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Cited by 311Suicide and Self-Harm StudiesHomicide, Infanticide, and Child AbuseInjury Epidemiology and Prevention

Clinical and social outcomes of adolescent self harm: population based birth cohort study

Open access
Mars, B., Heron, J., Crane, C., Hawton, K., Lewis, G., Macleod, J., Tilling, K., Gunnell, D.·2014·BMJ
DOI 10.1136/bmj.g5954PMC PMC4205277
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Abstract

OBJECTIVES: To investigate the mental health, substance use, educational, and occupational outcomes of adolescents who self harm in a general population sample, and to examine whether these outcomes differ according to self reported suicidal intent. DESIGN: Population based birth cohort study. SETTING: Avon Longitudinal Study of Parents and Children (ALSPAC), a UK birth cohort of children born in 1991-92. PARTICIPANTS: Data on lifetime history of self harm with and without suicidal intent were available for 4799 respondents who completed a detailed self harm questionnaire at age 16 years. Multiple imputation was used to account for missing data. MAIN OUTCOME MEASURES: Mental health problems (depression and anxiety disorder), assessed using the clinical interview schedule-revised at age 18 years, self reported substance use (alcohol, cannabis, cigarette smoking, and illicit drugs) at age 18 years, educational attainment at age 16 and 19 years, occupational outcomes at age 19 years, and self harm at age 21 years. RESULTS: Participants who self harmed with and without suicidal intent at age 16 years were at increased risk of developing mental health problems, future self harm, and problem substance misuse, with stronger associations for suicidal self harm than for non-suicidal self harm. For example, in models adjusted for confounders the odds ratio for depression at age 18 years was 2.21 (95% confidence interval 1.55 to 3.15) in participants who had self harmed without suicidal intent at age 16 years and 3.94 (2.67 to 5.83) in those who had self harmed with suicidal intent. Suicidal self harm, but not self harm without suicidal intent, was also associated with poorer educational and employment outcomes. CONCLUSIONS: Adolescents who self harm seem to be vulnerable to a range of adverse outcomes in early adulthood. Risks were generally stronger in those who had self harmed with suicidal intent, but outcomes were also poor among those who had self harmed without suicidal intent. These findings emphasise the need for early identification and treatment of adolescents who self harm.

AI snapshot

Written from the paper’s full text.

TL;DR

In ALSPAC, adolescents who self-harmed by age 16 had higher risks of mental health problems, future self-harm, and substance misuse by early adulthood, with stronger risks for suicidal self-harm. Suicidal self-harm was also linked to poorer educational and occupational outcomes, while non-suicidal self-harm still predicted adverse mental health and substance outcomes.

Key findings

  • 19% (894/4799) reported lifetime self-harm at age 16; these participants accounted for 40% of depressive and anxiety disorders and over 35% of problem substance use at age 18, and only 28% had good outcomes versus 59% of those without self-harm.
  • Adjusted for sex, socioeconomic position, and prior depression symptoms, depression at age 18 was associated with non-suicidal self-harm (OR 2.21, 95% CI 1.55 to 3.15) and suicidal self-harm (OR 3.94, 2.67 to 5.83) versus no self-harm; future self-harm at age 21 showed ORs of 4.48 (3.13 to 6.41) and 11.4 (7.90 to 16.4), respectively.
  • Suicidal self-harm, but not non-suicidal self-harm, was associated with poorer educational and occupational outcomes: not achieving ≥5 GCSEs at A*-C (adjusted OR 2.08, 1.47 to 2.95) and being NEET at age 19 (adjusted OR 1.96, 1.16 to 3.31).
  • Problem cannabis use and regular smoking were more strongly associated with suicidal than non-suicidal self-harm; for problem cannabis use, suicidal self-harm versus no self-harm had adjusted OR 5.77 (3.46 to 9.63) and non-suicidal self-harm had adjusted OR 2.75 (1.68 to 4.50).

Methods

  • Population-based birth cohort study using ALSPAC, a UK cohort of children born in 1991-92; 4799 respondents completed a detailed self-harm questionnaire at age 16, with outcomes assessed at ages 18, 19, and 21.
  • Logistic regression examined associations of self-harm with and without suicidal intent at age 16 with mental health, substance use, educational, occupational, and future self-harm outcomes; multiple imputation (100 datasets) was used for missing data.
  • Models controlled for sex, socioeconomic position, and prior depression symptoms; educational and occupational models additionally adjusted for IQ at age 8. Secondary onset models excluded participants with evidence of pre-existing problems.

