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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).
19
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.
23
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.
24
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
26
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
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Asarnow et al.
(2017)
1 18 368 Emergency
department,
Other forms of suicidal
thoughts or behaviour
Younger
people
35
USA
Beautrais et al.
(2003)
16 60 1060 Emergency
department,
New Zealand
Suicide Attempt Unspecified/
adults
Berrino et al.
(2011)
1 3 2000 Emergency
department,
Switzerland
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Bilen et al. (2010) 35 12 2297 Emergency
department,
Scandanavia
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Bostwick et al.
(2016)
5 168 84 General
Hospital, USA
Suicide Attempt Unspecified/
adults
36
Brown et al. (2005) 1 18 556 Emergency
department,
USA
Suicide Attempt Unspecified/
adults
Buglass et al.
(1974)
23 12 819 Regional
Poisoning
Centre,
Scotland
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Caldera et al.
(2007)
3 63.06 539 Emergency
unit,
Nicaragua
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Cebria et al. (2015) 5 60 206 Emergency
department,
Spain
Suicide Attempt Unspecified/
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
Suicide Attempt Unspecified/
adults
Cooper et al.
(2005)
60 24 377 Emergency
department,
England
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Crandall et al.
(2006)
78 72 132 Emergency
department,
USA
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Curran et al.
(1999)
3 102 598 Accident and
emergency
department,
Ireland
Other forms of suicidal
thoughts or behaviour
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
Other forms of suicidal
thoughts or behaviour
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
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Evans et al. (1999) 3 6 726 General
Hospital,
England
Other forms of suicidal
thoughts or behaviour
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
Suicide Attempt Unspecified/
adults
Finkelstein et al.
(2015)
126 86.4 85 General
Hospital,
Canada
Other forms of suicidal
thoughts or behaviour
Younger
people
Fleischmann et al.
(2008)
20 18 785 Emergency
department,
multiple
countries
Suicide Attempt Unspecified/
adults
Gardner et al.
(1977)
1 12 366 General
Hospital,
England
Other forms of suicidal
thoughts or behaviour
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
Suicide Attempt Unspecified/
adults
Goldacre et al.
(1985)
6 33.6 86 General
Hospital,
England
Other forms of suicidal
thoughts or behaviour
Younger
people
Grafstein et al.
(2013)
31 1 3310 Emergency
department,
Canada
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Greenfield et al.
(2008)
0 6 0 Emergency
department,
Canada
Other forms of suicidal
thoughts or behaviour
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
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Grimholt et al.
(2015)
2 6 1980 General
hospital,
Norway
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Groholt et al.
(2009)
2 109 250 General
Hospital,
Norway
Suicide Attempt Younger
people
Guthrie et al.
(2001)
0 6 0 Emergency
department,
England
Other forms of suicidal
thoughts or behaviour
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
Suicide Attempt Unspecified/
adults
Hawton et al.
(1988)
43 99 347 General
Hospital,
England
Suicide Attempt Unspecified/
adults
Hawton et al.
(2015)
513 90 170 Emergency
department,
England
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Herve et al. (1984) 2 42 555 Surgical
intensive care
unit, France
Suicide Attempt Unspecified/
adults
Hjelmeland et al. 24 12 1403 General Other forms of suicidal Unspecified/
43
(1996) Hospital,
Norway
thoughts or behaviour adults
Holley et al. (1998) 51 87.42 799 General
hospital,
Canada
Suicide Attempt Unspecified/
adults
Howson et al.
(2008)
8 12 1061 Emergency
department,
New Zealand
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Hvid et al. (2011) 3 12 2256 General
Hospital,
Denmark
Suicide Attempt Unspecified/
adults
Hvid et al. (2009) 2 12 1325 General
Hospital,
Denmark
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Jenkins et al. 12 261 394 General Other forms of suicidal Unspecified/
44
(2002) Hospital,
England
thoughts or behaviour adults
Johannessen et al.
(2011)
55 120 387 General
hospital,
Norway
Suicide Attempt Unspecified/
adults
Jokinen et al.
(2016)
15 108 751 Emergency
department,
Sweden
Other forms of suicidal
thoughts or behaviour
Older people
Karasouli et al.
(2015)
49 72 86 Emergency
department,
England
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Karasouli et al.
(2011)
32 198 213 Emergency
department,
England
Other forms of suicidal
thoughts or behaviour
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
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Kotila et al. (1989) 8 60 442 General
Hospital,
Finland
Suicide Attempt Younger
people
Kuo et al. (2012) 201 39.6 801 Accident and
emergency
department,
Taiwan
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
46
Lee et al. (2012) 5 12 3448 Emergency
department,
Taiwan
Suicide Attempt Unspecified/
adults
Lindh et al. (2018) 10 6 2488 General
Hospital,
Sweden
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Lonnqvist et al.
(1991)
54 54 750 Emergency
department,
Finland
Suicide Attempt Unspecified/
adults
Makela et al.
