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Predicting suicide following self-harm: systematic review of risk factors and risk scales

  • Melissa K. Y. Chan (a1), Henna Bhatti (a2), Nick Meader (a3), Sarah Stockton (a4), Jonathan Evans (a5), Rory C. O'Connor (a6), Nav Kapur (a7) and Tim Kendall (a4)...
Abstract
Background

People with a history of self-harm are at a far greater risk of suicide than the general population. However, the relationship between self-harm and suicide is complex.

Aims

To undertake the first systematic review and meta-analysis of prospective studies of risk factors and risk assessment scales to predict suicide following self-harm.

Method

We conducted a search for prospective cohort studies of populations who had self-harmed. For the review of risk scales we also included studies examining the risk of suicide in people under specialist mental healthcare, in order to broaden the scope of the review and increase the number of studies considered. Differences in predictive accuracy between populations were examined where applicable.

Results

Twelve studies on risk factors and 7 studies on risk scales were included. Four risk factors emerged from the metaanalysis, with robust effect sizes that showed little change when adjusted for important potential confounders. These included: previous episodes of self-harm (hazard ratio (HR) = 1.68, 95% CI 1.38–2.05, K = 4), suicidal intent (HR = 2.7, 95% CI 1.91–3.81, K = 3), physical health problems (HR = 1.99, 95% CI 1.16–3.43, K = 3) and male gender (HR = 2.05, 95% CI 1.70–2.46, K = 5). The included studies evaluated only three risk scales (Beck Hopelessness Scale (BHS), Suicide Intent Scale (SIS) and Scale for Suicide Ideation). Where meta-analyses were possible (BHS, SIS), the analysis was based on sparse data and a high heterogeneity was observed. The positive predictive values ranged from 1.3 to 16.7%.

Conclusions

The four risk factors that emerged, although of interest, are unlikely to be of much practical use because they are comparatively common in clinical populations. No scales have sufficient evidence to support their use. The use of these scales, or an over-reliance on the identification of risk factors in clinical practice, may provide false reassurance and is, therefore, potentially dangerous. Comprehensive psychosocial assessments of the risks and needs that are specific to the individual should be central to the management of people who have self-harmed.

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Copyright
Corresponding author
Melissa K. Y. Chan, University of Hong Kong, Centre for Suicide Research and Prevention, 5 Sassoon Road, Pok Fu Lam, Hong Kong. Email: ckymelissa@gmail.com
Footnotes
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Declaration of interest

N.K. and T.K. were chair and facilitator, respectively, of NICE clinical guideline 133 on self-harm (longer term management). The other authors were members of the guideline development group. N.K. sits on the Department of Health's (England) National Suicide Prevention Strategy Advisory Group. Some authors were also co-authors on primary studies included in the review.

Footnotes
References
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Predicting suicide following self-harm: systematic review of risk factors and risk scales

  • Melissa K. Y. Chan (a1), Henna Bhatti (a2), Nick Meader (a3), Sarah Stockton (a4), Jonathan Evans (a5), Rory C. O'Connor (a6), Nav Kapur (a7) and Tim Kendall (a4)...
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eLetters

Overstating the lack of evidence on suicide risk assessment

Achim Wolf, DPhil Student & Research Assistant, Department of Psychiatry, University of Oxford
Seena Fazel, Wellcome Trust Senior Research Fellow, Department of Psychiatry, University of Oxford
02 December 2016

Chan and colleagues provide an overview of risk factors and risk scales for suicide following self-harm (1). However, their conclusions go beyond their review findings and we think discounting the potential value of such tools on the basis of imperfect tools designed for other purposes is premature.



First, although we agree that the use of risk categories has its limitations (in particular when post-hoc cut-offs are used), this can be resolved if risk prediction tools use pre-specified cut-offs, and consider reporting absolute probabilities as well as risk categories (2). Absolute probabilities provide greater flexibility, and could help optimise treatment allocation, waiting list prioritisation, or referral for more detailed assessments. A multicentre study found that only 70% of hospital episodes of self-harm receive psychosocial assessments in three UK centres (3), and hence there will likely be further challenges linking those at risk with appropriate clinical services. Clearly, psychosocial assessments are recommended for all persons who self-harm but more personalised therapies will also involve a degree of triaging.



