---
title: "Non-suicidal self-injury and later suicide attempts or death: protocol for a temporally ordered sy"
id: "plos-one-3-non-suicidal-self-injury-and-subsequent-suicide-attempts-and-death-a-protocol"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-3-non-suicidal-self-injury-and-subsequent-suicide-attempts-and-death-a-protocol"
content_type: "clinical_feed_article"
specialty: "General"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977"
published_at: "2026-09-10T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Non-suicidal self-injury and later suicide attempts or death: protocol for a temporally ordered sy
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-3-non-suicidal-self-injury-and-subsequent-suicide-attempts-and-death-a-protocol
- **Specialty:** [General](https://medichelpline.com/clinical-feed/general.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977)
- **Published At:** 2026-09-10T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This protocol outlines a systematic review to synthesise evidence on whether **non-suicidal self-injury (NSSI)** temporally precedes and predicts later suicide attempts or suicide death, focusing on temporally ordered observational studies only. - The review will prioritise behaviourally enacted suicidal outcomes (attempts, death) rather than suicidal ideation or plans, to preserve clinical specificity and severity distinctions. - The team registered the protocol on the Open Science Framework (OSF) and reports following PRISMA-P 2015, with planned reporting using PRISMA 2020. - Searches will be run in MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science; eligible designs include prospective and retrospective observational studies demonstrating temporal ordering between NSSI (exposure) and subsequent suicidal behaviour (outcome). - NSSI is defined as deliberate, self-inflicted tissue damage without suicidal intent; studies using broader terms (self-harm) are eligible only when suicidal intent was explicitly assessed and absent or data separable. - Primary question: among people with NSSI history, what is the evidence from temporally ordered studies for later suicide attempts or death? - Secondary questions examine whether NSSI characteristics (frequency, repetition, number of methods, recency) alter risk of subsequent attempts or death and whether prior NSSI is associated with escalation in lethality or clinical severity of subsequent attempts. - Data extraction and risk-of-bias assessment will be conducted independently by two reviewers using Joanna Briggs Institute tools; expected heterogeneity will likely necessitate a structured narrative synthesis rather than meta-analysis. - The review intends to address gaps in prior reviews that combined heterogeneous outcomes or lacked temporal specificity, and to inform clinical formulation, safety planning, and suicide prevention research by clarifying temporally ordered relationships and severity indicators. - The authors declared no specific funding and no competing interests; this protocol was published in PLoS One and includes formal registration details on OSF.
## Clinical Analysis & Structured Key Points
[ Skip to main content ](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#main-content) Advertisement * [plos.org](https://plos.org/) * [Create account](https://community.plos.org/registration/new) * [Sign in](https://journals.plos.org/user/secure/login?page=%2Fplosone%2Farticle%3Fid%3D10.1371%2Fjournal.pone.0357977) * * About * Browse * Publish * [](https://journals.plos.org/plosone/ "PLOS One") * Search [advanced search](https://journals.plos.org/plosone/search) * [Browse Topics](https://journals.plos.org/plosone/subjectAreaBrowse) Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click [here](https://github.com/PLOS/plos-thesaurus/blob/master/README.md "Link opens in new window"). [](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977) [](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977) * 0 [Save](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357977#savedHeader) [Total Mendeley and Citeulike bookmarks.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357977#savedHeader) * 0 [Citation](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357977#citedHeader) [Paper's citation count computed by Dimensions.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357977#citedHeader) * 42 [View](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357977#viewedHeader) [PLOS views and downloads.