Suicide and Self-Harm:
             d Self Harm:
      Part I - MRCPsych April 2007



               Alex M
             ...
NHS Statistics
 •   13 million first outpatient appointments in secondary care
                                           ...
I: Self-Harm
Tree (nomenclature) of Har
                         rmful Behaviours

          Suicide Attempt                           ...
DSH Rates in Oxford City (1976-1998)
            Deliberate Self-Harm - Epid
                                      demiolo...
Rates of DSH for the Leices (1997/98)
                          ster

         600

         500

         400
 Rate per
 ...
Self-Harm by Time of Day




                           Data from Leeds
Deliberate Self-Harm - Com
                         mposition           B o rd e rlin e
       C o m p o s itio n o f D S ...
DSH and Pa
                                    atient Types
Deliberate Self-Harm - Cate
                          egories
...
Problems Repo
                                                orted upon DSH
Deliberate Self-Harm – Rea
                  ...
Methods of Self-Harm (No. & % shown)
 Paracetamol overdose                                                                ...
Time to Repe after DSH
                                                                               eat
Deliberate Self-...
Risk factors for repetition of self-harm
                                  f
                                             ...
Management of self-poisoning in 4 teaching hospitals


                                                                   ...
Recent National Guidance
Hazardous Outcome after DSH
 •   Suicide
     – 0.5-1% in 12 months
     – 3% at 8 years
            t

 •   Repetition of...
II: Suicide
http://www.nimhe.csip.org.uk/our-work/suicide-prevention/annual-report-on-progress-2006.html
                             ...
Table 13.1         Life years lost for those dy
                                              ying before age 65 (1989) ra...
Suicide Statistics in the UK
 •   Annual number of Suicides in UK     5,000
 •   Annual number of Homicides in UK    1,000...
Suicide and P
                                          Patient Types
Suicide Risk             FactorsII - Dem mographics
...
Suicide Rate (All Ages) En
                                                              ngland & Wales 1960-1998
     Sui...
Trend in suicide rate for young men (aged 20-34)
                            u
Male Suicide Rate by Age E
                                                                   England & Wales 1960-1998
  ...
Death rates from Intentional self-harm and injury of
Undetermined Intent 1993-2005 and target for the year 2010,
         ...
Suicide a
                                                                                    after DSH
            DSH – ...
DSH & Suicide Overview


                                                  0.01%
                                         ...
Predictors of Poor Outcome after DSH
                         e
    Risk Factor                      Suicid
              ...
Recent warnings about (SSRI’s) in depre
                                      essed young people.



  •   Committee on Sa...
Antidepressants & Suicide


                                                                               Suicide
       ...
E
                                       Energization
                                             i ti
                  ...
Antidepressants Prescriptions & Suicide
                          o
What treatments are availab ?
                          ble


 •   Antidepressants                          •   Psychother...
III: Risk and Prediction
Repetition after DSH (K reitman & Foster Scale)
                     Predictive Scales after DSH - Power
                 ...
Predictive Scales after DSH - Factors
                          H
 •   Kreitman & Foster DSH Outcome Scale   SAD PERSONS S...
Suicide and depression: hig risk factors
                          gh

 • Lifetime risk is 2%
      – Bostwick J.M., Pankr...
Suicide and schizophrenia: high risk factors

 • Lifetime risk of suicide is 5%
      – Palmer et al (2005) AGP 62: 247
  ...
Suicide and alcohol addictio high risk factors
                           on:

 • Lifetime risk of suicide is 3.4%
       ...
Improving DSH Manageme in Leicester
                     ent
 •   Simple referral form
 •   Education for A&E
 •   Satisfa...
10-Step Form Study
        100              437
                                                Frequency of Rep
         ...
0
                                   5
                                       10
                                         ...
Suicidal Plans or Conditional Threats?       4.345013258    1.65638E-05

Mood or Perceptions?                         4.10...
Advanced Suicide Intent Scales
                         c
IV: Extras
Mental State Examination

  a.                        p               j       p
                                          ...
How to Take a DSH History
                        y
a.   What were the precipitating events?

b.   What were the motives f...
Deliberate Self-Harm (DSH) in the elderly

  •   Usually failed serious suicide bids        •   Depression approx. 90%
  •...
MRCPsych I - Suicide and Self Harm (April 2007)
MRCPsych I - Suicide and Self Harm (April 2007)
MRCPsych I - Suicide and Self Harm (April 2007)
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MRCPsych I - Suicide and Self Harm (April 2007)

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This is an academic educational presentation given for those studying for MRCPsych (Royal College of Psychiatrists) Part I. It is from 2007, Leicester Partnership Trust. Apologies if this is difficult to follow when read in isolation.

