title: The development of a population-level clinical screening tool for self-harm repetition and suicide: the ReACT Self-Harm Rule.
abstract: BACKGROUND
  Self-harm is a common reason for Emergency Department (ED) attendance. We aimed to develop a clinical tool to help identify patients at higher risk of repeat self-harm, or suicide, within 6 months of an ED self-harm presentation.
  
  
  METHODS
  The tool, the ReACT Self-Harm Rule, was derived using multicentre data from a prospective cohort study. Binary recursive partitioning was applied to data from two centres, and data from a separate centre were used to test the tool. There were 29 571 self-harm presentations to five hospital EDs between January 2003 and June 2007, involving 18 680 adults aged ⩾16 years. We estimated sensitivity, specificity and positive and negative predictive values to measure the performance of the tool.
  
  
  RESULTS
  A self-harm presentation was classified as higher risk if at least one of the following factors was present: recent self-harm (in the past year), living alone or homelessness, cutting as a method of harm and treatment for a current psychiatric disorder. The rule performed with 95% sensitivity [95% confidence interval (CI) 94-95] and 21% specificity (95% CI 21-22), and had a positive predictive value of 30% (95% CI 30-31) and a negative predictive value of 91% (95% CI 90-92) in the derivation centres; it identified 83/92 of all subsequent suicides.
  
  
  CONCLUSIONS
  The ReACT Self-Harm Rule might be used as a screening tool to inform the process of assessing self-harm presentations to ED. The four risk factors could also be used as an adjunct to in-depth psychosocial assessment to help guide risk formulation. The use of multicentre data helped to maximize the generalizability of the tool, but we need to further verify its external validity in other localities.
authors.affiliation: Psychiatry Research Group, University of Manchester, UK.
authors.forename: S
authors.initials: S
authors.lastname: Steeg
authors.affiliation: Psychiatry Research Group, University of Manchester, UK.
authors.forename: N
authors.initials: N
authors.lastname: Kapur
authors.affiliation: Psychiatry Research Group, University of Manchester, UK.
authors.forename: R
authors.initials: R
authors.lastname: Webb
authors.affiliation: Psychiatry Research Group, University of Manchester, UK.
authors.forename: E
authors.initials: E
authors.lastname: Applegate
authors.affiliation: Psychiatry Research Group, University of Manchester, UK.
authors.forename: S L K
authors.initials: SL
authors.lastname: Stewart
authors.affiliation: The University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford, UK.
authors.forename: K
authors.initials: K
authors.lastname: Hawton
authors.affiliation: The University of Oxford, Department of Psychiatry, Warneford Hospital, Oxford, UK.
authors.forename: H
authors.initials: H
authors.lastname: Bergen
authors.affiliation: Resource Centre, Derbyshire Royal Infirmary, Derby, UK.
authors.forename: K
authors.initials: K
authors.lastname: Waters
authors.affiliation: Psychiatry Research Group, University of Manchester, UK.
authors.forename: J
authors.initials: J
authors.lastname: Cooper
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D004739:England / Q000453:epidemiology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011569:Psychiatric Status Rating Scales / Q000592:standards*; D011594:Psychometrics / Q000295:instrumentation*; D018570:Risk Assessment; D016728:Self-Injurious Behavior / Q000175:diagnosis* / Q000453:epidemiology; D055815:Young Adult