interaction between
gender and age (likelihood ratio test, 2=2.71,
P=0.1). Thus both male gender and increasing age appear to be
independent risk factors.
 View larger version (13K): [in a new window] [as a PowerPoint slide] |
Fig. 2 Cumulative percentages of suicides over time in males, categorised by age
group.
|
 View larger version (13K): [in a new window] [as a PowerPoint slide] |
Fig. 3 Cumulative percentages of suicides over time in females, categorised by age
group.
|
Risk and time period
We compared the risk of suicide during the follow-up period for patients
who first presented during each of four 5-year periods (1978–1982,
1983–1987, 1988–1992, 1993–1997). There was little
difference in risk (log rank 2=1.08, P=0.78),
indicating no major change in risk during the 20-year study period.
Risk of suicide in first year following deliberate self-harm
The overall age-standardised risk of suicide in the first year after
self-harm was 66 (95% CI 52–82) times the annual risk of suicide in the
general population of England and Wales during the study period (based on
averaging rates for 1978, 1988 and 1998). In males it was 64 (95% CI
46–85) times the general population risk and in females it was 90 (95%
CI 62–126) times the risk. The relative risk increased with age. In
those aged 10–24 years at initial presentation the risk was 35 (95% CI
16–79) times the population risk in males and 75 (95% CI 35–157)
times the risk in females, whereas in those aged 55 years and over the
comparable figures were 131 (95% CI 68–252) for men and 158 (95% CI
85–294) for women.
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
We have examined mortality from suicide over a long follow-up period in a large sample of people presenting for treatment of deliberate self-harm. The results show that the risk of suicide following self-harm is considerable and persists in the long term. It also varies with gender and age. Reduction in this risk must be a core element in national suicide prevention strategies (Department of Health, 2002).
Methodological issues
Follow-up to death or to the end of the follow-up period was possible in
92.6% of cases submitted for tracing. The main reason for failure of follow-up
was incomplete or inaccurate information on the individual's name or date of
birth. We do not know the impact of this on the results. The untraced patients
did not differ markedly from those who were traced with regard to age and
gender. There was a significant but small difference between the two groups of
patients in the methods of self-harm. The large sample size and high
proportion of traced patients mean, however, that this would have had little
impact on the results.
The identification of suicides through inclusion of death from undetermined cause and accidental poisonings as well as official suicides is accepted practice in suicide research (Charlton et al, 1992). Few deaths will be misidentified by this procedure (Linsley et al, 2001). However, some suicides may be missed owing to their inclusion in other categories (e.g. lone driver road traffic accidents).
Risk of suicide compared with other studies
The risk of suicide in the first year following deliberate self-harm (0.7%)
was somewhat lower than the 1% reported in an earlier study from the UK
(Hawton & Fagg, 1988). One
reason is that in our study we used survival analysis; using an analysis
comparable to that of the earlier study, the risk would be 0.8%. Because of
the much larger size of our study, the revised figure might be more accurate.
Other possible explanations for the difference include changes in the
characteristics of the self-harm population and improvements in clinical
services.
The risk in the first year after self-harm was 66 times the annual risk of suicide in England and Wales, confirming the large degree of excess risk of suicide in these patients. Although risk of suicide is highest in the initial period following self-harm there is clearly a significant risk even many years later. The proportion of the sample dying from suicide following self-harm is lower than in many studies from other countries (Rygnestad, 1988; Suokas & Lönnqvist, 1991; Nordentoft et al, 1993; Sakinofsky, 2000), and this has been confirmed in a recent systematic review (Owens et al, 2002). This probably reflects differences in the self-harm populations – such patients in the UK include more young people (Schmidtke et al, 1996), in whom we have shown that the risk is lower – and also differences in general population suicide rates.
Age and gender
In keeping with the findings of most earlier studies
(Nordström et al,
1995; Sakinofsky,
2000; Suokas et al,
2001) the risk of suicide was far higher in men than in women
throughout the follow-up period. We have shown that the risk increases
markedly with age at the time of self-harm. The risk in those aged 55 years
and over was seven times greater than in those aged 10–24 years in the
first year of follow-up, and nearly that after 5 years. This was reflected in
the risk relative to the general population rate in different age groups. This
underlines the need for clinicians to be especially vigilant for suicide risk
in older people presenting with deliberate self-harm.