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MRCPsych I - Suicide and Self Harm (April 2007)

  1. 1. Suicide and Self-Harm: d Self Harm: Part I - MRCPsych April 2007 Alex M Mitchell Consultant in Liaison Psychiatry, Leicester. n
  2. 2. NHS Statistics • 13 million first outpatient appointments in secondary care s • 15 million A&E episodes • (4 million emergency admissions) • (5.5 million planned admissions) • ? Suicides • ? DSH Episodes
  3. 3. I: Self-Harm
  4. 4. Tree (nomenclature) of Har rmful Behaviours Suicide Attempt Self-Harm Attempt Thoughts Alone Intent to die No intent to die Completed Near Miss Life-Thr reatening Physically Minor Violent Self-Poisoning Toxic Self-injury Hanging Paracetamol / Aspirin Carbon Monoxide Cutting g Jumping/RTA Psychotropic/ Trq Gas Other Antidepressant Physical Meds Alcohol / Illicit Drugs
  5. 5. DSH Rates in Oxford City (1976-1998) Deliberate Self-Harm - Epid demiology 600 500 400 300 Rate DSH (per 100,000) 200 Males Females 100 e 0 1974 1976 1978 1980 1982 1984 6 1986 1988 1990 1992 1994 1996 1998 2000
  6. 6. Rates of DSH for the Leices (1997/98) ster 600 500 400 Rate per 300 100 000 male 200 female 100 0 15-24 25-34 35-44 45-54 55-64 65-74 75-84 85+ Age group e Data from Leicester (Dennis)
  7. 7. Self-Harm by Time of Day Data from Leeds
  8. 8. Deliberate Self-Harm - Com mposition B o rd e rlin e C o m p o s itio n o f D S H P e rso n a lity A lco h o l D isin h itio n P sych ia tric 30% A ccid e n ta l 5% F a ile d S u icid e 25% 15% 25%
  9. 9. DSH and Pa atient Types Deliberate Self-Harm - Cate egories 100 Single 90 Employed 80 Psychiatric 70 Alcohol Abuse 60 Personality Disorder 50 Alcoholic 40 Drug Abuse 30 20 10 0 Single Employed Psychiatric Alco hol Personality Alcoholic Drug Abuse Abuuse Disorder
  10. 10. Problems Repo orted upon DSH Deliberate Self-Harm – Rea asons Given 100 Partner Family 90 Alcohol 80 Employment 70 Finances 60 Isolation Housing 50 43 Bereavement 40 35 Friends 29 30 Physical Health 25 20 20 18 17 Drugs 12 11 9 9 10 0 Partner Family Alcohol Employment Finances tion Isolat Housing Bereavement Friends Physical Drugs Health
  11. 11. Methods of Self-Harm (No. & % shown) Paracetamol overdose 386 41 Benzodiazepine overdose 160 17 Aspirin/non-steroid anti-inflammatory drug overdose 101 11 Tricyclic antidepressant overdose 75 8 Selective serotonin re-uptake inhibitor overdose 50 5 Other antidepressant overdose 10 1 Other psychotropic overdose 90 10 Other overdose 205 22 Deliberate illicit substance overdose 4 0.5 Wrist cutting 95 10 Other deliberate self-injury 56 6 Non-ingestibles 15 2 Carbon monoxide poisoning 7 1 Hanging g g 6 0.5 Other 1 0 Total no. of episodes of DSH = 934, 241 (26%) involved more than one meth hod Data from Leeds
  12. 12. Time to Repe after DSH eat Deliberate Self-Harm – Rep petition Rate 50 Cumulative 45 Proportion Repeating 40 35 30 After initial Aft i iti l presentation with DSH, 10% repeat t ti ith DSH t Percentage Repeating Per Year within one year and 30%+ within 10 years d 25 20 g 15 10 e 5 0 10 11 12 13 1 2 3 4 5 6 7 8 9 ar ar ar ar ar ar ar ar ar ar ar ar ar Ye Ye Ye Ye Ye Ye Ye Ye Ye Ye Ye Ye Ye
