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Risk of suicide and repeat self-harm after hospital attendance for non-fatal self-harm in Sri Lanka: a cohort study

Research output: Contribution to journalArticle

Original languageEnglish
JournalLancet Psychiatry
DateAccepted/In press - 3 May 2019

Abstract

Background:
Evidence from high income countries (HIC) suggests that individuals who present to
hospital following self-harm are an important target for suicide prevention, but evidence from low and middle-income countries (LMIC) is lacking. This study investigates risk of repeat self-harm and suicide, and factors associated with these outcomes, in a large cohort of self-harm patients presenting to hospital in rural Sri Lanka.

Methods:
Hospital presentations for self-harm at 13 hospitals in a rural area of North Central
Province (population 224,000), Sri Lanka were followed-up for up to 4.8 years using a self-harm surveillance system, established as part of a community randomised trial, and based on data from all hospitals, Coroners and police stations in the study area. Risk of repeat non-fatal and fatal self-harm, and risk factors for repetition, were estimated using Kaplan-Meier methods and Cox proportional hazard models. The socio-demographic (age, sex, socioeconomic position) and clinical (past selfharm and method of self-harm)) characteristics investigated were drawn from a household survey in the study area and information recorded at the time of index hospital presentation.

Outcomes:
In 2259 index presentations of self-harm, the risk of repeat self-harm (12 months: 3.1%, 95% CI 2.4 to 3.9%; 24 months: 5.2%, 95% CI 4.3 to 6.4%) and suicide (12 months: 0.6%, 95% CI 0.4 to 1.1%; 24 months: 0.8%, 95% CI 0.5 to 1.3%) was considerably lower than in HIC. A higher risk of repetition was observed in males (non-fatal and fatal), older individuals (fatal), and those who used methods other than poisoning in their index presentation. There was no evidence of increased risk of repeat self-harm or suicide in those with a history of self-harm prior to the index episode.

Interpretation:
This study suggests that, whilst people who self-harm are an important high-risk group, a focus of suicide prevention efforts on those who self-harm may be somewhat less important
in LMIC compared to HIC given the low risk of repetition and subsequent suicide death. Strategies which focus on other risk factors for suicide may be more effective in reducing suicide deaths in LMIC in South Asia. A better understanding of this low rate of repetition is also needed as it may contribute to prevention strategies in nations with a higher incidence of repetition and subsequent suicide death

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