Limitations

  • The paper states that questionnaire responders and non-responders differed, so data were not missing completely at random; suicidal intent could not be distinguished for past-year self-harm at age 21; reverse causation is possible for GCSE outcomes because examinations occurred around the time self-harm was measured; residual confounding cannot be ruled out; and self-reported suicidal intent may be biased or fluctuate over time.
  • The paper also notes that the hospital admission analysis had only 18 events and that onset models retained small numbers of suicidal self-harm participants with wide confidence intervals, so those findings need cautious interpretation.
  • Evident from the text: multiple imputation assumes data are missing at random, which the authors state cannot be guaranteed, though they argue the auxiliary information makes it plausible.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1136/bmj.g5954

Cites

44 of 44 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 33 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Participants who self harmed by age 16 accounted for 24% of those who were not in education, employment, or training (NEET) at age 19 years.

    “these participants account for 24% of those who were not in education, employment, or training (NEET) at age 19 years,”
    Quote in the paperNot a substantial claim
  • Findingown data

    Suicidal self harm at age 16 was associated with future self harm at age 21 (odds ratio 12.6, 95% confidence interval 8.91 to 17.8).

    “suicidal self harm 12.6, 8.91 to 17.8”
    Quote in the paperSubstantial claim
  • Findingown data

    Participants who self harmed by age 16 accounted for over 35% of those with problem substance use at age 18 years.

    “and over 35% of those with problem substance use at age 18 years.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Compared with never self harm, suicidal self harm at age 16 was associated with a fivefold increase in the odds of depression and anxiety disorder at age 18.

    “suicidal self harm with a fivefold increase in odds”
    Quote in the paperSubstantial claim
  • Findingown data

    Self harm with and without suicidal intent at age 16 was associated with later substance use at age 18.

    “Self harm with and without suicidal intent at age 16 years were associated with later substance use at 18 years (table 2).”
    Quote in the paperSubstantial claim
  • May combine two claims. 18
  • The quote only partly states this claim. 4
  • Classified as probably not a substantial claim. 12

  • May combine two claims.

    Findingown data

    Suicidal self harm, but not self harm without suicidal intent, was associated with poorer educational and employment outcomes.

    “Suicidal self harm, but not self harm without suicidal intent, was also associated with poorer educational and employment outcomes.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Data are missing at random, whereby any systematic differences between the missing and the observed values can be explained by differences in observed data.

  • The quote only partly states this claim.

    Findingown data

    In models adjusted for sex, socioeconomic position, and depression symptoms, the odds ratio for depression at age 18 was 3.94 (95% CI 2.67 to 5.83) in participants who had self harmed with suicidal intent at age 16 compared with no self harm.

    “and 3.94 (2.67 to 5.83) in those who had self harmed with suicidal intent.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Data are missing at random, whereby any systematic differences between the missing and the observed values can be explained by differences in observed data.

  • The quote only partly states this claim.

    Findingown data

    In models adjusted for sex, socioeconomic position, and depression symptoms, the odds ratio for depression at age 18 was 2.21 (95% CI 1.55 to 3.15) in participants who had self harmed without suicidal intent at age 16 compared with no self harm.

    “in models adjusted for confounders the odds ratio for depression at age 18 years was 2.21 (95% confidence interval 1.55 to 3.15) in participants who had self harmed without suicidal intent at age 16 years”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Data are missing at random, whereby any systematic differences between the missing and the observed values can be explained by differences in observed data.

  • May combine two claims.

    Findingown data

    The prevalence of NEET was similar among those with no self harm and with non-suicidal self harm, but higher among those with suicidal self harm.

    “The prevalence of NEET was similar among those with no self harm and with non-suicidal self harm, but higher among those with suicidal self harm.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Self harm with suicidal intent at age 16 is associated with increased risk of future self harm at age 21.

    “Participants who self harmed with and without suicidal intent at age 16 years were at increased risk of developing mental health problems, future self harm, and problem substance misuse, with stronger associations for suicidal self harm than for non-suicidal self harm.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Data are missing at random, whereby any systematic differences between the missing and the observed values can be explained by differences in observed data.

  • The quote only partly states this claim.

