· web viewsuicide rates among people discharged from non-psychiatric settings after presentation...

Suicide rates among people discharged from non-psychiatric settings after presentation with

suicidal thoughts or behaviours

Maggie Wang1, Sascha Swaraj1, Daniel Chung1, Clive Stanton2 , Navneet Kapur3 , Matthew Large1,2

1. Medicine, University of NSW, Kensington, Sydney, NSW, Australia

2. School of Psychiatry, University of NSW, Kensington, Sydney, NSW, Australia

3. Centre for Suicide Prevention, Centre for Mental Health and Safety, Division of Psychology and Mental Health, University of

Manchester and Greater Manchester Mental Health National Health Service Foundation Trust, M13 9PL,UK.

Conflicts of Interest

The authors have no conflicts of interest to declare

Funding

The study received no funding

1

Abstract

Objective: To quantify the suicide rate among people discharged from non-psychiatric facilities after presentations with suicidal

thoughts or behaviours.

Method: Meta-analysis of studies reporting suicide deaths among people with suicidal thoughts or behaviours (defined as suicide

attempts, self-harm, suicidal ideas or similar) after discharge from non-psychiatric settings (defined as emergency departments and

general hospital wards or similar) when the number of exposed person years was reported or could be calculated. A random-effects

model was used in the main analysis and within subgroups.

Results: 115 studies reported 167 cohorts including a total of 3 747 suicide deaths among 248 005 patients during 1 263 727 person-

years. The pooled suicide rate post-discharge was 483 suicide deaths per 100,000 person-years (95% confidence interval (CI) 445 –

520, prediction interval (PI) 200 to 770) with high between sample heterogeneity (I2=92). The suicide rate was highest in the first year

after discharge (851 per 100 000 person-years) but remained elevated compared to typical community suicide rates in the long term.

Suicide rates were elevated among samples of men (716 per 100 000 person-years) and older people (799 per 100 000 person-years)

but were lower in samples of younger people (107 per 100 000 person-years) and among studies published between 2010 and 2018

(329 per 100 000 person-years).

2

Conclusions: Despite a clinically meaningful decline in reported suicide rates post-discharge from non-psychiatric settings in recent

decades, people with suicidal thoughts or behaviours who are discharged from non-psychiatric facilities have highly elevated rates of

suicide. Every such patient warrants a careful assessment and individualised treatment.

3

Summations

The pooled suicide rate among patients with suicidal thoughts or behaviours following discharge from a non-psychiatric

facility was 483 per 100 000 person years (95% CI 445 to 520).

Suicide rates were lower among samples of younger people (<25 years of age) and among more recently published studies, but

were higher in the first year after discharge, among older people (>55 years of age), and men.

All patients presenting to non-psychiatric settings with suicidal thoughts or behaviours warrant a careful assessment and

individualised treatment planning.

Limitations

Very high between-study heterogeneity limits the extent to which the results can be regarded as a generalizable.

The meta-analysis could not examine many clinical factors that might contribute to variation in suicide rates.

Few studies could be included from low and middle-income countries.

4

Text

Suicide was the 17th ranked cause of mortality worldwide in 2015 causing about 800 000 deaths at a rate of 10.7 per 100 000 person-

years (1). The World Health Organisation (WHO) identifies suicide prevention as a major public health priority, and has called on

nations to make suicide prevention a ‘global imperative’(2). They recommend that suicide prevention be achieved by the systematic

consideration of ‘risk and protective factors and related interventions’. Specifically, the WHO advocates that ‘universal’ strategies should

target whole populations, ‘selective’ strategies should target higher-risk groups and ‘indicated’ strategies should protect individuals at

risk (2).

In recent years considerable doubt has been cast on the ability of health services to identify individuals who might benefit from

specifically ‘indicated’ suicide prevention strategies because suicide risk assessments produce an impractical number of false positives

and may prevent lower risk patients from receiving appropriate mental health care (3-6). In contrast, the WHO recommendation to

identify groups of people who might benefit from ‘selective’ suicide prevention strategies may be increasingly. One obvious group who

might benefit from selective strategies are people who present to hospitals seeking assistance with suicidal ideation, self-harm and

suicide attempts, referred to here as suicidal thoughts or behaviours. A recent meta-analysis estimated a pooled suicide rate of about 200

5

times the global suicide rate among people discharged from inpatient psychiatric care after admission with suicidal thoughts or

behaviours (7). However, most people who present to hospitals with suicidal thoughts or behaviours are not admitted for inpatient

psychiatric care but are instead discharged from non-psychiatric settings such as emergency departments (EDs), accident and

emergency centres (A&Es), casualty departments, the medical and surgical wards of general hospitals. The suicide rate among this

important group of patients has yet to be explored using meta-analysis.

An examination of primary research studies of people who present to non-psychiatric settings with suicidal thoughts or behaviours

reveals studies that differ in their methods and vary greatly in reported suicide rates. For example, Hawton and associates found that

people presenting with self-harm to emergency departments in the United Kingdom had a suicide rate of 170 per 100,000 person years

(8) while a Finnish study by Ostamo and associates found a rate of 1 302 per 100,000 person years among people presenting to general

hospitals after a suicide attempt (9). A 2014 meta-analysis of 40 studies of people who presented with self-harm to either psychiatric or

non-psychiatric hospitals estimated the 12 month cumulative suicide mortality to be 1.6%, equivalent to 1 600 per 100,000 person

years (10).

6

Knowledge of the extent and variation in the suicide rate among patients discharged with suicidal thoughts or behaviours from non-

psychiatric settings might be useful in guiding the rational allocation of suicide prevention and psychiatric resources between patients

discharged from psychiatric and non-psychiatric settings. Estimates of the suicide rate post-discharge from non-psychiatric settings are

also relevant because it has been suggested that many people who present with suicidal thoughts or behaviours receive no specialist

mental health care in this setting (11-13) and because this suicide rate is central to expected rates of suicide risk in groups of patients

that might be categorized as at higher or lower suicide risk by suicide risk assessments performed in non-psychiatric settings.

Aims

The primary aim was to calculate a pooled estimate of the suicide rate of people with suicidal thoughts or behaviours after discharge

from non-psychiatric facilities in total and over different periods of follow-up. We included studies of patients who exhibited broadly

defined suicidal thoughts or behaviours and focused on non-psychiatric settings with the aim of examining the risk of suicide associated

with the common situation of a person presenting to a non-psychiatric setting with a perceived suicide risk. We examined suicide rates

rather than the proportion of suicide deaths at various periods of follow-up in order to report conventional measures of suicide

mortality and to more clearly outline the trajectory of suicide risk over time. The secondary aims were to explore whether different

7

definitions of suicidal thoughts or behaviours, the setting of non-psychiatric care, patient characteristics, or other study characteristics

might explain between study heterogeneity in suicide rates.

Methods

Meta-analysis conforming to the Meta-analysis of Observation Studies in Epidemiology (MOOSE) (14) and Preferred Reporting Items for

Systematic Reviews and Meta-analyses (PRISMA) guidelines (15) and registered with PROSPERO (CRD42018088777).

Search Strategy

Two authors (ML and MW) independently searched using two search strategies (Figure 1.). The first search was for relevant English-

language papers indexed in Embase, Ovid MEDLINE(R) and PsychINFO from 1 January 1960 to 18 May 2018 located with the search

terms ((suicid*).m_titl. AND (emergency* OR accident and emergency OR casualty OR general hospital OR toxicology service).mp.). The

second search was for relevant English-language papers with abstracts published in PubMed from 1 January to 1960 to 13 January 2019

located with the search terms ((suicid* OR self harm OR self-harm OR self injury OR self-injury OR self poisoning OR self-poisoning OR

overdose OR para-suicide OR parasuicide [title/abstract]) AND (Emergency department OR emergency room OR Casualty OR general

8

hospital OR toxicology OR accident and emergency [all fields]) (for full search terms see data supplement 1). Electronic searches were

supplemented by hand-searches of the reference list of included studies.

Inclusion and Exclusion Criteria

Full text papers were examined for inclusion by two researchers (MW and ML) using the below eligibility criteria.

We included studies that either

reported the number of suicide deaths of people with suicidal thoughts or behaviours discharged from non-psychiatric facilities

and the number of person years in which the suicide deaths occurred or

studies from which this data could be calculated using the reported suicide rate, the average length of patient follow-up, or the

duration of study follow-up.

We excluded studies if they

followed up or included community presentations with suicidal thoughts or behaviours

reported on suicide deaths of current or discharged psychiatric inpatients

reported on the direct mortality of suicide attempts

9

were conducted before 1960

duplicated or overlapped with an included study with a larger number of patient years.

