10.1192/bjp.bp.105.

018085 Access the most recent version at DOI:

2006, 189:416-421. BJP
AMY JOHNSTON, JAYNE COOPER, ROGER WEBB and NAVNEET KAPUR
Individual- and area-level predictors of self-harm repetition
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Background Background No ecological studies No ecological studies
have examinedtherelationship between have examinedtherelationship between
area characteristics, individual area characteristics, individual
characteristics and self-harmrepetition. characteristics and self-harmrepetition.
Aims Aims Toinvestigatethe association Toinvestigatethe association
between area-level factors andincidence between area-level factors andincidence
andrepetitionof self-harm, andtoidentify andrepetitionof self-harm, andtoidentify
which area-level factors areindepen- which area-level factors areindepen-
dentlyassociatedwithrepetition after dentlyassociatedwithrepetition after
adjustment forindividual factors. adjustment forindividual factors.
Method Method Prospective cohort study Prospective cohort study
using the Manchester Self-Harm using the Manchester Self-Harm
database. Adults whowereresident in database. Adults whowereresident in
Manchester andpresentedto an Manchester andpresentedto an
emergencydepartment following self- emergencydepartment following self-
harmbetween1997 and 2002 were harmbetween1997 and 2002 were
included ( included (n n4743).The main outcome 4743).The main outcome
measure was repeat self-harmwithin 6 measure was repeat self-harmwithin 6
months of theindexepisode. months of theindexepisode.
Results Results Fourindividual factors Fourindividual factors
(previous self-harm, previous psychiatric (previous self-harm, previous psychiatric
treatment, employment status, marital treatment, employment status, marital
status) and one area-based factor status) and one area-based factor
(proportion of individuals whowere of (proportion of individuals whowere of
White ethnicity) wereindependently White ethnicity) wereindependently
associatedwithrepetition. associatedwithrepetition.
Conclusions Conclusions Repetition of self-harm Repetition of self-harm
maybe more stronglyrelatedtoindividual maybe more stronglyrelatedtoindividual
factors thanto area characteristics.We factors thanto area characteristics.We
needto better understandthe processes needto better understandthe processes
underlyingecological associations with underlyingecological associations with
suicidal behaviour before embarking on suicidal behaviour before embarking on
area-basedinterventions. area-basedinterventions.
Decl Declaration of interest aration of interest None. None.
Fundingdetailedin Acknowledgements. Fundingdetailedin Acknowledgements.
Self-harm is a major public health problem Self-harm is a major public health problem
(Schmidtke (Schmidtke et al et al, 1996; Kapur , 1996; Kapur et al et al, 1998; , 1998;
National Collaborating Centre for Mental National Collaborating Centre for Mental
Health, 2004; Kessler Health, 2004; Kessler et al et al, 2005) and an , 2005) and an
important risk factor for suicide (Depart- important risk factor for suicide (Depart-
ment of Health, 2002; Owens ment of Health, 2002; Owens et al et al, ,
2002). Repetition of self-harm is common. 2002). Repetition of self-harm is common.
Overall, 15% of individuals repeat within Overall, 15% of individuals repeat within
a year of presentation (Owens a year of presentation (Owens et al et al, ,
2002). Ecological studies have reported 2002). Ecological studies have reported
that socio-economic deprivation is strongly that socio-economic deprivation is strongly
associated with self-harming behaviour associated with self-harming behaviour
(Congdon, 1996; Gunnell (Congdon, 1996; Gunnell et al et al, 2000; , 2000;
Hawton Hawton et al et al, 2001). However, research , 2001). However, research
to date has considered rates of self-harm to date has considered rates of self-harm
rather than rates of repetition as the main rather than rates of repetition as the main
outcome measure. A limited number of outcome measure. A limited number of
measures of area characteristics have been measures of area characteristics have been
used, and these have tended to be census used, and these have tended to be census
based. Studies have not explored whether based. Studies have not explored whether
area-level factors are associated with self- area-level factors are associated with self-
harm independently of individual harm independently of individual
characteristics. This study had three main characteristics. This study had three main
objectives. First, to investigate the associa- objectives. First, to investigate the associa-
tion between a wide range of area-level tion between a wide range of area-level
factors and incidence rates of self-harm. factors and incidence rates of self-harm.
Second, to investigate the association Second, to investigate the association
between area-level factors and repetition between area-level factors and repetition
of self-harm. Third, to identify which of self-harm. Third, to identify which
area-level factors are independently asso- area-level factors are independently asso-
ciated with repetition after adjustment for ciated with repetition after adjustment for
individual factors. individual factors.
METHOD METHOD
Participants and setting Participants and setting
The Manchester Self-Harm (MASH) moni- The Manchester Self-Harm (MASH) moni-
toring system identifies all presentations toring system identifies all presentations
with self-harm to the three hospitals with self-harm to the three hospitals
providing emergency care in the city of providing emergency care in the city of
Manchester (Kelly Manchester (Kelly et al et al, 2004). The system , 2004). The system
monitors self-harm through hospital monitors self-harm through hospital
computerised records, and collects a range computerised records, and collects a range
of socio-demographic and clinical infor- of socio-demographic and clinical infor-
mation for patients through standardised mation for patients through standardised
assessment forms which are completed by assessment forms which are completed by
emergency department and psychiatric emergency department and psychiatric
staff. During the study period, data were staff. During the study period, data were
collected for 77% of eligible emergency collected for 77% of eligible emergency
department presentations. Limited infor- department presentations. Limited infor-
mation is collected on those for whom mation is collected on those for whom
forms are not completed but they are simi- forms are not completed but they are simi-
lar in terms of age (mean age 31.6 lar in terms of age (mean age 31.6 v. v. 32.4 32.4
years) to those for whom we have forms. years) to those for whom we have forms.
Those without forms are slightly more Those without forms are slightly more
likely to be male (45% likely to be male (45% v v. 39%) and to have . 39%) and to have
injured themselves (19% injured themselves (19% v v. 13%) than . 13%) than
those with forms. Data for individuals aged those with forms. Data for individuals aged
16 years and over, resident in the 16 years and over, resident in the
Metropolitan Borough of Manchester, Metropolitan Borough of Manchester,
were extracted from the MASH database were extracted from the MASH database
for the period 1 September 1997 to 29 for the period 1 September 1997 to 29
February 2002 ( February 2002 (n n4743). All participants 4743). All participants
were followed up for at least 6 months. were followed up for at least 6 months.