    Findingown data

    Self harm without suicidal intent at age 16 is associated with increased risk of future self harm at age 21.

    “Participants who self harmed with and without suicidal intent at age 16 years were at increased risk of developing mental health problems, future self harm, and problem substance misuse, with stronger associations for suicidal self harm than for non-suicidal self harm.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Data are missing at random, whereby any systematic differences between the missing and the observed values can be explained by differences in observed data.

  • May combine two claims.

    Findingown data

    In univariable analysis, non-suicidal self harm was associated with reduced odds of not achieving three or more A levels (odds ratio 0.85, 95% confidence interval 0.67 to 1.08), but the finding did not reach conventional levels of significance.

    “but reduced among those with non-suicidal self harm (GCSE 0.83, 0.62 to 1.11 and A level 0.85, 0.67 to 1.08), although findings for non-suicidal self harm did not reach conventional levels of significance.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For depression and anxiety disorder, associations with suicidal self harm were attenuated in onset models, resulting in an overall reduction in the difference in risk between the two self harm groups.

    “However, for depression and anxiety disorder, associations with suicidal self harm were attenuated, resulting in an overall reduction in the difference in risk between the two self harm groups.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At age 16, self harm with and without suicidal intent was associated with later depression and anxiety disorder at age 18 and future self harm at age 21.

    “Self harm with and without suicidal intent at age 16 years were strongly associated with later depression and anxiety disorder at age 18 years and with future episodes of self harm at age 21 years (table 2).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Strong evidence for a difference between the self harm groups was found only for problem cannabis use (odds ratio 2.32, 95% confidence interval 1.31 to 4.10) and smoking regularly (odds ratio 1.42, 95% confidence interval 1.00 to 2.00).

    “strong evidence for a difference between the self harm groups was found only for problem cannabis use (odds ratio 2.32, 95% confidence interval 1.31 to 4.10) and smoking regularly (1.42, 1.00 to 2.00).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Poorer educational achievement was most prevalent among those with suicidal self harm, although educational outcomes seem to have been slightly better among those with non-suicidal self harm than among those who had never self harmed.

    “Poorer educational achievement was also most prevalent among those with suicidal self harm, although educational outcomes seem to have been slightly better among those with non-suicidal self harm than among those who had never self harmed.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In univariable analysis, non-suicidal self harm was associated with reduced odds of not achieving five or more GCSEs (odds ratio 0.83, 95% confidence interval 0.62 to 1.11), but the finding did not reach conventional levels of significance.

    “but reduced among those with non-suicidal self harm (GCSE 0.83, 0.62 to 1.11 and A level 0.85, 0.67 to 1.08), although findings for non-suicidal self harm did not reach conventional levels of significance.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For mental health outcomes, future self harm, and substance use there was evidence of a dose-response relation with lifetime self harm at age 16 years; the prevalence of each outcome was highest among participants who had self harmed with suicidal intent, lowest among those with no history of self harm, and approximately midway between the two for those who had self harmed without suicidal intent.

    “For mental health outcomes, future self harm, and substance use there was evidence of a dose-response relation with lifetime self harm at age 16 years; the prevalence of each outcome was highest among participants who had self harmed with suicidal intent, lowest among those with no history of self harm, and approximately midway between the two for those who had self harmed without suicidal intent.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The prevalence of self harm in the past year was 16.4% at age 16 and 7.3% at age 21.

    “the prevalence of self harm in the past year was 16.4% at age 16 years and 7.3% at age 21 years.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Whereas Moran et al found that 9 out of 10 adolescents who self harmed reported no further episodes of self harm in adulthood, this study found strong evidence for a high level of continuity in self harm between age 16 and 21 years.

    “whereas Moran et al found that 9 out of 10 adolescents who self harmed reported no further episodes of self harm in adulthood, we found strong evidence for a high level of continuity in self harm between age 16 and 21 years.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [10] Moran P, Coffey C, Romaniuk H, Olsson C, Borschmann R, Carlin JB, et al. The natural history of self-harm from adolescence to young adulthood: a population-based cohort study. Lancet 2012; 379: 236-43. 22100201

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    In a longitudinal population study, Moran et al found that risk of self harm declined during late adolescence, with most adolescents who self harmed reporting no further acts in adulthood.

    “Moran et al10 found that risk declined during late adolescence, with most adolescents who self harmed reporting no further acts in adulthood.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Moran et al10

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Self harm in adolescents has a lifetime risk of 13-18% in community studies.

