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Predictive accuracy of risk scales following self-harm: Multicentre, prospective cohort study

  • Leah Quinlivan (a1), Jayne Cooper (a1), Declan Meehan (a2), Damien Longson (a2), John Potokar (a3), Tom Hulme (a4), Jennifer Marsden (a5), Fiona Brand (a6), Kezia Lange (a6), Elena Riseborough (a7), Lisa Page (a7), Chris Metcalfe (a8), Linda Davies (a9), Rory O'Connor (a10), Keith Hawton (a11), David Gunnell (a8) and Nav Kapur (a12)...

Scales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.


To evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.


A multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.


In total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0–5) for the SAD PERSONS scale, to 97% (95% CI 93–99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2–47) for the Modified SAD PERSONS Scale to 47% (95% CI 41–53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50–0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69–0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P < 0.001).


Risk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.

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This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.
Corresponding author
Leah Quinlivan, Jean McFarlane Building, University of Manchester, Oxford Road, Manchester M13 9PL, UK. Email:
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See editorial, pp. 384–386, this issue.

Declaration of interest

D.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the NICE guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for depression. R.O.C. was a member of the NICE guideline development group for the longer-term management of self-harm and is a member of the Scottish Government's suicide prevention implementation and monitoring group.

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Predictive accuracy of risk scales following self-harm: Multicentre, prospective cohort study

  • Leah Quinlivan (a1), Jayne Cooper (a1), Declan Meehan (a2), Damien Longson (a2), John Potokar (a3), Tom Hulme (a4), Jennifer Marsden (a5), Fiona Brand (a6), Kezia Lange (a6), Elena Riseborough (a7), Lisa Page (a7), Chris Metcalfe (a8), Linda Davies (a9), Rory O'Connor (a10), Keith Hawton (a11), David Gunnell (a8) and Nav Kapur (a12)...
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Suicide risk assessment tools do not perform worse than clinical judgement

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
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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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Dear Leah Quinlivan et al.,

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
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Conflict of interest: None Declared

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