The electoral ward of residence was es- The electoral ward of residence was es-
tablished by linking individuals postcodes tablished by linking individuals postcodes
to ward codes for boundaries using a geo- to ward codes for boundaries using a geo-
graphy conversion table provided by the graphy conversion table provided by the
Updated UK Area Master-files project Updated UK Area Master-files project
(Simpson & Yu, 1999). There were no (Simpson & Yu, 1999). There were no
ward boundary changes during the period ward boundary changes during the period
under study (Office for National Statistics, under study (Office for National Statistics,
2002). Patients with no fixed abode 2002). Patients with no fixed abode
( (n n128, 0.03%) and those for whom ward 128, 0.03%) and those for whom ward
of residence could not be established of residence could not be established
( (n n84, 0.02%) were excluded from 84, 0.02%) were excluded from
analysis. analysis.
Outcome measures Outcome measures
For each electoral ward in the Metropolitan For each electoral ward in the Metropolitan
Borough ( Borough (n n33), the self-harm incidence 33), the self-harm incidence
rate (per 100000 persons per year) was rate (per 100 000 persons per year) was
estimated using the resident population estimated using the resident population
estimate from the 2001 census as a estimate from the 2001 census as a
denominator. denominator.
Individuals who repeated self-harm Individuals who repeated self-harm
within 6 months of their first episode dur- within 6 months of their first episode dur-
ing the study period (index episode) were ing the study period (index episode) were
identified by linking episodes to individuals identified by linking episodes to individuals
on the MASH database. The cut-off point on the MASH database. The cut-off point
chosen was 6 months because the majority chosen was 6 months because the majority
(over 75%) of those who repeat within a (over 75%) of those who repeat within a
year do so within this time period (Gilbody year do so within this time period (Gilbody
et al et al, 1997). , 1997).
For each electoral ward in Manchester, For each electoral ward in Manchester,
the 6-month repetition rate was estimated the 6-month repetition rate was estimated
using the number of patients (per ward of using the number of patients (per ward of
residence) with an index self-harm episode residence) with an index self-harm episode
as the denominator. as the denominator.
Individual and ward characteristics Individual and ward characteristics
Individual-level socio-demographic and Individual-level socio-demographic and
clinical factors for analyses were obtained clinical factors for analyses were obtained
from the MASH database, which contains from the MASH database, which contains
a large number of variables. The individual a large number of variables. The individual
factors considered in this study were factors considered in this study were
416 416
BRI TI S H J OURNAL OF P SYCHI ATRY BRI TI S H J OURNAL OF P SYCHI ATRY ( 2 0 0 6 ) , 1 8 9, 4 1 6 ^ 4 21. doi : 1 0 . 11 9 2 / bj p . bp . 1 0 5 . 0 1 8 0 8 5 ( 2 0 0 6 ) , 1 8 9, 4 1 6 ^ 4 21. d oi : 1 0 . 11 9 2 / bj p . b p . 1 0 5 . 0 1 8 0 8 5
Individual- and area-level predictors Individual- and area-level predictors
of self-harm repetition of self-harm repetition
AMY JOHNSTON, JAYNE COOPER, ROGER WEBB and NAVNEET KAPUR AMY JOHNSTON, JAYNE COOPER, ROGER WEBB and NAVNEET KAPUR
PREDI CTORS OF S ELF - HARM REPE TI TION PREDI CTORS OF S ELF - HARM REPETI TION
specified specified a priori a priori on the basis of on the basis of
their clinical importance and their asso- their clinical importance and their asso-
ciation with repeat self-harm in previous ciation with repeat self-harm in previous
studies (NHS Centre for Reviews studies (NHS Centre for Reviews
and Dissemination, 1998; Sakinofsky, and Dissemination, 1998; Sakinofsky,
2000). 2000).
Ward-level socio-demographic vari- Ward-level socio-demographic vari-
ables were selected from various sources ables were selected from various sources
to provide indicators for a wide range of to provide indicators for a wide range of
area characteristics, including those found area characteristics, including those found
to be associated with area rates of self-harm to be associated with area rates of self-harm
in the general population. Measures for in the general population. Measures for
ward levels of unemployment, economic ward levels of unemployment, economic
inactivity due to permanent sickness or dis- inactivity due to permanent sickness or dis-
ability, population turnover, single-person ability, population turnover, single-person
households, White ethnicity and concen- households, White ethnicity and concen-
trated advantage (the proportion of house- trated advantage (the proportion of house-
holds where the head of the household is holds where the head of the household is
in a professional, managerial or technical in a professional, managerial or technical
job) were derived from Census 2001 tables job) were derived from Census 2001 tables
provided by the Office for National Statis- provided by the Office for National Statis-
tics on DVD in Supertable format. The tics on DVD in Supertable format. The
Townsend Index is a widely used composite Townsend Index is a widely used composite
deprivation measure derived using four deprivation measure derived using four
census variables: the proportion of non- census variables: the proportion of non-
owner-occupied households; the proportion owner-occupied households; the proportion
of households without access to a car; the of households without access to a car; the
proportion of overcrowded households; proportion of overcrowded households;
and the proportion of individuals who are and the proportion of individuals who are
unemployed (Townsend unemployed (Townsend et al et al, 1986). The , 1986). The
measure for social fragmentation is another measure for social fragmentation is another
composite measure based on four census composite measure based on four census
variables: population turnover; the propor- variables: population turnover; the propor-
tion of single-person households; the tion of single-person households; the
proportion of unmarried adults; and proportion of unmarried adults; and
the proportion of households living in the proportion of households living in
private rented accommodation (Congdon, private rented accommodation (Congdon,
1996). 1996).
Several indicators of deprivation were Several indicators of deprivation were
included to enable comparison with the included to enable comparison with the
Townsend Index, which has previously Townsend Index, which has previously
been found to be independently associated been found to be independently associated
with ward rates of self-harm (Congdon, with ward rates of self-harm (Congdon,
1996; Hawton 1996; Hawton et al et al, 2001). These included , 2001). These included
the Index of Multiple Deprivation (IMD) the Index of Multiple Deprivation (IMD)
2000 (Office for National Statistics, 2000 (Office for National Statistics,
2003), the separate IMD 2000 domains 2003), the separate IMD 2000 domains
and concentrated advantage. The IMD and concentrated advantage. The IMD
2000 is based on both census and adminis- 2000 is based on both census and adminis-
trative data sources, and provides an trative data sources, and provides an
overall measure and six separate domains overall measure and six separate domains
(income, employment, health, education, (income, employment, health, education,
housing and access to services) which housing and access to services) which
reflect different aspects of deprivation. A reflect different aspects of deprivation. A
seventh domain is also available (child seventh domain is also available (child
poverty), but this does not contribute to poverty), but this does not contribute to
the overall IMD score. The IMD was the overall IMD score. The IMD was
commissioned by the Department of commissioned by the Department of
Transport, Local Government and the Transport, Local Government and the
Regions, and was obtained by download Regions, and was obtained by download
from the neighbourhood statistics website from the neighbourhood statistics website
(Office for National Statistics, 2003). (Office for National Statistics, 2003).
