1
Bergen, H, Hawton, K, Waters, K, Cooper, J, Kapur, N. Psychosocial assessment and repetition of self-harm: the significance of single and multiple repeat episode analyses. J Affect Disord
2010; 127: 257–65.
2
Bergen, H, Hawton, K, Waters, K, Ness, J, Cooper, J, Steeg, S, et al. Premature death after self-harm: a multicentre cohort study. Lancet
2012; 380: 1568–74.
3
Hawton, K, Bergen, H, Cooper, J, Turnbull, P, Waters, K, Ness, J, et al. Suicide following self-harm: findings from the multicentre study of self-harm in England, 2000–2012. J Affect Disord
2015; 175: 147–51.
4
Haw, C, Bergen, H, Casey, D, Hawton, K. Repetition of deliberate self-harm: a study of the characteristics and subsequent deaths in patients presenting to a general hospital according to extent of repetition. Suicide Life Threat Behav
2007; 37: 379–96.
5
Zahl, DL, Hawton, K. Repetition of deliberate self-harm and subsequent suicide risk: long-term follow-up study of 11583 patients. Br J Psychiatry
2004; 185: 70–5.
6
National Institute for Health and Care Excellence. Self-harm. The NICE Guideline on Longer-Term Management. National Clinical Guideline Number 133.
The British Psychological Society and The Royal College of Psychiatrists, 2011.
7
Royal Australian and New Zealand College of Psychiatrists Clinical Practice Guidelines Team for Deliberate Self-harm. Australian and New Zealand clinical practice guidelines for the management of adult deliberate self-harm. Aust NZ J Psychiatry
2004; 38: 868–84.
8
Bolton, JM, Gunnell, D, Turecki, G. Suicide risk assessment and intervention in people with mental illness. BMJ
2015; 35: h4978.
9
Kapur, N, Murphy, E, Cooper, J, Bergen, H, Hawton, K, Simkin, S, et al. Psychosocial assessment following self-harm: results from the multi-centre monitoring of self-harm project. J Affect Disord
2008; 106: 285–93.
10
Hawton, K. Psychiatric assessment and management of deliberate self-poisoning patients. Medicine
2016; 44: 103–5.
11
Royal College of Psychiatrists. Self-Harm, Suicide, and Risk: Helping People who Self-Harm. Final Report of a Working Group.
Royal College of Psychiatrists, 2010.
12
Quinlivan, L, Cooper, J, Steeg, S, Davies, L, Hawton, K, Gunnell, D, et al. Scales for predicting risk following self-harm: an observational study in 32 hospitals in England. BMJ Open
2014; 4: e004732.
13
Quinlivan, L, Cooper, J, Davies, L, Hawton, K, Gunnell, D, Kapur, N, et al. Which are the most useful scales for predicting repeat self-harm? A systematic review evaluating risk scales using measures of diagnostic accuracy. BMJ Open
2016; 6: e009297.
14
Bilén, K, Ponzer, S, Ottosson, C, Castrén, M, Owe-Larsson, B, Ekdahl, K, et al. Can repetition of deliberate self-harm be predicted? A prospective multicenter study validating clinical decision rules. J Affect Disord
2013; 149: 253–8.
15
Bolton, JM, Spiwak, R, Sareen, J. Predicting suicide attempts with the SAD PERSONS scale: a longitudinal analysis. J Clin Psychiatry
2012; 76: e735–41.
16
Carter, GL, Clover, KA, Bryant, JL, Whyte, IM. Can the Edinburgh Risk of Repetition Scale predict repetition of deliberate self-poisoning in an Australian clinical setting?
Suicide Life Threat Behav
2002; 32: 230–9.
17
Cooper, J, Kapur, N, Dunning, J, Guthrie, E, Appleby, L, Mackway-Jones, K. A clinical tool for assessing risk after self-harm. Ann Emerg Med
2006; 48: 459–66.
18
Spittal, MJ, Pirkis, J, Miller, M, Carter, G, Studdert, DM. The Repeated Episodes of Self-Harm (RESH) score: a tool for predicting risk of future episodes of self-harm by hospital patients. J Affect Disord
2014; 161: 36–42.
19
Steeg, S, Kapur, N, Webb, R, Applegate, E, Stewart, SL, Hawton, K, et al. The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule. Psychol Med
2012; 42: 2383–94.
20
Randall, JR, Rowe, BH, Colman, I. Emergency department assessment of self-harm risk using psychometric questionnaires. Can J Psychiatry
2012; 57: 21.