(1984)
13 60 677 Emergency
room, Finland
Suicide Attempt Unspecified/
adults
Miller et al. (2017) 5 12 363 Emergency
department,
USA
Other forms of suicidal
thoughts or behaviour
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
Suicide Attempt Unspecified/
adults
Motto et al. (1965) 21 60 2176 General
hospital, USA
Suicide Attempt Unspecified/
adults
Mouaffak et al.
(2015)
1 12 352 Emergency
department,
France
Suicide Attempt Unspecified/
adults
Mousavi et al.
(2016)
1 8 2727 Poisoning
emergency,
Iran
Suicide Attempt Unspecified/
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
Suicide Attempt Unspecified/
adults
Nimeus et al. (2002 22 54 881 Medical
intensive care
unit, Sweden
Suicide Attempt Unspecified/
adults
Nordontoft et al.
(1993)
103 101.76 1247 Poisoning
treatment
centre,
Denmark
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Nordentoft et al.
(1993)
9 48 2250 General
Hospital,
Denmark
Suicide Attempt Unspecified/
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
Suicide Attempt Younger
people
O'Connor et al.
(2017)
3 6 1158 Acute
medical unit,
Scotland
Suicide Attempt Unspecified/
adults
Ojehagen et al.
(1992)
4 12 1688 Medical
intensive care
unit, Sweden
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
50
Olfson et al. (2018) 17 12 107 Emergency
department,
USA
Other forms of suicidal
thoughts or behaviour
Younger
people
Olfson et al. (2017) 85 12 341 Emergency
department,
USA
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Ostamo et al.
(2001)
192 63.6 1302 Emergency
room, Finland
Suicide Attempt Unspecified/
adults
Owens et al. (1991) 11 36 370 Accident and
Emergency
unit, England
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Paerregaard et al.
(1975)
65 60 2686 Poisoning
centre,
Denmark
Other forms of suicidal
thoughts or behaviour
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
Suicide Attempt Unspecified/
adults
Pavarin et al.
(2014)
26 54 1144 Emergency
department,
Italy
Suicide Attempt Unspecified/
adults
Pierce et al. (1982) 13 60 520 General
Hospital, UK
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Reith et al. (2004) 58 60 283 Toxicology
service,
Australia
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
52
Rojas et al. (2018) 7 24 3571 Emergency
department,
Argentina
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Rosen et al. (1976) 34 60 767 Poisoning
treatment
centre,
Scotland
Suicide Attempt Unspecified/
adults
Rosenman et al.
(1983)
7 60 534 Emergency
department,
Australia
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Ryan et al. (1996) 33 12 896 Accident and
emergency
department,
England
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Rygnestad et al. 41 60 777 Poisoning Other forms of suicidal Unspecified/
53
(1997) treatment
centre,
Norway
thoughts or behaviour adults
Safinofsky et al.
(2013)
2 12 995 General
Hospital,
Canada
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Sinclair et al.
(2010)
4 15 2238 General
Hospital, UK
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Skogman et al.
(2004)
63 77 933 Medical
emergency
inpatient
unit, Sweden
Suicide Attempt Unspecified/
adults
Sobolewski et al.
(2013)
0 2 0 Emergency
department,
Other forms of suicidal
thoughts or behaviour
Younger
people
54
USA
Spirito et al. (1994) 0 3 0 Emergency
department,
USA
Suicide Attempt Younger
people
Spirito et al. (1992) 0 3 0 General
Hospital, USA
Suicide Attempt Younger
people
Steeg et al. (2018) 18 6 909 Emergency
department,
England
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Steer et al. (1988) 28 90 748 General
Hospital, USA
Suicide Attempt Unspecified/
adults
Stewart et al.
(2001)
0 6 0 Emergency
room, Canada
Other forms of suicidal
thoughts or behaviour
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)
68 162 495 Emergency
unit, Finland
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Suominen et al.
(2004)
93 66 1411 General
hospital,
Finland
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Tyrer et al. (2003) 7 12 1741 General
Hospital, UK
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Vaiva et al. (2006) 4 13 610 Emergency
department,
France
Other forms of suicidal
thoughts or behaviour
Unspecified/
adults
Vajda et al. (2000) 5 12 4464 Emergency
department,
Australia
Suicide Attempt Younger
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
Suicide Attempt Unspecified/
adults
Vijayakumar et al.
(2011)
10 18 1072 Emergency
department,
India
Suicide Attempt Unspecified/
adults
Waern et al. (2010) 7 36 1414 Emergency
ward,
Sweden
Suicide Attempt Unspecified/
adults
Wang et al (2006) 5 366 131 Emergency
department,
Faroe Islands
Suicide Attempt Unspecified/
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
Other forms of suicidal
thoughts or behaviour
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
Suicide Attempt Unspecified/
adults
Zahl et al. (2004) 300 136.8 227 General
Hospital,
England
Other forms of suicidal
thoughts or behaviour
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
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
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
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