    “Self harm in adolescents is an important public health concern, with community studies from around the world reporting a lifetime risk of 13-18%.1 2 3 4 5”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [1] Evans E, Hawton K, Rodham K, Psychol C, Deeks J. The prevalence of suicidal phenomena in adolescents: a systematic review of population-based studies. Suicide Life Threat Behav 2005; 35: 239-50. 16156486

      Not checked in the free run.

    • cites [2] Kidger J, Heron J, Lewis G, Evans J, Gunnell D. Adolescent self-harm and suicidal thoughts in the ALSPAC cohort: A self-report survey in England. BMC Psychiatry 2012; 12: 69. 22737989 PMC3439325

      Not checked in the free run.

    • cites [3] Hawton K, Rodham K, Evans E, Weatherall R. Deliberate self harm in adolescents: self report survey in schools in England. BMJ 2002; 325: 1207-11. 12446536 PMC135492

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    Other longitudinal studies of suicidal self harm (suicide attempts) in adolescence report associations with increased risk of psychiatric disorder, substance misuse, and future self harm in adulthood.

    “Other longitudinal studies have focused on suicidal self harm (suicide attempts) in adolescence and report associations with a range of adverse outcomes in adulthood, including an increased risk of psychiatric disorder, substance misuse, and future self harm.11 12”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [11] Goldman-Mellor S, Caspi A, Harrington H, Hogan S, Nada-Raja S, Poulton R, et al. Suicide attempt in young people: a signal for long-term healthcare and social needs. JAMA Psychiatry 2014; 71: 119-27. 24306041 PMC3946312

      Not checked in the free run.

    • cites [12] Fergusson DM, Horwood LJ, Ridder EM, Beautrais AL. Suicidal behaviour in adolescence and subsequent mental health outcomes in young adulthood. Psychol Med 2005; 35: 983-94. 16045065

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Risks were generally stronger in those who had self harmed with suicidal intent, but outcomes were also poor among those who had self harmed without suicidal intent.

    “Risks were generally stronger in those who had self harmed with suicidal intent, but outcomes were also poor among those who had self harmed without suicidal intent.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: Data are missing at random, whereby any systematic differences between the missing and the observed values can be explained by differences in observed data.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Premisecitation

    The extent to which self harm with and without suicidal intent represent distinct concepts or more or less extreme versions of the same behaviour is a source of debate.

    “The extent to which self harm with and without suicidal intent represent distinct concepts or more or less extreme versions of the same behaviour is a source of debate.13 14 15 16 17”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [13] Kapur N, Cooper J, O’Connor RC, Hawton K. Non-suicidal self-injury v. attempted suicide: new diagnosis or false dichotomy? Br J Psychiatry 2013; 202: 326-8. 23637107

      Not checked in the free run.

    • cites [14] Muehlenkamp JJ, Kerr PL. Untangling a complex web: how non-suicidal self-injury and suicide attempts differ. Prev Res 2010; 17: 8-10.20835367

      Not checked in the free run.

    • cites [15] Nock MK. Self-injury. Ann Rev Clin Psychol 2010; 6: 339-63. 20192787

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Establishing suicidal intent accompanying an episode of self harm is problematic, particularly when assessed retrospectively, as reports can be influenced by current mood state and may change over time.

    “Establishing suicidal intent accompanying an episode of self harm is problematic, particularly when assessed retrospectively, as reports can be influenced by current mood state and may change over time.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Researchers have begun to investigate whether there are differences in cause between self harm with and without suicidal intent.

    “Although researchers have begun to investigate whether there are differences in cause between these behaviours,18 19 20”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [18] Wichstrøm L. Predictors of non-suicidal self-injury versus attempted suicide: similar or different? Arch Suicide Res 2009; 13: 105-22. 19363748

      Not checked in the free run.

    • cites [19] Hargus E, Hawton K, Rodham K. Distinguishing between subgroups of adolescents who self-harm. Suicide Life Threat Behav 2009; 39: 518-37. 19929152

      Not checked in the free run.

    • cites [20] Mars B, Heron J, Crane C, Hawton K, Kidger J, Lewis G, et al. Differences in risk factors for self-harm with and without suicidal intent: Findings from the ALSPAC cohort. J Affect Disord 2014; 168: 407-14. 25108277 PMC4160300

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The study's approach is in line with previous research where individuals are classified as having a history of suicidal self harm if they report any non-zero level of self reported suicidal intent.