  13. 13. Risk factors for repetition of self-harm f Key: R isk factor S tud ies P revious episode p 1-6 1. 1 Kessel & McCulloch, 1966 n 511 97 (19%) repeated McC lloch 1966: n=511, repeated; P revious psychiatric care 1, 3, 6 follow-up 1 year In current psychiatric care 1 2. Greer & Bagley, 1971: n=204, 53 (26%) repeated; follow- A lcohol problem s 1, 2, 3, 6 up 1-2 years D rug dependence 1, 2, 3, 6 3. Morgan et al, 1976: n=215, 56 (26%) repeated; follow-up n 215, follow up A ntisocial personality 1, 2, 3, 6 1-2 years C rim inal record 3, 6 4. Bancroft & Marsack, 1977: n=141, 36 (26%) repeated; S how ed lack of co-operation 2, 7 follow-up 3 years Low social class 3, 6 5. Wilkinson & Smeaton, 1987: n=1376, 259 (19%) S eparated from partner 1, 1 3 repeated; follow-u 1-2 years S ex: m ale 2 6. Buglass & Horton, 1974: n= 2809, 16% repeated; follow- fem ale 8* up 1-2 years A ge: 25-34 years 1* 7. Gardner et al, 1982: n=188, 50 (27%) repeated; follow- 35-54 years 35 54 8 8* up 1 year S eparated from m other before age 15 3 8. Kreitman, 1976: n=822; follow-up 1 year U nem ployed 6 R egrets about survival 3 U nprovoked index episode 3 Im pulsive self-harm act 1 * factor reported but not statistically significant
  14. 14. Management of self-poisoning in 4 teaching hospitals Proportion dis- Proportion of patients Number of deliberate Propoortion charged from A&E who received psycho- self poisoning self-poisoning discharge from ed Hospital without receiving social assessment at episodes in one acciden and nt psychosocial any stage during their m onth during 1996 emerg ency assessm ent hospital contact Leeds 101 18% % 15% 65% Leicester 111 55% % 21% 68% M anchester h t 100 71% % 46% 36% N ottingham 165 32% % 25% 48% All C entres 477 43% % 26% 54% eldm an E, Friedm an T, G uthrie E. BM J 1998; 316: 831-2 From : Kapur N , H ouse A, C reed F, Fe
  15. 15. Recent National Guidance
  16. 16. Hazardous Outcome after DSH • Suicide – 0.5-1% in 12 months – 3% at 8 years t • Repetition of DSH – A Approx. 15% i 12 months in th – Most repeats during 3 months of fi irst episode • General Mortality • Use of psychiatric services – 5-10% admitted to psychiatric unit – 20% outpatients • Subsequent Psychiatric Illness S b tP hi t i Ill Data from Leicester (Dennis)
  17. 17. II: Suicide
  18. 18. http://www.nimhe.csip.org.uk/our-work/suicide-prevention/annual-report-on-progress-2006.html v
  19. 19. Table 13.1 Life years lost for those dy ying before age 65 (1989) ranked by specific type of disease p yp Disease category (ICD codes) M ale Rank Fem ale Rank Heart disease (390-429) 450,979 1 165,248 1 Lung cancer (162) 115,751 115 751 3 68 686 68,686 3 Motor vehicle (E180-E189) traffic accidents 123,799 2 40,195 6 Breast cancer (174, 175) 429 19 150,282 2 Cerbrovascular (430-438) disease 64,484 5 63,350 4 Suicide (E950) and self-inflicted injury (E959) 82,161 4 24,050 9 Chronic obstructive pulmonary disease and alli ied 47,398 6 42,058 5 conditions Colorectal cancer (153-154) 44,516 7 38,981 7 Cervical cancer (180) 29,651 8 ( Pancreatic cancer (157) ) , 16,619 9 15,284 , 11 Due to alcohol (100% )* 23,025 8 15,461 10 Diabetes mellitus (250) 13,896 10 12,640 12 Bladder cancer (188) 10,156 13 4,816 16 Diseases of the oesophagus, stom ach and 9,242 15 6,254 13 duodenum (530-537) (530 537) Accidents caused by fire (E890-E899) 8,845 16 5,700 14 Homicide and assault (E960-E969 6,390 17 4,636 17 Accidental drowning (E910) 10,624 12 2,239 18 Prostatic cancer (185) 10,942 11 (E859-E858) Accidental poisoning (E859 E858) 9,783 9 783 14 5 168 5,168 15 Laryngeal cancer (161) 4,476 18 1,028 19 ICD, International Classification of Diseases, 9 th Edition * Includes ICD codes 291, 303, 305.0, 425.3, 5 571.0, 571.1, 571.2, 571.3, 980
  20. 20. Suicide Statistics in the UK • Annual number of Suicides in UK 5,000 • Annual number of Homicides in UK 1,000 • Annual number of Suicides in USA 30,000 • Annual number of Homicides in USA 15,000 • Suicide (all ages) is the 8th commonest cause of death • Suicide in adolescents is the 3rd commonest cause of death • A l Suicide t i Annual S i id rate is 10 per 100 000 population 100,000 l ti
