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Keywords:

  • Self-harm;
  • suicide;
  • adolescents;
  • epidemiology;
  • accident and emergency

Abstract

  1. Top of page
  2. Abstract
  3. Acknowledgement
  4. Correspondence
  5. References

The preceding article by Hawton and colleagues reporting on a prospective study of adolescents presenting with self-harm to Accident and Emergency departments (A&E) is one of the largest epidemiological studies to examine the long-term outcomes of selfharm in children and adolescents. After a median of 6 years nearly 30% re-presented to A&E with self-harm and 1% died, half of those due to likely suicide and the rest mainly due to accidents. It may be that many accidental deaths were also suicides judging from the method of death. In comparison to adults presenting with self-harm, the absolute risk of suicide was lower despite a high self-harm repetition rate. Self-injury by cutting was a strong independent predictor of suicide as was previous psychiatric treatment and previous self-harm. Finally the eventual method of suicide was different from that used at either the first or the last episode of selfharm. This is at odds with the data generated by adult literature which consistently shows that those with the most violent methods of selfharm, e.g. attempted hanging or shooting, tend to also die using these methods.

In summary the field of adolescent self-harm is of immense importance and requires urgent research to develop our ability to predict those likely to die of suicide, and to offer effective treatment to those at risk. The article by Hawton and colleagues is an important step in our understanding of the risk factors of suicide in those adolescents who present with self-harm and in highlighting the overlapping nature of self-injury and self-poisoning in relation to suicide.

The preceding article by Hawton and colleagues reporting on a prospective study of adolescents presenting with self-harm to Accident and Emergency departments (A&E; Hawton et al., 2012) is one of the largest epidemiological studies to examine the long-term outcomes of self-harm in children and adolescents. After a median of 6 years nearly 30% re-presented to A&E with self-harm and 1% died, half of those due to likely suicide and the rest mainly due to accidents. It may be that many accidental deaths were also suicides judging from the method of death. In comparison with adults presenting with self-harm, the absolute risk of suicide was lower despite a high self-harm repetition rate. Self-injury by cutting was a strong independent predictor of suicide as was previous psychiatric treatment and previous self-harm. Finally, the eventual method of suicide was different from that used at either the first or the last episode of self-harm. This is at odds with the data generated by adult literature, which consistently shows that those with the most violent methods of self-harm, e.g. attempted hanging or shooting, tend to also die using these methods.

Suicide is the second leading cause of adolescent deaths in most developed countries. Self-harm is one of the strongest predictors of suicide and reducing self-harm repetition is of utmost importance (Ougrin, Tranah, Leigh, Taylor, & Asarnow, 2012). The field of self-harm research is blighted by several theoretical and practical controversies and the linked study makes an important contribution in the following two areas: self-harm definition and prediction of suicide risk.

Self-harm as defined by many European authors and authorities includes both intentional self-injury and intentional self-poisoning irrespective of whether or not suicidal intent is present. Proponents of this definition of self-harm, to which the authors of the linked article belong, argue that both nonsuicidal self-harm and suicide attempts often occur in the same individual and share common risk factors that suicidal intent is fluid and its assessment remains unreliable and that professionals’ judgment about suicidal intent may be different from that stated by the young person. Proponents of this broad definition include both self-injury and self-poisoning into self-harm research. Reports from two major treatment trials indicate that initial history of self-injury without apparent suicidal intent (nonsuicidal self-injury, NSSI) at trial baseline predicted future suicide attempts in depressed youths. Furthermore, baseline history of NSSI was a stronger predictor of suicide attempts than baseline history of suicide attempt (Ougrin et al., 2012) pointing at a significant overlap between the two behaviours. A dichotomy of NSSI versus suicide attempts has another problem, as it leaves nonsuicidal self-poisoning as a residual category. Patients with this behaviour are at risk of being excluded from the studies of pure suicidal attempts or pure NSSI.

Many American researchers, on the other hand, increasingly differentiate between suicide attempts and nonsuicidal self-injury. There is some evidence that patients with these two behaviours have different motivations, may differ in the severity of their psychopathology (especially depression), cognitive characteristics (especially hopelessness) use different methods of self-harm and have different underlying neurobiology (Nock, 2010). Proponents of nonsuicidal self-injury as a distinct condition point to some evidence of the NSSI being most commonly used as a mood regulation strategy, being associated with higher pain thresholds, lower opioid activity and supersensitivity of the μ opioid receptors.

The precise role of suicidal intent remains an area of vigorous scientific pursuit especially in the light of the new category of nonsuicidal self-injury that is likely to appear in DSM-V. Self-harm in adolescents is likely to be associated with a spectrum of suicidal intent with purely suicidal and purely nonsuicidal groups at each end of the spectrum and the majority of adolescents reporting mixed or unstable intent. No study has as yet shown NSSI to be independently linked with a higher risk of completed suicide in adolescents. A measure of suicidal intent, therefore, would have been an extremely informative addition to the data presented in the linked study. If, as the data herein suggests, self-cutting is an independent risk factor for suicide, it would have been important to establish whether or not those presenting with self-injury by cutting had some or no suicidal intent. It is unfortunate that no firm conclusions could be drawn from this article on whether or not nonsuicidal self-injury or nonsuicidal self-poisoning are independent predictors of death by suicide.

Accurately predicting the 50 adolescents likely to die out of the 5,000 presenting to A&E with self-harm is a daunting prospect. The linked study adds to the literature by improving our understanding of the independent predictors of suicide after an episode of self-harm. Accurate prediction of the adolescents who are likely to die of suicide is hampered by low positive predictive value of most risk assessment tools.