Data for the proportion of school Data for the proportion of school
leavers entering continuing education were leavers entering continuing education were
collated by Career Partnership and were collated by Career Partnership and were
downloaded from the Community Health downloaded from the Community Health
Information Profile (CHIP) for Manchester Information Profile (CHIP) for Manchester
website (Manchester Geomatics Limited, website (Manchester Geomatics Limited,
2003). The measure of population density 2003). The measure of population density
was provided by Manchester City Council. was provided by Manchester City Council.
All these measures were complete for the 33 All these measures were complete for the 33
wards under study. wards under study.
Statistical analyses Statistical analyses
Analyses were conducted using Stata Analyses were conducted using Stata
software, release 8.0. The degree of software, release 8.0. The degree of
association between area-level explanatory association between area-level explanatory
variables and ward-level self-harm inci- variables and ward-level self-harm inci-
dence rates was first assessed using the dence rates was first assessed using the
non-parametric Spearman rank correlation non-parametric Spearman rank correlation
coefficient (Bland, 2000). Logistic regres- coefficient (Bland, 2000). Logistic regres-
sion models were then fitted to identify sion models were then fitted to identify
the predictors of self-harm repetition within the predictors of self-harm repetition within
6 months (the individual-level outcome). 6 months (the individual-level outcome).
Initially, univariate models were fitted. A Initially, univariate models were fitted. A
multivariate individual-level model was multivariate individual-level model was
then created using backwards elimination then created using backwards elimination
procedures to enable mutual adjustment procedures to enable mutual adjustment
for individual characteristics. The degree for individual characteristics. The degree
of association between the area-level expla- of association between the area-level expla-
natory variables and self-harm repetition natory variables and self-harm repetition
rates was then assessed using the non- rates was then assessed using the non-
parametric Spearman rank correlation parametric Spearman rank correlation
coefficient. Finally, the area-level explana- coefficient. Finally, the area-level explana-
tory variables that were statistically signifi- tory variables that were statistically signifi-
cant in the Spearman rank correlation cant in the Spearman rank correlation
analyses were iteratively added to the analyses were iteratively added to the
multivariate individual-level model in a multivariate individual-level model in a
forwards-stepwise fashion. As the final forwards-stepwise fashion. As the final
model was multi-level in nature, with vari- model was multi-level in nature, with vari-
ables at both individual and area level, a ables at both individual and area level, a
survey variance estimator that corrected survey variance estimator that corrected
for potential area-level clustering effects for potential area-level clustering effects
was involved. The adjusted population was involved. The adjusted population
attributable fraction (PAF) was used to attributable fraction (PAF) was used to
calculate the proportion of repetitions that calculate the proportion of repetitions that
were attributable to the risk factors in the were attributable to the risk factors in the
multivariate model (assuming a causal multivariate model (assuming a causal
relationship between risk factors and out- relationship between risk factors and out-
come). The PAF takes into account both come). The PAF takes into account both
the prevalence of a risk factor and its the prevalence of a risk factor and its
relative risk (Benichou, 2001). relative risk (Benichou, 2001).
RESULTS RESULTS
Study population Study population
Overall, 4743 individuals aged 16 years Overall, 4743 individuals aged 16 years
and over presented to participating emer- and over presented to participating emer-
gency departments during the study period. gency departments during the study period.
Of these, 516 (10.9%) re-attended with an Of these, 516 (10.9%) re-attended with an
episode of self-harm within 6 months of episode of self-harm within 6 months of
their initial presentation. their initial presentation.
Incidence of self-harm Incidence of self-harm
There was considerable variation between There was considerable variation between
the wards in the rates of self-harm the wards in the rates of self-harm
(Table 1). The associations between the (Table 1). The associations between the
area-level explanatory variables and the area-level explanatory variables and the
ward-level self-harm incidence rates (per ward-level self-harm incidence rates (per
100000 persons per year) are presented in 100 000 persons per year) are presented in
Table 2. The Spearman rank correlation Table 2. The Spearman rank correlation
analyses indicated strong associations for analyses indicated strong associations for
most of the explanatory variables, many most of the explanatory variables, many
of which were measures of material or of which were measures of material or
social deprivation. social deprivation.
Individual-level predictors Individual-level predictors
of self-harm repetition of self-harm repetition
A number of individual-level variables were A number of individual-level variables were
significantly associated with repetition. significantly associated with repetition.
These included both socio-demographic These included both socio-demographic
variables (for example, age, employment, variables (for example, age, employment,
marital status, living circumstances and marital status, living circumstances and
White ethnicity) and clinical variables (for White ethnicity) and clinical variables (for
example, previous self-harm, psychiatric example, previous self-harm, psychiatric
treatment, alcohol misuse and hopelessness treatment, alcohol misuse and hopelessness
at the index attempt). at the index attempt).
417 417
Table1 Table1 Summary statistics for counts and rates of self-harm and repetition of self-harm for 33 Manchester Summary statistics for counts and rates of self-harm and repetition of self-harm for 33 Manchester
wards wards
Self-harm Self-harm Minimum Minimum Maximum Maximum Mean Mean s.d. s.d.
Total Total
Ward counts Ward counts 81 81 254 254 157.9 157.9 41.2 41.2
Ward rates Ward rates
1 1
129.4 129.4 674.1 674.1 354.7 354.7 124.7 124.7
Reptition within 6 months Reptition within 6 months
Ward counts Ward counts 6 6 34 34 15.6 15.6 7.6 7.6
Ward rates Ward rates
2 2
4.1 4.1 17.3 17.3 10.7 10.7 3.2 3.2
1. Rates are per100 000 per year; population base is the ward population aged16+ years. 1. Rates are per100 000 per year; population base is the ward population aged16+ years.
2. Rates are per100 per year; population base is the self-harmpopulation aged16+ years. 2. Rates are per100 per year; population base is the self-harmpopulation aged16+ years.
J OHNS TON E T AL J OHNS TON E T AL
Area-level predictors Area-level predictors
of self-harm repetition of self-harm repetition
As with incidence rates, there was consider- As with incidence rates, there was consider-
able variation between the wards in rates of able variation between the wards in rates of
repetition of self-harm (Table 1). The asso- repetition of self-harm (Table 1). The asso-
ciations between the area-level explanatory ciations between the area-level explanatory
variables and ward-level self-harm repeti- variables and ward-level self-harm repeti-
tion within 6 months are presented in Table tion within 6 months are presented in Table
3. In contrast to the association between 3. In contrast to the association between
area measures and self-harm incidence rates area measures and self-harm incidence rates
(Table 2), there was little evidence that (Table 2), there was little evidence that
area-level measures predicted repetition at area-level measures predicted repetition at
ward level. The only variable significantly ward level. The only variable significantly
associated with poor outcome was the associated with poor outcome was the
proportion of individuals in a ward who proportion of individuals in a ward who
were from a White ethnic group. For this were from a White ethnic group. For this
variable, the negative Spearman correlation variable, the negative Spearman correlation
coefficient ( coefficient (7 70.39, 0.39, P P0.02) indicated that 0.02) indicated that
repetition rates were lower in wards with repetition rates were lower in wards with
a predominantly White ethnic profile. a predominantly White ethnic profile.