21
Waern, M, Sjöström, N, Marlow, T, Hetta, J. Does the Suicide Assessment Scale predict risk of repetition? A prospective study of suicide attempters at a hospital emergency department. Eur Psychiatry
2010; 25: 421–6.
22
Hockberger, RS, Rothstein, RJ. Assessment of suicide potential by nonpsychiatrists using the SAD PERSONS score. J Emerg Med
1988; 6: 99–107.
23
Patton, JH, Stanford, MS. Factor structure of the Barratt Impulsiveness Scale. J Clin Psychol
1995; 51: 768–77.
24
Randall, JR, Colman, I, Rowe, BH. A systematic review of psychometric assessment of self-harm risk in the emergency department. J Affect Disord
2011; 134: 348–55.
25
Larkin, C, Di Blasi, Z, Arensman, E. Risk factors for repetition of self-harm: a systematic review of prospective hospital-based studies. PLoS ONE
2014; 9: e84282.
26
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; 209: 277–83.
27
Bewick, V, Cheek, L, Ball, J. Statistics review 13: receiver operating characteristic curves. Critical Care
2004; 8: 508.
28
Kapur, N, Steeg, S, Webb, R, Haigh, M, Bergen, H, Hawton, K, et al. Does clinical management improve outcomes following self-harm? Results from the multicentre study of self-harm in England. PLoS ONE
2013; 8: e70434.
29
Majid, M, Tadros, M, Tadros, G, Singh, S, Broome, MR, Upthegrove, R, et al. Young people who self-harm: a prospective 1-year follow-up study. Soc Psychiatry Psychiatr Epidemiol
2016: 51: 171–81.
30
Kapur, N, Steeg, S, Turnbull, P, Webb, R, Bergen, R, Hawton, K, et al. Hospital management of suicidal behaviour and subsequent mortality: a prospective cohort study. Lancet Psychiatry
2015; 2: 809–16.
31
Steeg, S, Haigh, M, Webb, RT, Kapur, N, Awenat, Y, Gooding, P, et al. The exacerbating influence of hopelessness on other known risk factors for repeat self-harm and suicide. J Affect Disord
2016; 190: 522–8.
32
Kapur, N, Murphy, E, Cooper, J, Bergen, H, Hawton, K, Simkin, S, et al. Psychosocial assessment following self-harm: results from the multi-centre monitoring of self-harm project. J Affect Disord
2008; 106: 285–93.
33
Silverman, MM, Berman, AL, Sanddal, ND, O'Carroll, PW, Joiner, TE. Rebuilding the Tower of Babel: a revised nomenclature for the study of suicide and suicidal behaviors Part 1: background, rationale, and methodology. Suicide Life Threat Behav
2007; 37: 248–63.
34
O'Carroll, PW, Berman, AL, Maris, RW, Moscicki, EK, Tanney, BL, Silverman, MM. Beyond the Tower of Babel: a nomenclature for suicidology. Suicide Life Threat Behav
1996; 26: 237–52.
35
Andover, MS, Morris, BW, Wren, A, Bruzzese, ME. The co-occurrence of non-suicidal self-injury and attempted suicide among adolescents: distinguishing risk factors and psychosocial correlates. Child Adolesc Psychiatry Ment Health
2012; 6: 11.
36
Owens, D, Kelley, R, Munyombwe, T, Bergen, H, Hawton, K, Cooper, J, et al. Switching methods of self-harm at repeat episodes: findings from a multicentre cohort study. J Affect Disord
2015; 180: 44–51.
37
Clements, C, Jones, S, Morriss, R, Peters, S, Cooper, J, While, D, et al. Self-harm in bipolar disorder: findings from a prospective clinical database. J Affect Disord
2015; 173: 113–9.
38
Hawton, K, Zahl, D, Weatherall, R. Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry
2003; 182: 537–42.
39
Owens, D, Horrocks, J, House, A. Fatal and non-fatal repetition of self-harm. Br J Psychiatry
2002; 181: 193–9.
40
Carroll, R, Metcalfe, C, Gunnell, D. Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis. PLoS ONE
2014; 9: e89944.
41
Cooper, J, Kapur, N, Mackway-Jones, K. A comparison between clinicians' assessment and the Manchester Self-Harm Rule: a cohort study. Emerg Med J
2007; 24: 720–1.
42
Patterson, WM, Dohn, HH, Bird, J, Patterson, GA. Evaluation of suicidal patients: the SAD PERSONS scale. Psychosomatics
1983; 24: 343–9.