Data Extraction of effect size and moderator variables

Two authors (M.L and M.W) independently extracted the data. Disputed data-points were reconciled by re-examination by both authors.

The effect size data (outcome of interest) was the suicide rate derived from the number of suicide deaths per exposed person years after

discharge. When the number of person years was not reported directly it was calculated from the sample size and reported follow-up

periods. Where possible, study samples were separated into cohorts first by gender and then by age group. The moderator variables

were considered to be associated with either patient or study characteristics, including strength of reporting. Patient related

moderators were considered to be age group (<25 years of age, adults, >55 years of age or unspecified, as most commonly reported in

the primary literature), gender (male, female or both), presentation (suicide attempt or any other form of suicidal thoughts or behaviour

as defined in the primary research). Study related moderators were; duration of follow-up (months), year of publication, , the discharge

setting (emergency department or similar versus general hospital or similar), the strength of reporting and the country where the study

10

was conducted. A potential moderator of national suicide rates in the country of origin in the year of publication was also obtained using

WHO data (16, 17).

Strength of reporting

A 9 item scale for assessing the strength of reporting was adapted from the Newcastle Ottawa scale for assessing the quality of non-

randomized studies (18). We used the term strength of reporting rather than study quality or risk of bias in order to acknowledge that

the studies were likely to have adequate quality to meet the stated aims of the primary research. One strength of reporting point was

allocated to studies that had; i) had broad inclusion criteria (for example some studies excluded patients with severe psychiatric

disorders or substance abuse), ii) recruited patients from a defined catchment area, iii) only included patients with a first presentation

of suicidal thoughts or behaviour (because repeat presenters are at a higher risk), iv) counted people not admissions, v) was not

restricted to patients with a specified method type of self-harm (e.g. self-poisoning patients only), vi) included only patients who were

all regarded as having made a suicide attempt, vii) provided complete follow-up for more than 80% of patients, viii) used an external

mortality database (as this data is considered more reliable) ix) included undetermined coroners verdicts or similar. This generated a

scale with values from 0-9. Studies with a total score of six or greater were regarded as having stronger reporting.

11

Meta-analysis

Pooled suicide mortality per person year was estimated using Comprehensive Meta Analysis (CMA). A random-effects model was chosen

a priori because of likely high degree of between study heterogeneity. Suicide rates were converted to events per 100 000 person years

after the analysis to conform to conventional reporting. In the event that a study reported no completed suicide deaths, we allocated a

nominal 0.1 suicide death to allow effect size calculations in order to minimize bias away from zero event studies. Publication bias was

assessed using Egger’s test and the likely effect of missing studies was estimated using Duval and Tweedie’s trim and fill method.

Between-study heterogeneity was assessed using Q-value and I² statistics. Sub-group (sensitivity) analysis was assessed with a mixed

effects model between groups and continuous moderators were examined with random effects meta-regression. Moderator variables

that explained between study-heterogeneity at P <.05 were tested for statistical independence using a random-effects (method of

moments) multiple meta-regression.

12

Results

Study Sample

155 peer-reviewed publications met our inclusion criteria. Forty studies were further excluded because of identical or overlapping

patient samples. A total of 115 studies reporting 167 samples were included in the meta-analysis (8, 9, 19-131) (Supplementary

Material (SM) 2. Table of Included Studies and SM. 3 Data used in meta-analysis.) The samples included 46 samples of females, 46

samples of males and 75 samples of both sexes. There were 91 samples of people discharged directly from the emergency department

and similar and 76 samples were of people discharged from general hospitals non-psychiatric settings. There were 88 samples of people

considered to have made a suicide attempt and 79 samples of people defined by other forms of suicidal thoughts or behaviours

including, self-harm, deliberate self-poisoning, and suicidal ideation. There were 10 samples were older people (>55 years of age), 129

samples were of adults or unspecified regarding age, and 28 samples were of younger people (<25 years of age). There were 10 samples

from Asian countries, 69 samples from mainland Europe, 32 samples from North America, 12 samples from Oceania (including

13

Australia), 41 samples from the UK or Ireland, and 3 samples from other or multiple regions. The median year of study publication was

2006 (range 1965 to 2018, interquartile range 1993 to 2014).

The 167 samples reported 3 747 suicide deaths among 248 005 patients during 1 263 727 person-years. The mean number of suicide

deaths per sample was 22.4 (median 8, range 0 to 227) and the mean number of person years per sample was 7 567 years (median, 1

020; range, 5 to 147 391). The median suicide rate was 708 per 100 000 person years and the interquartile range was 326 to 1 324 per

100 000 person years. The median follow-up period was 54 months (range 1 – 323 months, interquartile range 12 to 78 months).

There were differences in 70 of the 668 effect size data points (suicides, patient numbers, patient years or duration of follow-up) or

between two authors (MW and ML). These were resolved by a joint re-examination of the data.

Meta-analytic pooled estimate

14

The pooled suicide rate in suicidal patients following discharge from a non-psychiatric facility was 483 per 100 000 person years (95%

CI 445 to 520, 95% prediction interval (PI), 200 to 770) with a high between-sample heterogeneity (Q-value=1 998, df =166, P<0.001,

I2=92).

Egger’s regression suggested there was significant publication bias towards samples reporting higher suicide rates (intercept=2.87, t-

value=13.76, P<.001). Duval and Tweedie’s trim and fill adjusted for 68 samples to the left of the mean (suggesting likely publication

bias towards smaller studies with a higher suicide rate) and recued the pooled estimate 30% to 338 per 100,000 person years (95% CI

300 to 375).

Moderators of suicide rates post-discharge

Samples with duration of follow-up of one year or less had the highest suicide rate and studies with follow-up of five years or more had

a lower rate of follow-up than samples with a shorter duration of follow-up (Table 1, see Figure 2 for the distribution of primary study

rates versus duration of follow-up). Meta regression suggested that the suicide rate declined by 3 suicide deaths per 100,000 patient per

15

additional month of follow-up (95% CI -1.5 to -4.7, z-score = -3.85, P<.001) equivalent to a fall in 36 suicides per 100 000 person years

for every year post-discharge.

More recently published studies had significantly lower suicide rates with a clinically meaningful stepwise decline in suicide rates in the

last three decades (Table 1). Meta-regression suggested that post-discharge suicides rates decline in 10 suicides per 100,000 person

years for every advancing year of publication (95% CI 3 to 17, z-value = -2.96, P =.003).

Rates of suicide were significantly higher in samples of men when compared to samples of women and of mixed gender (Table 1).

Samples of younger people had lower rates of suicide than samples of adults or samples that were unselected by age. Samples of older

people had higher rates than samples of adults or samples that were unselected by age (Table 1).

The geographic region of the study was significantly associated with variation in suicide rates post-discharge. Rates were highest in

samples from Asian regions and were lowest in studies from North America, the United Kingdom and Ireland (Table 1). There was also a

significant association between national suicide rates in the country and year of the study and the post-discharge suicide rate,

16

equivalent to an increase in 32 post-discharge suicides per 100 000 person years for every increased suicide death per 100 000 person

years in the national suicide rate in the year of publication (95% CI 16 to 49, z-value = 3.86, p <.0001).

17

The discharge setting (emergency departments or similar versus general hospital wards) was not significantly associated with the

suicide rate. Studies with a higher total strength of reporting score had a lower pooled suicide rate than studies with a lower strength of

reporting score (Table 1). Among the individual strength of reporting scale items, studies with broad inclusion criteria and studies that

included first presentations had lower rates of suicide, while studies that only included people who were regarded as having made a

suicide attempt had a higher suicide rate (Table 2).

Moderators that were significantly associated with between study heterogeneity were entered into a mixed-effects multiple meta-

regression model. The multiple meta-regression suggested that samples of males and samples from regions with a higher national

suicide rate had independently higher suicide rates, while samples of younger people, samples with a longer duration of follow-up, more

recently published samples, and samples with stronger reporting had independently lower post-discharge suicide rates. Whether or not

a sample was comprised only of suicide attempters did not contribute significantly to heterogeneity in post-discharge suicide rates in

the multiple meta-regression model (Table 3).

18

Discussion

This meta-analysis synthesized the results of 115 studies published over more than half a century. The pooled suicide rate among

people discharged from non-psychiatric settings after presenting with suicidal thoughts or behaviours over this period was was 483 per

100,000 person years. An unexpected but reassuring aspect of our findings was a meaningful fall in suicide rates such that studies

published since 2010 had a pooled suicide rate of 329 suicides per 100 000 person years. However, it is important to acknowledge that

this contemporary rate of post-discharge suicide is about 30 times that of the 2015 global rate of 10.7 per 100,000 person years.