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357977#viewedHeader) * 0 [Share](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357977#discussedHeader) [Sum of Facebook, Twitter, Reddit and Wikipedia activity.](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357977#discussedHeader) Open Access Study Protocol # Non-suicidal self-injury and subsequent suicide attempts and death: A protocol for a systematic review of temporally ordered evidence * Anvar Sadath , Roles Conceptualization, Investigation, Methodology, Project administration, Resources, Software, Supervision, Visualization, Writing – original draft, Writing – review & editing * E-mail: avakkayil@unomaha.edu Affiliation Grace Abbott School of Social Work, College of Public Affairs and Community Service, University of Nebraska at Omaha, Omaha, Nebraska, United States of America [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0003-1378-5006 ](https://orcid.org/0000-0003-1378-5006 "ORCID Registry") ⨯ * Muhammed Thalil, Roles Conceptualization, Methodology, Writing – review & editing Affiliation Population Research Institute, Center for Health Ageing, The Pennsylvania State University, University Park, Pennsylvania, United States of America ⨯ * Susan Reay, Roles Conceptualization, Methodology, Writing – review & editing Affiliation Grace Abbott School of Social Work, College of Public Affairs and Community Service, University of Nebraska at Omaha, Omaha, Nebraska, United States of America ⨯ * Jaiden Davis, Roles Conceptualization, Methodology, Writing – review & editing Affiliation Grace Abbott School of Social Work, College of Public Affairs and Community Service, University of Nebraska at Omaha, Omaha, Nebraska, United States of America ⨯ * Zubair Kabir Roles Conceptualization, Methodology, Writing – review & editing Affiliation School of Public Health, University College Cork, Cork, Ireland [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0003-1529-004X ](https://orcid.org/0000-0003-1529-004X "ORCID Registry") ⨯ # Non-suicidal self-injury and subsequent suicide attempts and death: A protocol for a systematic review of temporally ordered evidence * Anvar Sadath, * Muhammed Thalil, * Susan Reay, * Jaiden Davis, * Zubair Kabir ![PLOS](https://journals.plos.org/resource/img/logo-plos-full-color.svg) x * Published: September 10, 2026 * * [Article](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977) * [Authors](https://journals.plos.org/plosone/article/authors?id=10.1371/journal.pone.0357977) * [Metrics](https://journals.plos.org/plosone/article/metrics?id=10.1371/journal.pone.0357977) * [Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0357977) * [Media Coverage](http://plos.altmetric.com/details/doi/10.1371/journal.pone.0357977) * [Abstract](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#abstract0) * [Background](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#sec005) * [Methods](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#sec008) * [Discussion](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#sec026) * [Supporting information](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#sec027) * [References](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#references) * [Reader Comments](https://journals.plos.org/plosone/article/comments?id=10.1371/journal.pone.0357977) ## Abstract ### Background Non-suicidal self-injury (NSSI) is a prevalent and clinically significant behaviour, particularly among adolescents and young adults, and is strongly associated with suicidal behaviour. However, existing reviews have often combined heterogeneous outcomes, including suicidal ideation, plans, attempts, and death, limiting the identification of clinically meaningful pathways. ### Objective This protocol describes a systematic review that aims to synthesise evidence on the temporally ordered relationship between NSSI and subsequent suicide attempts or death, and to examine whether characteristics of NSSI are associated with increased risk or severity of later suicidal behaviour. ### Methods This protocol is reported in accordance with PRISMA-P 2015 and registered with the Open Science Framework (OSF; ). A comprehensive search will be conducted in MEDLINE, Embase, PsycINFO, CINAHL, and Web of Science. Eligible studies will include prospective and retrospective observational studies demonstrating temporal ordering between NSSI and subsequent suicide attempts or death. Studies focusing solely on suicidal ideation will be excluded. Data extraction and risk-of-bias assessment will be conducted independently by two reviewers using Joanna Briggs Institute tools. Due to anticipated heterogeneity, findings will be synthesised using a structured narrative approach. ### Conclusion This review will provide a focused synthesis of evidence on the relationship between NSSI and subsequent suicidal outcomes, addressing gaps related to temporality, outcome specificity, and severity. The findings are expected to inform clinical formulation, safety planning, and future research on suicide prevention by improving understanding of factors associated with subsequent suicidal behaviour. **Citation:** Sadath A, Thalil M, Reay S, Davis J, Kabir Z (2026) Non-suicidal self-injury and subsequent suicide attempts and death: A protocol for a systematic review of temporally ordered evidence. PLoS One 21(9): e0357977. https://doi.org/10.1371/journal.pone.0357977 **Editor:** Hongyu Zou, South China Normal University, CHINA **Received:** May 4, 2026; **Accepted:** August 25, 2026; **Published:** September 10, 2026 **Copyright:** © 2026 Sadath et al. This is an open access article distributed under the terms of the [Creative Commons Attribution License](http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. **Data Availability:** This is a systematic review protocol. No datasets were generated or analysed during the current study. **Funding:** The author(s) received no specific funding for this work. **Competing interests:** The authors have declared that no competing interests exist. ## Background