Keith Hawton

Background: Suicide risk is greatly increased in schizophrenia. Detection of those at risk is clinically important.Aims: To identify risk factors for suicide in schizophrenia.Method: The international literature on case-control and cohort studies of patients with schizophrenia or related conditions in which suicide was reported as an outcome was systematically reviewed. Studies were identified through searching electronic databases and reference lists, and by consulting experts.Results: Twenty-nine eligible studies were identified. Factors with robust evidence of increased risk of suicide were previous depressive disorders (OR=3.03, 95% CI 2.06–4.46), previous suicide attempts (OR=4.09, 95% CI 2.79–6.01), drug misuse (OR=3.21, 95% CI 1.99–5.17), agitation or motor restlessness (OR=2.61, 95% CI 1.54–4.41), fear of mental disintegration (OR=12.1, 95% CI 1.89–81.3), poor adherence to treatment (OR=3.75, 95% CI 2.20–6.37) and recent loss (OR=4.03, 95% CI 1.37–11.8). Reduced risk was associated with hallucinations (OR=0.50, 95% CI 0.35–0.71).Conclusions: Prevention of suicide in schizophrenia is likely to result from treatment of affective symptoms, improving adherence to treatment, and maintaining special vigilance in patients with risk factors, especially after losses.

A large (n = 14, 892) consecutive sample of deliberate self‐harm (attempted suicide) patients who presented to a general hospital in the United Kingdom during a 23‐year study period was examined (over two consecutive time periods) in order to compare the characteristics of those who used self‐cutting (n = 428) and those who self‐poisoned (n = 11, 065). Patients who used different methods on other occasions, or were not assessed by the psychiatric service, were excluded. In the first time period (January 1976—June 1988), the self‐cutters were distinguished from the self‐poisoners by more often being male, single, not employed, and having a history of previous deliberate self‐harm. In the second time period (July 1988—December 1998) the self‐cutters were again distinguished by more often being male and having a history of previous deliberate self‐harm, but also by being more likely to live alone, misuse alcohol, and have low suicidal intent scores. The finding ofan excess of males among the self‐cutters is contrary to the impression in the literature that self‐cutting presentations to general hospitals more often involve females. It also indicates that the treatment needs of those who deliberately cut themselves are likely to differ from those of self‐poisoners.

Introduction A 30 year old woman tells you she has experienced pain during sexual intercourse since the birth of her first baby a year ago. She has now lost interest in sex. Her husband is becoming impatient, and she asks you for help.

Objective: To determine the prevalence of deliberate self harm in adolescents and the factors associated with it. Design: Cross sectional survey using anonymous self report questionnaire. Setting: 41 schools in England. Participants: 6020 pupils aged 15 and 16 years. Main outcome measure: Deliberate self harm. Results: 398 (6.9%) participants reported an act of deliberate self harm in the previous year that met study criteria. Only 12.6% of episodes had resulted in presentation to hospital. Deliberate self harm was more common in females than it was in males (11.2% v 3.2%; odds ratio 3.9, 95% confidence interval 3.1 to 4.9). In females the factors included in a multivariate logistic regression for deliberate self harm were recent self harm by friends, self harm by family members, drug misuse, depression, anxiety, impulsivity, and low self esteem. In males the factors were suicidal behaviour in friends and family members, drug use, and low self esteem. Conclusions: Deliberate self harm is common in adolescents, especially females. School based mental health initiatives are needed. These could include approaches aimed at educating school pupils about mental health problems and screening for those at risk. What is already known on this topic: Deliberate self harm is a common reason for presentation of adolescents to hospital Community studies from outside the United Kingdom have shown much greater prevalence of self harm in adolescents than hospital based studies What this study adds: Deliberate self harm defined according to strict criteria is common in adolescents, especially females Associated factors include recent awareness of self harm in peers, self harm by family members, drug misuse, depression, anxiety, impulsivity, and low self esteem

Objective:  To investigate whether there are differences between the characteristics of deliberate self‐harm (DSH) patients with and without a family history of suicidal behaviour.Method:  In 146 DSH patients, those with and without a positive family history were compared with regard to the nature and repetition of their DSH episodes, and psychological and psychiatric characteristics.Results:  Fifty‐two (35.6%) patients had a family history of suicidal behaviour. DSH was more frequent in patients' mothers (17.1%) than fathers (2.7%). Patients with a family history of suicidal behaviour, especially females, had higher state anger scores.Conclusion:  Family history of suicidal behaviour appears to be associated with greater anger. Absence of other associations suggests that family history probably has less implication for individuals who have already engaged in DSH than in contributing to its initiation. Future studies should include patients with violent or life‐threatening DSH acts.