The majority of adolescents presenting with self-harm to A&E departments will satisfy the diagnostic criteria for one or more psychiatric disorders. It is important to establish if those presenting with self-harm receive evidence based treatment and if this treatment modifies their risk of death. Depression is extremely common among adolescents presenting with self-harm and is an important predictor of repetition of self-harm and suicide. For those adolescents with affective disorders who self-harm, it has been proposed that treatments targeting the depressive symptoms, rather than the self-harm, may be more effective. Treatment of adolescent depression, although probably efficacious is far from perfect. One possible promising avenue to improve its efficacy is to move away from a purely problem-based approach and to build on the young people’s strength and increase their connectedness with family members, school and friends.

There are also effective interventions for those adolescents who present with self-harm and who also suffer from anxiety disorders, psychosis and eating disorders. A hospital presentation with self-harm is an opportunity to engage young people with treatment. This opportunity is often missed. The majority of adolescents who present with self-harm are nonadherent with outpatient treatment and around 50% are likely to attend four or fewer outpatient follow-up sessions (Ougrin & Latif, 2011). The young people’s treatment in emergency departments is an important predictor of further engagement. Time delays between the initial and the follow-up appointments, delayed initial evaluation and the attitude of emergency department staff, all seem to influence engagement with treatment. Evidence points to the importance of brief psychotherapeutic interventions at the point of initial self-harm assessment to improve linkage with treatment (Ougrin et al., 2012a).

Effective interventions to reduce self-harm and suicide in adolescents are very much needed. Trials of cognitive behavioural therapy (CBT), dialectical behaviour therapy (DBT), mentalisation-based therapy and family therapy are yet to report results. It is clear, however, that several wider systems (school, family and peers) play important roles in modifying adolescent self-harm, and future research must take these into account.

A judicial use of adult self-harm literature may be sensible in the absence of evidence based interventions for adolescents (Ougrin et al. 2012a, Ougrin & Zundel, 2012b) DBT and CBT (especially its problem-solving component) tend to reduce suicidal self-harm in adults. Second-generation antipsychotics, mood stabilisers and ω-3 fatty acids may be of some benefit in adults with Borderline Personality Disorder many of whom self-harm. If non-suicidal self-injury is underlined by opioid dysfunction, this may be an important pointer for future interventions. Using animal models may be of great interest to test some of the basic assumptions about the neurobiology of self-harm.

Finally, vast majority of those who die of suicide are not known to secondary mental health services (Ougrin, Banarsee, Dunn-Toroosian, & Majeed, 2011). Using primary care and public health approaches to suicide and self-harm prevention as well as developing secondary care interventions is perhaps the most promising way forward.

In summary, the field of adolescent self-harm is of immense importance and requires urgent research to develop our ability to predict those likely to die of suicide, and to offer effective treatment to those at risk. Consensus about self-harm nomenclature is badly needed to facilitate this research. The article by Hawton and colleagues is an important step in our understanding of the risk factors of suicide in those adolescents who present with self-harm and in highlighting the overlapping nature of self-injury and self-poisoning in relation to suicide. We are, however, at the very beginning of a very long journey. The hope is that the journey will not be entirely in the dark.

Acknowledgement

  1. Top of page
  2. Abstract
  3. Acknowledgement
  4. Correspondence
  5. References

This Commentary article was invited by the Editors of JCPP and while it has not been subject to formal peer review, it has been subject to in-house editorial review. The author has declared that he has no competing or potential conflicts of interest.

Correspondence

  1. Top of page
  2. Abstract
  3. Acknowledgement
  4. Correspondence
  5. References

Dennis Ougrin, Child and Adolescent Psychiatry, Institute of Psychiatry PO85, De Crespigny Park, London SE5 8AF, UK; Email: dennis.ougrin@kcl.ac.uk

References

  1. Top of page
  2. Abstract
  3. Acknowledgement
  4. Correspondence
  5. References
  • Hawton, K., Bergen, H., Kapur, N., Cooper, J., Steeg, S., Ness, J., & Waters, K. (2012). Repetition of self-harm and suicide following self-harm in children and adolescents: Findings from the Multicentre Study of Self-harm in England. Journal of Child Psychology and Psychiatry, 53, 12121219.
  • Nock, M.K. (2010). Self-injury. Annual Review of Clinical Psychology, 6, 339363.
  • Ougrin, D., Banarsee, R., Dunn-Toroosian, V., & Majeed, A. (2011). Suicide survey in a London borough: Primary care and public health perspectives. Journal of Public Health (Oxford), 33, 385391.
  • Ougrin, D., & Latif, S. (2011). Specific psychological treatment versus treatment as usual in adolescents with self-harm. Crisis, 32, 7480.
  • Ougrin, D., Tranah, T., Leigh, E., Taylor, L., & Asarnow, J.R. (2012a). Practitioner Review: Self-harm in adolescents. Journal of Child Psychology and Psychiatry, 53, 337350.
  • Ougrin, D., & Zundel, T. (2012b). Therapeutic assessment for adolescents presenting with self-harm. In W. Yule (Ed.), Suicide and self-harm (pp. 3649). ACAMH Occasional Paper 31. London: Association for Child and Adolescent Mental Health.
  • Ougrin, D., Zundel, T., Kyriakopoulos, M., Banarsee, R., Stahl, D., & Taylor, E. (2012a). Adolescents with suicidal and nonsuicidal self-harm: clinical characteristics and response to therapeutic assessment. Psychol Assess, 24, 1120.