Self-injurious behaviours represent a major public health concern, particularly among adolescents and young adults [[1](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref001)]. Among these, non-suicidal self-injury (NSSI), defined as the deliberate, direct, and self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned (e.g., body piercing, tattooing), has emerged as a distinct clinical and research construct [[2](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref002),[3](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref003)]. Common methods of NSSI include cutting, hitting, scraping, burning, stabbing, and biting – with cutting (using knives) being the most prevalent practice [[4](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref004)], although emerging evidence indicates increased prevalence of scratching particularly in the clinical samples of adolescent and young adults [[5](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref005)]. NSSI is widely recognised as distinct from suicide attempts in terms of intent, lethality, function, and clinical presentation [[6](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref006),[7](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref007)]. In general, the most important distinction is the intention [[8](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref008)]. While suicide attempts are characterized by an intent to die, NSSI is typically performed to regulate emotional distress, reduce psychological tension, or cope with overwhelming affective states [[8](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref008)]. Despite these differences, a substantial body of research demonstrates that NSSI and suicidal behaviours are closely associated and frequently co-occur across both clinical and community populations [[9](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref009)]. Estimates suggest that a large proportion of individuals with a history of NSSI also report suicide attempts, highlighting the clinical importance of understanding this relationship [[9](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref009)]. Importantly, emerging evidence suggests that NSSI may not only co-occur with suicidal behaviour but may also precede and predict it [[10](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref010)]. Longitudinal and retrospective findings indicate that NSSI often occurs earlier in development than suicide attempts, with an observable temporal gap between onset of NSSI and subsequent suicidal behaviour [[9](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref009),[10](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref010)]. This temporal sequencing has led to increasing interest in NSSI as a potential precursor to subsequent suicidal behaviour [[9](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref009)]. The present review specifically focuses on the temporal transition from NSSI to subsequent suicide attempts or death, with particular emphasis on whether NSSI predicts not only occurrence but also greater lethality or clinical severity of later suicidal behaviour Theoretical models provide an important framework for understanding the progression from NSSI to more severe suicidal behaviour. The Interpersonal Theory of Suicide proposes that repeated exposure to painful and provocative experiences, such as NSSI, may increase an individual’s acquired capability for suicide through habituation to physical pain and reduced fear of death [[11](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref011),[12](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref012)]. Consistent with this theory, characteristics of NSSI, including greater frequency, repetition, and engagement in multiple methods, have been associated with later suicide attempts and more severe suicidal outcomes in some studies [[13](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref013),[14](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref014)]. The Integrated Motivational–Volitional (IMV) Model complements this perspective by distinguishing factors involved in the emergence of suicidal ideation from those that facilitate the transition to suicidal behaviour [[15](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref015)]. Together, these theoretical models provide a rationale for examining the temporal relationship between NSSI and subsequent suicide attempts or death. However, the extent to which longitudinal and retrospective evidence supports this relationship has not been comprehensively synthesised. Although prior reviews have established an association between NSSI and suicidal behaviour, important limitations remain. Narrative syntheses have primarily focused on shared risk factors and conceptual relationships rather than temporally ordered pathways [[16](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref016)]. Meta-analytic evidence from longitudinal studies has examined self-injurious thoughts and behaviours as a broad category, often combining suicidal ideation, plans, attempts, and death into a single outcome, thereby limiting the ability to isolate NSSI-specific trajectories or clinically meaningful temporal relationship [[17](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref017)]. Other