  21. 21. Suicide and P Patient Types Suicide Risk FactorsII - Dem mographics 100 Psychiatric 90 Psychotropic P h t i 80 GP Visit 70 Depressed 60 50 Physical Illness 40 Alcoholic 30 Schizophrenia 20 10 0 Psychiatric Psychotropic GP Visit Depressed Physical Alcoholic Schizophrenia Illness
  22. 22. Suicide Rate (All Ages) En ngland & Wales 1960-1998 Suicide EpidemiologyI - Tot tal 160 140 120 on) 100 Suicide Rate (pe millio 80 er 60 40 Males 20 Females S 0 The suicide 1960 higher 1975 1980 1985 1990 1955 rate is much 1965men, 1970 due to the5 in the rate in women since 1987 largely f fall 1995 2000
  23. 23. Trend in suicide rate for young men (aged 20-34) u
  24. 24. Male Suicide Rate by Age E England & Wales 1960-1998 Suicide EpidemiologyI – By Age 450 400 350 65+ 45-64 Suicide Rate (per million) 300 35-44 25-34 15-24 250 200 R 150 100 50 0 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 Suicide rates previously increased with age, but now are v very similar in men and woman across age groups
  25. 25. Death rates from Intentional self-harm and injury of Undetermined Intent 1993-2005 and target for the year 2010, 5
  26. 26. Suicide a after DSH DSH – Suicide Outcome 20 18 16 14 12 10 8 Cumulative Suicides (%) 6 4 2 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Years afte index Episode er DSH is an important risk factor for completed suicide, increasing the risk about 100 fold
  27. 27. DSH & Suicide Overview 0.01% General 1% Pop’n Depresse d (5%) DSH Sui icide 70% (150,000) (50 000) Depresse d (80%) 30% Depressed (30%)
  28. 28. Predictors of Poor Outcome after DSH e Risk Factor Suicid de Repeat DSH History of Previous DSH ☯☯☯ ☯☯ Psychiatric History ☯☯ ☯☯ Drug/Alcohol Abuse ☯ Personality Disorder ☯ Unemployment ☯ ☯ Lower Social Class / Stability ☯ Physical Illness ☯ Social Isolation ☯☯ ☯ High Suicidal Intent ☯ ☯
  29. 29. Recent warnings about (SSRI’s) in depre essed young people. • Committee on Safety of Medicines ( y (December 2003) contra-indicated all ) SSRI’s for depressed children, exce fluoxetine. ept medicines.mhra.gov.uk/ourworkmonitorsafequalmed/safetymessages/ssrioverview_101203.pdf • FDA issues Public Health Advice on cautions for use for use of n antidepressants in adults and children March 2004 ren. www.fda.gov/bbs/topics/ANSWERS/2004/ANSO128 83.html
  30. 30. Antidepressants & Suicide Suicide 5% 15% 70% 16% on antidepressants Depression 20% on ant tidepressants Suicide per 100,000 “depressed person years” - 141 on antidepressants n - 259 of antidepressants [RR 1.8] ff p If all depressed persons were treated with antidepressan suicide rate could be reduced by 2000 deaths per year nts,
  31. 31. E Energization i ti increases uicide risk Agitation increases then i th Net effect on decreases suicide risk Su Moodd improves s 1 2 3 4 weeks w Nutt 2003 – Journal of Psychophar rmacology 17: 4, 355-364 355-
  32. 32. Antidepressants Prescriptions & Suicide o
  33. 33. What treatments are availab ? ble • Antidepressants • Psychotherapy – Proven role where depression and/or – Some suggestion that dialectical behaviour anxiety therapy or IPT may reduce repetition • Problem Solving • Patient based self-help p – Benefits for depression, anxiety & – MACT only moderately successful in hopelessness but no effect on reducing repetition (confined to borderline repetition personality disorder) • Priority future treatment – ‘Green card studies’ showed no • GPs benefit – GP guidelines of no significant benefit • Follow-up – S Some b benefit with reduction of fit ith d ti f repetition Adapted from Original of Mick Dennis