43
Kapur, N, Cooper, J, Hiroeh, U, May, C, Appleby, L, House, A. Emergency department management and outcome for self-poisoning: a cohort study. Gen Hosp Psychiatry
2004; 26: 36–41.
44
Cooper, J, Steeg, S, Bennewith, O, Lowe, M, Gunnell, D, House, A, et al. Are hospital services for self-harm getting better? An observational study examining management, service provision and temporal trends in England. BMJ Open
2013; 3: e003444.
45
DerSimonian, R, Laird, N. Meta-analysis in clinical trials. Control Clin Trials
1986; 7: 177–88.
46
Higgins, JP, Green, S. Cochrane Handbook for Systematic Reviews Of Interventions (vol 5). Wiley Online Library, 2008.
47
Hosmer, DW Jr, Lemeshow, S, Sturdivant, RX. Applied Logistic Regression (vol 398). John Wiley & Sons, 2013.
48
DeLong, ER, DeLong, DM, Clarke-Pearson, DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics
1988; 44: 837–45.
49
Allison, PD. Missing Data (vol 136). Sage Publications, 2001.
50
Ness, J, Hawton, K, Bergen, H, Cooper, J, Steeg, S, Kapur, N, et al. Alcohol use and misuse, self-harm and subsequent mortality: an epidemiological and longitudinal study from the multicentre study of self-harm in England. Emerg Med J
2015; 32: 793–9.
51
Geulayov, G, Kapur, N, Turnbull, P, Clements, C, Waters, K, Ness, J, et al. Epidemiology and trends in non-fatal self-harm in three centres in England, 2000-2012: findings from the Multicentre Study of Self-Harm in England. BMJ Open
2016; 6: e010538.
52
Hawton, K, Witt, KG, Taylor Salisbury, TL, Arensman, E, Gunnell, D, Hazell, P, et al. Psychosocial Interventions for Self-Harm in Adults.
The Cochrane Library, 2016.
53
O'Connor, E, Gaynes, BN, Burda, BU, Soh, C, Whitlock, EP. Screening for and treatment of suicide risk relevant to primary care: a systematic review for the US Preventive Services Task Force. Ann Antern Med
2013; 158: 741–54.
54
O'Connor, RC, Nock, MK. The psychology of suicidal behaviour. Lancet Psychiatry
2014; 1: 73–85.
55
Saunders, K, Brand, F, Lascelles, K, Hawton, K. The sad truth about the SADPERSONS Scale: an evaluation of its clinical utility in self-harm patients. Emerg Med J
2014; 31: 796–8.
56
Carroll, R, Metcalfe, C, Steeg, S, Davies, NM, Cooper, J, Kapur, N, et al. Psychosocial assessment of self-harm patients and risk of repeat presentation: an instrumental variable analysis using time of hospital presentation. PLoS ONE
2016; 11: e0149713.
57
Smith, MJ, Bouch, J, Bradstreet, S, Lakey, T, Nightingale, A, O'Connor, RC. Health services, suicide, and self-harm: patient distress and system anxiety. Lancet Psychiatry
2015; 2: 275–80.
58
Hunter, C, Chantler, K, Kapur, N, Cooper, J. Service user perspectives on psychosocial assessment following self-harm and its impact on further help-seeking: a qualitative study. J Affect Disord
2013; 145: 315–23.
59
Abderhalden, C, Needham, I, Dassen, T, Halfens, R, Haug, HJ, Fischer, JE. Structured risk assessment and violence in acute psychiatric wards: randomised controlled trial. Br J Psychiatry
2008; 193: 44–50.
60
Troquete, NA, van den Brink, RH, Beintema, H, Mulder, T, van Os, TW, Schoevers, RA, et al. Risk assessment and shared care planning in out-patient forensic psychiatry: cluster randomised controlled trial. Br J Psychiatry
2013; 202: 365–71.
61
Coope, C, Donovan, J, Wilson, C, Barnes, M, Metcalfe, C, Hollingworth, W, et al. Characteristics of people dying by suicide after job loss, financial difficulties and other economic stressors during a period of recession (2010–2011): a review of coroners records. J Affect Disord
2015; 183: 98–105.
62
Haw, C, Hawton, K, Gunnell, D, Platt, S. Economic recession and suicidal behaviour: Possible mechanisms and ameliorating factors. Int J Soc Psychiatry
2015; 61: 73–81.