    “our approach is in line with previous research,15 where individuals are classified as having a history of suicidal self harm if they report any “non-zero” level of self reported suicidal intent.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [15] Nock MK. Self-injury. Ann Rev Clin Psychol 2010; 6: 339-63. 20192787

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Associations were generally stronger in relation to suicidal self harm, but non-suicidal self harm was also associated with adverse outcomes in adulthood.

    “Although associations were generally stronger in relation to suicidal self harm, non-suicidal self harm was also associated with adverse outcomes in adulthood.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The study extended previous work by investigating outcomes in a population based sample of adolescents.

    “We extended this by investigating outcomes in a population based sample of adolescents.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductown data

    Responders and non-responders to the self harm questionnaire at age 16 differed on a range of characteristics, showing that the data were not missing completely at random.

    “responders and non-responders to the self harm questionnaire administered at age 16 years differed on a range of characteristics, showing that the data were not missing completely at random”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    The study's findings add to the international debate about the extent to which these self harm behaviours represent distinct concepts or part of a continuum of suicidal behaviour.

    “Our findings add to the international debate about the extent to which these self harm behaviours represent distinct concepts or part of a continuum of suicidal behaviour.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The study's imputation models included a wealth of auxiliary information, which increases the plausibility of the missing at random assumption.

    “our imputation models included a wealth of auxiliary information, which increases the plausibility of the missing at random assumption.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The data are missing at random.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Determination of suicidal intent was based on self report and may include bias.

    “determination of suicidal intent was based on self report and may include bias”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Suicide attempts are strongly associated with psychiatric disorder.

    “Suicide attempts are strongly associated with psychiatric disorder,39 40”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [39] Hawton K, Saunders K, Topiwala A, Haw C. Psychiatric disorders in patients presenting to hospital following self-harm: a systematic review. J Affect Disord 2013; 151: 821-30. 24091302

      Not checked in the free run.

    • cites [40] Evans E, Hawton K, Rodham K. Factors associated with suicidal phenomena in adolescents: a systematic review of population-based studies. Clin Psychol Rev 2004; 24: 957-79. 15533280

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Existing follow-up studies have primarily been conducted in clinical samples, which account for less than 20% of self harm episodes in the community.

    “Existing follow-up studies have primarily been conducted in clinical samples, which account for less than 20% of self harm episodes in the community.2 3”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [2] Kidger J, Heron J, Lewis G, Evans J, Gunnell D. Adolescent self-harm and suicidal thoughts in the ALSPAC cohort: A self-report survey in England. BMC Psychiatry 2012; 12: 69. 22737989 PMC3439325

      Not checked in the free run.

    • cites [3] Hawton K, Rodham K, Evans E, Weatherall R. Deliberate self harm in adolescents: self report survey in schools in England. BMJ 2002; 325: 1207-11. 12446536 PMC135492

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    There is the possibility of residual confounding, whereby associations may be accounted for by an additional unmeasured variable.

    “There is also the possibility of residual confounding, whereby associations may be accounted for by an additional unmeasured variable.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Studies have suggested that those with a history of self harm are more likely to die by suicide if they have mental health or substance use problems.

    “as studies have suggested that those with a history of self harm are more likely to die by suicide if they have mental health or substance use problems.8 41”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [8] Hawton K, Harriss L. Deliberate self-harm in young people: characteristics and subsequent mortality in a 20-Year cohort of patients presenting to hospital. J Clin Psychiatry 2007; 68: 1574. 17960975

      Not checked in the free run.

    • cites [41] Hawton K, Fagg J, Platt S, Hawkins M. Factors associated with suicide after parasuicide in young people. BMJ 1993; 306: 1641. 8324431 PMC1678090

      Not checked in the free run.

  • May combine two claims.

    Interpretationnone given

    This is the first longitudinal study in the United Kingdom to examine outcomes of self harm in a general population sample, and the first study to investigate differences in clinical and social outcomes according to suicidal intent.

    “This is the first longitudinal study in the United Kingdom to examine outcomes of self harm in a general population sample, and it is the first study to investigate differences in clinical and social outcomes according to suicidal intent.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [2] Kidger J, Heron J, Lewis G, Evans J, Gunnell D. Adolescent self-harm and suicidal thoughts in the ALSPAC cohort: A self-report survey in England. BMC Psychiatry 2012; 12: 69. 22737989 PMC3439325

      Not checked in the free run.

