Case studies have linked SARS-CoV-2 infection to suicidal behaviour. However, conclusive evidence is lacking.

To examine whether a history of SARS-CoV-2 infection or SARS-CoV-2-related hospital admission was associated with self-harm in the general population and in high-risk groups.

A cohort design was applied to nationwide data on all people aged ≥15 years and living in Denmark between 27 February 2020 and 15 October 2021. Exposure was identified as having had a positive SARS-CoV-2 PCR test, and further assessed as SARS-CoV-2-related hospital admission. Rates of probable self-harm were examined using adjusted incidence rate ratios (aIRRs). The following subgroups were identified: (a) lower educational level, (b) chronic medical conditions, (c) disability pension, (d) mental disorders, (e) substance use disorders, and history of (f) homelessness and (g) imprisonment.

Among 4 412 248 included individuals, 260 663 (5.9%) had tested positive for SARS-CoV-2. Out of 5453 individuals presenting with self-harm, 131 (2.4%) had been infected. Individuals with a history of a positive SARS-CoV-2 test result had an aIRR for self-harm of 0.86 (95% CI 0.72–1.03) compared with those without. High rates were found after a SARS-CoV-2-related hospital admission (aIRR = 7.68; 95% CI 5.61–10.51) or a non-SARS-CoV-2-related admission (aIRR = 10.27; 95% CI 9.65–10.93) versus non-infected and not admitted. In sensitivity analyses with a more restrictive definition of self-harm, a positive PCR test was associated with lower rates of self-harm.

Individuals with a PCR-confirmed SARS-CoV-2 infection did not have higher rates of self-harm than those without. Hospital admission in general, rather than being SARS-CoV-2 positive. seemed to be linked to elevated rates of self-harm.

Evidence on the impact of the pandemic on healthcare presentations for self-harm has accumulated rapidly. However, existing reviews do not include studies published beyond 2020.

To systematically review evidence on presentations to health services following self-harm during the COVID-19 pandemic.

A comprehensive search of databases (WHO COVID-19 database; Medline; medRxiv; Scopus; PsyRxiv; SocArXiv; bioRxiv; COVID-19 Open Research Dataset, PubMed) was conducted. Studies published from 1 January 2020 to 7 September 2021 were included. Study quality was assessed with a critical appraisal tool.

Fifty-one studies were included: 57% (29/51) were rated as ‘low’ quality, 31% (16/51) as ‘moderate’ and 12% (6/51) as ‘high-moderate’. Most evidence (84%, 43/51) was from high-income countries. A total of 47% (24/51) of studies reported reductions in presentation frequency, including all six rated as high-moderate quality, which reported reductions of 17–56%. Settings treating higher lethality self-harm were overrepresented among studies reporting increased demand. Two of the three higher-quality studies including study observation months from 2021 reported reductions in self-harm presentations. Evidence from 2021 suggests increased numbers of presentations among adolescents, particularly girls.

Sustained reductions in numbers of self-harm presentations were seen into the first half of 2021, although this evidence is based on a relatively small number of higher-quality studies. Evidence from low- and middle-income countries is lacking. Increased numbers of presentations among adolescents, particularly girls, into 2021 is concerning. Findings may reflect changes in thresholds for help-seeking, use of alternative sources of support and variable effects of the pandemic across groups.

Deterioration in general population mental health since the start of the COVID-19 pandemic has been reported, but the impact of the pandemic on people with severe mental illness (SMI) has received less attention.

To understand the impact of the early stages of the pandemic on the patients with SMI, in terms of provision of mental health care and patient outcomes.

We examined records of 34,446 patients with SMI in Oxford Health Foundation Trust between March 2016 and July 2020. We used interrupted time-series analysis to estimate the immediate and subsequent changes in weekly rates of the use of community mental health services, hospitalization, and patient outcomes (as measured by Health of the Nation Outcome Scales, or HoNOS, scores) during the weeks of lockdown between March 23, 2020 and July 3, 2020.

