Geulayov Galit, Casey Deborah, Bale Liz, Brand Fiona, Clements Caroline, Farooq Bushra, Kapur Nav, Ness Jennifer, Waters Keith, Tsiachristas Apostolos, Hawton Keith
Centre for Suicide Research, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK.
Centre for Suicide Research, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, UK.
Lancet Psychiatry. 2019 Dec;6(12):1021-1030. doi: 10.1016/S2215-0366(19)30402-X. Epub 2019 Nov 6.
Self-harm is the strongest risk factor for subsequent suicide, but risk may vary. We compared the risk of suicide following hospital presentation for self-harm according to patient characteristics, method of self-harm, and variations in area-level socioeconomic deprivation, and estimated the incidence of suicide by time after hospital attendance.
In this ongoing Multicentre Study of Self-harm in England, the study population consists of individuals aged at least 15 years who had attended the emergency department of five general hospitals in Oxford, Manchester, and Derby after non-fatal self-harm between Jan 1, 2000, and Dec 31, 2013. Information on method of self-harm was obtained through systematic monitoring in hospitals. Level of socioeconomic deprivation was based on the Index of Multiple Deprivation (IMD) characterising the area where patients lived, grouping them according to IMD quintiles. Mortality follow-up was up to Dec 31, 2015, resulting in up to 16 years of follow-up. We calculated incidence of suicide since first hospital presentation by follow-up period and estimated the association between individual factors (age, gender, method of self-harm, IMD, and number of non-fatal self-harm presentations to hospital) and suicide using mixed-effect models.
Between Jan 1, 2000, and Dec 31, 2013, there were 92 177 presentations to the study hospitals by 51 108 individuals. 1325 patients involved in 1563 self-harm episodes were excluded from the study because they had missing information on gender, age, or mortality. The resulting study sample consisted of 90 614 hospital presentations by 49 783 individuals. By the end of follow-up on Dec 31, 2015, 703 patients had died by suicide. The overall incidence of suicide was 163·1 (95% CI 151·5-175·6) per 100 000 person-years, and 260·0 (237·4-284·8) per 100 000 person-years in men and 94·6 (83·3-107·4) per 100 000 person-years in women. The incidence of suicide was highest in the year following discharge from hospital (511·1 [451·7-578·2] per 100 000 person-years), particularly in the first month (1787·1 [1423·0-2244·4] per 100 000 person-years). Based on all presentations to hospital, men were three times more likely than women to die by suicide after self-harm (OR 3·36 [95% CI 2·77-4·08], p<0·0001). Age was positively related to suicide risk in both genders, with a 3% increase in risk for every one-year increase in age at hospital presentation (OR 1·03 [1·03-1·04], p<0·0001). Relative to hospital presentations after self-poisoning alone, presentations involving both self-injury and self-poisoning were associated with higher suicide risk (adjusted OR 2·06 [95% CI 1·42-2·99], p<0·0001], as were presentations after self-injury alone (adjusted OR 1·36 [1·09-1·70], p=0·007). Similarly, relative to self-harm by self-poisoning alone, attempted hanging or asphyxiation (adjusted OR 2·70 [1·53-4·78], p=0·001) and traffic-related acts of self-injury (adjusted OR 2·99 [1·17-7·65], p=0·022) were associated with greater risk of suicide. Self-cutting combined with self-poisoning was also associated with increased suicide risk (adjusted OR 1·36, [1·08-1·71], p=0·01). Compared with those patients living in the most deprived areas, those who lived in the least deprived areas (first national IMD quintile) had a greater risk of dying by suicide (adjusted OR 1·76 [1·32-2·34], p<0·0001) after adjusting for gender, age, previous self-harm, and psychiatric treatment, as did those living in the second least deprived areas (adjusted OR 1·64 [1·20-2·25], p=0·002).
