Risk factors for repetition and suicide following self-harm in older adults: multicentre cohort study {

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1 The British Joural of Psychiatry (2012) 200, doi: /bjp.bp Risk factors for repetitio ad suicide followig self-harm i older adults: multicetre cohort study { Elizabeth Murphy, Naveet Kapur, Roger Webb, Niti Puradare, Keith Hawto, Hele Berge, Keith Waters ad Jaye Cooper Backgroud Older adults have elevated suicide rates. Self-harm is the most importat risk factor for suicide. There are few populatio-based studies of self-harm i older adults. Aims To calculate self-harm rates, risk factors for repetitio ad rates of suicide followig self-harm i adults aged 60 years ad over. Method We studied a prospective, populatio-based self-harm cohort presetig to six geeral hospitals i three cities i Eglad durig 2000 to Results I total 1177 older adults preseted with self-harm ad 12.8% repeated self-harm withi 12 moths. Idepedet risk factors for repetitio were previous self-harm, previous psychiatric treatmet ad age years. Followig selfharm, 1.5% died by suicide withi 12 moths. The risk of suicide was 67 times that of older adults i the geeral populatio. Me aged 75 years ad above had the highest suicide rates. Coclusios Older adults presetig to hospital with self-harm are a high-risk group for subsequet suicide, particularly older me. Declaratio of iterest Noe. Self-harm is the most importat risk factor for suicide, ad the risk icreases markedly with age. 1 Older adults have high suicide rates i may coutries. 2 Icreases i suicide rates with advacig age were see i approximately half of coutries examied i a recet World Health Orgaizatio (WHO) study. 3 I the UK older adult suicide rates have declied i recet years, therefore rates are curretly highest i youger age groups. 4 However, the rate ratio of self-harm to completed suicide coverges from greater tha 30 i all ages to less tha 10 amog those aged 60 years ad over. 5 It has therefore bee suggested that self-harm i older age more closely resembles suicide, ad ivolves greater suicidal itet ad lethality of method. 6 Despite the elevated risk of suicide i older adults who self-harm, there are few large prospective populatio-based studies of this group. 7 Few studies have examied risk factors for repetitio of self-harm or for suicide, ad these have mostly bee coducted i small ad selective samples. 8,9 Oe previous study did iclude a large sample of older adults ad a 20-year follow-up period, but was limited to oe cetre. 10 Also, i applyig log observatio periods to maximise statistical power, strog temporal effects may be overlooked i pooled aalyses across the whole study period. 11 We coducted a large populatio-based study of patiets presetig with self-harm i three cetres i Eglad. 12 The objectives of the study were to examie older adults presetig to hospital with self-harm with respect to age- ad geder-specific rates of self-harm, risk factors for repetitio of self-harm ad rates of suicide followig self-harm. Method Desig ad settig The Multicetre Moitorig of Self Harm Project is a prospective cohort study of self-harm presetatios to emergecy departmets { See editorial, pp , this issue. at six geeral hospitals i three cetres i Eglad: Oxford (oe hospital), Machester (three hospitals) ad Derby (two hospitals). 12 The city of Machester is a urba area with a populatio of ; Derby uitary area comprises a urba area surrouded by rural districts ad has a populatio of ; ad Oxford city cotais rural areas both withi ad aroud the city ad has a populatio of Accordig to the UK govermet s Idex of Multiple Deprivatio, i which 353 local authority areas i Eglad were give a overall deprivatio score, Machester was raked the 4th most deprived, Derby was raked 69th ad Oxford was raked 156th. 14 Ethical cosideratios Oxford ad Derby both have approval from local Natioal Health Service (NHS) research ethics committees to collect data o selfharm for local moitorig ad multicetre projects. The moitorig of self-harm i Machester is part of a cliical audit system ad has bee ratified as such by local research ethics committees. Thus, formal ethics committee approval was ot required for that cetre. All cetres are fully compliat with the UK Data Protectio Act 1998, ad have support uder sectio 251 of the NHS Act 2006 regardig the use of patiet-idetifiable iformatio. Data collectio We defied older adults as idividuals aged 60 years ad above. This is cosistet with previous UK studies of self-harm amog older adults, 10,15 as well as i other coutries. 