Our results can be compared to those of the 2014 meta-analyses by Carroll and associates that synthesized 40 studies reporting suicide

deaths after hospital treated self-harm. Carroll and associates estimated a cumulative suicide mortality of 1.6% at 1 year or 1 600

suicides per 100 000 person-years (132) which is almost double our one year follow up rate of 851 per 100 000 person years. The

reasons for the difference between the two estimates may include that our meta-anlysis included more recent data than might report

lower rates, sampled about three times the number of primary research studies, used a broader definition of suicidal thoughts or

behaviours and, excluded patients discharged from psychiatric hospitals (7).

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Our results can also be compared to the recent meta-analysis of suicide rates post-psychiatric discharge (7). Acknowledging the very

high degree of between study heterogeneity in both studies, the pooled suicide rate among people with suicidal thoughts or behaviours

discharged from non-psychiatric settings of 483 suicide deaths per 100 000 person years was about one quarter of the reported suicide

rate of patients with suicidal thoughts or behaviours discharged from psychiatric facilities, estimated to be 2 078 per 100 000 person

years. A notable difference between our results and that of the meta-analysis of post-psychiatric discharge rates is the significant

increase in suicide risk associated with samples of men in the present study that had a pooled rate of male suicide of about 1.8 times

that of the female rate. This is similar to the global ratio of male : female suicides of 1.8 (1) and suggests that male sex is a similar risk

factor for suicide among people discharged from non-psychiatric settings as it is in the general community. A common trend in this

meta-analysis and the meta-analysis of suicide rates post-discharge from inpatient psychiatric care is the elevated suicide risk in older

people and a lower risk among younger people.

We found differences between suicide rates in different geographic regions with samples from UK or Ireland and North America

reporting almost half of the pooled rate whereas Asian studies reported almost three times the pooled rate. One likely reason for

geographic differences is the existence of common factors underlying community suicide rates and post-discharge rates as supported by

20

our finding of a significant association between national suicide rates of studies in the year of publication and the suicide rate post-

discharge. However, other reasons for differences in rates according to geographic regions might be differences in national efforts to

reduce patient suicide, the availability of mental health care post-discharge, differences in threshold of severity at which people present

to hospital in different countries, or national differences in the definition of suicidal thoughts or behaviours.

Our results suggest that there has been a meaningful decline in rates of suicide reported in more recent studies. While lowered

thresholds of severity of suicide thoughts of behaviours of patients presenting to non-psychiatric settings might have contributed to this

finding, publication year was independently associated with lower suicide rates in the multivariate analysis, suggesting that improved

standards of routine care might have assisted people with suicide thoughts or behaviours in non-psychiatric settings.

The absence of any statistical difference between rates of suicide post emergency department and general hospital discharge was a

surprising finding given that individuals with a medically serious suicide attempt are more likely to be admitted into hospital and might

have more suicidal intent. One possible explanation for this could be the difference in the management of these two populations. People

admitted into hospital might receive more thorough assessments and higher quality discharge plans whereas people discharged from

emergency departments may receive less complete assessments and less adequate treatment planning.

21

Our subgroup analysis found a statistical difference in the suicide rate between samples of people who are all regarded as having made a

suicide attempt and samples defined by a broader definition of suicidal thoughts or behaviours. However, the meta-regression analysis

casts doubt on whether this difference in suicide rates is independent of other study characteristics. More importantly, the suicide rate

in both groups is high enough to diminish the clinical importance of any distinction. In fact, our data suggests that there is a danger of

false reassurance when self-harming behaviour is present without expressed suicidal intent and that all presentations of suicidal

thoughts or behaviours should be treated seriously.

The first limitation of this study is the high between-sample heterogeneity meaning that the results might not be generalizable to all

non-psychiatric settings. While we identified a number of variables that explained between study heterogeneity, a large number of

potentially important variables that might also moderate suicide rates were not reported in the primary studies and could not be

examined by meta-analysis. These include patient level risk factors such as rates of depression, substance use, previous or subsequent

admissions to psychiatric hospitals and the quantity and quality of post-discharge care.

22

A second limitation is the observed publication bias in favor of studies with a lower number of suicides and person years with a higher

suicide rate. While studies with short durations of follow-up will tend to have fewer suicides and person years, such studies but might

also have high suicide rates because post-discharge suicide rates decline over time. However, it is also true that chance higher rates are

more likely in studies in smaller studies and such studies might be more likely to be published because they report a more alarming

suicide rate.

A third limitation results from the preponderance of primary studies from high income regions. It is known that the majority of all global

suicide deaths occur in low-and-middle income countries where data about suicide is often under-reported or unavailable (133, 134).

Our data were overwhelmingly from studies in developed countries and might not be applicable to settings in low-and-middle income

countries.

Finally, there was insufficient data to meta-analyze the rate of post-discharge over periods of follow-up of less than a year. Studies of

psychiatric patients have shown the period after discharge is the period of highest risk for suicide (135, 136). It is likely that this may be

the case for people with suicidal thoughts or behaviours who are discharged from non-psychiatric settings.

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Conclusion

Patients with suicidal thoughts or behaviours have highly elevated rates of suicide. This suggests a window of opportunity for suicide

prevention. We believe that the appropriate selective intervention for every patient presenting with suicide thoughts and behaviours to

a non-psychiatric setting is a timely, thorough, and sympathetic assessment of their situation and clinical needs. What should follow is

an individually tailored treatment plan, aimed to assist the very broad spectrum of psychiatric, psychological and social issues faced by

this readily identifiable and very vulnerable population.

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0 50 100 150 200 250 300 3500

500

1000

1500

2000

2500

3000

3500

4000

4500

Duration of follow-up in months

Suci

des

per

100

000

pers

on y

ears

Figure 2. Scatter plot of suicide rates after discharge and the duration of follow-up.

25

Table 1: Main results and subgroup analysis

Variable No. of

Samp

les

No. of

Suicid

e

deaths

Total Person

years

Estimated suicide rate

per 100,000 years

(95% CI)

Q

value

(betwe

en

groups

)

P value

Main Result

Random

Effects167 3 747 1 263 727 483 (445 to 520)

Sex

Women 46 1 228 544 942 364 (314 to 415)

45.6 <0.001Men 46 1 686 386 062 716 (628 to 805)

Mixed 75 833 332 723 445 (378 to 513)

Age groups

< 25 28 281 298 885 107 (72 to 143) 247.2 <0.001

27

Adults and

unspecified

by age

129 3 336 943 638 563 (516 to 610)

> 55 10 130 22 204 799 (522 to 1075)

Duration of Follow-up

0-1 year 44 332 52 972 851 (652 to 1050)

62.6 <0.0011-3 years 30 198 39 554 539 (384 to 694)

3-5 years 36 888 122 773 845 (698 to 991)

5 + years 57 2 339 1 048 428 354 (313 to 394)

Discharge Setting

Emergency

department

s

91 2 068 713 901 460 (409 to 511)

3.6 0.06General

hospital

admission

76 1 679 549 826 537 (477 to 598)

28

Definition of suicide thoughts or behaviours

Suicide

attempt88 1 687 374 591 647 (573 to 721)

39.1 <0.001

Other

definitions

of suicide

thoughts or

behaviour

79 2 060 889 135 374 (330 to 417)

Year of publication

29

1960-1989 28 372 56 344 719 (548-891)

55.2 <.0011990-1999 38 718 174 384 716 (598-833)

2000-2009 39 1 120 308 807 531 (446-616)

2010-2018 62 1 537 742 129 329 (279-378)

Geographic Region

Asia 10 287 29 795 1344 (854 to 1833)117.1 <0.001

Mainland

Europe and

Nordic

regions

69 1 299 222 322 824 (716 to 931)

North

America

33 467 268 071 264 (193 to 335)

30

Oceania 12 271 46 659 731 (455 to 1008)

UK or

Ireland40 1 393 693 618 273 (228 to 318)

Mixed and

other3 30 3 261 864 (202-1526)

Strength of Reporting

5 or less 81 956 195 671 728 (629 to 827)31.7 <0.001

6 or more 86 2 791 1 068 056 420 (378 to 461)

31

Table 2. Association between strength of reporting items and suicide rate

Covariate CoefficientStandard

ErrorZ-value P-value

Had broad inclusion

criteria-.0038 .001 -2.88 .004

Sampled a defined

population -.0005 .0009 -.59 .55

Only included first

presentations-.0028 .0013 -2.06 .04

Counted people not

discharges.0043 .0036 1.18 .24

Not restricted by self

harm methods-.0010 .0010 -1.02 .3

Reported on suicide

attempters.0016 .0008 1.87 .06

32

Followed up more than

80% of presentations <.0001 .0015 -.02 .99

Used external mortality

data base-.0007 .0010 -.73 .47

Included undetermined

deaths-.0003 .0009 -.33 .74

33

Table 3. Multiple meta-regression of moderator variables associated with post-

discharge suicide rates

Sample characteristics CoefficientStandard

ErrorZ-value P-value

Men .0029 .0007 3.97 .0001

Child and adolescent -.004 .0009 -4.64 <.0001

Suicide attempters .0013 .0007 1.71 0.09

Longer follow-up -.00003 .00001 -4.68 <.0001

Year of publication -.00007 .00003 -2.37 .02

Stronger reporting -.0020 .0007 -2.74 .006

National suicide rates .0002 .0007 3.17 <.0001

Intercept .14 .056 2.47 .01

R-Square analogue = 54.6%

34

Supplementary Material SM 1: Table of included studies

Study Suicide

deaths

Months of

follow-up

Suicide deaths per

100,000 person years

Discharge

setting

Presentation Age group

Allard et al. (1992) 4 24 1333 Emergency

department,

Canada

Suicide Attempt Unspecified/

adults

Amadeo et al.

