Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis

Abstract

Background: Non-fatal self-harm is one of the most frequent reasons for emergency hospital admission and the strongest risk factor for subsequent suicide. Repeat self-harm and suicide are key clinical outcomes of the hospital management of self-harm. We have undertaken a comprehensive review of the international literature on the incidence of fatal and non-fatal repeat self-harm and investigated factors influencing variation in these estimates as well as changes in the incidence of repeat self-harm and suicide over the last 30 years.

Methods and findings: Medline, EMBASE, PsycINFO, Google Scholar, article reference lists and personal paper collections of the authors were searched for studies describing rates of fatal and non-fatal self-harm amongst people who presented to health care services for deliberate self-harm. Heterogeneity in pooled estimates of repeat self-harm incidence was investigated using stratified meta-analysis and meta-regression. The search identified 177 relevant papers. The risk of suicide in the 12 months after an index attempt was 1.6% (CI 1.2-2.4) and 3.9% (CI 3.2-4.8) after 5 years. The estimated 1 year rate of non-fatal repeat self-harm was 16.3% (CI 15.1-17.7). This proportion was considerably lower in Asian countries (10.0%, CI 7.3-13.6%) and varies between studies identifying repeat episodes using hospital admission data (13.7%, CI 12.3-15.3) and studies using patient report (21.9%, CI 14.3-32.2). There was no evidence that the incidence of repeat self-harm was lower in more recent (post 2000) studies compared to those from the 1980s and 1990s.

Conclusions: One in 25 patients presenting to hospital for self-harm will kill themselves in the next 5 years. The incidence of repeat self-harm and suicide in this population has not changed in over 10 years. Different methods of identifying repeat episodes of self-harm produce varying estimates of incidence and this heterogeneity should be considered when evaluating interventions aimed at reducing non-fatal repeat self-harm.

Figure 1. Literature review flow chart.

Figure 2. Forest plot of 1 year non-fatal repetition rates (%).

Where findings were reported for several different centres/time periods/cohorts within one publication, results from each centre/time period/cohort appear separately.

Figure 3. Individual study estimates of non-fatal repeat self-harm by duration of follow-up weighted by cohort size with overall pooled 1, 2 and 5 year estimates highlighted.

Studies with follow-up over 10 years (n = 3) are not visible in this graph. Larger studies are indicated by larger circles.

Figure 4. Forest plot of 1 year fatal repetition rates.

Where findings were reported for several different centres/time periods/cohorts within one publication, results from each centre/time period/cohort appear separately.

Figure 5. Individual study estimates of fatal repeat self-harm by years of follow-up weighted by cohort size with overall 1, 2, 5 and 10 year estimates.

Larger studies are indicated by larger circles.