Mean total HoNOS scores for all patients deteriorated in the weeks subsequent to lockdown (0.060 per week; 95%CI: 0.033, 0.087). Scores for patients with a history of psychosis deteriorated immediately (0.63; 95% CI: 0.26, 1.0). There was an immediate decrease in weekly referrals to community and outpatient services (−196; 95%CI: −300, −91) and no immediate change in weekly inpatient admissions (−4.2; 95%CI: −9.9, 1.5) or weekly total contacts (−26; 95%CI: −475, 423).

Patients with SMI were negatively impacted during the early stages of the COVID-19 pandemic. Patients with a history of psychosis experienced distinct and immediate impacts. During the same period, referrals to community and outpatient services fell with no consequent impact on inpatient admissions.

Mood stabilisers are the main treatment for bipolar disorder. However, it is uncertain which drugs have the best outcomes.

To investigate whether rates of suicide, self-harm and psychiatric hospital admission in individuals with bipolar disorder differ between mood stabilisers.

A cohort design was applied to people aged ≥15 years who were diagnosed with bipolar disorder and living in Denmark during 1995–2016. Treatment with lithium, valproate, other mood stabilisers and antipsychotics were compared in between- and within-individual analyses, and adjusted for sociodemographic characteristics and previous self-harm.

A total of 33 337 individuals with bipolar disorder were included (266 900 person-years). When compared with individuals not receiving treatment, those receiving lithium had a lower rate of suicide (hazard ratio 0.40, 95% CI 0.31–0.51). When comparing treatment and non-treatment periods in the same individuals, lower rates of self-harm were found for lithium (hazard ratio 0.74, 95% CI 0.61–0.91). Lower rates of psychiatric hospital admission were found for all drug categories compared with non-treatment periods in within-individual analyses (P<0.001). The low rates of self-harm and hospital admission for lithium in within-individual analyses were supported by results of between-individual analyses.

Lithium was associated with lower rates of suicide, self-harm and psychiatric hospital readmission in all analyses. With respect to suicide, lithium was superior to no treatment. Although confounding by indication cannot be excluded, lithium seems to have better outcomes in the treatment of bipolar disorder than other mood stabilisers.

People who experience homelessness are thought to be at high risk of suicide, but little is known about self-harm in this population.

To examine characteristics and outcomes in people experiencing homelessness who presented to hospital following self-harm.

Data were collected via specialist assessments and/or hospital patient records from emergency departments in Manchester, Oxford and Derby, UK. Data were collected from 1 January 2000 to 31 December 2016, with mortality follow-up via data linkage with NHS Digital to 31 December 2019. Trend tests estimated change in self-harm over time; descriptive statistics described characteristics associated with self-harm. Twelve-month repetition and long-term mortality were analysed using Cox proportional hazards models and controlled for age and gender.

There were 4841 self-harm presentations by 3270 people identified as homeless during the study period. Presentations increased after 2010 (IRR = 1.09, 95% CI 1.04–1.14, P < 0.001). People who experienced homelessness were more often men, White, aged under 54 years, with a history of previous self-harm and contact with psychiatric services. Risk of repetition was higher than in domiciled people (HR = 2.05, 95% CI 1.94–2.17, P < 0.001), as were all-cause mortality (HR = 1.45, 95% CI 1.32–1.59. P < 0.001) and mortality due to accidental causes (HR = 2.93, 95% CI 2.41–3.57, P < 0.001).

People who self-harm and experience homelessness have more complex needs and worse outcomes than those who are domiciled. Emergency department contact presents an opportunity to engage people experiencing homelessness with mental health, drug and alcohol, medical and housing services, as well as other sources of support.

Guidance in England recommends psychosocial assessment when presenting to hospital following self-harm but adherence is variable. There is some evidence suggesting that psychosocial assessment is associated with lower risk of subsequent presentation to hospital for self-harm, but the potential cost-effectiveness of psychosocial assessment for hospital-presenting self-harm is unknown.

A three-state four-cycle Markov model was used to assess cost-effectiveness of psychosocial assessment after self-harm compared with no assessment over 2 years. Data on risk of subsequent self-harm and hospital costs of treating self-harm were drawn from the Multicentre Study of Self-Harm in England, while estimates of effectiveness of psychosocial assessment on risk of self-harm, quality of life, and other costs were drawn from literature. Incremental cost-effectiveness ratios (ICERs) for cost per Quality Adjusted Life Year (QALY) gained were estimated. Parameter uncertainty was addressed in univariate and probabilistic sensitivity analyses.