(2015)

2 18 702 Psychiatric

emergency

unit, Tahiti

Other forms of suicidal

thoughts or behaviour

Unspecified/

adults

Ando et al. (2013) 2 12 3030 Emergency

department,

Japan



Unspecified/

adults

Asarnow et al.

(2017)

1 18 368 Emergency

department,



Younger

people

35

USA

Beautrais et al.

(2003)

16 60 1060 Emergency

department,

New Zealand


adults

Berrino et al.

(2011)

1 3 2000 Emergency

department,

Switzerland



Unspecified/

adults

Bilen et al. (2010) 35 12 2297 Emergency

department,

Scandanavia



Unspecified/

adults

Bostwick et al.

(2016)

5 168 84 General

Hospital, USA


adults

36

Brown et al. (2005) 1 18 556 Emergency

department,

USA


adults

Buglass et al.

(1974)

23 12 819 Regional

Poisoning

Centre,

Scotland



Unspecified/

adults

Caldera et al.

(2007)

3 63.06 539 Emergency

unit,

Nicaragua



Unspecified/

adults

Cebria et al. (2015) 5 60 206 Emergency

department,

Spain


adults

Cheung et al.

(2017)

7 12 2065 Emergency

department,

Other forms of suicidal Older people

37

New Zealand thoughts or behaviour

Choi et al. (2012) 2 30 762 Emergency

room, South

Korea


adults

Cooper et al.

(2005)

60 24 377 Emergency

department,

England



Unspecified/

adults

Crandall et al.

(2006)

78 72 132 Emergency

department,

USA



Unspecified/

adults

Curran et al.

(1999)

3 102 598 Accident and

emergency

department,

Ireland



Unspecified/

adults

Davidson et al. 1 3 20000 Accident and Other forms of suicidal Unspecified/

38

(2014) emergency

department,

Scotland

thoughts or behaviour adults

Deykin et al.

(1986)

2 18 418 Emergency

room, USA



Younger

people

Donaldson et al.

(1997)

0 3.1 0 Emergency

department,

USA

Suicide Attempt Younger

people

Ekeberg et al.

(1991)

34 60 728 General

Hospital,

Norway



Unspecified/

adults

Evans et al. (1999) 3 6 726 General

Hospital,

England



Unspecified/

adults

Fedyszyn et al. 160 72 226 Emergency Suicide Attempt Unspecified/

39

(2016) department,

Denmark

adults

Ferreira et al.

(2016)

3 24 581 Emergency

unit, Brazil


adults

Finkelstein et al.

(2015)

126 86.4 85 General

Hospital,

Canada



Younger

people

Fleischmann et al.

(2008)

20 18 785 Emergency

department,

multiple

countries


adults

Gardner et al.

(1977)

1 12 366 General

Hospital,

England



Unspecified/

adults

Gehin et al. (2009) 2 120 541 General Suicide Attempt Younger

40

Hospital,

France

people

Gibb et al. (2005) 170 60 921 General

Hospital, New

Zealand


adults

Goldacre et al.

(1985)

6 33.6 86 General

Hospital,

England



Younger

people

Grafstein et al.

(2013)

31 1 3310 Emergency

department,

Canada



Unspecified/

adults

Greenfield et al.

(2008)

0 6 0 Emergency

department,

Canada



Younger

people

Greer et al. (1967) 2 30 1538 General Suicide Attempt Unspecified/

41

Hospital,

England

adults

Greer et al. (1971) 4 18 1307 Casualty

department,

England



Unspecified/

adults

Grimholt et al.

(2015)

2 6 1980 General

hospital,

Norway



Unspecified/

adults

Groholt et al.

(2009)

2 109 250 General

Hospital,

Norway


people

Guthrie et al.

(2001)

0 6 0 Emergency

department,

England



Unspecified/

adults

Gysin-Maillart et al. 2 24 877 Emergency Suicide Attempt Unspecified/

42

(2016) unit,

Switzerland

adults

Hall et al. (1998) 214 156 198 General

Hospital,

Scotland


adults

Hawton et al.

(1988)

43 99 347 General

Hospital,

England


adults

Hawton et al.

(2015)


department,

England



Unspecified/

adults

Herve et al. (1984) 2 42 555 Surgical

intensive care

unit, France


adults

Hjelmeland et al. 24 12 1403 General Other forms of suicidal Unspecified/

43

(1996) Hospital,

Norway


Holley et al. (1998) 51 87.42 799 General

hospital,

Canada


adults

Howson et al.

(2008)

8 12 1061 Emergency

department,

New Zealand



Unspecified/

adults

Hvid et al. (2011) 3 12 2256 General

Hospital,

Denmark


adults

Hvid et al. (2009) 2 12 1325 General

Hospital,

Denmark



Unspecified/

adults

Jenkins et al. 12 261 394 General Other forms of suicidal Unspecified/

44

(2002) Hospital,

England


Johannessen et al.

(2011)

55 120 387 General

hospital,

Norway


adults

Jokinen et al.

(2016)


department,

Sweden



Older people

Karasouli et al.

(2015)

49 72 86 Emergency

department,

England



Unspecified/

adults

Karasouli et al.

(2011)


department,

England



Unspecified/

adults

Kawanishi et al. 57 39 1919 Emergency Suicide Attempt Unspecified/

45

(2014) department,

Japan

adults

Kessel et al. (1966) 8 12 1566 General

Hospital,

Scotland



Unspecified/

adults

Kotila et al. (1989) 8 60 442 General

Hospital,

Finland


people

Kuo et al. (2012) 201 39.6 801 Accident and

emergency

department,

Taiwan



Unspecified/

adults

46

Lee et al. (2012) 5 12 3448 Emergency

department,

Taiwan


adults

Lindh et al. (2018) 10 6 2488 General

Hospital,

Sweden



Unspecified/

adults

Lonnqvist et al.

(1991)

54 54 750 Emergency

department,

Finland


adults

Makela et al.

(1984)

13 60 677 Emergency

room, Finland


adults

Miller et al. (2017) 5 12 363 Emergency

department,

USA



Unspecified/

adults

Moller et al. (1989) 6 12 2632 Toxicology Suicide Attempt Unspecified/

47

department,

Germany

adults

Morthorst et al.

(2012)

1 12 427 General

Hospital,

Denmark


adults

Motto et al. (1965) 21 60 2176 General

hospital, USA


adults

Mouaffak et al.

(2015)

1 12 352 Emergency

department,

France


adults

Mousavi et al.

(2016)

1 8 2727 Poisoning

emergency,

Iran


adults

Mullinax et al.

(2017)

3 12 1087 Emergency

department,

Other forms of suicidal Unspecified/

48

USA thoughts or behaviour adults

Nakagawa et al.

(2009)

7 21 2778 Emergency

department,

Japan


adults

Nimeus et al. (2002 22 54 881 Medical

intensive care

unit, Sweden


adults

Nordontoft et al.

(1993)

103 101.76 1247 Poisoning

treatment

centre,

Denmark



Unspecified/

adults

Nordentoft et al.

(1993)

9 48 2250 General

Hospital,

Denmark


adults

Nordstrom et al. 90 60 1144 Psychiatric Suicide Attempt Unspecified/

49

(1995) emergency

room,

Sweden

adults

Normand et al.

(2017)

0 12 0 Emergency

department,

France


people

O'Connor et al.

(2017)

3 6 1158 Acute

medical unit,

Scotland


adults

Ojehagen et al.