Methods of suicide
The methods of suicide used by the people investigated in this study
differed somewhat from suicides in general in the UK in that in males
self-poisoning was more common. The fact that most of the latter had used
self-poisoning in their initial self-harm episodes indicates that persistence
with the original method is not uncommon. The majority of suicides, however,
involved a method different from that used in the original episode.
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
CLINICAL IMPLICATIONS
- The risk of suicide following deliberate self-harm emphasises the need for
greater attention to reducing risk.
- The continuing risk even many years after deliberate self-harm highlights
the need to take account of any previous episode in assessing risk.
- The increased risk in older people underlines the need for clinicians to be
especially vigilant for suicide risk in these patients.
LIMITATIONS
- The study was based on patients presenting to only one general
hospital.
- Not all patients could be traced.
- Some suicides will have been missed owing to their classification as other
types of death.
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
The authors thank the staff of the Office for National Statistics for England and Wales, the General Register Office for Scotland and the Central Services Agency in Northern Ireland for their assistance with this project, and Douglas Altman for commenting on the manuscript. Staff at the Department of Psychological Medicine at the John Radcliffe Hospital in Oxford, and Elizabeth Bale and Alison Bond, assisted with original identification of the patients included in the study. The study was funded by a grant from the National Health Service Executive for England; K.H. is also funded by Oxfordshire Mental Healthcare Trust.
|
TOPABSTRACTINTRODUCTIONMETHODRESULTSDISCUSSIONClinical Implications and...ACKNOWLEDGMENTSREFERENCES |
|---|
- Cantor, C. H. (2000) Suicide in the Western World. In The International Handbook of Suicide and Attempted Suicide (eds K. Hawton & K.Van Heeringen), pp. 9–28. Chichester: John Wiley & Sons.
- Charlton, J., Kelly, S., Dunnell, K., et al (1992) Trends in suicide deaths in England and Wales. Population Trends, 69, 10–16.
- Department of Health (2002) National Suicide Prevention Strategy for England. London: DoH.
- Foster, T., Gillespie, K. & McClelland, R.
(1997) Mental disorders and suicide in Northern Ireland.
British Journal of Psychiatry,
170,
447–452.
[Abstract/Free Full Text] - Hawton, K. & Fagg, J. (1988) Suicide, and
other causes of death, following attempted suicide. British Journal
of Psychiatry, 152,
359–366.
[Abstract/Free Full Text] - Hawton, K., Fagg, J., Simkin, S., et al
(1997) Trends in deliberate self-harm in Oxford,
1985–1995. Implications for clinical services and the prevention of
suicide. British Journal of Psychiatry,
171,
556–560.
[Abstract/Free Full Text] - Kapur, N., House, A., Creed, F., et al
(1998) Management of deliberate self poisoning in adults in
four teaching hospitals: descriptive study. BMJ,
316,
831–832.
[Free Full Text] - Linsley, K. R., Schapira, K. & Kelly, T. P.
(2001) Open verdict v. suicide – importance to
research. British Journal of Psychiatry,
178,
465–468.
[Abstract/Free Full Text] - Nordentoft, M., Breum, L., Munch, L., et al
(1993) High mortality by natural and unnatural causes: a
10-year follow-up study of patients admitted to a poisoning treatment centre
after suicide attempts. BMJ,
306,
1637–1641.
[Abstract/Free Full Text] - Nordström, P., Samuelsson, M. & Åsberg, M. (1995) Survival analysis of suicide risk after attempted suicide. Acta Psychiatrica Scandinavica, 91, 336–340.[Medline]
- Owens, D., Horrocks, J. & House, A. (2002)
Fatal and non-fatal repetition of self-harm. Systematic review.
British Journal of Psychiatry,
181,
193–199.