Patients attending hospital for self-harm are at high risk of suicide, especially immediately after hospital attendance. Certain patient characteristics and methods of self-harm, together with living in areas of low socioeconomic deprivation, can increase patients' subsequent suicide risk. However, while specific risk factors can be usefully integrated into the assessment process, individual factors have poor utility in predicting suicide, so the needs and risks of all patients should be assessed to develop appropriate aftercare plan, including early follow-up.
UK Department of Health and Social Care.
自残是后续自杀的最强风险因素，但风险可能存在差异。我们根据患者特征、自残方式以及地区层面社会经济剥夺程度的差异，比较了因自残住院后自杀的风险，并估计了出院后不同时间的自杀发生率。
在这项正在进行的英国自残多中心研究中，研究人群包括2000年1月1日至2013年12月31日期间因非致命性自残到牛津、曼彻斯特和德比的五家综合医院急诊科就诊的至少15岁的个体。通过医院系统监测获取自残方式的信息。社会经济剥夺程度基于描述患者居住地区的多重剥夺指数（IMD），并根据IMD五分位数对患者进行分组。死亡率随访至2015年12月31日，随访时间长达16年。我们计算了自首次住院以来不同随访期的自杀发生率，并使用混合效应模型估计个体因素（年龄、性别、自残方式、IMD以及非致命性自残住院次数）与自杀之间的关联。
2000年1月1日至2013年12月31日期间，51108名个体到研究医院就诊92177次。1325名患者参与了1563次自残事件，因性别、年龄或死亡率信息缺失而被排除在研究之外。最终的研究样本包括49783名个体的90614次住院就诊。到2015年12月31日随访结束时，703名患者自杀死亡。自杀的总体发生率为每10万人年163.1例（95%CI 151.5 - 175.6），男性为每10万人年260.0例（237.4 - 284.8），女性为每10万人年94.6例（83.3 - 107.4）。自杀发生率在出院后的第一年最高（每10万人年511.1例[451.7 - 578.2]），尤其是在第一个月（每10万人年1787.1例[1423.0 - 2244.4]）。基于所有住院就诊情况，自残后男性自杀死亡的可能性是女性的三倍（OR 3.36 [95%CI 2.77 - 4.08]，p<0.0001）。年龄与两性的自杀风险均呈正相关，住院时年龄每增加一岁，风险增加3%（OR 1.03 [1.03 - 1.04]，p<0.0001）。相对于仅中毒后的住院就诊，涉及自我伤害和中毒的就诊与更高的自杀风险相关（调整后OR 2.06 [95%CI 1.42 - 2.99]，p<0.0001），仅自我伤害后的就诊情况也是如此（调整后OR 1.36 [1.09 - 1.70]，p = 0.007）。同样，相对于仅中毒自残，企图上吊或窒息（调整后OR 2.70 [1.53 - 4.78]，p = 0.001）以及与交通相关的自我伤害行为（调整后OR 2.99 [1.17 - 7.65]，p = 0.022）与更高的自杀风险相关。割伤与中毒相结合也与自杀风险增加相关（调整后OR 1.36，[1.08 - 1.71]，p = 0.01）。与生活在最贫困地区的患者相比，生活在最不贫困地区（全国IMD五分位数中的第一组）的患者在调整性别、年龄、既往自残和精神治疗后自杀死亡的风险更高（调整后OR 1.76 [1.32 - 2.34]，p<0.0001），生活在第二最不贫困地区的患者也是如此（调整后OR 1.64 [1.20 - 2.25]，p = 0.002）。
因自残住院的患者自杀风险很高，尤其是在住院后立即自杀的风险更高。某些患者特征、自残方式以及生活在社会经济剥夺程度低的地区会增加患者后续的自杀风险。然而，虽然特定风险因素可有效地纳入评估过程，但个体因素在预测自杀方面效用不佳，因此应评估所有患者的需求和风险，以制定适当的后续护理计划，包括早期随访。
英国卫生和社会保健部。
