Psychosocial assessment following self-harm: Results from the
Multi-Centre Monitoring of Self-Harm Project
Navneet Kapura,⁎, Elizabeth Murphya, Jayne Coopera, Helen Bergenb, Keith Hawtonb,
Sue Simkinb, Deborah Caseyb, Judith Horrocksc, Rachael Lilleyc,
Rachael Noblec, David Owensc
aCentre for Suicide Prevention, Williamson Building, University of Manchester, Oxford Road, Manchester M13 9PL, UK
bCentre for Suicide Research, University of Oxford, UK
cAcademic Unit of Psychiatry and Behavioural Sciences, University of Leeds, UK
Received 26 March 2007; received in revised form 10 July 2007; accepted 11 July 2007
Available online 29 August 2007
Background: Psychosocial assessment is central to the management of self-harm, but not all individuals receive an assessment
following presentation to hospital. Research exploring the factors associated with assessment and non-assessment is sparse. It is
unclear how assessment relates to subsequent outcome.
Methods: We identified episodes of self-harm presenting to six hospitals in the UK cities of Oxford, Leeds, and Manchester over an
18-month period (1st March 2000 to 31st August 2001). We used established monitoring systems to investigate: the proportion of
episodes resulting in a specialist assessment in each hospital; the factors associated with assessment and non-assessment; the
relationship between assessment and repetition of self-harm.
Results: A total of 7344 individuals presented with 10,498 episodes of self-harm during the study period. Overall, 60% of episodes
resulted in a specialist psychosocial assessment. Factors associated with an increased likelihood of assessment included age over
55 years, current psychiatric treatment, admission to a medical ward, and ingestion of antidepressants. Factors associated with a
decreased likelihood of assessment included unemployment, self-cutting, attending outside normal working hours, and self-
discharge. We found no overall association between assessment and self-harm repetition, but there were differences between
hospitals – assessments were protective in one hospital but associated with an increased risk of repetition in another.
Limitations: Some data may have been more likely to be recorded if episodes resulted in a specialist assessment. This was a non-
experimental study and so the findings relating specialist assessment to repetition should be interpreted cautiously.
Conclusion: Many people who harm themselves, including potentially vulnerable individuals, do not receive an adequate
assessment while at hospital. Staff should be aware of the organizational and clinical factors associated with non-assessment.
Identifying the active components of psychosocial assessment may help to inform future interventions for self-harm.
© 2007 Elsevier B.V. All rights reserved.
Keywords: Suicide; Self-harm; Psychosocial assessment; Service provision; Outcome
Self-harm is a major public health problem (National
Collaborating Centre for Mental Health, 2004) and is
Journal of Affective Disorders 106 (2008) 285–293
E-mail address: firstname.lastname@example.org (N. Kapur).
0165-0327/$ - see front matter © 2007 Elsevier B.V. All rights reserved.
strongly associated with subsequent suicide (Owens et al.,
2002). The association between self-harm and mental
illness is more contentious but studies using standardised
interviews suggest that over 90% of individuals have
with affective disorder being the single most common
diagnosis (Haw et al., 2001). Clinicians (Isacsson and
Psychiatrists, 2004; National Collaborating Centre for
Mental Health, 2004) agree that psychosocial assessment-
assessment of personal circumstances, social context,
mental state, risk, and needs-is central to the clinical
an assessment. It may improve access to aftercare (Kapur
et al., 1999; Barr et al., 2005) or may be therapeutic in its
own right (Whitehead, 2002; National Collaborating
Centre for Mental Health, 2004). However, there are
wide variations in practice between hospitals in England
with many patients not receiving an assessment (Kapur
et al., 1998; Bennewith et al., 2004). There is also
confusion about who should carry out psychosocial
assessments. Although non-specialist staff can be trained
to perform assessments, in practice most centres rely on
mental health staff (Royal College of Psychiatrists, 2004).
have been carried out in single centres (Hickey et al.,
2001; Barr et al., 2005) or in multiple centres over short
time periods using limited measures (Kapur et al., 1999;
Gunnell et al., 2004; Bennewith et al., 2005). There has
been little investigation of how assessment influences
outcome. Data from two small studies suggest that
psychosocial assessments may be protective — they
appear to be associated with a reduced risk of self-harm
repetition (Hickey et al., 2001; Kapur et al., 2002).