16 We used established moitorig methods to idetify cosecutive episodes of self-harm presetig to the study hospitals, as described i full elsewhere. 17,18 Self-harm was defied as itetioal self-poisoig or self-ijury, irrespective of motivatio ad degree of suicidal itet, 19 ad this was applied cosistetly across all three cetres. Demographic data ad details o method of self-harm were 399

2 Murphy et al collected from emergecy departmet records for all episodes. Most participats received a psychosocial assessmet from emergecy departmet staff ad/or metal health specialists. Cliicias recorded sociodemographic data, method of self-harm, precipitatig factors ad other cliical iformatio. The latter icluded self-reported previous self-harm, drug or alcohol misuse ad psychiatric treatmet (icludig atidepressat treatmet by a geeral practitioer as well as psychiatric out-patiet or i-patiet treatmet). For participats who were ot assessed by cliicias (for example, because they refused or took early discharge), basic iformatio was collected by research clerks from medical records. Self-harm repetitio was defied as a secod presetatio with o-fatal self-harm to ay of the hospitals withi each study cetre durig the study period. Idetificatio of repeat self-harm ivolved a comprehesive data likage process at each cetre based o idividual idetifiers. Suicide followig self-harm was defied as deaths by suicide (ICD-10 codes X60 X84) ad udetermied cause (Y10 Y34, excludig Y33.9), hereafter referred to as suicides. 20 Verdicts of udetermied cause are covetioally icluded i research o suicide ad i official suicide statistics, 21 ad the exclusio of ICD-10 code Y33.9 refers to cases where the coroer s verdict was still pedig. A comprehesive matchig process was used to idetify cases of suicide from atioal death registers across the UK through the Medical Research Iformatio Service of the NHS. The matchig process also revealed whether participats had died from causes other tha suicide, or had left atioal health registers (for example, owig to emigratio) at the ed of follow-up (see Appedix). Statistical aalysis Self-harm data were aalysed for a 8-year study period for Oxford ad Derby (1 Jauary 2000 to 31 December 2007). For Machester, data were uavailable for o-assessed episodes prior to September Therefore, Machester self-harm data were aalysed for a period of 5 years ad 4 moths (1 September 2002 to 31 December 2007), whe data were available for both assessed ad o-assessed idividuals. The study period for idetificatio of deaths bega at the start of the self-harm observatio period at each cetre, util 31 December 2008, thus allowig a additioal 12 moths of mortality follow-up. The aalyses were coducted usig SPSS versio 16.0 for Widows ad Itercooled Stata versio 10. Aalysis was based o a idividual s first presetatio of self-harm at the age of 60 years or over. First, self-harm rates per perso-years were calculated for idividuals aged at least 60 years ad with a postcode withi the city catchmet area of each of the hospitals i Machester, Derby ad Oxford. Populatio estimates were obtaied for each city for the idividual years 2000 to 2007 from the Office for Natioal Statistics. 13 We chose a upper age bad of 75 years or over as used i previous studies of suicidal behaviour. 