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Psychosocial therapy and causes of death after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching

  • J. Birkbak (a1), E. A. Stuart (a2) (a3), B. D. Lind (a4), P. Qin (a5), E. Stenager (a6), K. J. Larsen (a7), A. G. Wang (a8), A. C. Nielsen (a9), C. M. Pedersen (a10), J.-H. Winsløv (a11), C. Langhoff (a12), C. Mühlmann (a1) (a13), M. Nordentoft (a1) (a13) and A. Erlangsen (a1) (a2) (a13) (a14)...

Psychosocial therapy after deliberate self-harm might be associated with reduced risk of specific causes of death.


In this matched cohort study, we included patients, who after an episode of deliberate self-harm received psychosocial therapy at a Suicide Prevention Clinic in Denmark between 1992 and 2010. We used propensity score matching in a 1:3 ratio to select a comparison group from 59 046 individuals who received standard care. National Danish registers supplied data on specific causes of death over a 20-year follow-up period.


At the end of follow-up, 391 (6.9%) of 5678 patients in the psychosocial therapy group had died, compared with 1736 (10.2%) of 17 034 patients in the matched comparison group. Lower odds ratios of dying by mental or behavioural disorders [0.54, 95% confidence interval (CI) 0.37–0.79], alcohol-related causes (0.63, 95% CI 0.50–0.80) and other diseases and medical conditions (0.61, 95% CI 0.49–0.77) were noted in the psychosocial therapy group. Also, we found a reduced risk of dying by suicide as well as other external causes, however, not by neoplasms and circulatory system diseases. Numbers needed to treat were 212.9 (95% CI 139.5–448.4) for mental or behavioural disorders as a cause of death, 111.1 (95% CI 79.2–210.5) for alcohol-related causes and 96.8 (95% CI 69.1–161.8) for other diseases and medical conditions.


Our findings indicate that psychosocial therapy after deliberate self-harm might reduce long-term risk of death from select medical conditions and external causes. These promising results should be tested in a randomized design.