The Multi-Centre Monitoring of Self-Harm Project
was initiated in response to the National Suicide
Prevention Strategy for England (Department of Health,
2002). Its purpose is to provide high quality data from
national trends in self-harm. The current study reports
data from the first phase of the project. Our aim was to
investigate the role of specialist psychosocial assessment
in the management of patients following self-harm.
We had three specific objectives:
• To establish the proportion of episodes resulting in a
specialist assessment in each hospital.
• To investigate the determinants of assessment and
• To investigate the relation between assessment and
outcome, specifically the repetition of self-harm.
2.1. Setting and participants
The study centres (Oxford, Leeds, Manchester) have
been described in detail elsewhere (Hawton et al., 2007).
The study was carried out at the general hospitals that
hospital, Leeds — two hospitals, and Manchester —
three hospitals). Although all hospitals had multi-
disciplinary self-harm teams, the professional mix of
these teams, their working hours, and their supervision
arrangements varied (Table 1). Our focus in the current
study was the psychosocial assessment undertaken by
mental health specialists. In Oxford and Leeds specialist
staff carried out all psychosocial assessments. In Man-
chester, in addition to assessments by specialists, more
limited proforma-based assessments were carried out by
as specialist assessments in the current study. We iden-
tified episodes of hospital attendance due to self-harm
2001). Self-harm was defined as intentional self-poi-
soning or self-injury, irrespective of motivation (Hawton
et al., 2003).
2.2. Data collection
We used established monitoring systems which had
and clinical data and details of hospital management for
each episode. Each centre collected data acording to
clearly defined methodology (Horrocks et al., 2002;
Hawton et al., 2003; Kelly et al., 2004). In Oxford this
involved completion of self-harm assessment forms by
specialist clinicians at the time of assessment and
examination of case records by research staff for non-
assessed patients. In Manchester, data were collected
using forms that were completed by emergency depart-
data were collected primarily by detailed examination of
in this study included sociodemographic characteristics
(age, gender, employment status), clinical characteristics
(method of self-harm (with subgroups for poisoning, self-
cutting, and other self-injury — e.g. jumping, asphyxia-
tion, drowning), time of presentation to the emergency
department, alcohol use at the time of the episode or up to
history of self-harm, admission to a medical ward), and
information relating to the main categories of substance
taken in overdose.
286N. Kapur et al. / Journal of Affective Disorders 106 (2008) 285–293
The different methods of data collection meant that
not all variables were available for all centres. More
recently, the study centres have collected data on all self-
harm episodes but for this study period data coverage
varied. For example, in Manchester no data were col-
lected for those who left before an assessment could be
carried out. Repeat episodes were determined in each
centre by data linkage using individual identifiers. The
three sets of data were then pseudonymised and merged.
2.3. Data analysis
Analyses were carried out using SPSS version 12.0
for Windows (SPSS Inc, 2003) and Intercooled Stata
version 8.0 (Statacorp, 2003a). We wished to use the
whole dataset to investigate which variables were
associated with receipt of a specialist psychosocial
assessment and so we carried out an episode-based
data did not constitute a random sample due to the
method of data collection, and so we repeated the
analysis after weighting for the total number of episodes
in each hospital and adjusting for clustering (Statacorp,
2003b). Variables that were statistically significant
( pb0.05) and available for all centres were then entered
into a multivariate model to examine which factors were
independently associated with assessment. In order to
examine the association between psychosocial assess-
ment and repetition we used survival analysis (Cox's
regression) to compare the risk of repetition in in-
dividuals who did and did not receive a psychosocial
assessment following their first self-harm presentation
during the study period. The resulting hazard ratios were
then adjusted for baseline differences in case mix by
including age, sex, previous self-harm, and method of
harm in the regression model. Hazard ratios were
calculated for the whole sample and then for individual
Self-harm services and the proportion of episodes resulting in a specialist psychosocial assessment
Oxford Leeds Manchester
Hospital A Hospital BHospital C Hospital D Hospital EHospital F
Mixed urban and
Urban — relatively deprivedUrban — significantly deprived
Personnel Self-harm team
9am–5pm 7 days
(psychiatric nurses, social
workers and dedicated
junior psychiatrists) 9am–
5pm 5 days a week. ED
mental health community
nurses for non-assessed
(psychiatric nurses, social
workers and junior
psychiatrists on a rota).