(1992)

4 12 1688 Medical

intensive care

unit, Sweden



Unspecified/

adults

50

Olfson et al. (2018) 17 12 107 Emergency

department,

USA



Younger

people

Olfson et al. (2017) 85 12 341 Emergency

department,

USA



Unspecified/

adults

Ostamo et al.

(2001)

192 63.6 1302 Emergency

room, Finland


adults

Owens et al. (1991) 11 36 370 Accident and

Emergency

unit, England



Unspecified/

adults

Paerregaard et al.

(1975)

65 60 2686 Poisoning

centre,

Denmark



Unspecified/

adults

Pallis et al. (1984) 15 24 594 General Other forms of suicidal Unspecified/

51

Hospital, UK thoughts or behaviour adults

Parra-Uribe et al.

(2017)

15 42 345 Emergency

department,

Spain


adults

Pavarin et al.

(2014)


department,

Italy


adults

Pierce et al. (1982) 13 60 520 General

Hospital, UK



Unspecified/

adults

Reith et al. (2004) 58 60 283 Toxicology

service,

Australia



Unspecified/

adults

52

Rojas et al. (2018) 7 24 3571 Emergency

department,

Argentina



Unspecified/

adults

Rosen et al. (1976) 34 60 767 Poisoning

treatment

centre,

Scotland


adults

Rosenman et al.

(1983)

7 60 534 Emergency

department,

Australia



Unspecified/

adults

Ryan et al. (1996) 33 12 896 Accident and

emergency

department,

England



Unspecified/

adults

Rygnestad et al. 41 60 777 Poisoning Other forms of suicidal Unspecified/

53

(1997) treatment

centre,

Norway


Safinofsky et al.

(2013)

2 12 995 General

Hospital,

Canada



Unspecified/

adults

Sinclair et al.

(2010)

4 15 2238 General

Hospital, UK



Unspecified/

adults

Skogman et al.

(2004)

63 77 933 Medical

emergency

inpatient

unit, Sweden


adults

Sobolewski et al.

(2013)

0 2 0 Emergency

department,



Younger

people

54

USA

Spirito et al. (1994) 0 3 0 Emergency

department,

USA


people

Spirito et al. (1992) 0 3 0 General

Hospital, USA


people

Steeg et al. (2018) 18 6 909 Emergency

department,

England



Unspecified/

adults

Steer et al. (1988) 28 90 748 General

Hospital, USA


adults

Stewart et al.

(2001)

0 6 0 Emergency

room, Canada



Younger

people

Sundqvist-

Stensman et al.

68 54 1193 Intensive

care unit,

Other forms of suicidal Unspecified/

55

(1988) Sweden thoughts or behaviour adults

Suokas et al.

(2001)


unit, Finland



Unspecified/

adults

Suominen et al.

(2004)

93 66 1411 General

hospital,

Finland



Unspecified/

adults

Tyrer et al. (2003) 7 12 1741 General

Hospital, UK



Unspecified/

adults

Vaiva et al. (2006) 4 13 610 Emergency

department,

France



Unspecified/

adults

Vajda et al. (2000) 5 12 4464 Emergency

department,

Australia


people

Van Aalast et al. 0 33.96 0 General Suicide Attempt Unspecified/

56

(1992) Hospital, USA adults

Van Heeringen et

al. (1995)

13 12 3325 Accident and

emergency

department,

Belgium


adults

Vijayakumar et al.

(2011)


department,

India


adults

Waern et al. (2010) 7 36 1414 Emergency

ward,

Sweden


adults

Wang et al (2006) 5 366 131 Emergency

department,

Faroe Islands


adults

Wharff et al. 0 3 0 Emergency Other forms of suicidal Younger

57

(2012) room, USA thoughts or behaviour people

Wharff et al.

(2017)

0 1 0 Emergency

department,

USA



Younger

people

Wiktorsson et al.

(2011)

2 12 3333 Emergency

department,

Sweden

Suicide Attempt Older people

Yeh et al. (2012) 5 12 3448 Emergency

department,

Taiwan


adults

Zahl et al. (2004) 300 136.8 227 General

Hospital,

England



Unspecified/

adults

58

References

1. WHO. Suicide data. World Health Organization; Available from:

http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/.

2. WHO. Preventing suicide: A global imperative; 2014.

3. LARGE MM, RYAN CJ, CARTER G, KAPUR N. Can we usefully stratify

patients according to suicide risk? Bmj. 2017 Oct 17;359:j4627.

4. CHAN MK, BHATTI H, MEADER N, et al. Predicting suicide following self-

harm: systematic review of risk factors and risk scales. The British journal of

psychiatry : the journal of mental science. 2016 Jun 23.

5. CARTER G, MILNER A, MCGILL K, PIRKIS J, KAPUR N, SPITTAL MJ.

Predicting suicidal behaviours using clinical instruments: systematic review and

meta-analysis of positive predictive values for risk scales. The British journal of

psychiatry : the journal of mental science. 2017 Mar 16.

6. LARGE M, KANESON M, MYLES N, MYLES H, GUNARATNE P, RYAN C.

Meta-Analysis of Longitudinal Cohort Studies of Suicide Risk Assessment among

Psychiatric Patients: Heterogeneity in Results and Lack of Improvement over

Time. PloS one. 2016;11:e0156322.

7. CHUNG DT, RYAN CJ, HADZI-PAVLOVIC D, SINGH SP, STANTON C, LARGE

MM. Suicide Rates After Discharge From Psychiatric Facilities: A Systematic

Review and Meta-analysis. JAMA psychiatry. 2017 May 31.

8. HAWTON K, BERGEN H, COOPER J, et al. Suicide following self-harm:

findings from the multicentre study of self-harm in England, 2000–2012. Journal

of Affective Disorders. 2015;175:147-51.

9. OSTAMO A, LÖNNQVIST J. Excess mortality of suicide attempters. Social

Psychiatry and Psychiatric Epidemiology. 2001;36:29-35.

59

http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/

10. CARROLL R, METCALFE C, GUNNELL D. Hospital management of self-

harm patients and risk of repetition: systematic review and meta-analysis.

Journal of affective disorders. 2014 Oct;168:476-83.

11. BRUFFAERTS R, DEMYTTENAERE K, HWANG I, et al. Treatment of

suicidal people around the world. The British Journal of Psychiatry.

2011;199:64-70.

12. URBAN C, ARIAS SA, SEGAL DL, et al. Emergency department patients

with suicide risk: differences in care by acute alcohol use. General hospital

psychiatry. 2018.

13. BENNEWITH O, PETERS T, HAWTON K, HOUSE A, GUNNELL D. Factors

associated with the non-assessment of self-harm patients attending an Accident

and Emergency Department: results of a national study. Journal of affective

disorders. 2005;89:91-7.

14. STROUP DF, BERLIN JA, MORTON SC, et al. Meta-analysis of observational

studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational

Studies in Epidemiology (MOOSE) group. JAMA : the journal of the American

Medical Association. 2000 Apr 19;283:2008-12.

15. LIBERATI A, ALTMAN DG, TETZLAFF J, et al. The PRISMA statement for

reporting systematic reviews and meta-analyses of studies that evaluate health

care interventions: explanation and elaboration. Journal of clinical epidemiology.

2009 Oct;62:e1-34.

16. LEE L, ROSER M, ORTIZ-OSPINA E. Suicide.

https://ourworldindata.org/suicide; 2018 [updated 2018; cited 24 November

2018]; Available from.

60

https://ourworldindata.org/suicide

17. WHO. Global Health Observatory data repository. Suicide rate estimates,

crude estimates by country.

http://apps.who.int/gho/data/view.main.MHSUICIDEv?lang=en; 2018.

18. WELLS GA, SHEA B, O'CONNNELL D, et al. The Newcastle-Ottawa Scale

(NOS) for assessing the quality of nonrandomised studies in meta-analyses.

Accessed from http://wwwohrica/programs/clinical_epidemiology/oxfordasp.

2013.

19. ALLARD R, MARSHALL M, PLANTE MC. Intensive follow up does not ‐

decrease the risk of repeat suicide attempts. Suicide and Life Threatening ‐

Behavior. 1992;22:303-14.

20. AMADEO S, REREAO M, MALOGNE A, et al. Testing brief intervention and

phone contact among subjects with suicidal behavior: A randomized controlled

trial in French Polynesia in the frames of the World Health Organization/Suicide

Trends in At-Risk Territories study. Mental Illness. 2015;7:48-53.

21. ASARNOW, BARAFF L, BERK M, et al. Effects of an Emergency Department

Mental Health Intervention for Linking Pediatric Suicidal Patients to Follow-Up

Mental Health Treatment: A Randomized Controlled Trial. Psychiatric services

(Washington, DC). 2011;62:1303-9.