    • cites [3] Hawton K, Rodham K, Evans E, Weatherall R. Deliberate self harm in adolescents: self report survey in schools in England. BMJ 2002; 325: 1207-11. 12446536 PMC135492

      Not checked in the free run.

34 of 34

  • The paper relies on this without support.

    Suicide attempts comprise a relatively small proportion of self harm acts.

    “However, suicide attempts comprise a relatively small proportion of self harm acts, and the longer term outcomes associated with non-suicidal self harm are not known.”

  • The paper relies on this without support.

    The longer term outcomes associated with non-suicidal self harm are not known.

    “However, suicide attempts comprise a relatively small proportion of self harm acts, and the longer term outcomes associated with non-suicidal self harm are not known.”

  • The paper relies on this without support.

    No studies have examined whether there are differences in outcomes, other than for repetition of self harm, between self harm with and without suicidal intent.

    “we are not aware of any studies that have examined whether there are differences in outcomes, other than for repetition of self harm.”

  • The authors state this as an assumption.

    Data are missing at random, whereby any systematic differences between the missing and the observed values can be explained by differences in observed data.

    “This method assumes that data are missing at random, whereby any systematic differences between the missing and the observed values can be explained by differences in observed data.38”

  • The authors state this as an assumption.

    The data are missing at random.

    “Under the missing at random assumption, multiple imputation should correct biases that may arise in the complete case analyses.”
    “Although we cannot say with certainty that the data are missing at random, our imputation models included a wealth of auxiliary information, which increases the plausibility of the missing at random assumption.”

  • The paper relies on this without support.

    Little is known about the longer term clinical and social outcomes of self harm in adolescents and whether outcomes differ among those who self harm with suicidal intent and those who self harm without suicidal intent.

    “Little is known about the longer term clinical and social outcomes of self harm in adolescents and whether outcomes differ among those who self harm with suicidal intent and those who self harm without suicidal intent”
6 of 6

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Authors
Mars, B., Heron, J., Crane, C., Hawton, K., Lewis, G., Macleod, J., Tilling, K., & Gunnell, D.
Affiliations
  • University of Bristol (GB)
  • Warneford Hospital (GB)
  • University College London (GB)
Corresponding author
Mars, B.
ORCID
Venue
BMJ
Publisher
BMJ
Published
2014-10-21
Volume
349
Issue
oct20 5
Pages
g5954-g5954
ISSN
1756-1833 (ISSN-L)
DOI
10.1136/bmj.g5954
PMC
PMC4205277
OpenAlex
W2169077504
Semantic Scholar
78a6dd8b03ff5113be280b748fe1fff44a8e8dd9
Cited by
311
References
44
Citations by year
2026: 25 · 2025: 32 · 2024: 30 · 2023: 28 · 2022: 29 · 2021: 34 · 2020: 36 · 2019: 19 · 2018: 29 · 2017: 17 · 2016: 16 · 2015: 12 · 2014: 3 · 2013: 1
FWCI
18.79
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • BMJ (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • HighWire Press Open Archive (submittedVersion)
  • Bristol Research (University of Bristol) (submittedVersion, other-oa)
  • Explore Bristol Research (submittedVersion, other-oa)
Funders
  • Wellcome Trust (102215, 092731, 104908)
  • National Institute for Health and Care Research (NF-SI-0508-10053, NF-SI-0512-10068)
  • University of Bristol (092731)
  • Medical Research Council (MR/J012661/1, MR/K023233/1, MC_PC_15018, MR/K006525/1, 092731)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
  • Social Sciences › Sociology and Political Science › Homicide, Infanticide, and Child Abuse
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Injury Epidemiology and Prevention
Keywords
adolescent self-harm, suicidal self-harm, non-suicidal self-injury, suicidal intent, depression, anxiety disorders, substance use, educational attainment, employment effects, early adulthood outcomes, mental health, Avon Longitudinal Study of Parents and Children
MeSH terms
Adolescent, Anxiety Disorders, Depressive Disorder, Educational Status, Employment, United Kingdom, Humans, Longitudinal Studies, Prognosis, Risk Factors, Self-Injurious Behavior, Substance-Related Disorders, Young Adult, Suicidal Ideation

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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