Predicting suicide following self-harm: systematic review of risk factors and risk scales

BACKGROUND: People with a history of self-harm are at a far greater risk of suicide than the general population. However, the relationship between self-harm and suicide is complex.

AIMS: To undertake the first systematic review and meta-analysis of prospective studies of risk factors and risk assessment scales to predict suicide following self-harm.

METHOD: We conducted a search for prospective cohort studies of populations who had self-harmed. For the review of risk scales we also included studies examining the risk of suicide in people under specialist mental healthcare, in order to broaden the scope of the review and increase the number of studies considered. Differences in predictive accuracy between populations were examined where applicable.

RESULTS: Twelve studies on risk factors and 7 studies on risk scales were included. Four risk factors emerged from the meta-analysis, with robust effect sizes that showed little change when adjusted for important potential confounders. These included: previous episodes of self-harm (hazard ratio (HR) = 1.68, 95% CI 1.38-2.05, K = 4), suicidal intent (HR = 2.7, 95% CI 1.91-3.81, K = 3), physical health problems (HR = 1.99, 95% CI 1.16-3.43, K = 3) and male gender (HR = 2.05, 95% CI 1.70-2.46, K = 5). The included studies evaluated only three risk scales (Beck Hopelessness Scale (BHS), Suicide Intent Scale (SIS) and Scale for Suicide Ideation). Where meta-analyses were possible (BHS, SIS), the analysis was based on sparse data and a high heterogeneity was observed. The positive predictive values ranged from 1.3 to 16.7%.

CONCLUSIONS: The four risk factors that emerged, although of interest, are unlikely to be of much practical use because they are comparatively common in clinical populations. No scales have sufficient evidence to support their use. The use of these scales, or an over-reliance on the identification of risk factors in clinical practice, may provide false reassurance and is, therefore, potentially dangerous. Comprehensive psychosocial assessments of the risks and needs that are specific to the individual should be central to the management of people who have self-harmed.