4,22 Approximate perso-years at risk were geerated by multiplyig geder- ad age-specific populatio estimates for each catchmet area by the applicable study period for that cetre. Mortality rate ratios categorised by geder ad age group were calculated usig Poisso regressio models, with o sigificat evidece of overdispersio. Exact 95% cofidece itervals were calculated for the rate ratios. Secod, we examied repetitio of self-harm as a outcome. The risk of repetitio withi 12 moths was calculated (excludig idividuals with fewer tha 365 days of follow-up durig the study period). Potetial risk factors for repetitio were ivestigated usig hazard ratios (HRs) geerated by Cox s proportioal hazards models. Patiets were cesored at the default study exit date, or earlier i case of death or emigratio. Uivariate associatios were examied iitially, ad the domai-specific multivariate models were geerated usig backwards elimiatio procedures (separate models for domais of sociodemographic factors, circumstaces of self-harm, cliical factors ad precipitats). Explaatory variables were retaied i these models if P was less tha 0.2. The idepedet predictors from all the domai-specific models were the fitted i a fial multivariate model. Explaatory variables were retaied i the fial model if P was less tha Third, we examied suicide as a outcome followig selfharm. Suicide rates followig self-harm per perso-years at risk were calculated. Poisso regressio was used to examie suicide rates categorised by geder ad age group (with o sigificat evidece of overdispersio) ad exact 95% cofidece itervals were calculated for the mortality rate ratios. We calculated age- ad geder-stadardised mortality ratios to compare the umber of suicides i the self-harm cohort with the expected umber of suicides i the geeral populatio. Idirect stadardisatio was used to adjust for age (stratified i 10-year bads) ad geder differeces betwee the study populatio ad that of Eglad ad Wales from 2000 to A stadardised mortality ratio (SMR) for youger adults aged years was geerated for compariso with the older adult SMR. We also calculated the risk of suicide withi 12 moths of self-harm amog older adults aged 60 years ad over (excludig idividuals with fewer tha 365 days of follow-up owig to death from other causes or leavig atioal health registers). Fially, potetial risk factors for suicide were examied usig Cox s proportioal hazard models. Results A total of adults aged at least 20 years preseted with selfharm over the study period. The study cohort cosisted of 1177 idividuals who preseted with self-harm at age 60 years or over (Derby = 421, Machester = 404, Oxford = 352). The maximum age was 97 years (media 68 years, iterquartile rage 63 77) ad 56% of the cohort were female. The most commo method of harm used by older adults was self-poisoig aloe (88%), followed by self-ijury icludig cuttig (9%) ad violet methods such as hagig or asphyxiatio (3%). Wome were more likely to self-poiso (93% v. 81%, P50.001) ad me were more likely to self-ijure (13% v. 6%, P50.001) ad use violet methods (7% v. 1%, P50.001). Amog me, those over 75 years old were most likely to use violet methods (10% v. 5% aged years, P50.01). Followig self-harm, 81% received a psychosocial assessmet ad 75% were admitted to a medical ward. Aftercare referrals were made for 90%, icludig out-patiet care (36%), psychiatric i-patiet care (19%) ad geeral practitioer care aloe (36%). Rates of self-harm The rate of self-harm for idividuals aged 60 years ad over was 65 per i both me ad wome (Derby 62, Machester 69 ad Oxford 64 per ). This compares with a rate of 380 per i youger adults aged years. Table 1 shows rate ratios for self-harm i older adults by age group, for all cetres combied. Amog wome, rates were sigificatly lower for those aged 75 years ad over v. those aged years. Rates of self-harm amog older me did ot differ sigificatly by age group. We tested for differeces betwee cetres i the rate ratios usig a Wald chi-squared test for heterogeeity. The rate ratios did ot vary sigificatly by cetre for wome (w 2 = 0.81, P = 0.37). 400