22. BERRINO A, OHLENDORF P, DURIAUX S, BURNAND Y, LORILLARD S,

ANDREOLI A. Crisis intervention at the general hospital: An appropriate

treatment choice for acutely suicidal borderline patients. Psychiatry Research.

2011;186:287-92.

23. BILÉN K, OTTOSSON C, CASTRÉN M, et al. Deliberate self-harm patients in

the emergency department: factors associated with repeated self-harm among

1524 patients. Emergency Medicine Journal. 2010:emj. 2010.102616.

61

http://wwwohrica/programs/clinical_epidemiology/oxfordasp

http://apps.who.int/gho/data/view.main.MHSUICIDEv?lang=en

24. BOSTWICK JM, PABBATI C, GESKE JR, MCKEAN AJ. Suicide attempt as a

risk factor for completed suicide: even more lethal than we knew. American

journal of psychiatry. 2016;173:1094-100.

25. CHOI JW, PARK S, YI KK, HONG JP. Suicide mortality of suicide attempt

patients discharged from emergency room, nonsuicidal psychiatric patients

discharged from emergency room, admitted suicide attempt patients, and

admitted nonsuicidal psychiatric patients. Suicide and Life Threatening ‐

Behavior. 2012;42:235-43.

26. COOPER J, KAPUR N, WEBB R, et al. Suicide after deliberate self-harm: a 4-

year cohort study. American Journal of Psychiatry. 2005;162:297-303.

27. CRANDALL C, FULLERTON GLEASON L, AGUERO R, LAVALLEY J. ‐

Subsequent suicide mortality among emergency department patients seen for

suicidal behavior. Academic Emergency Medicine. 2006;13:435-42.

28. CURRAN S, FITZGERALD M, GREENE VT. Psychopathology 8½ years post

parasuicide. Crisis: The Journal of Crisis Intervention and Suicide Prevention.

1999;20:115.

29. DEYKIN EY, CHUNG-CHEN H, JOSHI N, MCNAMARRA JJ. Adolescent

suicidal and self-destructive behavior. Results of an intervention study. Journal

of Adolescent Health Care. 1986;7:88-95.

30. DONALDSON D, SPIRITO A, ARRIGAN M, ASPEL JW. Structured disposition

planning for adolescent suicide attempters in a general hospital: Preliminary

findings on short-term outcome. Archives of Suicide Research. 1997;3:271-82.

31. EKEBERG Ø, ELLINGSEN Ø, JACOBSEN D. Suicide and other causes of

death in a five year follow up of patients treated for self poisoning in Oslo. Acta ‐ ‐ ‐

psychiatrica scandinavica. 1991;83:432-7.

62

32. EVANS MO, MORGAN H, HAYWARD A, GUNNELL DJ. Crisis telephone

consultation for deliberate self-harm patients: effects on repetition. The British

Journal of Psychiatry. 1999;175:23-7.

33. FEDYSZYN IE, ERLANGSEN A, HJORTHOJ C, MADSEN T, NORDENTOFT M.

Repeated suicide attempts and suicide among individuals with a first emergency

department contact for attempted suicide: A prospective, nationwide, danish

register-based study. Journal of Clinical Psychiatry. 2016;77:832-40.

34. FERREIRA AD, SPONHOLZ A, MANTOVANI C, et al. Clinical Features,

Psychiatric Assessment, and Longitudinal Outcome of Suicide Attempters

Admitted to a Tertiary Emergency Hospital. Archives of suicide research : official

journal of the International Academy for Suicide Research. 2016;20:191-204.

35. FINKELSTEIN Y, MACDONALD EM, HOLLANDS S, et al. Long-term

outcomes following self-poisoning in adolescents: a population-based cohort

study. The Lancet Psychiatry. 2015;2:532-9.

36. FLEISCHMANN A, BERTOLOTE JM, WASSERMAN D, et al. Effectiveness of

brief intervention and contact for suicide attempters: a randomized controlled

trial in five countries. Bulletin of the World Health Organization. 2008;86:703-9.

37. GARDNER R, HANKA R, O'BRIEN V, PAGE AJF, REES R. Psychological and

social evaluation in cases of deliberate self-poisoning admitted to a general

hospital. Br Med J. 1977;2:1567-70.

38. GÉHIN A, KABUTH B, PICHENÉ C, VIDAILHET C. Ten year follow-up study

of 65 suicidal adolescents. Journal of the Canadian Academy of Child and

Adolescent Psychiatry. 2009;18:117.

63

39. GIBB SJ, BEAUTRAIS AL, FERGUSSON DM. Mortality and further suicidal

behaviour after an index suicide attempt: a 10-year study. Australian & New

Zealand Journal of Psychiatry. 2005;39:95-100.

40. GOLDACRE M, HAWTON K. Repetition of self-poisoning and subsequent

death in adolescents who take overdoses. The British Journal of Psychiatry.

1985;146:395-8.

41. GRAFSTEIN E, STENSTROM R, CHRISTENSON J, G.INNES,

SCHEUERMEYER FX. Regional 30-day outcomes in patients presenting to the ED

with suicidal ideation or overdose attempt. Canadian Journal of Emergency

Medicine. 2013;15:S14.

42. GREENFIELD B, HENRY M, WEISS M, et al. Previously suicidal adolescents:

Predictors of six-month outcome. Journal of the Canadian Academy of Child and

Adolescent Psychiatry. 2008;17:197-201.

43. GREER S, BAGLEY C. Effect of psychiatric intervention in attempted

suicide: a controlled study. Br Med J. 1971;1:310-2.

44. GREER S, LEE H. Subsequent progress of potentially lethal attempted

suicides. Acta Psychiatrica Scandinavica. 1967;43:361-71.

45. GROHOLT B, EKEBERG Ø. Prognosis after adolescent suicide attempt:

mental health, psychiatric treatment, and suicide attempts in a nine-year follow-

up study. Suicide and Life-Threatening Behavior. 2009;39:125-36.

46. GUTHRIE E, PATTON GC, KAPUR N, et al. Randomised controlled trial of

brief psychological intervention after deliberate self poisoningCommentary:

Another kind of talk that works? Bmj. 2001;323:135.

47. GYSIN-MAILLART A, SCHWAB S, SORAVIA L, MEGERT M, MICHEL K. A

novel brief therapy for patients who attempt suicide: A 24-months follow-up

64

randomized controlled study of the attempted suicide short intervention

program (ASSIP). PLoS medicine. 2016;13:e1001968.

48. HALL DJ, O'BRIEN F, STARK C, PELOSI A, SMITH H. Thirteen-year follow-

up of deliberate self-harm, using linked data. The British Journal of Psychiatry.

1998;172:239-42.

49. HAWTON K, FAGG J. Suicide, and Other Causes of Death, Following

Attempted Suicide. British Journal of Psychiatry. 1988;152:359-66.

50. HERVÉ C, GAILLARD M, MARTEL S, HUGUENARD P. Serious suicides.

Short and long-term results. One hundred and fifty six cases with a follow-up

period of 1 to 7 years. Acta anaesthesiologica Belgica. 1984;35:353-9.

51. HJELMELAND H. Verbally expressed intentions of parasuicide: II.

Prediction of fatal and nonfatal repetition. Crisis. 1996;17:10-4.

52. HOLLEY H, FICK G, LOVE EJ. Suicide following an inpatient hospitalization

for a suicide attempt: a Canadian follow-up study. Social psychiatry and

psychiatric epidemiology. 1998;33:543-51.

53. HOWSON MA, YATES KM, HATCHER S. Re-presentation and suicide rates

in emergency department patients who self-harm. EMA - Emergency Medicine

Australasia. 2008;20:322-7.

54. HVID M, WANG AG. Preventing repetition of attempted suicide—I.

Feasibility (acceptability, adherence, and effectiveness) of a Baerum-model like

aftercare. Nordic journal of psychiatry. 2009;63:148-53.

55. JENKINS GR, HALE R, PAPANASTASSIOU M, CRAWFORD MJ, TYRER P.

Suicide rate 22 years after parasuicide: cohort study. BMJ. 2002;325:1155.

65

56. JOHANNESSEN HA, DIESERUD G, DE LEO D, CLAUSSEN B, ZAHL P-H.

Chain of care for patients who have attempted suicide: a follow-up study from

Bærum, Norway. BMC Public Health. 2011 February 04;11:81.

57. JOKINEN J, MATTSSON P, NORDSTRÖM P, SAMUELSSON M. High Early

Suicide Risk in Elderly Patients After Self-Poisoning. Archives of Suicide

Research. 2016;20:683-8.

58. KARASOULI E, OWENS D, ABBOTT R, HURST K, DENNIS M. All-cause

mortality after non-fatal self-poisoning: a cohort study. The International Journal

for Research in Social and Genetic Epidemiology and Mental Health Services.