Cost per QALY gained from psychosocial assessment was £10,962 (95% uncertainty interval [UI] £15,538–£9,219) from the National Health Service (NHS) perspective and £9,980 (95% UI £14,538–£6,938) from the societal perspective. Results were generally robust to changes in model assumptions. The probability of the ICER being below £20,000 per QALY gained was 78%, rising to 91% with a £30,000 threshold.

Psychosocial assessment as implemented in the English NHS is likely to be cost-effective. This evidence could support adherence to NICE guidelines. However, further evidence is needed about the precise impacts of psychosocial assessment on self-harm repetition and costs to individuals and their families beyond immediate hospital stay.

We compared the risk of death by suicide following hospital presentation for self-harm according to site of self-cut/stab.

We included 54 999 self-harm presentations (involving 31 419 individuals) to hospitals in the Multicentre Study of Self-harm in England (1/1/2004–31/12/2014), with mortality follow-up to 31/12/2019. Information on method of self-harm was obtained through monitoring in hospitals. Information about mortality was obtained through linkage with NHS Digital. We assessed the association of site of self-cut with death by suicide using mixed effect models.

In total, 10 790 (19.6%) hospital presentations involved self-cutting/stabbing, 7489 of which (69.4%) were due to laceration to the arm/wrist alone, 1846 episodes (17.1%) involved cutting elsewhere on the body, and 1455 (13.5%) were due to laceration to unknown site. Controlling for confounders, presentation to a hospital following self-cut/stab to bodily parts other than wrist/arm was associated with greater chance of subsequent suicide relative to presentation after self-poisoning alone [adjusted odds ratio (aOR) 1.75, 95% confidence interval (CI) 1.03–2.96, p = 0.038]. The likelihood of suicide after presentation for cutting/stabbing the wrist/arm alone was comparable to that of patients who had self-poisoned alone. Presentations after laceration involving the neck were associated with a four-fold greater chance of subsequent suicide relative to self-poisoning (aOR 4.09, 95% CI 1.80–9.30, p = 0.001).

Patients who attend hospital after self-cutting/stabbing are a heterogeneous group in terms of characteristics, methods of cutting/stabbing and risk of subsequent suicide. Risk of suicide is greater in individuals who self-cut/stab to parts of the body other than the wrist or arm, especially the neck.

Ketamine has recently received considerable attention regarding its antidepressant and anti-suicidal effects. Trials have generally focused on short-term effects of single intravenous infusions. Research on patient experiences is lacking.

To investigate the experiences over time of individuals receiving ketamine treatment in a routine clinic, including impacts on mood and suicidality.

Twelve fee-paying patients with treatment-resistant depression (6 females, 6 males, age 21–70 years; 11 reporting suicidality and 6 reporting self-harm) who were assessed as eligible for ketamine treatment participated in up to three semi-structured interviews: before treatment started, a few weeks into treatment and ≥2 months later. Data were analysed thematically.

Most participants hoped that ketamine would provide respite from their depression. Nearly all experienced improvement in mood following initial treatments, ranging from negligible to dramatic, and eight reported a reduction in suicidality. Improvements were transitory for most participants, although two experienced sustained consistent benefit and two had sustained but limited improvement. Some participants described hopelessness when treatment stopped working, paralleled by increased suicidal ideation for three participants. The transient nature and cost of treatment were problematic. Eleven participants experienced side-effects, which were significant for two participants. Suggestions for improving treatment included closer monitoring and adjunctive psychological therapy.

Ketamine treatment was generally experienced as effective in improving mood and reducing suicidal ideation in the short term, but the lack of longer-term benefit was challenging for participants, as was treatment cost. Informed consent procedures should refer to the possibilities of relapse and associated increased hopelessness and suicidality.

Individuals attending emergency departments following self-harm have increased risks of future self-harm. Despite the common use of risk scales in self-harm assessment, there is growing evidence that combinations of risk factors do not accurately identify those at greatest risk of further self-harm and suicide.