Individual and area-level Individual and area-level
multivariate model multivariate model
The final multivariate model, combining The final multivariate model, combining
variables at both individual and area levels variables at both individual and area levels
is presented in Table 4. Variance inflation is presented in Table 4. Variance inflation
factors indicated that the model was not factors indicated that the model was not
subject to collinearity problems. Four subject to collinearity problems. Four
individual-level predictors (previous self- individual-level predictors (previous self-
harm, previous psychiatric treatment, harm, previous psychiatric treatment,
employment status and marital status) were employment status and marital status) were
found to be independently associated with found to be independently associated with
repetition, together with one area-level repetition, together with one area-level
variable (proportion of individuals with variable (proportion of individuals with
White ethnicity). This variable was re- White ethnicity). This variable was re-
categorised into tertiles in order to enhance categorised into tertiles in order to enhance
interpretability. People living in wards with interpretability. People living in wards with
a lower proportion of White residents had a a lower proportion of White residents had a
higher risk of repetition which was inde- higher risk of repetition which was inde-
pendent of the individual-level covariates. pendent of the individual-level covariates.
A A post-hoc post-hoc analysis showed that this analysis showed that this
relationship did not vary according to the relationship did not vary according to the
ethnicity of the individual ( ethnicity of the individual (P P value for value for
interaction interaction 0.98). The ecological associa- 0.98). The ecological associa-
tion was in the opposite direction to that tion was in the opposite direction to that
observed for the individual-level ethnicity observed for the individual-level ethnicity
variable; the univariate model indicated variable; the univariate model indicated
that White individuals were at higher risk that White individuals were at higher risk
of repetition (OR of repetition (OR1.70, 95% CI 1.19 1.70, 95% CI 1.19
2.42), although this variable was dropped 2.42), although this variable was dropped
from the multivariate model owing to from the multivariate model owing to
non-significance. non-significance.
The adjusted PAF estimates for the co- The adjusted PAF estimates for the co-
variates in the final model are also variates in the final model are also
presented in Table 4. These were large, presented in Table 4. These were large,
ranging from 15.9% for White ethnicity ranging from 15.9% for White ethnicity
(area-level) to 44.4% for previous self- (area-level) to 44.4% for previous self-
harm (individual-level), which partly re- harm (individual-level), which partly re-
flects the high prevalence of the risk factors flects the high prevalence of the risk factors
in this high-risk sample. The combined in this high-risk sample. The combined
adjusted PAF for all variables in the model adjusted PAF for all variables in the model
indicated that 78.8% of all self-harm repe- indicated that 78.8% of all self-harm repe-
titions were attributable to these indepen- titions were attributable to these indepen-
dent predictors. However, this estimate dent predictors. However, this estimate
should be treated cautiously, as the expla- should be treated cautiously, as the expla-
natory variables in general are not modifi- natory variables in general are not modifi-
able and the associations are unlikely to able and the associations are unlikely to
be causal. be causal.
418 418
Table 2 Table 2 Associations between area-level explanatory variables and ward-level deliberate self-harmincidence Associations between area-level explanatory variables and ward-level deliberate self-harmincidence
rate (per100 000 persons per year) rate (per100 000 persons per year)
Area-level explanatory variable Area-level explanatory variable Spearman rank Spearman rank
correlation coefficient correlation coefficient
P P
Index of Multiple Deprivation 2000 Index of Multiple Deprivation 2000 0.91 0.91 5 50.001 0.001
Income domain Income domain 0.89 0.89 5 50.001 0.001
Employment domain Employment domain 0.89 0.89 5 50.001 0.001
Health domain Health domain 0.77 0.77 5 50.001 0.001
Education domain Education domain 0.61 0.61 5 50.001 0.001
Housing domain Housing domain 0.51 0.51 0.002 0.002
Access domain Access domain 7 70.36 0.36 0.04 0.04
Child poverty domain Child poverty domain 0.76 0.76 5 50.001 0.001
Concentrated advantage Concentrated advantage 7 70.68 0.68 5 50.001 0.001
Towsend Index of Deprivation Towsend Index of Deprivation 0.73 0.73 5 50.001 0.001
Unemployment Unemployment 0.81 0.81 5 50.001 0.001
Registered sick Registered sick 0.75 0.75 5 50.001 0.001
Social fragmentation Social fragmentation 0.03 0.03 0.86 0.86
% population turnover % population turnover 7 70.06 0.06 0.75 0.75
% single-person households % single-person households 0.40 0.40 0.02 0.02
Population density Population density 7 70.30 0.30 0.09 0.09
% continuing education % continuing education 7 70.46 0.46 0.007 0.007
% White ethnicity % White ethnicity 7 70.03 0.03 0.88 0.88
Table 3 Table 3 Associations between area-level explanatory variables andward-level deliberate self-harmrepetition Associations between area-level explanatory variables andward-level deliberate self-harmrepetition
rate (% within 6 months) rate (% within 6 months)
Area-level explanatory variable Area-level explanatory variable Spearman rank Spearman rank
correlation coefficient correlation coefficient
P P
Index of Multiple Deprivation 2000 Index of Multiple Deprivation 2000 0.02 0.02 0.90 0.90
Income domain Income domain 0.05 0.05 0.77 0.77
Employment domain Employment domain 0.12 0.12 0.50 0.50
Health domain Health domain 7 70.02 0.02 0.91 0.91
Education domain Education domain 7 70.23 0.23 0.19 0.19
Housing domain Housing domain 0.27 0.27 0.13 0.13
Access domain Access domain 7 70.14 0.14 0.43 0.43
Child poverty domain Child poverty domain 7 70.02 0.02 0.90 0.90
Concentrated advantage Concentrated advantage 0.25 0.25 0.17 0.17
Townsend Index of Deprivation Townsend Index of Deprivation 0.12 0.12 0.51 0.51
Unemployment Unemployment 0.1 0.1 0.60 0.60
Registered sick Registered sick 7 70.07 0.07 0.69 0.69
Social fragmentation Social fragmentation 0.25 0.25 0.15 0.15
% population turnover % population turnover 0.24 0.24 0.17 0.17
% single-person households % single-person households 0.07 0.07 0.70 0.70
Population density Population density 0.03 0.03 0.88 0.88
% continuing education % continuing education 0.26 0.26 0.14 0.14
% White ethnicity % White ethnicity 7 70.39 0.39 0.02 0.02
PREDI CTORS OF S ELF - HARM REPE TI TION PREDI CTORS OF S ELF - HARM REPETI TION
DISCUSSION DISCUSSION
Main findings Main findings
We found a strong ecological association We found a strong ecological association
between the socio-economic characteristics between the socio-economic characteristics
of areas and their incidence rates of of areas and their incidence rates of
self-harm, with deprived areas generally self-harm, with deprived areas generally
having the highest rates. By contrast, few having the highest rates. By contrast, few
area-level characteristics appeared to influ- area-level characteristics appeared to influ-
ence the likelihood of repetition the only ence the likelihood of repetition the only
factor that was significantly associated with factor that was significantly associated with
outcome was the proportion of individuals outcome was the proportion of individuals
in the ward who were of White ethnicity. in the ward who were of White ethnicity.