3 Self-harm ad suicide i older adults Table 1 Self-harm rates ad rate ratios ( = 604) a Self-harm Persoyears Rate/ RR (95% CI) Me years years ( ) Wome years years ( ) RR, rate ratio. a. Sample size = 604 as populatio-based rates are calculated oly for idividuals with a postcode of residece withi the city catchmet area of each hospital i Derby, Machester ad Oxford. Amog me the heterogeeity i the rate ratios was ot statistically sigificat (w 2 = 3.11, P = 0.08). Repetitio of self-harm A total of 196 idividuals (16.7%) repeated self-harm before the ed of the study period. The icidece of repeat self-harm withi 12 moths was 12.8% (95% CI ) (117 of 917 idividuals, excludig those with fewer tha 365 days of follow-up). Predictors of repetitio of self-harm are show i Tables 2 ad 3. Sigificat sociodemographic predictors i the uivariate model icluded: age years; ot beig married or partered; ad ot livig with parter, relative or fried (Table 2). Cliical predictors icluded: curret psychiatric treatmet; previous psychiatric treatmet; previous self-harm; ad alcohol or drug problems as a precipitatig factor for self-harm (Table 3). I the multivariate model, idepedet predictors of repetitio were age years v. 75 years ad over (HR = 1.8, 95% CI ), previous psychiatric treatmet (HR = 1.8, 95% CI ) ad previous self-harm (HR = 1.9, 95% CI ). We repeated the aalysis usig a cut-off of 65 years ad the results were similar: previous self-harm (HR = 3.0, 95% CI ) ad age less tha 75 years (HR = 1.7, 95% CI ) remaied as idepedet risk factors. Suicide followig self-harm I total, 24 of the 1177 idividuals (2.0%) subsequetly died by suicide, of whom 14 were me ad 10 were wome. The majority of suicides occurred soo after self-harm; 50% died by suicide withi 6 moths, 67% withi 12 moths ad 83% withi 18 moths. The icidece of suicide withi 1 year of the self-harm episode was 1.5% (95% CI ) (16 out of 1064, allowig all idividuals 365 days of follow-up). Cosiderig the fial methods used by the 24 idividuals who died by suicide, the majority ivolved violet meas (58%, icludig hagig, drowig, jumpig ad firearms) followed by self-poisoig (25%) ad self-ijury (17%). Violet methods of suicide were used more ofte by me (79% v. 30%, P = 0.04, Fisher s exact test). Prior to suicide, the most commo method of self-harm used i the idex episode was self-poisoig (75%; = 18), followig which 50% switched to a violet method i the fial act. We also examied uivariate predictors of suicide followig self-harm. The oly sigificat risk factor was the use of a violet Table 2 Risk factors for self-harm repetitio: sociodemographic characteristics ad circumstaces of self-harm ( = 1177) Repeated self-harm (%) Hazard ratio (uivariate) HR (95% CI) Sociodemographic characteristics a Age, years (8) (21) 2.4 ( )* Geder Female (16) 1.0 Male (17) 1.1 ( ) Ethicity White (18) 1.0 Other ethic group 16 2 (13) 0.7 ( ) Marital status Married, partered (17) 1.0 Sigle, divorced or widowed (22) 1.5 ( )* Livig arragemets Spouse/parter, relative or fried (16) 1.0 Aloe (22) 1.5 ( )* Other (hostel, istitutio, other) (30) 2.3 ( )* Circumstaces of self-harm Method of self-harm Self-poisoig oly (17) 1.0 Self-ijury (cut, stab, other ijury) (12) 0.7 ( ) Violet method (e.g. hagig) 39 5 (13) 0.7 ( ) Alcohol use at time of harm No (15) 1.0 Yes (21) 1.3 ( ) *P a. The level of data completeess for each of the variables raged from 70% to 100%, with the exceptio of marital status (52%) ad livig arragemets (48%). Table 3 Risk factors for self-harm repetitio: cliical characteristics ad precipitats ( = 1177) Repeated self-harm (%) Hazard ratio (uivariate) HR (95% CI) Cliical characteristics a Curret psychiatric treatmet No (15) 1.0 Yes (20) 1.4 ( )* Previous psychiatric treatmet No (10) 1.0 Yes (24) 2.3 ( )* Previous self-harm No (11) 1.0 Yes (27) 2.5 ( )* Precipitats a Physical health problem No (19) 1.0 Yes (15) 0.9 ( ) Relatioship problem No (17) 1.0 Yes (17) 0.9 ( ) Metal health problem No (17) 1.0 Yes (18) 1.1 ( ) Bereavemet No (18) 1.0 Yes (16) 0.9 ( ) Alcohol problem No (16) 1.0 Yes (28) 1.9 ( )* Drug problem No (17) 1.0 Yes 4 3 (75) 4.8 ( )* *P a. The level of data completeess for each of the variables raged from 70% to 100%. 401