Seena Fazel, Wellcome Trust Senior Research Fellow, Department of Psychiatry, University of Oxford
Achim Wolf, DPhil Student & Research Assistant, Department of Psychiatry, University of Oxford
11 May 2017
The study by Quinlivan and colleagues (1) could be interpreted to suggest that clinician and patient ratings are better than actuarial tools in predicting self-harm after an emergency hospital presentation with self-harm. However, we would argue that this is an incorrect interpretation.
First, the clinical evaluation appears to have occurred after these tools were completed by the same clinician, and, although they were masked to the overall score, the clinical impression will therefore have been strongly informed by the items in these suicide risk assessment tools. In fact, the study does not appear to be a comparison between actuarial tools and a distinct, unstructured clinical judgement, but a comparison between actuarial tools and what is called a structured clinical judgement approach (where structured questions about relevant risk factors are asked, and then a clinical judgement is made about an individual’s overall risk level). Clarification of the exact procedure used is important for interpreting the findings.
Second, the authors correctly point out that, on the basis of ROC curves, risk assessment tools performed no better than clinician ratings. The other way of looking at this, however, is that clinician ratings performed no better than risk scales. In particular, the Manchester Self-Harm Rule (2), a 4-item tool, performed just as well. Importantly, the authors found no evidence of between-hospital heterogeneity for this tool’s performance. Clinician ratings on the other hand showed substantial heterogeneity between hospitals, with specificity ranging from 58% to 82%. The lack of variability in the actuarial tools could be argued to be an advantage when performance between clinician rating and assessment tool is no different. Furthermore, tools like this will be considerably quicker, leaving more clinician time for risk management (as opposed to assessment).
Third, the clinicians were based in teaching hospitals (Brighton, Bristol, Derby, Manchester, and Oxford) with longstanding research interests in self-harm. Whether the reported predictive accuracy of clinician ratings is generalizable to non-specialist centres is an empirical question.
Fourth, the patient rating may also have been influenced by the questions asked by the tools (which tend to be categorical and therefore easy to work out what constitutes a risk factor). In a sense, then, the patient rating is a form of structured judgement.
Comparing risk tools with clinicians may not be informative, or even feasible, as clinical interviews already include many of the items used in risk tools. Instead, future research should compare actuarial scores with or without additional clinician input. In other words, if clinicians disagree with the risk level provided by actuarial tools, does this reclassification lead to an improvement in predictive performance? As the AUCs for the tools in this study ranged from 0.55 to 0.72, there may be considerable room for improvement by incorporating novel and modifiable risk factors as has been shown in violence risk assessment in patients with severe mental illness (3). Ultimately, randomized studies will be required to establish the effects of different approaches to risk assessment on patient and service outcomes.
1 Quinlivan L, Cooper J, Meehan D, Longson D, Potokar J, Hulme T, Marsden J, Brand F, Lange K, Riseborough E, Page L. Predictive accuracy of risk scales following self-harm: multicentre, prospective cohort study. British Journal of Psychiatry. 2017. DOI: 10.1192/bjp.bp.116.189993
2 Cooper J, Kapur N, Dunning J, Guthrie E, Appleby L, Mackway-Jones K. A clinical tool for assessing risk after self-harm. Annals of Emergency Medicine. 2006; 48(4), 459-466.
3Fazel S, Wolf A, Larsson H, Lichtenstein P, Mallett S, Fanshawe TR. Identification of low risk of violent crime in severe mental illness with a clinical prediction tool (Oxford Mental Illness and Violence tool [OxMIV]): a derivation and validation study. Lancet Psychiatry. 2017. DOI: 10.1016/S2215-0366(17)30109-8 ... More
Conflict of interest: S.F. has published on risk assessment, including a platform for risk assessment tools (OxRisk). A.W. is currently researching violence risk assessment.
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Emily Kruger, Assistant Psychologist, Child and Adolescent Mental Health Service (CAMHS)
26 March 2017
Thank you for publishing such an interesting, in depth study. As one who is very interested in ways to recognise and prevent self harm and crisis situations, I am pleased to see an article dedicating research to such an important area. Thus, in order to prevent crisis situations, it is paramount that reliable and valid measures are used to assess in clinical settings.
I only have one criticism of the paper. In terms of your introduction, I would have liked to see more information R.E self harm and risk factors of self-harming behaviours, in order to set the scene. In addition, it may have been useful to state what self harm consists of and the controversies surrounding this in order to inform a ready of whom may be unaware of the details.
Again, I thank you for a compelling read.
Many thanks,
Emily Kruger ... More
Conflict of interest: None Declared
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