In the final multivariate model, several In the final multivariate model, several
individual-level characteristics were found individual-level characteristics were found
to independently predict repetition. The to independently predict repetition. The
area-level characteristic the relative size area-level characteristic the relative size
of the White population predicted repeti- of the White population predicted repeti-
tion independently of the individual-level tion independently of the individual-level
covariates. Collectively, the variables in covariates. Collectively, the variables in
the model accounted for almost 80% of the model accounted for almost 80% of
the cases of repetition within 6 months, the cases of repetition within 6 months,
with 16% of cases being accounted for by with 16% of cases being accounted for by
the area-level characteristic. the area-level characteristic.
Methodological issues Methodological issues
We used a wide variety of area-based We used a wide variety of area-based
measures from a number of sources, and measures from a number of sources, and
our multivariate analysis took account of our multivariate analysis took account of
ward-level clustering effects. Our study is ward-level clustering effects. Our study is
the first, to our knowledge, to attempt to the first, to our knowledge, to attempt to
quantify the association between individual quantify the association between individual
and area-level factors and repetition of self- and area-level factors and repetition of self-
harm. However, as with all studies of this harm. However, as with all studies of this
type, we were restricted in the amount of type, we were restricted in the amount of
data we could analyse we did not data we could analyse we did not
measure all possible confounding and measure all possible confounding and
explanatory variables. explanatory variables.
The findings of the current study need The findings of the current study need
to be interpreted in the context of its speci- to be interpreted in the context of its speci-
fic methodological shortcomings. First, this fic methodological shortcomings. First, this
study investigated individuals who pre- study investigated individuals who pre-
sented to teaching hospitals serving a sented to teaching hospitals serving a
relatively deprived inner-city area, and the relatively deprived inner-city area, and the
results may not be generalisable to other results may not be generalisable to other
settings. Equally, our findings may not be settings. Equally, our findings may not be
applicable to those who do not present for applicable to those who do not present for
treatment following self-harm or those treatment following self-harm or those
who choose not to wait after presenting to who choose not to wait after presenting to
hospital. Second, although the response hospital. Second, although the response
rate for the MASH project is good and we rate for the MASH project is good and we
have no evidence that the response rate have no evidence that the response rate
varied systematically by ward, males and varied systematically by ward, males and
those who use cutting as a method of harm those who use cutting as a method of harm
may be under-represented in our sample. may be under-represented in our sample.
Third, it is possible that, for wards on the Third, it is possible that, for wards on the
periphery of the study area, a proportion periphery of the study area, a proportion
of patients attended hospitals which were of patients attended hospitals which were
not included in the MASH project. We do not included in the MASH project. We do
not have a direct estimate of the size of this not have a direct estimate of the size of this
effect for index episodes, but data from effect for index episodes, but data from
within the Manchester district suggest that within the Manchester district suggest that
repeat episodes are followed by presenta- repeat episodes are followed by presenta-
tion to the same hospitals as the index tion to the same hospitals as the index
episodes in 8090% of cases. Fourth, the episodes in 8090% of cases. Fourth, the
number of repeat self-harm attempts in number of repeat self-harm attempts in
some wards was relatively small and we some wards was relatively small and we
did not use statistical techniques such as did not use statistical techniques such as
Bayesian modelling (Richardson Bayesian modelling (Richardson et al et al, ,
2004) to smooth the underlying risk esti- 2004) to smooth the underlying risk esti-
mates. However, the sensitivity of Bayesian mates. However, the sensitivity of Bayesian
disease-mapping models is low when (as in disease-mapping models is low when (as in
this study) the raised risks are moderate and this study) the raised risks are moderate and
the expected counts are less than 50 the expected counts are less than 50
(Richardson (Richardson et al et al, 2004). Fifth, we did not , 2004). Fifth, we did not
adjust for the fact that wards in close proxi- adjust for the fact that wards in close proxi-
mity to one another were likely to have mity to one another were likely to have
similar exposure prevalence (spatial auto- similar exposure prevalence (spatial auto-
correlation), but spatial autocorrelation correlation), but spatial autocorrelation
may not be a major issue with ecological may not be a major issue with ecological
studies of suicidal behaviour (Wasserman studies of suicidal behaviour (Wasserman
& Stack, 1995). Sixth, we only considered & Stack, 1995). Sixth, we only considered
two levels in this study: individual and two levels in this study: individual and
small-area. There are suggestions that small-area. There are suggestions that
419 419
Table 4 Table 4 Multivariate logistic regression model Multivariate logistic regression model
1 1
for independent individual- and area-level predictors of repetition of self-harmwithin 6 months for independent individual- and area-level predictors of repetition of self-harmwithin 6 months
Explanatory variables Explanatory variables Adjusted OR Adjusted OR (95% CI) (95% CI) Prevalence of Prevalence of
risk factor (%) risk factor (%)
PAF (%) PAF (%)
3 3
(adjusted) (adjusted) (95% CI) (95% CI)
Previous self-harm Previous self-harm
No No 1.00 1.00 ^ ^ ^ ^ ^ ^ ^ ^
Yes Yes 2.57 2.57 (2.00^3.29) (2.00^3.29) 55 55 44.4 44.4 (34.3^52.9) (34.3^52.9)
Previous psychiatric treatment Previous psychiatric treatment
No No 1.00 1.00 ^ ^ ^ ^ ^ ^ ^ ^
Yes Yes 1.73 1.73 (1.41^2.12) (1.41^2.12) 51 51 26.4 26.4 (17.0^34.7) (17.0^34.7)
Employment status Employment status
Employed Employed 1.00 1.00 ^ ^ ^ ^ ^ ^ ^ ^
Unemployed Unemployed 1.41 1.41 (1.06^1.87) (1.06^1.87) 45 45 13.2 13.2 ^ ^
Registered sick Registered sick 1.67 1.67 (1.12^2.51) (1.12^2.51) 11 11 6.0 6.0 ^ ^
Other inactive Other inactive 1.10 1.10 (0.84^1.44) (0.84^1.44) 19 19 1.2 1.2 ^ ^
Total for variable Total for variable ^ ^ ^ ^ ^ ^ (20.5) (20.5) (4.0^34.1) (4.0^34.1)
Marital status Marital status
Married/partnered Married/partnered 1.00 1.00 ^ ^ ^ ^ ^ ^ ^ ^
Single/separated/divorced/widowed Single/separated/divorced/widowed 1.39 1.39 (1.09^1.76) (1.09^1.76) 70 70 18.9 18.9 (5.3^30.6) (5.3^30.6)
% White population (area-level) % White population (area-level)
High ^ 1st tertile (93.5^95.6) High ^ 1st tertile (93.5^95.6) 1.00 1.00
2 2
^ ^ ^ ^ ^ ^ ^ ^
Medium ^ 2nd tertile (82.4^93.5) Medium ^ 2nd tertile (82.4^93.5) 1.15 1.15
2 2
(0.88^1.51) (0.88^1.51) 31 31 3.5 3.5 ^ ^
Low ^ 3rd tertile (47.3^82.0) Low ^ 3rd tertile (47.3^82.0) 1.45 1.45
2 2
(1.14^1.84) (1.14^1.84) 39 39 12.5 12.5 ^ ^
Total for variable Total for variable ^ ^ ^ ^ ^ ^ (15.9) (15.9) (3.6^26.7) (3.6^26.7)
PAF, population attributable fraction. PAF, population attributable fraction.