  34. 34. III: Risk and Prediction
  35. 35. Repetition after DSH (K reitman & Foster Scale) Predictive Scales after DSH - Power H 70 Pe rce nta ge Re pe a ting 60 Num be r Re pe a ting 50 on) Repetition (Number vs Proportio 40 30 s 20 10 R 0 0 1 2 3 4 5 6 7 8 9 10 11 12 Patients who score highly on the Kreitman & Foster sca are more likely to repeat, ale Positive Pr but the majority who repeat do not score highly redictive items
  36. 36. Predictive Scales after DSH - Factors H • Kreitman & Foster DSH Outcome Scale SAD PERSONS Scale – Previous Para-suicide S Sex – Personality Disorder A Age – Alcohol Abuse D Depression – Previous Psychiatric Treatment P Previous Attempts – Unemployment E Ethanol Abuse – Social Class V R Rational Thinking Loss – Drug Abuse S Social Support Lacking – Criminal Record O Organised Plan – Violence N No Spouse – Age 25-54 yrs S Sickness – Single, Divorced or Separated ∗ Br J Psychiatr (1991)
  37. 37. Suicide and depression: hig risk factors gh • Lifetime risk is 2% – Bostwick J.M., Pankratz, V.S., (2 Bostwick, J M Pankratz V S 2000) Affective disorders and suicide 2000). risk: a reexamination. Am. J. Psy ychiatry 157 (12), 1925– 1932. • Male, older [normal demographics] • Persistent insomnia [severity] • us] Previous act of deliberate self-harm [previou • Self-neglect [severity] • Severe Illness [severity] • ?Impaired memory [severity] • Physical illness [co-morbidity] • Agitation [co-morbidity] • Panic P i attacks [ k [co-morbidity] bidi ] Adapted from Original of Mick Dennis
  38. 38. Suicide and schizophrenia: high risk factors • Lifetime risk of suicide is 5% – Palmer et al (2005) AGP 62: 247 ( ) • Male [normal demographics] • Younger [normal demographics] • Unemployed [normal demographics] • Previous act of deliberate self-harm [previous s] • Depressive episodes [co-morbidity] • Anorexia/weight loss [co-morbidity] • More serious illness [severity] • Recurrent relapse [severity] • Recent diagnosis, recent discharge • Fear of deterioration, especially in those of high intellectual ability Adapted from Original of Mick Dennis
  39. 39. Suicide and alcohol addictio high risk factors on: • Lifetime risk of suicide is 3.4% % Murphy et al (1990) AGP • Male ( k M l (peak age 40 – 60 years ) normal demog ld graphics hi • High level of dependency [severity] • Long history of drinking [severity] • Disruption of major interpersonal relationships [social] • Depressed mood [co-morbidity] • Poor physical health [ P h i l h lth [co-morbidity] bidit ] • Poor work record in previous four years [nor rmal demographics] • Past DSH history [previous] Adapted from Original of Mick Dennis
  40. 40. Improving DSH Manageme in Leicester ent • Simple referral form • Education for A&E • Satisfaction survey • Quality of referral survey • Prediction of DSH repetition study
  41. 41. 10-Step Form Study 100 437 Frequency of Rep petitions of Self Harm 90 90 80 70 60 50 40 30 25 20 10 7 5 4 0 ns n ns ns ns ns io o io io io io it iti et it it it it et et et et et ep ep ep ep ep ep R R R R R R 1 5+ 0 2 3 4
  42. 42. 0 5 10 15 20 25 1 D ay 12 2- 7 Da y s 14 8- 14 D ay s 9 10-Step Form Study 15 -2 8 D ay s 17 29 -5 9 D ay s 13 60 -9 0 D ay s 16 90 -1 8 0 Da y s 23 18 1- 36 4 D ay s 23 36 5 D ay s+ 3