[Abstract/Free Full Text] - Pocock, S., Clayton, T. & Altman, D. (2002) Survival plots of time-to-event outcomes in clinical trials: good practice and pitfalls. Lancet, 359, 1686–1689.[CrossRef][Medline]
- Rygnestad, T. (1988) A prospective 5-year follow-up study of self-poisoned patients. Acta Psychiatrica Scandinavica, 77, 328–333.[Medline]
- Sakinofsky, I. (2000) Repetition of suicidal behaviour. In The International Handbook of Suicide and Attempted Suicide (eds K. Hawton & K.Van Heeringen), pp. 385–404. Chichester: John Wiley & Sons.
- Schmidtke, A., Bille Brahe, U., De Leo, D., et al (1996) Attempted suicide in Europe: rates, trends and sociodemographic characteristics of suicide attempters during the period 1989–1992. Results of the WHO/EURO Multicentre Study on Parasuicide. Acta Psychiatrica Scandinavica, 93, 327–338.[Medline]
- Sellar, C., Goldacre, M. J. & Hawton, K.
(1990) Reliability of routine hospital data on poisoning as
measures of deliberate self poisoning in adolescents. Journal of
Epidemiology and Community Health,
44,
313–315.
[Abstract/Free Full Text] - SPSS (2000) SPSS Base 10.0 Users' Guide. Upper Saddle River, NJ: Prentice Hall.
- StataCorp (2001) Stata Statistical Software: Release 7.0. College Station, TX: Stata Corp.
- Suokas, J. & Lönnqvist, J. (1991) Outcome of attempted suicide and psychiatric consultation: risk factors and suicide mortality during a five-year follow-up. Acta Psychiatrica Scandinavica, 84, 545–549.[Medline]
- Suokas, J., Suominen, K., Isometsa, E., et al (2001) Long-term risk factors for suicide mortality after attempted suicide – findings of a 14-year follow-up study. Acta Psychiatrica Scandinavica, 104, 117–121.[CrossRef][Medline]
- Taylor, S. J., Kingdon, D. & Jenkins, R. (1997) How are the nations trying to prevent suicide? An analysis of national suicide prevention strategies. Acta Psychiatrica Scandinavica, 95, 457–463.[Medline]
- World Health Organization (1992) International Statistical Classification of Diseases and Related Health Problems (ICD–10).Geneva: WHO.
Related articles in BJP:
- Highlights of this issue
- ELIZABETH WALSH
BJP 2003 182: 465-a23.[Full Text]
This article has been cited by other articles:
 |
|
 |
|
  For questions on page 471 Emerg. Med. J., July 1, 2009; 26(7): 545 - 545. [Full Text] [PDF]
|
|
|
|
 |
|
 K. Hawton, L. Harriss, D. Casey, S. Simkin, K. Harrison, I. Bray, and N. Blatchley Self-harm in UK armed forces personnel: descriptive and case-control study of general hospital presentations The British Journal of Psychiatry, March 1, 2009; 194(3): 266 - 272. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. L. Taylor, K. Hawton, S. Fortune, and N. Kapur Attitudes towards clinical services among people who self-harm: systematic review The British Journal of Psychiatry, February 1, 2009; 194(2): 104 - 110. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
F. Heyerdahl, M. A. Bjornaas, R. Dahl, K. E. Hovda, A. K. Nore, O. Ekeberg, and D. Jacobsen Repetition of acute poisoning in Oslo: 1-year prospective study The British Journal of Psychiatry, January 1, 2009; 194(1): 73 - 79. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Hawton, H. Bergen, D. Casey, and S. Simkin General hospital presentations of non-fatal hanging over a 28-year period: case-control study The British Journal of Psychiatry, December 1, 2008; 193(6): 503 - 504. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. Oldershaw, C. Richards, M. Simic, and U. Schmidt Parents' perspectives on adolescent self-harm: qualitative study The British Journal of Psychiatry, August 1, 2008; 193(2): 140 - 144. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. Lilley, D. Owens, J. Horrocks, A. House, R. Noble, H. Bergen, K. Hawton, D. Casey, S. Simkin, E. Murphy, et al. Hospital care and repetition following self-harm: multicentre comparison of self-poisoning and self-injury The British Journal of Psychiatry, June 1, 2008; 192(6): 440 - 445. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Haukka, K. Suominen, T. Partonen, and J. Lonnqvist Determinants and Outcomes of Serious Attempted Suicide: A Nationwide Study in Finland, 1996-2003 Am. J. Epidemiol., May 15, 2008; 167(10): 1155 - 1163. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. Slee, N. Garnefski, R. van der Leeden, E. Arensman, and P. Spinhoven Cognitive-behavioural intervention for self-harm: randomised controlled trial The British Journal of Psychiatry, March 1, 2008; 192(3): 202 - 211. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N. Greenberg, A. Henderson, V. Langston, A. Iversen, and S Wessely Peer responses to perceived stress in the Royal Navy Occup. Med., September 1, 2007; 57(6): 424 - 429. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S B Rafnsson, J J Oliver, R A Elton, and D N Bateman Poisons admissions in Edinburgh 1981-2001: agent trends and predictors of hospital readmissions Human and Experimental Toxicology, January 1, 2007; 26(1): 49 - 57. [Abstract] [PDF]
|
|
|
|
|
|
V. DUNN and I. M. GOODYER Longitudinal investigation into childhood- and adolescence-onset depression: psychiatric outcome in early adulthood The British Journal of Psychiatry, March 1, 2006; 188(3): 216 - 222. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. OWENS, C. WOOD, D. C. GREENWOOD, T. HUGHES, and M. DENNIS Mortality and suicide after non-fatal self-poisoning: 16-year outcome study The British Journal of Psychiatry, November 1, 2005; 187(5): 470 - 475. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Wright, S. Briggs, and J. Behringer Attachment and the Body in Suicidal Adolescents: A Pilot Study Clinical Child Psychology and Psychiatry, October 1, 2005; 10(4): 477 - 491. [Abstract] [PDF]
|
|
|
|
 |
|
 A. Beautrais Suicidality in pre-adolescence and early adulthood is associated with psychosocial and psychiatric problems in young adulthood Evid. Based Ment. Health, May 1, 2005; 8(2): 48 - 48. [Full Text] [PDF]
|
|
|
|
|
|
G. Carter, D. M. Reith, I. M. Whyte, and M. McPherson Repeated self-poisoning: increasing severity of self-harm as a predictor of subsequent suicide The British Journal of Psychiatry, March 1, 2005; 186(3): 253 - 257. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Cooper, N. Kapur, R. Webb, M. Lawlor, E. Guthrie, K. Mackway-Jones, and L. Appleby Suicide After Deliberate Self-Harm: A 4-Year Cohort Study Am J Psychiatry, February 1, 2005; 162(2): 297 - 303. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Harriss, K. Hawton, and D. Zahl Value of measuring suicidal intent in the assessment of people attending hospital following self-poisoning or self-injury The British Journal of Psychiatry, January 1, 2005; 186(1): 60 - 66. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. L. Zahl and K. Hawton Repetition of deliberate self-harm and subsequent suicide risk: long-term follow-up study of 11 583 patients The British Journal of Psychiatry, July 1, 2004; 185(1): 70 - 75. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. Tyrer The risk of suicide after deliberate self harm was significant and persistent over the long term Evid. Based Med., March 1, 2004; 9(2): 59 - 59. [Full Text] [PDF]
|
|
|
|
 |
|
 Other articles noted: 25 Jul 03 to 7 Nov 03 Evid. Based Nurs., January 1, 2004; 7(1): e1 - 1. [Full Text] [PDF]
|
|
|
|
|
|
B. F Walker Risk of suicide remains high fifteen years after deliberate self-harm Evid. Based Ment. Health, November 1, 2003; 6(4): 106 - 106. [Full Text] [PDF]
|
|
|
|
 |
|
 Preventing Teen Suicide Journal Watch Women's Health, September 4, 2003; 2003(904): 5 - 5. [Full Text]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||