To evaluate and compare predictive accuracy in prediction of repeat self-harm from clinician and patient ratings of risk, individual risk-scale items and a scale constructed with top-performing items.

We conducted secondary analysis of data from a five-hospital multicentre prospective cohort study of participants referred to psychiatric liaison services following self-harm. We tested predictive utility of items from five risk scales: Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS, Modified SAD PERSONS, Barratt Impulsiveness Scale and clinician and patient risk estimates. Area under the curve (AUC), sensitivity, specificity, predictive values and likelihood ratios were used to evaluate predictive accuracy, with sensitivity analyses using classification-tree regression.

A total of 483 self-harm episodes were included, and 145 (30%) were followed by a repeat presentation within 6 months. AUC of individual items ranged from 0.43–0.65. Combining best performing items resulted in an AUC of 0.56. Some individual items outperformed the scale they originated from; no items were superior to clinician or patient risk estimations.

No individual or combination of items outperformed patients’ or clinicians’ ratings. This suggests there are limitations to combining risk factors to predict risk of self-harm repetition. Risk scales should have little role in the management of people who have self-harmed.

Although research has identified a wide range of risk factors for suicidal behavior in prisoners, it does not establish who is most likely to act on their suicidal thoughts while incarcerated.

Self-report data were collected from a random sample of 1,203 adult men incarcerated across 15 prisons in Belgium, who represent 12% of all male prisoners nationwide.

One-third (33%) of participants reported having suicidal thoughts during their incarceration, of whom 26% attempted suicide in prison (9% of all prisoners). Factors independently associated with suicide attempt among prisoners with suicidal ideation were violent offending (adjusted odds ratio [aOR] = 2.64, 95% confidence interval [CI] 1.33–5.23), in-prison drug use (aOR = 2.30, 95% CI 1.25–4.22), exposure to suicidal behavior (aOR = 1.96, 95% CI 1.04–3.68), and a lifetime history of nonsuicidal self-injury (aOR = 1.90, 95% CI 1.08–3.36). While related to suicidal thoughts, markers of psychiatric morbidity and aspects of the prison regime were not associated with the progression to suicide attempt.

Many prisoners who think about suicide do not attempt suicide while incarcerated. Factors associated with suicidal ideation are distinct from those that govern the transition to suicidal behavior. Our findings lend support to the hypothesis that behavioral disinhibition might act as a catalyst in the translation of suicidal thoughts into action.

A few previous studies suggest that a large number of individuals do not present at hospital following a suicide attempt, complicating recurrence prevention and prevalence estimation.

Data were extracted from a regular phone survey in representative samples of the French population aged 18–75 years old. Five surveys between 2000 and 2017 collected data about the occurrence of a previous suicide attempt and subsequent care contacts. A total of 102,729 individuals were surveyed. Among them, 6,500 (6.4%) reported a lifetime history of suicide attempt.

Following their last suicide attempt, 39.3% reported they did not present to hospital (53.4% in 18–24 year-olds), with limited changes in rates with time. Risk factors for non-presentation were being male [adjusted odds ratio = 1.3, 95% confidence interval (1.1–1.5)], living with someone [1.2 (1.0–1.4)], being a non-smoker [1.4 (1.2–1.6)], and being younger at time of attempt [0.97 (0.96–0.98) per year]. Of those who did not present to hospital, only 37.7% reported visiting a doctor or a psychiatrist/psychologist after their act v. 67.1% in those who presented to hospital (as a second health contact). In both cases, half disclosed their act to someone else. Prevalence rates of suicide attempts reported in community were 4.6 times higher than those in hospital administrative databases.

This survey at a national level confirmed that a large proportion of individuals does not go to the hospital and does not meet any health care professionals following a suicidal act. Assessment of unmet needs is necessary.

Self-harm is common in prisoners. There is an association between self-harm in prisoners and subsequent suicide, both within prison and on release. The aim of this study is to develop and evaluate a prediction model to identify male prisoners at high risk of self-harm.

We developed an 11-item screening model, based on risk factors identified from the literature. This screen was administered to 542 prisoners within 7 days of arrival in two male prisons in England. Participants were followed up for 6 months to identify those who subsequently self-harmed in prison. Analysis was conducted using Cox proportional hazard regression. Discrimination and calibration were determined for the model. The model was subsequently optimized using multivariable analysis, weighting variables, and dropping poorly performing items.