1. Multivariate model created using 91% (4336/4743) of the whole sample.Variance estimation in this model was corrected for area-level clustering effects. 1. Multivariate model created using 91% (4336/4743) of the whole sample.Variance estimation in this model was corrected for area-level clustering effects.
2. Evidence of linear trend in risk of repetition across tertiles ( 2. Evidence of linear trend in risk of repetition across tertiles (Z Z3.19, 3.19, P P0.003). 0.003).
3. Estimate for combined effect of all covariates: PAF 3. Estimate for combined effect of all covariates: PAF78.8% (95% CI 71.1^84.4). 78.8% (95% CI 71.1^84.4).
J OHNS TON E T AL J OHNS TON E T AL
exposures which occur at other levels (for exposures which occur at other levels (for
example, at the level of household) may example, at the level of household) may
also be important determinants of mental also be important determinants of mental
health (Weich health (Weich et al et al, 2005). , 2005).
We could have elected to analyse the We could have elected to analyse the
data using survival methods and we have data using survival methods and we have
used this approach in previous individual- used this approach in previous individual-
level studies (Cooper level studies (Cooper et al et al, 2005). Using , 2005). Using
survival analysis would have allowed us to survival analysis would have allowed us to
make full use of the data by including vary- make full use of the data by including vary-
ing lengths of follow-up. However, the in- ing lengths of follow-up. However, the in-
fluence of area on repetition risk may vary fluence of area on repetition risk may vary
according to the length of time since the according to the length of time since the
index episode. Longer periods of follow- index episode. Longer periods of follow-
up would also have made it more likely that up would also have made it more likely that
an individual would have moved between an individual would have moved between
areas. We therefore decided areas. We therefore decided a priori a priori to in- to in-
vestigate repetition within a fixed period vestigate repetition within a fixed period
of 6 months. of 6 months.
Interpretation of findings Interpretation of findings
It was striking that only one area-based It was striking that only one area-based
variable was associated with repetition of variable was associated with repetition of
self-harm. Why might this be? It is possible self-harm. Why might this be? It is possible
that the lower number of repeat episodes of that the lower number of repeat episodes of
self-harm (when compared with index self-harm (when compared with index
episodes) limited the power of this study episodes) limited the power of this study
to detect significant associations. However, to detect significant associations. However,
the coefficients reported in Table 4 are less the coefficients reported in Table 4 are less
than 0.3 in either direction (with the excep- than 0.3 in either direction (with the excep-
tion of the significant variable White tion of the significant variable White
ethnicity), and type II error is therefore ethnicity), and type II error is therefore
unlikely to be the explanation. It is also unlikely to be the explanation. It is also
possible that our unit of analysis for area possible that our unit of analysis for area
effects (electoral ward) was too large and effects (electoral ward) was too large and
heterogeneous to detect contextual influ- heterogeneous to detect contextual influ-
ences on repetition. However, the self-harm ences on repetition. However, the self-harm
event data would have become too sparse if event data would have become too sparse if
we had used a smaller area-level unit than we had used a smaller area-level unit than
the ward. Of course, it may be that our the ward. Of course, it may be that our
findings are correct and that area-based in- findings are correct and that area-based in-
fluences were much more important for fluences were much more important for
index cases of self-harm than for repeat epi- index cases of self-harm than for repeat epi-
sodes. Our failure to find area-based pre- sodes. Our failure to find area-based pre-
dictors of repetition in this comparatively dictors of repetition in this comparatively
large study could reflect the fact that such large study could reflect the fact that such
influences are not clinically important. influences are not clinically important.
Only very few studies to date have found Only very few studies to date have found
an association between area-based factors an association between area-based factors
and mental health after adjustment for and mental health after adjustment for
individual factors (Skapinakis individual factors (Skapinakis et al et al, 2005). , 2005).
Individual-level risk factors appeared to Individual-level risk factors appeared to
be more important determinants of repeat be more important determinants of repeat
self-harm than area characteristics. How- self-harm than area characteristics. How-
ever, our final model did suggest that both ever, our final model did suggest that both
individual- and area-based factors were individual- and area-based factors were
independently associated with repetition. independently associated with repetition.
The finding, that the risk of self-harm The finding, that the risk of self-harm
increased as the proportion of individuals increased as the proportion of individuals
who were from a White ethnic background who were from a White ethnic background
decreased, appears counter-intuitive. Being decreased, appears counter-intuitive. Being
of White ethnicity (on an individual level) of White ethnicity (on an individual level)
was associated with increased risk of repeti- was associated with increased risk of repeti-
tion. This is an example of how area-based tion. This is an example of how area-based
and individual-level exposures may affect and individual-level exposures may affect
risk differently. There are several possible risk differently. There are several possible
explanations for this finding. First, the explanations for this finding. First, the
association may be spurious. A wards association may be spurious. A wards
ethnic composition may simply be a proxy ethnic composition may simply be a proxy
indicator of other exposures, for example indicator of other exposures, for example
relative deprivation or degree of social relative deprivation or degree of social
cohesion or other factors which we did cohesion or other factors which we did
not measure. A second explanation relates not measure. A second explanation relates
to the distribution of people who repeat to the distribution of people who repeat
self-harm within the borough. It is plausible self-harm within the borough. It is plausible
that, given their characteristics, more of that, given their characteristics, more of
these individuals live in hostels, temporary these individuals live in hostels, temporary
accommodation and supported housing accommodation and supported housing
and that these types of accommodation and that these types of accommodation
may be concentrated in wards with more may be concentrated in wards with more
ethnically mixed populations. Third, the ethnically mixed populations. Third, the
finding could reflect the underlying charac- finding could reflect the underlying charac-
teristics of the individuals who live in these teristics of the individuals who live in these
ethnically diverse areas. Fourth, it could be ethnically diverse areas. Fourth, it could be
a true effect, with the individuals risk being a true effect, with the individuals risk being
modified by the prevalence of the exposure modified by the prevalence of the exposure
(in this case ethnicity) at a ward level. (in this case ethnicity) at a ward level.