4 Murphy et al method i the idex episode (HR = 4.3, 95% CI ). This was based o 3 of 34 idividuals (9%) who self-harmed with a violet method. All three were male, ad they subsequetly also used a violet method i the fial act. Stadardised mortality ratios The umber of suicides i the self-harm cohort was 67 times higher (95% CI 45 99) tha the expected umber of deaths based o age- ad geder-equivalet suicide rates i the geeral populatio (Table 4). This compares with a SMR of 24 (95% CI 21 27) amog youger adults aged years. The SMR amog older adults was 2.8 times higher (95% CI ) tha i youger adults. Suicide rates categorised by geder ad age The rate of suicide withi the self-harm cohort was higher i me tha i wome (Table 4), but the differece did ot reach statistical sigificace (rate ratio RR = 2.0, 95% CI ). Whe the cohort was stratified by age group, there was o differece betwee female v. male rates of suicide for those aged years (RR = 1.1, 95% CI ). For wome, 9 of 10 suicides were amog those aged years, a rate of 520 per A reliable rate could ot be calculated for wome aged 75 years or over. However, of the 14 male suicides, 8 were amog those aged 75 years ad above, a rate of 1624 per This was sigificatly higher tha the suicide rate of 477 per i me aged years (RR = 3.4, 95% CI ). Discussio We foud that the risk of suicide was 67 times higher amog older adults presetig to hospital with self-harm relative to the geeral populatio. The relative risk i older adults was almost three times greater tha the relative risk amog youger patiets presetig with self-harm. Me aged 75 years ad over were at highest risk of suicide followig self-harm. Use of a violet method of harm may also be a risk factor for subsequet suicide. Idepedet risk factors for o-fatal repetitio of self-harm were age years, previous self-harm ad previous psychiatric treatmet. Stregths ad limitatios The mai stregth of this study is its populatio-based prospective cohort desig, based o large cohorts from three cetres, usig a recet follow-up period reflective of cotemporary services. We used a comprehesive tracig process to idetify all suicides i the UK. We were able to cesor cases of people who died from causes other tha suicide or who left the coutry, although we were uable to idetify suicides amog idividuals Table 4 Suicide rates i me ad wome aged 60 years ad over followig self-harm Suicide Persoyears a Rate/ SMR (95% CI) All idividuals (45 99) Me (36 102) Wome (42 146) SMR, stadardised mortality ratio. a. Based o the total sum of years betwee each perso s idex self-harm episode util date of death, or ed date of the study period if livig, or date of leavig atioal health registers (e.g. owig to emigratio). who emigrated. We defied older adults as idividuals aged 60 years ad over. There is o stadard criterio for defiig older age, although the ages of 60 or 65 years are ofte used. 23 We chose 60 years as cosistet with previous studies. 10,15,16 I the UK etry ito older adult psychiatric services begis at 65 years. However, most self-harm presetatios occur outside ormal office hours, 17 ad these people are likely to be see by o-call juior doctors i psychiatry or liaiso metal health urses. Whe the aalysis was repeated usig a cut-off of 65 years, the results for risk factors for repetitio were similar to the primary aalysis usig the cut-off of 60 years. Despite the large size of our cohort, the relatively small umber of suicides affected the power of the study. We were therefore uable to comprehesively examie risk factors for completed suicide. However, this limitatio was also observed i the oly previous cohort study to examie suicide followig self-harm i older adults. 10 There were some missig data o cliical predictors of repetitio for idividuals who did ot receive a psychosocial assessmet, which may be a source of bias. However, o-assessed idividuals did ot differ i terms of age ad geder. Fially, our data o o-fatal repeated self-harm were based o hospital presetatios. We did ot collect data o repeat self-harm i the commuity. We were iterested i hospital presetatios because of their impact o resource use ad because repeated hospital presetatio for self-harm is associated with suicide. 