Elsevier

The Lancet

Volume 380, Issue 9853, 3–9 November 2012, Pages 1568-1574
The Lancet

Articles
Premature death after self-harm: a multicentre cohort study

https://doi.org/10.1016/S0140-6736(12)61141-6Get rights and content

Summary

Background

People who self-harm have an increased risk of premature death. The aim of this study was to investigate cause-specific premature death in individuals who self-harm, including associations with socioeconomic deprivation.

Methods

We undertook a cohort study of patients of all ages presenting to emergency departments in Oxford, Manchester, and Derby, UK, after self-poisoning or self-injury between Jan 1, 2000, and Dec 31, 2007. Postcodes of individuals' place of residence were linked to the Index of Multiple Deprivation 2007 in England. Mortality information was supplied by the Medical Research Information Service of the National Health Service. Patients were followed up to the end of 2009. We calculated age-standardised mortality ratios (SMRs) and years of life lost (YLL), and we tested for associations with socioeconomic deprivation.

Findings

30 950 individuals presented with self-harm and were followed up for a median of 6·0 years (IQR 3·9–7·9). 1832 (6·1%) patients died before the end of follow-up. Death was more likely in patients than in the general population (SMR 3·6, 95% CI 3·5–3·8), and occurred more in males (4·1, 3·8–4·3) than females (3·2, 2·9–3·4). Deaths due to natural causes were 2–7·5 times more frequent than was expected. For individuals who died of any cause, mean YLL was 31·4 years (95% CI 30·5–32·2) for male patients and 30·7 years (29·5–31·9) for female patients. Mean YLL for natural-cause deaths was 25·9 years (25·7–26·0) for male patients and 25·5 years (25·2–25·8) for female patients, and for external-cause deaths was 40·2 years (40·0–40·3) and 40·0 years (39·7–40·5), respectively. Disease of the circulatory (13·1% in males; 13·0% in females) and digestive (11·7% in males; 17·8% in females) systems were major contributors to YLL from natural causes. All-cause mortality increased with each quartile of socioeconomic deprivation in male patients (χ2 trend 39·6; p<0·0001), female patients (13·9; p=0·0002), and both sexes combined (55·4; p<0·0001). Socioeconomic deprivation was related to mortality in both sexes combined from natural causes (51·0; p<0·0001) but not from external causes (0·30; p=0·58). Alcohol problems were associated with death from digestive-system disease, drug misuse with mental and behavioural disorders, and physical health problems with circulatory-system disease.

Interpretation

Physical health and life expectancy are severely compromised in individuals who self-harm compared with the general population. In the management of self-harm, clinicians assessing patients' psychosocial problems should also consider their physical needs.

Funding

Department of Health Policy Research Programme.

Introduction

People who self-harm have an increased risk of premature death: studies from the 1980s showed that risk of suicide was 25 times greater, accidental death seven times higher, and death from natural causes two times greater in individuals who self-harm than in the general population.1 Subsequent studies2, 3, 4, 5, 6, 7 established that all-cause and natural-cause mortality was increased in people who self-harm, although estimates varied widely across countries, perhaps due to differences in suicide or self-harm rates, periods investigated, and sample characteristics. Both self-harm8, 9 and suicide10 are associated with socioeconomic status. Yet, as far as we are aware only one study11 has investigated the association between socioeconomic deprivation and suicide after self-harm, and none has examined deprivation in relation to all-cause or natural-cause mortality after self-harm. The scarcity of data is surprising in view of the profound effect of deprivation on mortality in the general population10 and on premature mortality in the UK.12

Researchers have argued that studies of the association between premature mortality and psychological disorders should include all causes of death,13 and that primary prevention of suicide should focus on overall improvement of health by targeting vulnerabilities that increase risk of natural death.1 Physical health problems are often poorly treated in people with mental disorders, leading to reduced life expectancy.14, 15 As well as being at high risk for suicide, most patients who self-harm have psychiatric disorders.16, 17 It is important to know the extent of physical health problems in this population, and the study of mortality after self-harm is one approach. Patients' characteristics and health risk behaviour could inform clinical practice in relation to management of physical disorders in the context of self-harm.

The aims of this study were to investigate excess all-cause and cause-specific mortality and years of life lost (YLL) in individuals who self-harm compared with the general population. Additionally, we hoped to identify associations between mortality and socioeconomic deprivation and between problems with alcohol, illicit drugs, and physical health identified at the time of self-harm and subsequent mortality.

Section snippets

Study design and participants

A cohort study was undertaken in Oxford, Manchester, and Derby, UK, where centres are taking part in the Multicentre Study of Self-harm in England.18 Data were obtained for all individuals who presented with non-fatal self-harm to one general hospital emergency department in Oxford, three in Manchester, and two in Derby between Jan 1, 2000, and Dec 31, 2007. Non-fatal self-harm was defined as intentional self-poisoning or self-injury, irrespective of motivation.19 The sample,20 risks of suicide

Results

30 950 individuals presented with self-harm to the six hospitals and were followed up for a median of 6·0 years (IQR 3·9–7·9). 748 (2·4%) individuals were not traced by the MRIS, 29 (0·1%) were younger than 15 years at the end of follow-up, and 41 (0·1%) were of unknown age and so were excluded from the analyses. Of the remaining 30 132 individuals, 17 671 (58·6%) were female and 12 444 (41·3%) were male (17 individuals were of unknown sex). Age distributions by sex and centre are presented in

Discussion

We have shown that individuals who presented to emergency departments after self-harm between 2000 and 2007 had a greater risk of death from any cause than did the general population. Roughly 6% of our cohort died, many prematurely, such that at least 30 years of life was lost by each individual. Deaths were not only due to external causes—as might be expected in view of the high suicide risk in this population2, 3—but also to natural causes. These findings are higher than estimates of a loss

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