Neeleman Neeleman et al et al (2001) found that the risk (2001) found that the risk
of self-harm behaviour associated with of self-harm behaviour associated with
individual ethnicity was mediated by the individual ethnicity was mediated by the
local size of the individuals ethnic group local size of the individuals ethnic group
(as the size of the local ethnic population (as the size of the local ethnic population
increased, the risk associated with Black increased, the risk associated with Black
and minority ethnicity on an individual and minority ethnicity on an individual
level decreased). It could be that the degree level decreased). It could be that the degree
to which an individual fits with the social to which an individual fits with the social
environment influences the risk of adverse environment influences the risk of adverse
outcomes. outcomes.
Clinical implications Clinical implications
If our findings are correct, then the repeti- If our findings are correct, then the repeti-
tion of self-harm may be more strongly tion of self-harm may be more strongly
related to individual factors than to the related to individual factors than to the
characteristics of the areas in which people characteristics of the areas in which people
live. This might suggest that the most live. This might suggest that the most
productive strategy to reduce repetition productive strategy to reduce repetition
would be to focus on individual-level inter- would be to focus on individual-level inter-
ventions. However, area-based risk factors ventions. However, area-based risk factors
might also warrant consideration in our might also warrant consideration in our
study, such factors accounted for approxi- study, such factors accounted for approxi-
mately 16% of repeat episodes in the mately 16% of repeat episodes in the
population. It is possible that area-based population. It is possible that area-based
interventions which, for example, seek to interventions which, for example, seek to
address issues related to social and material address issues related to social and material
deprivation, might be more effective in pre- deprivation, might be more effective in pre-
venting the incidence of self-harm rather venting the incidence of self-harm rather
than its repetition. We need to better under- than its repetition. We need to better under-
stand the processes underlying ecological stand the processes underlying ecological
associations with suicidal behaviour before associations with suicidal behaviour before
embarking on area-based interventions. embarking on area-based interventions.
ACKNOWLEDGEMENTS ACKNOWLEDGEMENTS
We thank the staff from the MASH project and the We thank the staff from the MASH project and the
clinicians at the participating hospitals. A preliminary clinicians at the participating hospitals. A preliminary
version of the protocol for this study was presented version of the protocol for this study was presented
at the British Isles Workshop on Suicidal Behaviour, at the British Isles Workshop on Suicidal Behaviour,
Oxford 2002, and we thank the participants for Oxford 2002, and we thank the participants for
their help. their help.
This study was funded by the Manchester Mental This study was funded by the Manchester Mental
Health and Social CareTrust. Health and Social CareTrust.
REFERENCES REFERENCES
Benichou, J. (2001) Benichou, J. (2001) A review of adjusted estimators of A review of adjusted estimators of
attributable risk. attributable risk. Statistical Methods in Medical Research Statistical Methods in Medical Research, ,
10 10, 195^216. , 195^216.
Bland, M. (2000) Bland, M. (2000) An Introduction to Medical Statistics An Introduction to Medical Statistics, ,
3rd edn. Oxford: Oxford University Press. 3rd edn. Oxford: Oxford University Press.
Congdon, P. (1996) Congdon, P. (1996) Suicide and parasuicide in London: Suicide and parasuicide in London:
a small area study. a small area study. Urban Studies Urban Studies, , 33 33, 137^158. , 137^158.
Cooper, J., Kapur, N., Webb, R., Cooper, J., Kapur, N., Webb, R., et al et al (2005) (2005) Suicide Suicide
after deliberate self-harm: a 4-year cohort study. after deliberate self-harm: a 4-year cohort study.
American Journal of Psychiatry American Journal of Psychiatry, , 162 162, 297^303. , 297^303.
Department of Health (2002) Department of Health (2002) National Suicide National Suicide
Prevention Strategy for England Prevention Strategy for England. London: Department of . London: Department of
Health. Health.
Gilbody, S., House, A. & Owens, D. (1997) Gilbody, S., House, A. & Owens, D. (1997) The early The early
repetition of deliberate self harm. repetition of deliberate self harm. Journal of the Royal Journal of the Royal
College of Physicians College of Physicians, , 31 31, 171^172. , 171^172.
Gunnell, D., Shepherd, M. & Evans, M. (2000) Gunnell, D., Shepherd, M. & Evans, M. (2000) Are Are
recent increases in deliberate self-harm associated with recent increases in deliberate self-harm associated with
changes in socio-economic conditions? An ecological changes in socio-economic conditions? An ecological
analysis of patterns of deliberate self-harmin Bristol analysis of patterns of deliberate self-harmin Bristol
1972^3 and 1995^6. 1972^3 and1995^6. Psychological Medicine Psychological Medicine, , 30 30, ,
1197^1203. 1197^1203.
Hawton, K., Harris, L., Hodder, K., Hawton, K., Harris, L., Hodder, K., et al et al (2001) (2001) The The
influence of the economic and social environment on influence of the economic and social environment on
deliberate self-harm and suicide: an ecological and deliberate self-harm and suicide: an ecological and
person-based study. person-based study. Psychological Medicine Psychological Medicine, , 31 31, 827^836. , 827^836.
Kapur, N., House, A., Creed, F., Kapur, N., House, A., Creed, F., et al et al (1998) (1998)
Management of deliberate self-poisoning in adults in four Management of deliberate self-poisoning in adults in four
teaching hospitals: descriptive study. teaching hospitals: descriptive study. BMJ BMJ, , 316 316, 831^832. , 831^832.
Kelly, J., Cooper, J., Johnston, A., Kelly, J., Cooper, J., Johnston, A., et al et al (2004) (2004)
Manchester Self-Harm Project, 5thYear Report Manchester Self-Harm Project, 5thYear Report. .
Manchester: University of Manchester. Manchester: University of Manchester.
Kessler, R. C., Berghund, P., Borges, G., Kessler, R. C., Berghund, P., Borges, G., et al et al (2005) (2005)
Trends in suicide ideation, plans, gestures and attempts Trends in suicide ideation, plans, gestures and attempts
in the United States, 1990^1992 to 2001^2003. in the United States, 1990^1992 to 2001^2003. JAMA JAMA, ,
293 293, 2487^2495. , 2487^2495.
Manchester Geomatics Limited Manchester Geomatics Limited (2003) (2003) Community Community
health information profile (CHIP) for Manchester, health information profile (CHIP) for Manchester,
Salford and Trafford, 2003. http:// Salford and Trafford, 2003. http://
www.healthprofile.org.uk (accessed 4 August 2003). www.healthprofile.org.uk (accessed 4 August 2003).
