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We thank Dr Roaldset for his thoughtful comments on our meta-analysis, and appreciate the opportunity to discuss the important issue raised in Roaldset (2016). In his letter, Roaldset proposes an explanation for the poor predictive ability of prior self-injurious thoughts and behaviors (SITBs). Specifically, he hypothesized that when an individual is known to have a history of prior SITBs, other individuals (e.g. healthcare providers, researchers, family, friends) will invariably intervene to prevent future suicidal thoughts and behaviors. This is a reasonable and interesting potential explanation that we also considered upon obtaining our results. However, we were unable to find any empirical evidence to support this possibility; instead, we found several lines of evidence that led us to conclude that this explanation was unlikely.
First, large cross-national, population-based studies have found that most individuals who engage in SITBs do not receive treatment, with fewer than 40% of suicidal individuals worldwide receiving any form of intervention (Bruffaerts et al. 2011). The most common reason for not seeking treatment was low perceived need for care, followed by attitudinal (e.g. desire to handle one's problems) and structural barriers (e.g. financial concerns; Bruffaerts et al. 2011). Second, treatment usage has increased among individuals who engage in SITBs in recent decades; despite this, rates of suicidal thoughts and behaviors have remained virtually unchanged (Kessler et al. 2005). Third, existing evidence indicates that prior psychiatric treatment is associated with increased (rather than decreased) rates of future suicidal thoughts and behaviors (e.g. Dahlsgaard et al. 1998; Qin & Nordentoft, 2005). Aggregating across all existing longitudinal studies, our recent meta-analysis found that prior psychiatric treatment was the single strongest predictor of suicide death, and among the top predictors of suicide ideation and attempt (J. C. Franklin et al. unpublished data). These unfortunate patterns are inconsistent with the idea that prior SITBs are poor predictors because individuals with a SITB history commonly receive effective treatment or care.
We suggest an alternative interpretation of our findings. We hypothesize that prior SITBs are poor longitudinal predictors (i.e. risk factors) of future suicidal thoughts and behaviors because they have typically been considered in isolation. The processes that lead to suicidal thoughts and...