title: Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies.
abstract: BACKGROUND
  A history of self-injurious thoughts and behaviors (SITBs) is consistently cited as one of the strongest predictors of future suicidal behavior. However, stark discrepancies in the literature raise questions about the true magnitude of these associations. The objective of this study is to examine the magnitude and clinical utility of the associations between SITBs and subsequent suicide ideation, attempts, and death.
  
  
  METHODS
  We searched PubMed, PsycInfo, and Google Scholar for papers published through December 2014. Inclusion required that studies include at least one longitudinal analysis predicting suicide ideation, attempts, or death using any SITB variable. We identified 2179 longitudinal studies; 172 met inclusion criteria.
  
  
  RESULTS
  The most common outcome was suicide attempt (47.80%), followed by death (40.50%) and ideation (11.60%). Median follow-up was 52 months (mean = 82.52, s.d. = 102.29). Overall prediction was weak, with weighted mean odds ratios (ORs) of 2.07 [95% confidence interval (CI) 1.76-2.43] for ideation, 2.14 (95% CI 2.00-2.30) for attempts, and 1.54 (95% CI 1.39-1.71) for death. Adjusting for publication bias further reduced estimates. Diagnostic accuracy analyses indicated acceptable specificity (86-87%) and poor sensitivity (10-26%), with areas under the curve marginally above chance (0.60-0.62). Most risk factors generated OR estimates of <2.0 and no risk factor exceeded 4.5. Effects were consistent regardless of sample severity, sample age groups, or follow-up length.
  
  
  CONCLUSIONS
  Prior SITBs confer risk for later suicidal thoughts and behaviors. However, they only provide a marginal improvement in diagnostic accuracy above chance. Addressing gaps in study design, assessment, and underlying mechanisms may prove useful in improving prediction and prevention of suicidal thoughts and behaviors.
authors.affiliation: Department of Psychology,Harvard University,Cambridge,MA,USA.
authors.forename: J D
authors.initials: JD
authors.lastname: Ribeiro
authors.affiliation: Department of Psychology,Harvard University,Cambridge,MA,USA.
authors.forename: J C
authors.initials: JC
authors.lastname: Franklin
authors.affiliation: Department of Psychology,Harvard University,Cambridge,MA,USA.
authors.forename: K R
authors.initials: KR
authors.lastname: Fox
authors.affiliation: Center for Anxiety and Related Disorders,Boston University,Boston,MA,USA.
authors.forename: K H
authors.initials: KH
authors.lastname: Bentley
authors.affiliation: Department of Psychology,Harvard University,Cambridge,MA,USA.
authors.forename: E M
authors.initials: EM
authors.lastname: Kleiman
authors.affiliation: Department of Medicine,Columbia University,New York,NY,USA.
authors.forename: B P
authors.initials: BP
authors.lastname: Chang
authors.affiliation: Department of Psychology,Harvard University,Cambridge,MA,USA.
authors.forename: M K
authors.initials: MK
authors.lastname: Nock
mesh_terms: D006801:Humans; D008137:Longitudinal Studies; D009026:Mortality; D012307:Risk Factors; D016728:Self-Injurious Behavior / Q000453:epidemiology* / Q000523:psychology; D059020:Suicidal Ideation; D013405:Suicide / Q000523:psychology / Q000706:statistics & numerical data; D013406:Suicide, Attempted / Q000523:psychology / Q000706:statistics & numerical data*
keywords: Longitudinal; meta-analysis; prediction; suicidal ideation; suicide; suicide attempt