title: Which are the most useful scales for predicting repeat self-harm? A systematic review evaluating risk scales using measures of diagnostic accuracy.
abstract: OBJECTIVE
  The aims of this review were to calculate the diagnostic accuracy statistics of risk scales following self-harm and consider which might be the most useful scales in clinical practice.
  
  
  METHODS
  Systematic review.
  
  
  METHODS
  We based our search terms on those used in the systematic reviews carried out for the National Institute for Health and Care Excellence self-harm guidelines (2012) and evidence update (2013), and updated the searches through to February 2015 (CINAHL, EMBASE, MEDLINE, and PsychINFO). Methodological quality was assessed and three reviewers extracted data independently. We limited our analysis to cohort studies in adults using the outcome of repeat self-harm or attempted suicide. We calculated diagnostic accuracy statistics including measures of global accuracy. Statistical pooling was not possible due to heterogeneity.
  
  
  RESULTS
  The eight papers included in the final analysis varied widely according to methodological quality and the content of scales employed. Overall, sensitivity of scales ranged from 6% (95% CI 5% to 6%) to 97% (CI 95% 94% to 98%). The positive predictive value (PPV) ranged from 5% (95% CI 3% to 9%) to 84% (95% CI 80% to 87%). The diagnostic OR ranged from 1.01 (95% CI 0.434 to 2.5) to 16.3 (95%CI 12.5 to 21.4). Scales with high sensitivity tended to have low PPVs.
  
  
  CONCLUSIONS
  It is difficult to be certain which, if any, are the most useful scales for self-harm risk assessment. No scales perform sufficiently well so as to be recommended for routine clinical use. Further robust prospective studies are warranted to evaluate risk scales following an episode of self-harm. Diagnostic accuracy statistics should be considered in relation to the specific service needs, and scales should only be used as an adjunct to assessment.
authors.affiliation: Centre for Mental Health and Safety, University of Manchester, Manchester, UK.
authors.forename: L
authors.identifier: http://orcid.org/0000-0002-3944-3613
authors.initials: L
authors.lastname: Quinlivan
authors.affiliation: Centre for Mental Health and Safety, University of Manchester, Manchester, UK.
authors.forename: J
authors.initials: J
authors.lastname: Cooper
authors.affiliation: Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: L
authors.initials: L
authors.lastname: Davies
authors.affiliation: Department of Psychiatry, Centre for Suicide Research, University, Warneford Hospital, Oxford, UK.
authors.forename: K
authors.initials: K
authors.lastname: Hawton
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: D
authors.initials: D
authors.lastname: Gunnell
authors.affiliation: Centre for Mental Health and Safety, University of Manchester, Manchester, UK Manchester Mental Health and Social Care Trust, Manchester, UK.
authors.forename: N
authors.initials: N
authors.lastname: Kapur
mesh_terms: D000328:Adult; D006801:Humans; D018570:Risk Assessment / Q000706:statistics & numerical data*; D016728:Self-Injurious Behavior / Q000175:diagnosis* / Q000453:epidemiology; D012680:Sensitivity and Specificity; D013406:Suicide, Attempted / Q000706:statistics & numerical data
keywords: Diagnostic accuracy; HEALTH SERVICES ADMINISTRATION & MANAGEMENT; PSYCHIATRY; PUBLIC HEALTH