Second, the review identified three tools used in practice: Beck Hopelessness Scale, Scale for Suicidal Ideation, and Suicide Intent Scale. However, none of these were developed for the purposes of risk prediction and thus critiquing the whole field on the basis of these tools goes beyond the evidence.



All risk prediction tools should be critically evaluated in terms of discrimination, calibration, and reclassification -- but the same high standards should also be applied to alternative approaches. What would be the performance of not using risk assessment, through purely qualitative or needs-based approaches? Without this information, this review might encourage a return to more subjective risk assessment approaches, which in the field of violence risk assessment have been shown to perform less well than structured methods (4).



Whilst purely qualitative and needs-based approaches have a strong intuitive appeal, risk assessment, if it can be linked to treatment, is likely to play a role in reducing suicide risk.

1. Chan MK, Bhatti H, Meader N, Stockton S, Evans J, O'Connor R, et al. Predicting suicide following self-harm: A systematic review of risk factors and risk scales. Br J Psychiatry. 2016.

2. Fazel S, Chang Z, Fanshawe T, Långström N, Lichtenstein P, Larsson H, et al. Prediction of violent reoffending on release from prison: derivation and external validation of a scalable tool. Lancet Psych. 2016; 3(6): 535-43.

3. Hawton K, Bergen H, Casey D, Simkin S, Palmer B, Cooper J, et al. Self-harm in England: a tale of three cities. Soc Psychiatry Psychiatr Epidemiol. 2007; 42(7): 513-21.

4. Ægisdóttir S, White MJ, Spengler PM, Maugherman AS, Anderson LA, Cook RS, et al. The meta-analysis of clinical judgment project: Fifty-six years of accumulated research on clinical versus statistical prediction. Couns Psychol. 2006; 34(3): 341-82.
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Conflict of interest: SF has published on violence risk assessment, including a tool (OxRec). AW is currently researching violence risk assessment.

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Two meta analyses demonstrate the limits of suicide risk assessment

Matthew M Large, Psychiatrist, School of Psychiatry, University of New South Wales, Sydney, Australia.
28 June 2016

Chan and associates report a well conducted meta-analysis of the association between a high score on suicide risk assessment scales and later suicide among cohorts of patients with a history of self-harm (1). They synthesized the results of to seven studies, finding highly heterogeneous results. The authors rightly conclude that “no scales have sufficient evidence to support their use. The use of these scales, or an over-reliance on the identification of risk factors in clinical practice, may provide false reassurance and is, therefore, potentially dangerous”. These comments might equally have been made about suicide risk assessment of any patient group. We recently published a meta-analysis with broader inclusion criteria that synthesised the results of 37 cohort studies that used either suicide risk scales or multivariate models to predict suicides by psychiatric patients, including those who had self-harmed (2). Like the Chan study we found a high degree of between study heterogeneity and a modest association between a high-risk categorisation and suicide. Both meta-analyses highlight the extent to which the utility of suicide risk assessment has been overstated. However, our study with broader inclusion criteria, sheds some light on why suicide risk assessment performs so poorly. Overall, the predictive strength of the 37 studies performed little better than the many well established single risk factors. Within the 37 studies, those that used more factors or items performed no better those that relied on less information. This strongly suggests that the uncertainty about future suicide results more from chance than from a lack of knowledge. These results have two implications. First, suicide risk assessment should not form the basis for coercive treatment – we simply cannot be confident enough in our judgements about future suicide to override the patient’s wishes. Second, in the common situation where there are competing demands for a helpful and empathic assessment versus one that is more complete but potentially traumatic for the patient, the more empathic yet less complete assessment should be chosen every time.

1.Chan MK, Bhatti H, Meader N, Stockton S, Evans J, O'Connor RC, et al. Predicting suicide following self-harm: systematic review of risk factors and risk scales. Br J Psychiatry. 2016.

2.Large M, Kaneson M, Myles N, Myles H, Gunaratne P, Ryan C. Meta-Analysis of Longitudinal Cohort Studies of Suicide Risk Assessment among Psychiatric Patients: Heterogeneity in Results and Lack of Improvement over Time. PLoS One. 2016; 11(6): e0156322.

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Conflict of interest: None Declared

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