  43. 43. Suicidal Plans or Conditional Threats? 4.345013258 1.65638E-05 Mood or Perceptions? 4.109159234 4.57034E-05 Previous Self-Harm? 3.441581787 0.000621875 Difficult Personal History? 3.116435435 0.001925556 Intended to die? 2.642627391 0.008459658 Housing problems? 1.583840408 0.113801724 Past Medical history? 1.369505014 0.171397338 Lack of social support? 1.276507103 0.202312118 Relationship problems? 1.189983947 1 189983947 0.234563323 0 234563323 Work or Financial problems? 1.10905884 0.267886875 Admission required (if so where)? 0.866449824 0.386619302 Past Psychiatric history? 0.858214753 0.391145703 Psychosis (odd thinking or beliefs)? 0.851262598 0.394990629 Antidote, sutures required? 0.821525679 0.411700936 Dementia (memory, odd behaviour)? 0.717845981 0.473154302 Appearance or Behaviour? 0.65807167 0.510764942 Unusual or risky circumstances? 0.344064704 0.730928415 Cognition or Insight? 0.121893386 0.903027575 Believed method was dangerous/fatal? 0.024546168 0.980425812 Alcohol or Illicit Drug User? 0.020860174 0.983364721 Depression (low interest, self-esteem)? -0.044587427 0.964452202 ICU/ITU or Resuscitation required? R it ti i d? -0.11292289 0 11292289 0.910132669 0 910132669 Medical Complications or detoxification? -0.202967858 0.839234812 Personality (self-destructive, impulsive)? -0.311688368 0.755394419 Current Suicidal Intent? -0.419258092 0.675189743 Refuses assessment? -0.669399303 0.503519167 Delirium (poor orientation or attention)? -1.300189309 0.194075771 Hopeless or Suicidal Thoughts? -1.658102832 0.097861755 Attempts at concealment or Final acts? -1.82325173 0.068804974 Speech or Thoughts? -1.871696803 0.061774313
  44. 44. Advanced Suicide Intent Scales c
  45. 45. IV: Extras
  46. 46. Mental State Examination a. p j p pp Consider whether the patient is of dejected ap ppearance, agitated, restless or depressed. g p b. Ask specifically whether the patient is depres ssed on waking and whether the mood lifts during the day (i.e.. diurnal variation) c. Does the patient have impaired sleep (difficul in getting off to sleep, frequent or early morning lty waking?) d. Is the patient experiencing feelings of guilt, unworthiness or self-blame? e. Is the patient suffering impaired appetite with weight loss? h f. Ask specifically about suicidal thoughts and intentions? g. Is the patient pessimistic about his or her ability to resume and cope with normal life? h. Is another psychiatric syndrome present? Adapted from Original of Mick Dennis
  47. 47. How to Take a DSH History y a. What were the precipitating events? b. What were the motives for the act? c. What were the circumstances of the act? d. Were any precautions taken against discovery? yp g y e. Were there any preparatory acts, e.g.. procuring mea ans, putting affairs in order, warning statements or suicide note? f. How violent was the method? g. How lethal (potentially) were the drugs or poison use ed? h. Have there been symptoms of depression, such as li istlessness or social withdrawal, preceding the act? i. Is there any sign of the use or abuse of alcohol (whic is a depressant and also a disinhibitor)? ch Adapted from Original of Mick Dennis
  48. 48. Deliberate Self-Harm (DSH) in the elderly • Usually failed serious suicide bids • Depression approx. 90% • 90% self-poisoning • 2/3 physical illness – commonly analgesics & benzodiazepine es • high suicide intent scores • previous psychiatric history 30-55% • previous self-harm 30-40% i lf h 30 40% • high rates of subsequent suicide, especially those with persistent depression Adapted from Original of Mick Dennis

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