Development of effective treatments for patients following deliberate self‐harm (self‐poisoning or self‐injury) is a very important element in suicide prevention. The randomized controlled trial (RCT...

Background: Previous UK studies have reported much lower rates of psychiatric and personality disorder in those who attempt suicide than in those who die by suicide.Aims: To determine the nature and prevalence of psychiatric and personality disorders in deliberate self-harm (DSH) patients.Method: A representative sample of 150 DSH patients who presented to a general hospital were assessed using a structured clinical interview and a standardised instrument. Follow-up interviews were completed for 118 patients approximately 12–16 months later.Results: ICD–10 psychiatric disorders were diagnosed in 138 patients (92.0%), with comorbidity of psychiatric disorders in 46.7%. The most common diagnosis was affective disorder (72.0%). Personality disorder was identified in 45.9% of patients interviewed at follow-up. Comorbidity of psychiatric and personality disorder was present in 44.1%.Conclusions: Psychiatric and personality disorders, and their comorbidity, are common in DSH patients. This has important implications for assessment and management.

BACKGROUND Suicide rates in young males in the UK have risen markedly in recent years. AIMS To investigate the characteristics of a series of consecutive suicides in under-25-year-olds. METHOD We studied coroners' inquest notes, general practitioners' records and psychiatric case notes of 174 individuals (148 males and 26 females) whose deaths received a verdict of suicide or an open or accidental verdict (excluding traffic accidents) where the circumstances strongly suggested suicide. RESULTS More individuals were of lower social class and unemployed than in the local population. Hanging and carbon monoxide poisoning were the most frequent methods of suicide, and coproxamol was the drug most often used in overdoses. Previous self-harm had occurred in 44.8%, nearly half of these having carried out multiple episodes and 80% having self-harmed within the previous year. Little support was found for an earlier finding of increasing frequency of general practitioner visits shortly before death. Only 22.4% of individuals were in the care of psychiatric services. CONCLUSIONS Diverse strategies are required to prevent suicide in the very young.

Objective: To identify and synthesise the findings from all randomised controlled trials that have examined the effectiveness of treatments of patients who have deliberately harmed themselves. Design: Systematic review of randomised controlled trials of psychosocial and physical treatments. Studies categorised according to type of treatment. When there was more than one investigation in a particular category a summary odds ratio was estimated with the Mantel-Haenszel method. Setting: Randomised trials available in electronic databases in 1996, in the Cochrane Controlled Trials Register in 1997, and from hand searching of journals to 1997. Subjects: Patients who had deliberately harmed themselves shortly before entry into the trials with information on repetition of behaviour. The included trials comprised 2452 randomised participants with outcome data. Main outcome measure: Repetition of self harm. Results: 20 trials reported repetition of self harm as an outcome variable, classified into 10 categories. Summary odds ratio (all for comparison with standard aftercare) indicated reduced repetition for problem solving therapy (0.73; 95% confidence interval 0.45 to 1.18) and for provision of an emergency contact card in addition to standard care (0.45; 0.19 to 1.07). The summary odds ratios were 0.83 (0.61 to 1.14) for trials of intensive aftercare plus outreach and 1.19 (0.53 to 2.67) for antidepressant treatment compared with placebo. Significantly reduced rates of further self harm were observed for depot flupenthixol versus placebo in multiple repeaters (0.09; 0.02 to 0.50) and for dialectical behaviour therapy versus standard aftercare (0.24; 0.06 to 0.93). Conclusion: There remains considerable uncertainty about which forms of psychosocial and physical treatments of patients who harm themselves are most effective. Further larger trials of treatments are needed. Key messages: A systematic review of the effectiveness of psychosocial and drug treatments of patients who deliberately harm themselves identified 20 randomised controlled trials in which repetition of self harm was reported as an outcome Promising results were found for problem solving therapy, provision of a card to allow patients to make emergency contact with services, depot flupenthixol for recurrent self harm, and long term psychological therapy for female patients with borderline personality disorder and recurrent self harm Assertive outreach can help to keep patients in treatment Nearly all the trials included too few patients to detect clinically significant differences in repetition of self harm, and even synthesis of results by meta-analysis did not have the power to detect such differences There is an urgent need for large trials of promising therapies for this substantial clinical population