reviews have focused on co-occurrence [[18](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref018)] or the longitudinal course of NSSI itself rather than its role as a predictor of subsequent suicidal outcomes [[3](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref003)]. While some previous reviews have examined specific aspects of the relationship between NSSI and suicidal behaviour, these have generally been limited in scope, included relatively small numbers of studies, or focused on selected outcomes rather than providing a comprehensive synthesis of temporally ordered evidence [[7](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref007)]. In addition, previous reviews have not systematically examined important dimensions such as suicide death, method lethality, or clinical severity. Furthermore, recent work highlights the limited availability of prospective evidence and the need for a better understanding of the temporal relationship between NSSI and subsequent suicidal behaviour [[9](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref009)]. Severity of suicide attempts may be reflected in indicators such as method lethality, degree of medical injury, or the need for clinical intervention, each representing distinct dimensions of risk. Importantly, combining heterogeneous outcomes -particularly suicidal ideation with suicide attempts and death—may obscure clinically meaningful differences in risk processes and severity. In contrast, suicide attempts and suicide death are behaviourally enacted outcomes with direct clinical and public health relevance. To our knowledge, no previous systematic review has comprehensively synthesised observational evidence while simultaneously: (1) defining NSSI as an exposure of interest (2) restricting outcomes to temporally ordered to suicide attempts or death, and (3) examining indicators of method lethality or clinical severity. By integrating these elements within a single systematic review, the present study is expected to provide a more focused understanding of the temporal relationship between NSSI and subsequent suicidal outcomes and to strengthen the evidence base for clinical formulation, safety planning, and future suicide prevention research. Contemporary clinical guidance recommends moving beyond categorical suicide risk stratification towards comprehensive psychosocial assessment, clinical formulation, and safety planning [[19](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref019),[20](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.ref020)]. ### Primary review question Among individuals with a history of non-suicidal self-injury, what is the evidence for a temporal relationship between NSSI and subsequent suicide attempts or death based on prospective or retrospective studies? ### Secondary review questions Within studies demonstrating temporal ordering: 1. To what extent do characteristics of NSSI (e.g., frequency, repetition, number of methods, or recency) influence the risk of subsequent suicide attempts or death? 2. Is prior NSSI associated with escalation in the lethality or clinical severity of subsequent suicide attempts (e.g., method lethality, medical consequences, or need for clinical intervention)? ## Methods This protocol describes a systematic review examining the temporal relationship between non-suicidal self-injury (NSSI) and subsequent suicide attempts or death, with particular attention to indicators of lethality and clinical severity. The protocol has been developed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 guidelines ([S1 Checklist](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0357977#pone.0357977.s001)). The completed review will be reported following the PRISMA 2020 statement. This systematic review protocol was prospectively registered with the Open Science Framework (OSF) Registries ( ). Any amendments to the protocol will be documented with the date, description of the change, and rationale, and updated in the registry. ### Eligibility criteria Eligibility criteria are structured using a Population–Exposure–Comparator–Outcome–Study design (PECO) framework. ### Population Studies will be eligible if they include individuals of any age who have engaged in self-injurious behaviours explicitly reported without suicidal intent. Eligible populations may include clinical samples, community samples, school-based populations, emergency department cohorts, and population-based datasets. Studies focusing exclusively on suicidal ideation/thinking or planning without behavioural self-injury will be excluded. ### Exposure The exposure of interest is non-suicidal self-injury (NSSI), defined as deliberate, self-inflicted injury without suicidal intent, as specified by the original study authors. Eligible exposures include: * NSSI assessed at baseline in prospective studies * history of NSSI (e.g., lifetime or past-year) in retrospective studies * self-injurious behaviour where suicidal intent is explicitly assessed and reported as absent Studies using broader terms such as “self-harm” or “deliberate self-harm” will be included only when suicidal intent is explicitly assessed and reported as absent, or when data relating sp
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