11 Fidigs i relatio to previous studies The overall self-harm rate of 65 per is cosistet with a previous study coducted i several Europea coutries. 2 Further breakdow by age showed a decrease i self-harm amog the oldest wome. Thus, me aged 75 years ad over had higher rates tha their female couterparts. This mirrors previous fidigs that the high female to male ratio of self-harm see i youger adulthood coverges ad reverses i older age. 24 This may reflect differet motivatios for self-harm; for example, a declie i the use of self-harm as a copig strategy, 24 ad a closer resemblace betwee self-harm ad suicide amog older adults. 6 Although the overall icidece of self-harm i older adults was lower tha i youger groups, the risk of suicide followig selfharm was markedly raised. The SMR i this study was somewhat higher tha previously reported. 10 However, there were methodological differeces, icludig a 20-year study period i a sigle cetre, i which cohort effects may have bee operatig. I additio, we observed that rates of suicide followig self-harm were strikigly raised amog me aged 75 years ad over, which has ot bee previously reported. This may reflect icreasig suicidal itet with icreasig old age, 25,26 as well as greater use of violet methods of self-harm amog the oldest me, as observed i our study. Furthermore, medical complicatios are commo followig self-harm i older adults, 27 ad the oldest idividuals may be eve less likely to survive the ijuries resultig from a repeat attempt. Coversely, amog wome most suicides occurred i the year age group. This is cosistet with previous fidigs that wome i a youg old group aged years used self-harm methods of greater lethality tha those over 70 years old, which is the reverse of the tred see i me. 28 The rate of repetitio of self-harm was somewhat lower tha that observed i adults of all ages. 29,30 This has bee reported i previous studies of older adults. 8,10,25 Factors associated with repetitio, such as persoality disorder ad drug ad alcohol misuse, are less commo amog older adults. 6,8 Furthermore, repetitio i older adults may be carried out for differet motivatios, i.e. to ed life rather tha for other reasos. 6 We also 402

5 Self-harm ad suicide i older adults foud that idividuals aged 75 years ad over were at lower risk of repetitio compared with those aged years. This may be due to the oldest idividuals havig higher mortality rates due to suicide or other causes, 10 rather tha re-presetig with o-fatal self-harm. Although there are few prospective studies of self-harm repetitio i older adults, the risk factors were cosistet with those foud i adults of all ages, particularly the importace of previous self-harm. 29 Cotact with psychiatric services has also bee associated with repetitio amog older adults, 8 ad such factors are useful for iformig risk assessmet. I the uivariate aalysis we also idetified the social risk factors of livig aloe ad ot havig a parter, ad cliical risk factors of alcohol ad substace misuse. These have bee highlighted as risk factors for suicidal behaviour i case cotrol studies. 31 Although the latter factors were ot idepedet predictors for repetitio i our study, they are potetially modifiable; for example, itervetios that improve social cotact, support ad itegratio i the commuity, 32 or that treat alcohol misuse, might be of beefit. Fially, with respect to predictors of suicide, we idetified violet method of self-harm as beig a possible risk factor. However, this fidig should be iterpreted cautiously, as it was based o oly three cases of suicide. Previous studies have ot idetified violet method as a risk factor i older adults, most probably owig to uderpowered sample sizes. However, violet method has bee idetified as a predictor of suicide i a recet atioal Swedish cohort study, which had greater power to examie this effect. 