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The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule

  • S. Steeg (a1), N. Kapur (a1), R. Webb (a1), E. Applegate (a1), S. L. K. Stewart (a1), K. Hawton (a2), H. Bergen (a2), K. Waters (a3) and J. Cooper (a1)...



Self-harm is a common reason for Emergency Department (ED) attendance. We aimed to develop a clinical tool to help identify patients at higher risk of repeat self-harm, or suicide, within 6 months of an ED self-harm presentation.


The tool, the ReACT Self-Harm Rule, was derived using multicentre data from a prospective cohort study. Binary recursive partitioning was applied to data from two centres, and data from a separate centre were used to test the tool. There were 29 571 self-harm presentations to five hospital EDs between January 2003 and June 2007, involving 18 680 adults aged ⩾16 years. We estimated sensitivity, specificity and positive and negative predictive values to measure the performance of the tool.


A self-harm presentation was classified as higher risk if at least one of the following factors was present: recent self-harm (in the past year), living alone or homelessness, cutting as a method of harm and treatment for a current psychiatric disorder. The rule performed with 95% sensitivity [95% confidence interval (CI) 94–95] and 21% specificity (95% CI 21–22), and had a positive predictive value of 30% (95% CI 30–31) and a negative predictive value of 91% (95% CI 90–92) in the derivation centres; it identified 83/92 of all subsequent suicides.


The ReACT Self-Harm Rule might be used as a screening tool to inform the process of assessing self-harm presentations to ED. The four risk factors could also be used as an adjunct to in-depth psychosocial assessment to help guide risk formulation. The use of multicentre data helped to maximize the generalizability of the tool, but we need to further verify its external validity in other localities.


Corresponding author

*Address for correspondence: Ms. S. Steeg, Centre for Suicide Prevention, 2nd Floor, Jean McFarlane Building, University of Manchester, Oxford Road, Manchester M13 9PL, UK. (Email:


