Abstract
BackgroundRisk scales are used widely in the management of patients presenting to hospital following self-harm. However, there is evidence that their diagnostic accuracy in predicting repeat self-harm is limited. Their predictive accuracy in population settings, and in identifying those at highest risk of suicide is not known.MethodWe compared the predictive accuracy of the Manchester Self-Harm Rule (MSHR), ReACT Self-Harm Rule (ReACT), SAD PERSONS Scale (SPS) and Modified SAD PERSONS Scale (MSPS) in an unselected sample of patients attending hospital following self-harm. Data on 4000 episodes of self-harm presenting to Emergency Departments (ED) between 2010 and 2012 were obtained from four established monitoring systems in England. Episodes were assigned a risk category for each scale and followed up for 6 months.ResultsThe episode-based repeat rate was 28% (1133/4000) and the incidence of suicide was 0.5% (18/3962). The MSHR and ReACT performed with high sensitivity (98% and 94% respectively) and low specificity (15% and 23%). The SPS and the MSPS performed with relatively low sensitivity (24–29% and 9–12% respectively) and high specificity (76–77% and 90%). The area under the curve was 71% for both MSHR and ReACT, 51% for SPS and 49% for MSPS. Differences in predictive accuracy by subgroup were small. The scales were less accurate at predicting suicide than repeat self-harm.ConclusionsThe scales failed to accurately predict repeat self-harm and suicide. The findings support existing clinical guidance not to use risk classification scales alone to determine treatment or predict future risk.
Highlights
Risk scales are used widely in the management of patients presenting to hospital following self-harm
The majority of episodes involved selfpoisoning with drugs or other substances (81%, 3241) and 19% (759) presentations were by individuals who had self-injured. 55% (2206) of episodes received a psychosocial assessment
The reverse pattern was seen for the SAD PERSONS Scale (SPS) and the Modified SAD PERSONS Scale (MSPS): relatively low sensitivity with high specificity resulted in the correct prediction of the majority of episodes that were not followed by repetition of self-harm as low risk
Summary
Risk scales are used widely in the management of patients presenting to hospital following self-harm. Psychosocial assessment by a mental health clinician is a central component of clinical care and is recommended for each episode of self-harm [5]. These in-depth assessments help clinicians to formulate decisions about follow-. One study of 32 hospitals across England found that over 20 different risk scales were being used with people who presented after self-harm [8]. This suggests they are in widespread use, with little consensus about which should be used or how well they predict future risk
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