Seventeen (3.1%) of the participants self-harmed during follow up (median 53 days). The strongest risk factors were previous self-harm in prison (adjusted hazard ratio [aHR] = 9.3 [95% CI: 3.3–16.6]) and current suicidal ideation (aHR = 7.6 [2.1–27.4]). As a continuous score, a one-point increase in the suicide screen was significantly associated with self-harm (HR = 1.4, 1.1–1.7). At the prespecified cut off score of 5, the screening model was associated with an area under the curve (AUC) of 0.66 (0.53–0.79), with poor calibration. The optimized model saw two items dropped from the original screening tool, weighting of risk factors based on a multivariable model, and an AUC of 0.84 (0.76–0.92).

Further work is necessary to clarify the association between risk factors and self-harm in prison. Despite good face validity, current screening tools for self-harm need validation in new prison samples.

The aim of this study was to estimate incidence of self-harm presentations to hospitals and their associated hospital costs across England.

We used individual patient data from the Multicentre Study of Self-harm in England of all self-harm presentations to the emergency departments of five general hospitals in Oxford, Manchester and Derby in 2013. We also obtained cost data for each self-harm presentation from the hospitals in Oxford and Derby, as well as population and geographical estimates from the Office for National Statistics. First, we estimated the rate of self-harm presentations by age and gender in the Multicentre Study and multiplied this with the respective populations to estimate the number of self-harm presentations by age and gender for each local Clinical Commissioning Group (CCG) area in England. Second, we performed a regression analysis on the cost data from Oxford and Derby to predict the hospital costs of self-harm in Manchester by age, gender, receipt of psychosocial assessment, hospital admission and type of self-harm. Third, the mean hospital cost per age year and gender were combined with the respective number of self-harm presentations to estimate the total hospital costs for each CCG in England. Sensitivity analysis was performed to address uncertainty in the results due to the extrapolation of self-harm incidence and cost from the Multicentre Study to England.

There were 228 075 estimated self-harm presentations (61% were female) by 159 857 patients in 2013 in England. The largest proportions of self-harm presentations were in the age group 40–49 years (30%) for men and 19–29 years (28%) for women. Associated hospital costs were approximately £128.6 (95% CI 117.8−140.9) million in 2013. The estimated incidence of self-harm and associated hospital costs were lower in the majority of English coastal areas compared to inland regions but the highest costs were in Greater London. Costs were also higher in more socio-economically deprived areas of the country compared with areas that are more affluent. The sensitivity analyses provided similar results.

The results of this study highlight the extent, hospital costs and distribution of self-harm presentations to hospitals in England and identify potential sub-populations that might benefit from targeted actions to help prevent self-harm and assist those who have self-harmed. They can support national as well as local health stakeholders in allocating funds and prioritising interventions in areas with the greatest need for preventing and managing self-harm.

Complex challenges may arise when patients present to emergency services with an advance decision to refuse life-saving treatment following suicidal behaviour.

To investigate the use of advance decisions to refuse treatment in the context of suicidal behaviour from the perspective of clinicians and people with lived experience of self-harm and/or psychiatric services.

Forty-one participants aged 18 or over from hospital services (emergency departments, liaison psychiatry and ambulance services) and groups of individuals with experience of psychiatric services and/or self-harm were recruited to six focus groups in a multisite study in England. Data were collected in 2016 using a structured topic guide and included a fictional vignette. They were analysed using thematic framework analysis.

Advance decisions to refuse treatment for suicidal behaviour were contentious across groups. Three main themes emerged from the data: (a) they may enhance patient autonomy and aid clarity in acute emergencies, but also create legal and ethical uncertainty over treatment following self-harm; (b) they are anxiety provoking for clinicians; and (c) in practice, there are challenges in validation (for example, validating the patient’s mental capacity at the time of writing), time constraints and significant legal/ethical complexities.

The potential for patients to refuse life-saving treatment following suicidal behaviour in a legal document was challenging and anxiety provoking for participants. Clinicians should act with caution given the potential for recovery and fluctuations in suicidal ideation. Currently, advance decisions to refuse treatment have questionable use in the context of suicidal behaviour given the challenges in validation. Discussion and further patient research are needed in this area.