National Collaborating Centre for Mental Health National Collaborating Centre for Mental Health
(2004) (2004) Self-Harm. The Short-Term Physical and Self-Harm. The Short-Term Physical and
Psychological Management and Secondary Prevention of Psychological Management and Secondary Prevention of
Self-Harm in Primary and Secondary Care. Self-Harm in Primary and Secondary Care. Leicester & Leicester &
London: British Psychological Society & Gaskell. London: British Psychological Society & Gaskell.
Neeleman, J., Wilson-Jones, C. & Wessely, S. (2001) Neeleman, J., Wilson-Jones, C. & Wessely, S. (2001)
Ethnic density and deliberate self-harm: small area study Ethnic density and deliberate self-harm: small area study
in south-east London. in south-east London. Journal of Epidemiology and Journal of Epidemiology and
Community Health Community Health, , 55 55, 85^90. , 85^90.
4 2 0 4 2 0
PREDI CTORS OF S ELF - HARM REPE TI TION PREDI CTORS OF S ELF - HARM REPETI TION
NHS Centre for Reviews and Dissemination (1998) NHS Centre for Reviews and Dissemination (1998)
Deliberate self-harm. Deliberate self-harm. Effective Health Care Bulletin Effective Health Care Bulletin, , 4 4, ,
1^12. 1^12.
Office for National Statistics (2002) Office for National Statistics (2002) Ward History Ward History
Database. http://www.stistics.gov.uk (accessed 21 Database. http://www.stistics.gov.uk (accessed 21
August 2003). August 2003).
Office for National Statistics (2003) Office for National Statistics (2003) Index of Multiple Index of Multiple
Deprivation 2000. http://neighbourhood.statistics. Deprivation 2000. http://neighbourhood.statistics.
gov.uk (accessed 4 May 2003). gov.uk (accessed 4 May 2003).
Owens, D., Horrocks, J. & House, A. (2002) Owens, D., Horrocks, J. & House, A. (2002) Fatal Fatal
and non-fatal repetition of self-harm. Systematic review. and non-fatal repetition of self-harm. Systematic review.
British Journal of Psychiatry British Journal of Psychiatry, , 181 181, 193^199. , 193^199.
Richardson, S., Thomson, A., Best, N., Richardson, S., Thomson, A., Best, N., et al et al (2004) (2004)
Interpreting posterior relative risk estimates in disease- Interpreting posterior relative risk estimates in disease-
mapping studies. mapping studies. Environmental Health Perspectives Environmental Health Perspectives, , 112 112, ,
1016^1025. 1016^1025.
Sakinofsky, I. (2000) Sakinofsky, I. (2000) Repetition of suicidal behaviour. In Repetition of suicidal behaviour. In
Suicide and Attempted Suicide Suicide and Attempted Suicide (eds K. Hawton & K.Van (eds K. Hawton & K.Van
Heeringen), pp. 385^404. Chichester: Wiley. Heeringen), pp. 385^404. Chichester: Wiley.
Schmidtke, A., Bille-Brahe, U., DeLeo, D., Schmidtke, A., Bille-Brahe, U., DeLeo, D., et al et al
(1996) (1996) Attempted suicide in Europe: rates, trends and Attempted suicide in Europe: rates, trends and
sociodemographic characteristics of suicide attempters sociodemographic characteristics of suicide attempters
during the period1989^1992. Results of the WHO/ during the period 1989^1992. Results of the WHO/
EURO Multicentre Study on Parasuicide. EURO Multicentre Study on Parasuicide. Acta Acta
Psychiatrica Scandinavica Psychiatrica Scandinavica, , 93 93, 327^338. , 327^338.
Simpson, L. & Yu, A. (1999) Simpson, L. & Yu, A. (1999) Updated UK Area Updated UK Area
Master-files. http://convert.mimas.ac.uk (accessed 22 Master-files. http://convert.mimas.ac.uk (accessed 22
February 2005). February 2005).
Skapinakis, P., Lewis, G., Araya, R., Skapinakis, P., Lewis, G., Araya, R., et al et al (2005) (2005)
Mental health inequalities in Wales, UK: multi-level Mental health inequalities in Wales, UK: multi-level
investigation of the effect of area deprivation. investigation of the effect of area deprivation. British British
Journal of Psychiatry Journal of Psychiatry, , 186 186, 417^422. , 417^422.
Townsend, P., Phillimore, P. & Beattie, A. (1986) Townsend, P., Phillimore, P. & Beattie, A. (1986)
Health and Deprivation: Inequality and the North Health and Deprivation: Inequality and the North. London: . London:
Croom Helm. Croom Helm.
Wasserman, I. M. & Stack, S. (1995) Wasserman, I. M. & Stack, S. (1995) Geographical Geographical
spatial autocorrelation and United States suicide spatial autocorrelation and United States suicide
patterns. patterns. Archives of Suicide Research Archives of Suicide Research, , 1 1, 121^129. , 121^129.
Weich, S., Twigg, L., Lewis, G., Weich, S., Twigg, L., Lewis, G., et al et al (2005) (2005)
Geographical variation in rates of common mental Geographical variation in rates of common mental
disorders in Britain: prospective cohort study. disorders in Britain: prospective cohort study. British British
Journal of Psychiatry Journal of Psychiatry, , 187 187, 29^34. , 29^34.
4 21 4 21
AMY JOHNSTON, MSc, JAYNE COOPER, PhD, Centre for Suicide Prevention, University of Manchester, UK; AMY JOHNSTON, MSc, JAYNE COOPER, PhD, Centre for Suicide Prevention, University of Manchester, UK;
ROGERWEBB, MSc, Centre for Womens Mental Health, University of Manchester, UK; NAVNEET KAPUR, ROGERWEBB, MSc, Centre for Womens Mental Health, University of Manchester, UK; NAVNEET KAPUR,
MD, MRCPsych, Centre for Suicide Prevention, University of Manchester, UK MD, MRCPsych, Centre for Suicide Prevention, University of Manchester, UK
Correspondence: Dr N. Kapur, Centre for Suicide Prevention,Williamson Building,University of Correspondence: Dr N. Kapur, Centre for Suicide Prevention,Williamson Building,University of
Manchester, Oxford Road, Manchester M13 9PL,UK. Tel: +44 (0)161275 0733; Manchester, Oxford Road, Manchester M13 9PL,UK. Tel: +44 (0)161275 0733;
fax: +44 (0)161275 0716; email: nav.kapur fax: +44 (0)161275 0716; email: nav.kapur@ @manchester.ac.uk manchester.ac.uk
(First received 7 October 2005, final revision 22 May 2006, accepted 4 July 2006) (First received 7 October 2005, final revision 22 May 2006, accepted 4 July 2006)