33 Appedix Idetificatio of self-harm repetitio Repeat presetatios of self-harm to emergecy departmets at the six geeral hospitals withi the study cetres were idetified by likig idividuals o ame ad date of birth. For cases where there was ay doubt, additioal idetifiers were used (hospital umber ad postcode of residece). The hospitals i each study cetre covered a geographically defied city catchmet area, ad there was o other emergecy departmet withi the city where adults could have preseted. Outside the cities of Oxford ad Derby there was o other hospital withi the immediate viciity. For Machester, we did ot have a direct estimate of how may self-harm episodes may have preseted to hospitals i the surroudig districts. However, a recet audit of all hospitals withi a 24 km radius suggested that less that 5% of all attedaces by Machester residets occurred at hospitals outside the study area. Idetificatio of suicide cases Details of all idividuals ame, geder, date of birth, postcode of residece ad Natioal Health Service (NHS) umber were submitted to the Medical Research Iformatio Service of the NHS for matchig with atioal death registers. Cases were matched automatically i the first istace. For cases where a sigle correspodig match was ot retured, maual searchig was carried out to idetify the matchig patiet etry. Matchig revealed whether idividuals were alive or dead, icludig the date ad cause of death if applicable, or whether a idividual had left the register for other reasos (such as emigratio). A successful match was retured for 98% of adults aged 20 years ad over, ad for all adults aged 60 years ad over. Implicatios of the study Older adults presetig to hospital with self-harm are a high-risk group for subsequet suicide, ad emergecy departmets may therefore be a key settig i terms of their potetial for suicide prevetio. All older adults presetig with self-harm should be cosidered as beig at elevated risk of suicide uless detailed psychosocial assessmet idicates otherwise. I particular, me over 75 years old eed to be carefully moitored ad assessed, as the risk of suicide is particularly icreased i this group. These fidigs emphasise the requiremet for all older adults to receive a detailed psychosocial assessmet by a metal health practitioer experieced i the assessmet of older people, i accordace with atioal guidace. 34,35 Elizabeth Murphy, BSc, Naveet Kapur, FRCPsych, Roger Webb, PhD, Niti Puradare, FRCPsych, Cetre for Metal Health ad Risk, Uiversity of Machester; Keith Hawto, FRCPsych, Hele Berge, PhD, Cetre for Suicide Research, Uiversity of Oxford; Keith Waters, RMN, Metal Health Liaiso Team, Rehabilitatio Cetre, Royal Derby Hospital, Derbyshire; Jaye Cooper, PhD, Cetre for Metal Health ad Risk, Uiversity of Machester, UK Correspodece: Ms Elizabeth Murphy, Cetre for Metal Health ad Risk, Uiversity of Machester, Jea McFarlae Buildig, Oxford Road, Machester M13 9PL, UK. elizabeth.murphy@machester.ac.uk First received 12 Mar 2011, fial revisio 22 Jul 2011, accepted 15 Sep 2011 Fudig We ackowledge fiacial support from the UK Departmet of Health uder the Natioal Health Service Research ad Developmet programme (DH/DSH2008). K.H. is a Natioal Istitute for Health Research seior ivestigator. Ackowledgemets The authors thak their respective research teams, ad cliical ad admiistrative staff i Oxford, Machester ad Derby, for their assistace with self-harm data collectio. Refereces 1 Hawto K, Zahl D, Weatherall R. Suicide followig deliberate self-harm: log-term follow-up of patiets who preseted to a geeral hospital. Br J Psychiatry 2003; 182: De Leo D, Padoai W, Scocco P, Lie D, Bille-Brahe U, Aresma E, et al. Attempted ad completed suicide i older subjects: results from the WHO/ EURO Multicetre study of suicidal behaviour. It J Geriatr Psychiatry 2001; 16: Shah A. The relatioship betwee suicide rates ad age: a aalysis of multiatioal data from the World Health Orgaizatio. It Psychogeriatr 2007; 19: Shah A, Bhat R, MacKezie S, Koe C. Elderly suicide rates: cross-atioal comparisos of treds over a 10-year period. It Psychogeriatr 2008; 20: Hawto K, Harriss L. 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