Corresponding author
*Address for correspondence: A. Erlangsen, Ph.D., Research Unit, Mental Health Centre Copenhagen, Kildegårdsvej 28, Opg. 15, 4, DK-2900 Hellerup, Denmark. (Email:
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Bergen, H, Hawton, K, Waters, K, Ness, J, Cooper, J, Steeg, S, Kapur, N (2012). Premature death after self-harm: a multicentre cohort study. Lancet 380, 15681574.
Boden, JM, Fergusson, DM, Horwood, LJ (2008). Cigarette smoking and suicidal behaviour: results from a 25-year longitudinal study. Psychological Medicine 38, 433439.
Brown, GK, Green, KL (2014). A review of evidence-based follow-up care for suicide prevention: where do we go from here? American Journal of Preventive Medicine 47, S209S215.
Brown, GK, Jager-Hyman, S (2014). Evidence-based psychotherapies for suicide prevention: future directions. American Journal of Preventive Medicine 47, S186S194.
Erlangsen, A, Fedyszyn, I (2015). Danish nationwide registers for public health and health-related research. Scandinavian Journal of Public Health 43, 333339.
Erlangsen, A, Lind, BD, Stuart, EA, Qin, P, Stenager, E, Larsen, KJ, Wang, AG, Hvid, M, Nielsen, AC, Pedersen, CM, Winsløv, JH, Langhoff, C, Mühlmann, C, Nordentoft, M (2014). Short-term and long-term effects of psychosocial therapy for people after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching. Lancet Psychiatry 2, 4958.
Fleischmann, A, Bertolote, JM, Wasserman, D, De, Leo D, Bolhari, J, Botega, NJ, De, Silva D, Phillips, M, Vijayakumar, L, Värnik, A, Schlebusch, L, Thanh, HT (2008). Effectiveness of brief intervention and contact for suicide attempters: a randomized controlled trial in five countries. Bulletin of the World Health Organization 86, 703709.
Hawton, K, Harriss, L, Zahl, D (2006). Deaths from all causes in a long-term follow-up study of 11,583 deliberate self-harm patients. Psychological Medicine 36, 397405.
Hawton, K, van Heeringen, K (2009). Suicide. Lancet 373, 13721381.
Hawton, K, Witt, KG, Taylor Salisbury, TL, Arensman, E, Gunnell, D, Hazell, P, Townsend, E, van Heeringen, K (2016). Psychosocial interventions for self-harm in adults. Cochrane Database of Systematic Reviews 5, CD012189.
Hawton, K, Witt, KG, Taylor Salisbury, TL, Arensman, E, Gunnell, D, Townsend, E, van Heeringen, K, Hazell, P (2015). Interventions for self-harm in children and adolescents. Cochrane Database of Systematic Reviews 12, CD012013.
Jollant, F, Bellivier, F, Leboyer, M, Astruc, B, Torres, S, Verdier, R, Castelnau, D, Malafosse, A, Courtet, P (2005). Impaired decision making in suicide attempters. American Journal of Psychiatry 162, 304310.
Mann, JJ, Waternaux, C, Haas, GL, Malone, KM (1999). Toward a clinical model of suicidal behavior in psychiatric patients. American Journal of Psychiatry 156, 181189.
Mellqvist, FM, Ostling, S, Braam, AW, Backman, K, Copeland, JR, Fichter, M, Kivela, SL, Lawlor, BA, Lobo, A, Magnusson, H, Prince, MJ, Reischies, FM, Turrina, C, Wilson, K, Skoog, I, Waern, M (2014). Functional disability and death wishes in older Europeans: results from the EURODEP concerted action. Social Psychiatry and Psychiatric Epidemiology 49, 14751482.
Nordentoft, M, Breum, L, Munck, LK, Nordestgaard, AG, Hunding, A, Laursen Bjaeldager, PA (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. British Medical Journal 306, 16371641.
O'Neil, ME, Peterson, K, Low, A, Carson, S, Denneson, LM, Haney, E, Shiroma, P, Kansagara, D (2012). Suicide Prevention Interventions and Referral/Follow-Up Services: A Systematic Review. Department of Veterans Affairs: Washington, DC.
Pan, YJ, Chang, WH, Lee, MB, Chen, CH, Liao, SC, Caine, ED (2013). Effectiveness of a nationwide aftercare program for suicide attempters. Psychological Medicine 43, 14471454.
Pavarin, RM, Fioritti, A, Fontana, F, Marani, S, Paparelli, A, Boncompagni, G (2014). Emergency department admission and mortality rate for suicidal behavior. A follow-up study on attempted suicides referred to the ED between January 2004 and December 2010. Crisis 35, 406414.
Pedersen, W, von Soest, T (2009). Smoking, nicotine dependence and mental health among young adults: a 13-year population-based longitudinal study. Addiction 104, 129137.
Pederson, AM, Tefft, BM, Babigian, HM (1975). Risks of mortality of suicide attempters compared with psychiatric and general populations. Suicide 5, 145157.
SAS Institute (2003). SAS system for SunOP (9.3). SAS Institute Inc.: Cary, NC.
Tang, NK, Crane, C (2006). Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links. Psychological Medicine 36, 575586.
Wahlbeck, K, Westman, J, Nordentoft, M, Gissler, M, Laursen, TM (2011). Outcomes of Nordic mental health systems: life expectancy of patients with mental disorders. British Journal of Psychiatry 199, 453458.
World Health Organization (1965). International Statistical Classification of Diseases and Related Health Problems, 8th revision edn. WHO: Geneva.
World Health Organization (2014). Preventing Suicide: A Global Imperative. WHO: Geneva.
World Health Organization (2015 a). The top ten causes of death ( Accessed June 2015.
World Health Organization (2015 b). ICD-10 Online ( Accessed June 2015.
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Psychological Medicine
  • ISSN: 0033-2917
  • EISSN: 1469-8978
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