9am–5pm 5 days a week.
ED mental health
community nurses for
9am–5pm 5 days a week.
Mental health liaison
team (psychiatric nurses)
covering 7 days a week
until 11pm. Junior
psychiatrists on rota basis
for out of area patientsa
On call junior
7 days a
7 days a
Out of hours On call junior
On call junior
On call junior
71% (1710/2401) 63% (1265/2004)
Initial assessments and
outpatient aftercare for
Initial assessments and
outpatient aftercare for
Initial assessments and
outpatient aftercare for
54% (847/1564)42% (551/1304)
For Oxford assessment status known for all episodes, for Manchester assessment status known for all episodes with assessment forms (approximately
70% of all episodes), for Leeds assessment status known for 80% of episodes (Hospital B) and 67% of episodes (Hospital C) because access to
hospital in-patient notes was not permitted. All denominators include valid cases only.
aIn Hospitals D,E,F, patients not seen by specialists were assessed by Emergency Department doctors using a structured proforma.
287 N. Kapur et al. / Journal of Affective Disorders 106 (2008) 285–293
2.4. Ethical approval
The monitoring systems in Oxford and Leeds have
approval from their Local Research EthicsCommittees. In
Manchester the self-harm monitoring is part of a clinical
audit system, and has permission to operate as such from
the three Local Research Ethics Committees in Manche-
ster. All monitoring systems are fully compliant with the
provisions of the Data Protection Act of 1998. All centres
also have approval under Section 60 of the Health and
Social Care Act 2001 regarding the use of patient
3.1. General characteristics of the sample
The sample consisted of 7344 individuals presenting
with 10,498 episodes of self-harm in the 18-month
period, 1st March 2000 to 31st August 2001. Their
Factors associated with specialist psychosocial assessment
Variable CategoriesNumber of
Up to 24
Other (e.g. retired,
household duties, student)
Age in years
Method of self-harm Self-poisoning only
Self-poisoning and self-injury
Office hrs (9am–5pm)
Early morning (1am–9am)
Time of presentation to emergency department
Current psychiatric treatment1
Admission to medical ward2
Substances taken in overdose
SSRI or SNRI
1Data from one centre only;2Data from two centres only. The level of data completeness for all variables was 84% or higher.
288N. Kapur et al. / Journal of Affective Disorders 106 (2008) 285–293
median age was 30 years (IQR 22 to 40 years, range
from 11 to 100 years) and 4186 (57%) were female. The
most common method of harm was self-poisoning with
drugs (8483 episodes, 81%) and the substances most
commonly ingested in overdose (categories not mutu-
ally exclusive) were pure paracetamol (2621 episodes,
31%), antidepressants (1865 episodes, 21%), and
benzodiazepines (1216 episodes, 14%). In total 1,234
individuals (16.8%, 95%CI: 16.0% to 17.7%) repeated
self-harm within the whole study period. The majority
of these subjects (706, 57%) repeated on a single
occasion, but the number of repetitions ranged from 1 to
Information on whether or not a psychosocial
assessment had been carried out was available for
9231 episodes (88%). The analyses below refer to these
3.2. Specialist psychosocial assessment
Overall, 5546/9231 episodes (60%) resulted in a
specialist psychosocial assessment. This proportion
varied between hospitals (42% to 71%) — Table 1.