2011;46:455-62.

59. KARASOULI E, OWENS D, LATCHFORD G, KELLEY R. Suicide After

Nonfatal Self-Harm: A Population Case-Control Study Examining Hospital Care

and Patient Characteristics. Crisis: The Journal of Crisis Intervention and Suicide

Prevention. 2015;36:65-70.

60. KAWANISHI C, ARUGA T, ISHIZUKA N, et al. Assertive case management

versus enhanced usual care for people with mental health problems who had

attempted suicide and were admitted to hospital emergency departments in

Japan (ACTION-J): A multicentre, randomised controlled trial. The Lancet

Psychiatry. 2014;1:193-201.

61. KESSEL N, MCCULLOCH W. Repeated Acts of Self-Poisoning and Self-

Injury. Journal of the Royal Society of Medicine. 1966;59:89-92.

62. KOTILA L, LÖNNQVIST J. Suicide and violent death among adolescent

suicide attempters. Acta Psychiatrica Scandinavica. 1989;79:453-9.

66

63. KUO C-J, GUNNELL D, CHEN C-C, YIP PSF, CHEN Y-Y. Suicide and non-

suicide mortality after self-harm in Taipei City, Taiwan. The British journal of

psychiatry : the journal of mental science. 2012;200:405.

64. LEE Y, LIN PY, YEH WC, et al. Repeated suicide attempts among suicidal

cases: Outcome of one year follow up. Asia Pacific Psychiatry. 2012;4:174-80.‐ ‐ ‐

65. LÖNNQVIST J, OSTAMO A. Suicide following the first suicide attempt: A

five-year follow-up using a survival analysis. Psychiatria Fennica. 1991;22:171-9.

66. MAKELA R, HONKANEN R. Attempted suicides treated at a casualty

department. Psychiatria Fennica. 1984;15:127-34.

67. MILLER IW, CAMARGO CA, ARIAS SA, et al. Suicide prevention in an

emergency department population: The ED-safe study. JAMA Psychiatry.

2017;74:563-70.

68. MOLLER HJ. Efficacy of different strategies of aftercare for patients who

have attempted suicide. Journal of the Royal Society of Medicine. 1989;82:643-7.

69. MORTHORST B, KROGH J, ERLANGSEN A, ALBERDI F, NORDENTOFT M.

Effect of assertive outreach after suicide attempt in the AID (assertive

intervention for deliberate self harm) trial: randomised controlled trial. BMJ :

British Medical Journal. 2012;345.

70. MOTTO JA. Suicide attempts. A longitudinal view. Archives of general

psychiatry. 1965;13:516.

71. MOUAFFAK F, MARCHAND A, CASTAIGNE E, ARNOUX A, HARDY P. OSTA

program: A French follow-up intervention program for suicide prevention.

Psychiatry research. 2015;230:913.

72. MULLINAX S, CHALMERS CE, BRENNAN J, VILKE GM, NORDSTROM K,

WILSON MP. Suicide screening scales may not adequately predict disposition of

67

suicidal patients from the emergency department. The American journal of

emergency medicine. 2018;36:1779.

73. NAKAGAWA M, YAMADA T, YAMADA S, NATORI M, HIRAYASU Y,

KAWANISHI C. Follow-up study of suicide attempters who were given crisis

intervention during hospital stay: Pilot study. Psychiatry and Clinical

Neurosciences. 2009;63:122-3.

74. NIMÉUS A, ÉN M, TRÄSKMAN-BENDZ L. High Suicidal Intent Scores

Indicate Future Suicide. Archives of Suicide Research. 2002;6:211-9.

75. NORDENTOFT M, BREUM L, MUNCK LK, NORDESTGAARD AG, HUNDING

A, LAURSEN BJAELDAGER PA. High mortality by natural and unnatural causes: A

10 year follow-up study of patients admitted to a poisoning treatment centre

after suicide attempts. British Medical Journal. 1993;306:1637-41.

76. NORDSTROM P, SAMUELSSON M, ASBERG M. Survival analysis of suicide

risk after attempted suicide. Acta Psychiatrica Scandinavica. 1995;91:336-40.

77. NORMAND D, COLIN S, GABOULAUD V, BAUBET T, TAIEB O. How to stay

in touch with adolescents and young adults after a suicide attempt?

Implementation of a 4-phones-calls procedure over 1 year after discharge from

hospital, in a Parisian suburb. Encephale. 2017.

78. O'CONNOR RC, FERGUSON E, SCOTT F, et al. A brief psychological

intervention to reduce repetition of self-harm in patients admitted to hospital

following a suicide attempt: a randomised controlled trial. The Lancet Psychiatry.

2017;4:451-60.

79. OJEHAGEN A, DANIELSSON M, TRASKMANBENDZ L. DELIBERATE SELF-

POISONING - TREATMENT FOLLOW-UP OF REPEATERS AND NONREPEATERS.

Acta Psychiatr Scand. 1992;85:370-5.

68

80. OLFSON M, WALL M, WANG S, et al. Suicide After Deliberate Self-Harm in

Adolescents and Young Adults. Pediatrics. 2018;141.

81. OLFSON M, WALL M, WANG S, CRYSTAL S, GERHARD T, BLANCO C.

Suicide Following Deliberate Self-Harm. The American journal of psychiatry.

2017;174:765.

82. OWENS D, DENNIS M, JONES S, DOVE A, DAVE S. Self-poisoning patients

discharged from accident and emergency: risk factors and outcome. Journal of

the Royal College of Physicians of London. 1991 Jul;25:218-22.

83. PAERREGAARD G. Suicide among Attempted Suicides: A 10-Year Follow-

Up. Suicide. 1975;5:140.

84. PALLIS DJ, GIBBONS JS, PIERCE DW. Estimating suicide risk among

attempted suicides. II. Efficiency of predictive scales after the attempt. The

British journal of psychiatry : the journal of mental science. 1984;144:139.

85. PARRA-URIBE I, BLASCO-FONTECILLA H, GARCIA-PARES G, et al. Risk of

re-attempts and suicide death after a suicide attempt: A survival analysis. BMC

Psychiatry. 2017;17.

86. PAVARIN RM, FIORITTI A, FONTANA F, MARANI S, PAPARELLI A,

BONCOMPAGNI G. Emergency department admission and mortality rate for

suicidal behavior. A follow-up study on attempted suicides referred to the ED

between January 2004 and December 2010. Crisis. 2014;35:406-14.

87. PIERCE DW. The predictive validation of a suicide intent scale: a five year

follow-up. The British journal of psychiatry : the journal of mental science.

1981;139:391.

69

88. REITH DM, WHYTE I, CARTER G, MCPHERSON M, CARTER N. Risk factors

for suicide and other deaths following hospital treated self-poisoning in

Australia. Australian and New Zealand Journal of Psychiatry. 2004;38:520-5.

89. ROSEN DH. The serious suicide attempt. Five-year follow-up study of 886

patients. JAMA. 1976;235:2105.

90. ROSENMAN SJ. Subsequent deaths after attempted suicide by drug

overdose in the western region of Adelaide, 1976. Med J Aust. 1983 Nov

12;2:496-9.

91. RYAN J, RUSHDY A, PEREZ-AVILA CA, ALLISON R. Suicide rate following

attendance at an accident and emergency department with deliberate self harm.

Journal of Accident and Emergency Medicine. 1996;13:101-4.

92. RYGNESTAD T. Mortality after deliberate self-poisoning. Social Psychiatry

and Psychiatric Epidemiology. 1997 November 01;32:443-50.

93. SAKINOFSKY I, ROBERTS RS, BROWN Y, CUMMING C, JAMES P. Problem

resolution and repetition of parasuicide. A prospective study. The British journal

of psychiatry : the journal of mental science. 1990;156:395.

94. SINCLAIR JMA, HAWTON K, GRAY A. Six year follow-up of a clinical

sample of self-harm patients. Journal of affective disorders. 2010;121:247.

95. SKOGMAN K, ALSÉN M, ÖJEHAGEN A. Sex differences in risk factors for

suicide after attempted suicide. Social Psychiatry and Psychiatric Epidemiology.

2004;39:113-20.

96. SOBOLEWSKI B, RICHEY L, KOWATCH RA, GRUPP-PHELAN J. Mental

Health Follow-Up among Adolescents with Suicidal Behaviors after Emergency

Department Discharge. Archives of Suicide Research. 2013;17:323-34.

70

97. SPIRITO A, LEWANDER WJ, LEVY S, KURKJIAN J, FRITZ G. Emergency

department assessment of adolescent suicide attempters: Factors related to

short-term follow-up outcome. Pediatric Emergency Care. 1994;10:6-12.