D.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for Depression. K.H. and D.G. are NIHR Senior Investigators. K.H. is also supported by the Oxford Health NHS Foundation Trust and N.K. by the Greater Manchester Mental Health NHS Foundation Trust.

In England suicide rates are highest in midlife (defined as age 40–59). Despite a strong link with suicide there has been little focus on self-harm in this age group.

To describe characteristics and treatment needs of people in midlife who present to hospital following self-harm.

Data from the Multicentre Study of Self-harm in England were used to examine rates over time and characteristics of men and women who self-harm in midlife. Data (2000–2013) were collected via specialist assessments or hospital records. Trends were assessed by negative binomial regression models. Comparative analysis used logistic regression models for binary outcomes. Repetition and suicide mortality were assessed by Cox proportional hazards models.

A quarter of self-harm presentations were made by people in midlife (n = 24 599, 26%). Incidence rates increased over time in men, especially after 2008 (incidence rate ratio [IRR] 1.07, 95% CI 1.02–1.12, P < 0.01), and were positively correlated with national suicide incidence rates (r = 0.52, P = 0.05). Rates in women remained relatively stable (IRR 1.00, 95% CI 1.00–1.02, P = 0.39) and were not correlated with suicide. Alcohol use, unemployment, housing and financial factors were more common in men; whereas indicators of poor mental health were more common in women. In men and women 12-month repetition was 25%, and during follow-up 2.8% of men and 1.2% of women died by suicide.

Self-harm in midlife represents a key target for intervention. Addressing underlying issues, alcohol use and economic factors may help prevent further self-harm and suicide.

K.H. and N.K. are members of the Department of Health's National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group which developed the quality standards for self-harm services. N.K. also chairs the NICE guideline committee for the management of depression. All other authors declare no conflict of interest.

Death of patients by suicide can have powerful effects on psychiatrists. We report the findings of a survey completed by 174 psychiatrists on the effects of patient suicide on their emotional well-being and clinical practice, and the support and resources they felt would be helpful.

The death of a patient by suicide usually had a major effect on respondents. Clinical practice was often negatively affected, and over a quarter of respondents considered a change of career path as a result. There were some gender differences in responses, with women reporting more sense of responsibility for the deaths and a greater effect on their clinical confidence. Desired support included a senior suicide lead clinician, support during formal post-suicide processes, opportunity for reflection on practice, information about resources to support families and help communicating with families and friends of the deceased.

High body mass index (BMI) has been associated with lower risks of suicidal behaviour and being underweight with increased risks. However, evidence is inconsistent and sparse, particularly for women. We aim to study this relationship in a large cohort of UK women.

In total 1.2 million women, mean age 56 (s.d. 5) years, without prior suicide attempts or other major illness, recruited in 1996–2001 were followed by record linkage to national hospital admission and death databases. Cox regression yielded relative risks (RRs) and 95% confidence intervals (CIs) for attempted suicide and suicide by BMI, adjusted for baseline lifestyle factors and self-reported treatment for depression or anxiety.

After 16 (s.d. 3) years of follow-up, 4930 women attempted suicide and 642 died by suicide. The small proportion (4%) with BMI <20 kg/m2 were at clearly greater risk of attempted suicide (RR = 1.38, 95% CI 1.23–1.56) and suicide (RR = 2.10, 1.59–2.78) than women of BMI 20–24.9 kg/m2; p < 0.0001 for both comparisons. Small body size at 10 and 20 years old was also associated with increased risks. Half the cohort had BMIs >25 kg/m2 and, while risks were somewhat lower than for BMI 20–24.9 kg/m2 (attempted suicide RR = 0.91, 0.86–0.96; p = 0.001; suicide RR = 0.79, 0.67–0.93; p = 0.006), the reductions in risk were not strongly related to level of BMI.

Being underweight is associated with a definite increase in the risk of suicidal behaviour, particularly death by suicide. Residual confounding cannot be excluded for the small and inconsistent decreased risk of suicidal behaviour associated with being overweight or obese.