Table 2 shows the association of sociodemographic
and clinical variables with specialist psychosocial assess-
ment. Factors associated with an increased likelihood of
an assessment included age over 55 years, current psy-
chiatric treatment, admission to a medical ward, and in-
gestion of antidepressants. Factors associated with a
decreased likelihood of an assessment included unem-
ployment, ‘other occupational status’, self-cutting, pre-
sentation outside normal working hours, and self-
discharge. Weighting and adjusting for clustering made
little difference to the results — all the statistically sig-
nificant factors in Table 2 remained significant. The
factors associated with assessment did not vary markedly
We included only a limited number of variables in the
multi-variate model (age, method of harm, time of
presentation, self-discharge, ingestion of an antidepres-
sant) so the results should be interpreted cautiously. The
following were independently associated with receiving
a specialist psychosocial assessment (OR (95%CI)): age
over 55 years (1.45 (1.0 to 2.11)) and taking an
antidepressant in overdose (1.71 (1.30 to 2.27)). Factors
associated with decreased likelihood of assessment
were: self-cutting as a method of harm (0.47 (0.29 to
0.78)) and self-discharge (0.02 (0.01 to 0.07)).
3.3. Specialist psychosocial assessment and repetition
Fig. 1 shows the association between specialist
assessment and subsequent self-harm repetition. Overall
we found no association between assessment and
repetition, but there were some interesting differences
in the hazard ratios between hospitals. Specialist
assessment was associated with a significantly reduced
risk of repetition in hospital A (which had the highest
proportion of assessed episodes) but with a significantly
increased risk of repetition in hospital D (which had the
lowest proportion of assessed episodes). Adjusting for
age, sex, previous self-harm, and method of harm made
little difference to the hazard ratios.
Fig. 1. Hazard ratios for repetition of self-harm. The hazard ratios compare the risk of repetition for individuals who received a psychosocial
assessment following their first self-harm presentation during the study period with those who did not. The hazard ratios are presented for all centres
together and then by individual hospital.
289 N. Kapur et al. / Journal of Affective Disorders 106 (2008) 285–293
4.1. Main findings
Everyone attending hospital should receive an ade-
quate assessment following an episode of self-harm.
Overall we found that only 60% of episodes resulted in
such an assessment, and the proportion varied markedly
by hospital. The three centres included in this study had
well established self-harm teams and monitoring sys-
a whole an even smaller proportion of episodes are
assessed (Gunnell et al., 2004).
We found that certain groups such as the unem-
ployed, the young and those who cut themselves, were
less likely to receive a specialist assessment. This is of
concern because these are groups for whom the risk of
adverse outcomes may be elevated (Zahl and Hawton,
2004; Cooper et al., 2005; Kapur et al., 2006). Our
findings suggest that the reasons for non-assessment
may be both administrative (for example, attending
outside of office hours, discharge directly from the
emergency department, self discharge)and clinical (self-
cutting as a method of harm, absence of factors
indicating current psychiatric disorder or treatment).
Our results are consistent with those of large-scale
surveys involving limited numbers of predictor vari-
ables (Gunnell et al., 2004; Bennewith et al., 2005).
However, a study involving more detailed data collec-
tion in a single hospital suggested that certain high risk
clinical groups (for example, those who took medically
serious overdoses, those without social support, those
with alcohol or mental health problems, those in contact
with specialist services) were more likely to receive an
assessment (Barr et al., 2005).