98. SPIRITO A, PLUMMER B, GISPERT M, et al. Adolescent suicide attempts:

Outcomes at follow-up. American Journal of Orthopsychiatry. 1992;62:464-8.

99. STEEG S, QUINLIVAN L, NOWLAND R, et al. Accuracy of risk scales for

predicting repeat self-harm and suicide: a multicentre, population-level cohort

study using routine clinical data. BMC Psychiatry. 2018;18:1-11.

100. STEER RA, BECK AT, GARRISON B, LESTER D. Eventual Suicide in

Interrupted and Uninterrupted Attempters: A Challenge to the Cry for Help ‐ ‐

Hypothesis. Suicide and Life Threatening Behavior. 1988;18:119-28.‐

101. STEWART SE, MANION IG, DAVIDSON S, CLOUTIER P. Suicidal children

and adolescents with first emergency room presentations: Predictors of six-

month outcome. Journal of the American Academy of Child and Adolescent

Psychiatry. 2001;40:580-7.

102. SUNDQVIST-STENSMAN UB. Suicides among persons treated for self-

poisoning at an ICU. Opuscula Medica. 1988;33:71-6.

103. SUOKAS J, SUOMINEN K, ISOMETSAE E, OSTAMO A, LOENNQVIST J. Long-

term risk factors for suicide mortality after attempted suicide - Findings of a 14-

year follow-up study. Acta Psychiatrica Scandinavica. 2001;104:117-21.

104. SUOMINEN K, ISOMETSÄ E, HAUKKA J, LÖNNQVIST J. Substance use and

male gender as risk factors for deaths and suicide. Social Psychiatry and

Psychiatric Epidemiology. 2004;39:720-4.

105. TYRER P, THOMPSON S, SCHMIDT U, et al. Randomized controlled trial of

brief cognitive behaviour therapy versus treatment as usual in recurrent

71

deliberate self-harm: the POPMACT study. Psychological Medicine. 2003;33:969-

76.

106. VAIVA G, DUCROCQ F, MEYER P, et al. Effect of telephone contact on

further suicide attempts in patients discharged from an emergency department:

Randomised controlled study. British Medical Journal. 2006;332:1241-4.

107. VAJDA J, STEINBECK K. Factors Associated with Repeat Suicide Attempts

among Adolescents. Australian and New Zealand Journal of Psychiatry.

2000;34:437-45.

108. VAN AALST JA, SHOTTS SD, VITSKY JL, et al. Long-term follow-up of

unsuccessful violent suicide attempts: risk factors for subsequent attempts. The

Journal of trauma. 1992;33:457.

109. VAN HEERINGEN C, JANNES S, BUYLAERT W, HENDERICK H, DE

BACQUER D, VAN REMOORTEL J. The management of non-compliance with

referral to out-patient after-care among attempted suicide patients: a controlled

intervention study. Psychol Med. 1995;25:963-70.

110. VIJAYAKUMAR L, UMAMAHESWARI C, SHUJAATH ALI ZS, DEVARAJ P,

KESAVAN K. Intervention for suicide attempters: A randomized controlled study.

Indian Journal of Psychiatry. 2011 Jul-Sep;53:244-8.

111. WAERN M, SJOSTROM 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. European Psychiatry.

2010;25:421-6.

112. WANG AG, MORTENSEN G. Core features of repeated suicidal behaviour: a

long-term follow-up after suicide attempts in a low-suicide-incidence population.

Social psychiatry and psychiatric epidemiology. 2006;41:103.

72

113. WHARFF AE, GINNIS BK, ROSS MA, WHITE ME, WHITE TM, FORBES WP.

Family-Based Crisis Intervention With Suicidal Adolescents: A Randomized

Clinical Trial. Pediatric Emergency Care. 2017.

114. WHARFF EA, GINNIS KM, ROSS AM. Family-Based Crisis Intervention with

Suicidal Adolescents in the Emergency Room: A Pilot Study. Social Work.

2012;57:133-43.

115. WIKTORSSON S, MARLOW T, RUNESON B, SKOOG I, WAERN M.

Prospective cohort study of suicide attempters aged 70 and above: one-year

outcomes. Journal of affective disorders. 2011;134:333.

116. YEH AWC, HUNG CF, LEE Y, et al. Development and validation of the

Assessment for Repeated Suicide. Asia-Pacific Psychiatry. 2012;4:20-9.

117. ZAHL DL, HAWTON K. Repetition of deliberate self-harm and subsequent

suicide risk: Long-term follow-up study of 11 583 patients. British Journal of

Psychiatry. 2004;185:70-5.

118. BEAUTRAIS AL. Subsequent mortality in medically serious suicide

attempts: a 5 year follow-up. Australian and New Zealand Journal of Psychiatry.

2003;37:595-9.

119. BROWN GK, TEN HAVE T, HENRIQUES GR, XIE SX, HOLLANDER JE, BECK

AT. Cognitive therapy for the prevention of suicide attempts: A randomized

controlled trial. Journal of the American Medical Association. 2005;294:563-70.

120. BUGLASS D, HORTON J. The repetition of parasuicide: a comparison of

three cohorts. The British Journal of Psychiatry. 1974;125:168-74.

121. CALDERA T, HERRERA A, KULLGREN G, RENBERG ES. Suicide intent

among parasuicide patients in Nicaragua: a surveillance and follow-up study.

Archives of Suicide Research. 2007;11:351-60.

73

122. CEBRIA AI, PEREZ-BONAVENTURA I, CUIJPERS P, et al. Telephone

Management Program for Patients Discharged From an Emergency Department

After a Suicide Attempt: A 5-Year Follow-Up Study in a Spanish Population.

Crisis. 2015;36:345-52.

123. CHEUNG G, FOSTER G, DE BEER W, et al. Predictors for repeat self-harm

and suicide among older people within 12 months of a self-harm presentation.

International psychogeriatrics. 2017;29:1237-45.

124. HVID M, VANGBORG K, SØRENSEN HJ, NIELSEN IK, STENBORG JM, WANG

AG. Preventing repetition of attempted suicide—II. The Amager project, a

randomized controlled trial. Nordic journal of psychiatry. 2011;65:292-8.

125. ANDO S, MATSUMOTO T, KANATA S, et al. One year follow-up after ‐

admission to an emergency department for drug overdose in J apan. Psychiatry

and clinical neurosciences. 2013;67:441-50.

126. DAVIDSON KM, BROWN TM, JAMES V, KIRK J, RICHARDSON J. Manual-

assisted cognitive therapy for self-harm in personality disorder and substance

misuse: a feasibility trial. The Psychiatric Bulletin. 2014;38:108-11.

127. GRIMHOLT TK, JACOBSEN D, HAAVET OR, et al. Effect of systematic

follow-up by general practitioners after deliberate self-poisoning: a randomised

controlled trial. PLoS One. 2015;10:e0143934.

128. LINDH ÅU, WAERN M, BECKMAN K, RENBERG ES, DAHLIN M, RUNESON

B. Short term risk of non-fatal and fatal suicidal behaviours: the predictive

validity of the Columbia-Suicide Severity Rating Scale in a Swedish adult

psychiatric population with a recent episode of self-harm. BMC psychiatry.

2018;18:319.

74

129. MOUSAVI SG, AMINI M, MAHAKI B, BAGHERIAN-SARAROUDI R. Effect of

phone call versus face-to-face follow-up on recurrent suicide attempts

prevention in individuals with a history of multiple suicide attempts. Advanced

biomedical research. 2016;5.

130. NORDENTOFT M, RUBIN P. Mental illness and social integration among

suicide attempters in Copenhagen: Comparison with the general population and

a four year follow up study of 100 patients. Acta Psychiatrica Scandinavica. ‐ ‐

1993;88:278-85.

131. ROJAS SM, SKINNER KD, FELDNER MT, et al. Lethality of Previous Suicidal

Behavior among Patients Hospitalized for Suicide Risk Predicts Lethality of

Future Suicide Attempts. Suicide and Life Threatening Behavior. 2018.‐

132. 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.

133. VIJAYAKUMAR L. Suicide prevention: the urgent need in developing

countries. World psychiatry. 2004;3:158-9.

134. WHO. Mortality Database. Geneva. 2003.

135. GOLDACRE M, SEAGROTT V, HAWTON K. Suicide after discharge from

psychiatric inpatient care. The Lancet. 1993;342:283-6.

136. QIN P, NORDENTOFT M. Suicide risk in relation to psychiatric

hospitalization: evidence based on longitudinal registers. Archives of general

psychiatry. 2005;62:427-32.

75

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