Soc Psychiatry Psychiatr Epidemiol (2011) 46:517–520 Table 1 Clinical and sociodemographic characteristics of patients with and without a history of previous self-harm Previous self-harm (n = 61) 25 (41.0) 36 (59) 29 (IQR 20–36) 37 (60.6) 24 (39.4) 28 (45.9) 4 (6.6) No previous self- harm (n = 637) 206 (32.3) 431 (67.7) 23 (IQR 18–34) 309 (48.5) 328 (51.5) 285 (44.7) 39 (6.1) Peradeniya (n, %) Polonnaruwa (n, %) Median age (IQR) Male (n, %) Female (n, %) Ingesting pesticides (n, %) Deaths (n, %) Discussion Only 8.7% of patients reported previous episodes of self- harm. This ﬁnding is consistent with a previous study from rural Sri Lanka which reported that only 8% of self-harm patients had previously self-harmed [17] and half that reported for urban Sri Lanka (17%) [7]. These ﬁgures are considerably lower than those reported in the West [3–6]. The main strengths of our study are its large size (n = 698 self-harm patients) and clinical assessment of past episodes of self-harm. However, it has a few limitations. Firstly, prospective data on repeat self-harm were not available as long-term follow-up of the study patients was not possible due to limited resources. Secondly, we relied on patient self- report of past self-harm; whilst under-reporting is possible, we found no evidence of previous episodes of self-harm from a search of the study databases in one of the hospitals. Lastly, patients who died at home or prior to transfer from rural hospital to our study hospitals were not included in our study; such patients may have a different proﬁle of previous self- harm compared to study participants. It is important to better understand the reasons for the low levels of repeat self-harm in rural Asia compared to the West. Possible explanations include: the high case-fatality ([5%) associated with the ﬁrst episode [18], meaning high- risk patients are removed from the pool of patients at risk of repetition; different approaches to the clinical manage- ment of index episodes with low levels of mental health follow-up; and differences in the aetiology of self-harm in rural Asia. Furthermore, the longer lengths of hospital stay in Sri Lankan hospitals (average 3–4 days) [19], in part due to the greater toxicity of the substances taken in episodes of self-poisoning and decisions by some physicians to observe patient on the medical ward, may contribute because the risk of repeat self-harm is greatest in the days immediately following an index event [6] and patients are less likely to repeat self-harm whilst in hospital. In contrast, in the West, the median length of hospital stay is around 1 day and many patients who present to hospital following self-harm are not admitted [6, 20]. Thus many patients at high risk of 519 Total (n = 698) 231 (33.0) 467 (67.0) 24 (IQR 19–35) 346 (49.5) 352 (50.5) 313 (44.8) 43 (6.1) repetition may be returned to their community and the pre- existing circumstances that surrounded their original self- poisoning within hours of their episode of self-harm. The case fatality amongst self-poisoning patients included over the period of our study was 7.7% (63/816). This ﬁgure is considerably higher than that reported in the West (0.5–1.5%) [21, 22]; but is in keeping with previous reports from Sri Lanka [18] and other studies from devel- oping countries in Asia [23, 24]. The higher case fatality mainly reﬂects the greater toxicity of the substances com- monly ingested by people who self-poison in Sri Lanka (pesticides and yellow oleander) compared to those taken by self-poisoning patients in the West (analgesics and psychotropic medications). Conclusion These data indicate that repetition of self-harm in Sri Lanka is very low, although prospective community-based studies are needed to conﬁrm this. Approaches to suicide prevention in rural Sri Lanka focussing on self-harm patients may therefore have limited impact on the inci- dence of fatal and non-fatal repeat self-harm. Acknowledgments We thank SACTRC doctors, directors, medical and nursing staff of the study hospitals for their immense support. The work was funded by a Wellcome Trust/NHMRC International Col- laborative Research Grant GR071669MA to SACTRC and a Career Development Fellowship to ME (GR063560MA). DG is a senior investigator at National Institute for Health Research (NIHR). Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which per- mits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited. References 1. WHO (2002) The world health report 2002. Reducing risks, promoting healthy life. WHO 123