The provision of a specialist assessment may influ-
ence the future risk of repetition and this relationship
may vary across centres. We found that in the hospital
with the highest proportion of assessed episodes,
specialist assessment appeared to be protective. This
could reflect improved access to services-there is limited
evidence from previous studies that receiving a
specialist assessment increases the likelihood of psy-
chiatric out-patient or in-patient referral (Kapur et al.,
1999; Barr et al., 2005). In the hospital with the lowest
proportion of assessed episodes, assessment was asso-
ciated with an increased likelihood of repetition. We do
not think this latter finding indicates that psychosocial
assessments are harmful. It is more likely to reflect a
‘high risk’ approach to management. That is, only the
patients at highest risk of future suicidal behaviour
receive a specialist assessment in hospitals where the
overall rate of assessment is low, hence accounting for
the apparent association of assessment with repetition.
4.2. Methodological issues
episodes in three centres, with good case ascertainment.
The sample size was over twice that included in previous
studies (Bennewith et al., 2004) allowing us to estimate
with precision the association between a wide range of
patient related variables and psychosocial assessment.
Our findings need to be interpreted in the context of a
number of methodological issues. A bias may have been
introducedbecause somedata may have been more likely
to be recorded if episodes resulted in a specialist
assessment. We attempted to minimise this by only con-
sidering a limited range of core variables for which there
were relatively complete data. A major task for the first
18monthsofthe Multi-CentreProject was harmonisation
of the databases and we do not think that the difference in
the methods of data capture between sites was a major
source of bias. However, we cannot dismiss this pos-
data collection across centres.
This study involved a non-random sample of six hos-
pitals. Although we repeated our analysis after weighting
to the findings) caution is needed in generalizing the
results to other centres. Although case ascertainment was
good, non ascertainment may also have resulted in bias.
For example, in Manchester no data were collected for
who were not assessed by hospital staff for other reasons.
Males and those who cut themselves may thereby have
been somewhat under-represented in the Manchester
we did not have details of assessment status for some
episodes. Using the available data in this study, those for
whom assessment status was not known were similar in
terms of gender and age to those for whom assessment
status was known, but were slightly more likely to have
did not result in a specialist assessment are overrepresent-
ed in this ‘not known’ group. This may mean that the
figures for the proportion of episodes assessed in Leeds
and Manchester hospitals in Table 2 are overestimates.
This was a non-experimentalstudy andsothe findings
relating specialist assessment to repetition should be
interpreted cautiously. Although we attempted to adjust
for some baseline differences between groups, the
apparent associations between assessment and repetition
290N. Kapur et al. / Journal of Affective Disorders 106 (2008) 285–293
could simply reflect the characteristics of those who did
and did not receive an assessment.
We chose to study repetition in this study because it is
one ofthe mostthe mostcommonlyreportedoutcomesin
studies of self-harm (Owens et al., 2002). It is also one of
the most important because of the scale of repetition
(Kapur et al., 2006) and the association with completed
suicide (Zahl and Hawton 2004; Cooper et al., 2005). In
common with the vast majority of hospital-based stud-
ies of self-harm, we did not include repeat episodes for
Evidence suggests that the majority of treated episodes of
suicidal behavior in the British Isles present to hospital –
very few are seen by general practitioners (Crawford and
Wessley, 1998; Corcoran et al., 2004). However, we
would not have picked up repeat episodes in the
community that did not come to medical attention. We
did not obtain data on repeat self-harm episodes of
individuals who subsequently attended non-participating
hospitals. The hospitals had geographically defined
catchment areas and in Oxford and Leeds there were no
other hospitals inthe immediate vicinity(soattendanceto
non-participating centres is unlikely to have been a major
how many self-harm episodes presented out of area, but
data from within the Manchester district suggested first
repeat episodes resulted in presentation to the same
hospitals as the index episodes in 80–90% of cases
(Kapur et al., 2006). A recent audit of local emergency
departments, suggested that less than 5% of all atten-
dances by Manchester residents occurred to hospitals
outside the study area. Examination of other outcomes
example, admissions (both voluntary and under the
Mental Health Act), other onward referrals, receipt of
psychological therapies, and completed suicide. We plan
related to multi-centre monitoring. However, the inves-
tigation of outcomes such as in-patient and outpatient
psychiatric referral in relation to receipt of a specialist
assessment may be problematic. In many hospitals
patients may only be able to access psychiatric care
following an assessment by a mental health specialist.
