Mullins et al's study of accident and emergency (A&E) presentations following self-harm added to the evidence for poor uptake of psychosocial assessments in the initial management of self-harm. ^{Reference Mullins, MacHale and Cotter1} Of particular concern was the finding that single men under 45 represented 39% of those not assessed. Although suicide rates among men in the UK fell between 1992 and 2007, the 2008 figures show a rise to 17.7 per 100 000, with highest rates seen in men aged 15-44. ² A young man's presentation to A&E following self-harm is a valuable opportunity to offer interventions which reduce his risk of repetition. The paradox is that with many of these opportunities being missed researchers cannot evaluate the effectiveness of interventions to reduce repetition in this group.

Those who discharge themselves from A&E before completed assessment are 3 times more likely to repeat self-harm in the following year than those who are assessed. ^{Reference Crawford and Wessely3} It is possible that impulsive personality traits are more heavily implicated than the lack of an assessment, but we need to know more about this group's behavioural characteristics so that we can learn how to engage them as soon as they present. From the Mullins et al study it is not clear whether patient factors or staff factors were more influential in determining completion of a psychosocial assessment. The National Institute for Health and Clinical Excellence (NICE) recommends that patients who self-harm are ‘treated with the same care, respect and dignity as other patients’, ⁴ and reforms to medical and nursing training in some areas of the UK have managed to achieve cultural change. ^{Reference Pitman and Tyrer5} This is crucial because a humiliating or uncomfortable experience in A&E is likely to dissuade a patient from presenting should they self-harm again, and in cases of overdose this may increase mortality risk.

It is striking that of the 341 patients in Mullins et al's study who did not receive a psychosocial assessment, 141 (41%) subsequently presented within the year of data collection having self-harmed, of whom 74 (52%) slipped through the net a second time. We are unclear of the demographic characteristics of this subgroup, or whether there was a tendency for these individuals to leave A&E at the same stage in the referral process. However, if a study of this kind was repeated across a larger geographical area, it could be sufficiently powered to reveal valuable predictors which would help A&E staff decide which patients to fast-track.

Finally, NICE recommendations on the communication of findings after self-harm assessments require auditing in future similar studies. A patient's general practitioner (GP) or community mental health team may remain completely unaware of their presentation to A&E following self-harm unless a copy of the assessment is communicated to the relevant professionals. Even if the full psychosocial assessment was not performed, an outline of the presenting complaint would be of value. Armed with this information, a GP or key worker would be able to discern any patterns emerging in self-harm presentations, sometimes to many different hospitals, and would be in a unique position to manage apparent escalations in risk.