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Adelstein, A, Mardon, C (1975). Suicides 1961–1974. Population Trends 2, 4855.
Altman, DG, Mackin, D, Byrant, TN, Gardner, MJ (2000). Statistics with Confidence, 2nd edn. BMJ Books: London.
Beghi, M, Rosenbaum, JF (2010). Risk factors for fatal and nonfatal repetition of suicide attempt: a critical appraisal. Current Opinion in Psychiatry 23, 349355.
Bergen, H, Hawton, K, Waters, K, Cooper, J, Kapur, N (2010). Epidemiology and trends in non-fatal self-harm in three centres in England: 2000–2007. British Journal of Psychiatry 197, 493498.
Bilén, K, Ottosson, C, Castrén, M, Ponzer, S, Ursing, C, Ranta, P, Ekdahl, K, Pettersson, H (2010). Deliberate self-harm patients in the emergency department: factors associated with repeated self-harm among 1524 patients. Emergency Medicine Journal 28, 10191025.
Breiman, L, Friedman, JH, Olshen, RA, Stone, CJ (1984). Classification and Regression Trees. Wadsworth: Belmont, CA.
Camp, NJ, Slattery, ML (2002). CART analysis: a statistical tool to investigate risk factor interactions with an example for colon cancer (US). Cancer Causes and Control 13, 813823.
Cochrane-Brink, KA, Lofchy, JS, Sakinofsky, I (2000). Clinical rating scales in suicide risk assessment. General Hospital Psychiatry 445, 445451.
Cooper, J, Kapur, N, Dunning, J, Guthrie, E, Appleby, L (2006). A clinical tool for assessing risk after self-harm. Annals of Emergency Medicine 48, 459466.
Cooper, J, Kapur, N, Mackway-Jones, K (2007). A comparison between clinicians' assessment and the Manchester Self-Harm Rule: a cohort study. Emergency Medicine Journal 24, 720721.
Cooper, J, Kapur, N, Webb, R, Lawlor, M, Guthrie, E, Mackway-Jones, K, Appleby, L (2005). Suicide after deliberate self-harm: a 4-year cohort study. America Journal of Psychiatry 162, 297303.
Deeks, JJ, Altman, DG (2004). Diagnostic tests 4: likelihood ratios. British Medical Journal 329, 168169.
Department for Communities and Local Government (2008). The English Indices of Deprivation 2007. Communities and Local Government: London.
Department of Health (2002). National Suicide Prevention Strategy for England. The Stationery Office: London.
Gaddis, G (2006). Improving the design of the assessment of emergency department patients at risk for self-harm. Annals of Emergency Medicine 48, 467469.
Haw, C, Hawton, K, Casey, D (2006). Deliberate self-harm patients of no fixed abode: a study of characteristics and subsequent deaths in patients presenting to a general hospital. Social Psychiatry and Psychiatric Epidemiology 41, 918925.
Hawton, K, Bergen, H, Casey, D, Simkin, S, Palmer, B, Cooper, J, Kapur, N, Horrocks, J, House, A, Lilley, R, Noble, R, Owens, D (2007). Self-harm in England: a tale of three cities. Multicentre study of self-harm. Social Psychiatry and Psychiatric Epidemiology 42, 513521.
Hawton, K, Zahl, D, Weatherall, R (2003). Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. British Journal of Psychiatry 182, 537542.
HESA (2007). Students by Mode and Level of Study: 2006/07 Students by Mode and Level ( Higher Education Information Database for Institutions (HEIDI) ID: 145052. Higher Education Statistics Agency (HESA), Cheltenham, UK. Accessed 4 October 2010.
Hockberger, RS, Rothstein, RJ (1988). Assessment of suicide potential by nonpsychiatrists using the sad persons score. Journal of Emergency Medicine 6, 99–107.
Kapur, N (2006). Self-harm in the general hospital. Clinical Medicine 6, 529532.
Kapur, N (2009). Health services and suicide prevention. Journal of Mental Health 18, 15.
Kapur, N, Cooper, J, King-Hele, S, Webb, R, Lawlor, M, Rodway, C, Appleby, L (2006). The repetition of suicidal behavior: a multicenter cohort study. Journal of Clinical Psychiatry 67, 15991609.
Kapur, N, Murphy, E, Cooper, J, Bergen, H, Hawton, K, Simkin, S, Casey, D, Horrocks, J, Lilley, R, Noble, R, Owens, D (2008). Psychosocial assessment following self-harm: results from the Multi-Centre Monitoring of Self-Harm Project. Journal of Affective Disorders 106, 285293.
Kreitman, N, Foster, J (1991). The construction and selection of predictive scales, with special reference to parasuicide. British Journal of Psychiatry 159, 185192.
Lemon, SC, Roy, J, Clark, MA, Friedmann, PD, Rakowski, W (2003). Classification and regression tree analysis in public health: methodological review and comparison with logistic regression. Annals of Behavioural Medicine 26, 172181.
Lilley, R, Owens, D, Horrocks, J, House, A, Noble, R, Bergen, H, Hawton, K, Casey, D, Simkin, S, Murphy, E, Cooper, J, Kapur, N (2008). Hospital care and repetition following self-harm: multicentre comparison of self-poisoning and self-injury. British Journal of Psychiatry 192, 440445.
McMillan, D, Gilbody, S, Bereford, E, Neilly, L (2007). Can we predict suicide and non-fatal self-harm with the Beck Hopelessness Scale? A meta-analysis. Psychological Medicine 37, 769778.
Monahan, J, Steadman, HJ, Applebaum, PS, Robbins, PC, Mulvey, EP, Silver, E, Roth, LH, Grisso, T (2000). Developing a clinically useful actuarial tool for assessing violence risk. British Journal of Psychiatry 176, 312319.
Muller, R, Möckel, M (2008). Logistic regression and CART in the analysis of multimarker studies. Clinica Chimica Acta 394, 16.
NHS Information Centre (2010). Medical Research Information Service (MRIS), Merseyside (
NICE (2004). NICE implementation uptake report: insomnia – newer hypnotic drugs. NICE Technology Appraisal Guidance 77. National Institute for Health and Clinical Excellence: London.
NICE (2011). Self-harm: longer-term management (full guideline). Clinical Guideline 16. National Institute for Health and Clinical Excellence:London.
ONS (2009 a). Mid-2008 Population Estimates: Quinary Age Groups and Sex for Local Authorities in the United Kingdom. Office for National Statistics:Durham.
ONS (2009 b). Nomis official labour market statistics. Manchester ( Office for National Statistics: Durham.
ONS (2009 c). Nomis official labour market statistics. Oxford ( Office for National Statistics: Durham.
ONS (2009 d). Nomis official labour market statistics. Derby ( Office for National Statistics: Durham.
ONS (2009 e). Estimated resident population by broad ethnic group and sex, mid-2007 (experimental statistics): Manchester. Office for National Statistics: Durham.
ONS (2009 f). Estimated resident population by broad ethnic group and sex, mid-2007 (experimental statistics): Oxford. Office for National Statistics: Durham.
ONS (2009 g). Estimated resident population by broad ethnic group and sex, mid-2007 (experimental statistics): Derby. Office for National Statistics: Durham.
Owens, D, Horrocks, J, House, A (2002). Fatal and non-fatal repetition of self-harm. British Journal of Psychiatry 181, 193199.
Patterson, WM, Bird, J, Patterson, GA (1983). Evaluation of suicidal patients: the Sad Persons Scale. Psychosomatics 24, 343349.
Randall, JR, Colman, I, Rowe, BH (2011). A systematic review of psychometric assessment of self-harm risk in the emergency department. Journal of Affective Disorders 134, 248355.
Royal College of Psychiatrists (2004). Assessment Following Self-Harm in Adults. Royal College of Psychiatrists: London.
Salford Systems (2007). CART: Version 6.0. Salford Systems: San Diego, CA.
Scheet, LJ, Zhang, J, Kolassa, J (2009). Classification tree modelling to identify severe and moderate vehicular injuries in young and middle-aged adults. Artificial Intelligence in Medicine 45, 110.
Scottish Executive (2002). The National Strategy and Action Plan to Prevent Suicide in Scotland. The Stationery Office: Edinburgh.
Steinberg, D (President and founder of Salford Systems). Email correspondence April 2011.
Stiell, IG, Wells, GA (1999). Methodologic standards for the development of clinical decision rules in emergency medicine. Annals of Emergency Medicine 33, 437447.
Twala, B (2009). An empirical comparison of techniques for handling incomplete data using decision trees. Applied Artificial Intelligence 23, 373405.
Wadsworth, JT, Somers, KD, Cazares, LH, Malik, G, Adam, BL, Stack, BC, Wright, GL, Semmes, OJ (2004). Serum protein profiles to identify head and neck cancer. Clinical Cancer Research 10, 16251632.
Walters, JTR, Bisson, JI, Sheperd, JP (2007). Predicting post-traumatic stress disorder: validation of the Trauma Screening Questionnaire in victims of assault. Psychological Medicine 37, 143150.
Zahl, DL, Hawton, K (2004). Repetition of deliberate self-harm and subsequent suicide risk: long-term follow-up study of 11 583 patients. British Journal of Psychiatry 181, 7075.


The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule

  • S. Steeg (a1), N. Kapur (a1), R. Webb (a1), E. Applegate (a1), S. L. K. Stewart (a1), K. Hawton (a2), H. Bergen (a2), K. Waters (a3) and J. Cooper (a1)...


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