In our analysis we could have chosen to consider the
first episode of self-harm by each individual during the
study period rather than all episodes. However, restrict-
ing our analysis in this way would have excluded
over 2500 repeat episodes. Most clinicians would agree
that every incident of self-harm should result in a
specialist assessment. It is possible that our episode-
based analysis may have exaggerated some of the odds
ratios in Table 2 — but only if the assessment status of
individuals did not vary between episodes. When we
examine assessment in this way, our data suggest that
only 60% of individuals receive the same management
(in terms of a psychosocial assessment) for their first and
second episodes during the study. In fact, a post hoc
analysis showed that analysis according to first (rath-
er than all) episodes had little effect- only one of the
significant odds ratios in Table 2 failed to reach sta-
tistical significance (other antidepressant OR (95%CI):
1.53 (0.97 to 2.40)).
Previous self-harm was a binary variable in this study,
but it would have been interesting to investigate assess-
as the frequency of prospectively identified self-harm
increases, the likelihood of a psychosocial assessment
period to 53% for the fifth or subsequent episode).
4.3. Clinical and research implications
There is consensus among professionals and service
users that all patients who present to hospital following
self-harm should receive an adequate assessment (Na-
tional Collaborating Centre for Mental Health, 2004).
Non-specialist staff can be trained to assess suicidal
individuals (Morriss et al., 1999) and the use of audit
forms and checklists can help (Kelly et al., 2004; Dennis
training and time to carry out detailed assessments, and
these will be carried out by mental health staff in most
centres (Royal College of Psychiatrists, 2004). However,
recent changes to patterns of working mean that junior
psychiatrists (who still carry out the bulk of out of hours
undertake supervised assessments (Woodall et al., 2006).
Service configuration also has a key role to play in the
Psychiatrists, 2004 for a fuller discussion).
Our findings suggest that certain groups of potentially
vulnerable individuals who have self-harmed tend to be
excluded from the assessment process. Clinicians should
be aware of the organizational and clinical factors
associated with non-assessment. Steps should be taken
to ensure that everyone who attends is seen by
appropriately trained staff. Self-harm care pathways and
protocols may increase the rate of assessment (Lepping et
prematurely, proactive follow up may be beneficial
(National Collaborating Centre for Mental Health, 2004).
There seems to be some evidence from this study and
others that psychosocial assessments may be protective in
291N. Kapur et al. / Journal of Affective Disorders 106 (2008) 285–293
certain circumstances; this proposal needs to be investi-
gated in future work, although randomised trials are
wider range of outcomes, should examine temporal trends,
and might be strengthened by consistent methods of data
capture. As well as reducing repetition, assessments may
also have other positive implications for the managements
of patients who self-harm, for example appropriate
recognition and management of psychiatric disorders
(Isacsson and Rich, 2001), assessment of risks and needs
(National Collaborating Centre for Mental Health, 2004),
2005). Of course, such assessments are important not only
in those who self-harm but in individuals with mental
psychosocial assessments could relate to the assessor, the
need to be delineated in future studies. This could help to
inform interventions for self-harm, particularly with
respect to patient recruitment and engagement, which
may be problematic in this population (Hawton and
Role of funding source
Funding for this study was provided by the National Institute of
of the report; and in the decision to submit the paper for publication.
Conflict of interest
The authors from Oxford thank Elizabeth Bale and
Anna Shepherd and members of the general hospital
psychiatric services for their assistance with data
collection. The authors from Manchester would like to
forms and the research team for the data collection (Ben
Palmer, Iain Donaldson, Maria Healey and Stella
Dickson). The authors from Leeds thank colleagues in
the Emergency Departments — the clinicians and, in
particular, the clerical and administrative staff. We would
also like to thank two anonymous reviewers for their
comments on the manuscript. The views expressed are
solely those of the authors.
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