In this article we look at the factors that surround the issue of adolescent deliberate self harm. We critically examine the literature on the subject and endeavour to distil the significant factors that are relevant to the aetiology of the situation. Having done that, we then look at the conclusions that we can draw from the studies of efficacy of various treatment modalities and the long term outcome studies.
We also examine the issue of adolescent suicide, which some authorities suggest should be viewed as a continuation of a clinical spectrum that progresses through the varying degrees of deliberate self harm, and is clearly related to the issue as an effect rather than a cause.
In the UK we know that deliberate self harm is a comparatively common reason for an adolescent to present to hospital - generally a casualty department. Hawton (et al. 2000) estimate the total to be in the region of 25,000 per year. This is the tip of the iceberg. As we shall discuss in greater detail, Hawton (et al. 2002) point out that this represents only about 12% of the cases of deliberate self harm in the adolescent population.
It is clarified further by Choquet (et al. 1994) and Kann (et al. 1999) who tell us that the typical adolescent who repeatedly engages in episodes of deliberate self harm, is less likely to attend a hospital casualty department than the adolescent who may only self harm on one occasion. The significance of this figure is brought into sharp clarity by the observation from Hawton(et al.1999) that an episode of clinically untreated deliberate self harm may actually be a precursor to successful suicide.
Both Foster (et al. 1997) and Bancroft & Marsack (1977) report that about half of all successful suicides have a past history of deliberate self harm episodes with at least one episode having occurred within a year of their death.
Suicide is thought to be a comparatively rare event in the under 15 yr. age group. The exact figures are not known and Hawton (2005) suggests that the figure is likely to be underrepresented by virtue of the fact that Coroners have an intrinsic reluctance to assign the verdict of suicide in this age range being more likely to ascribe it to some other cause. Hawton asserts that a large proportion of open verdicts (undetermined cause) are, in fact, suicides - particularly so in the female subgroup.
This fact is reinforced by the Department of Health’s document “National Suicide Prevention Strategy for England” (NSPSE) (2002) where it quotes ‘undetermined’ deaths as probable suicides. This particular document sets out the proposed strategy to try to reduce the number of suicides (currently about 5,000 per year and rising), by introducing a nationally accepted framework structure to act as a catalyst for a response. One of the prime elements in this framework is the encouragement of research into suicide and related areas in order to gain further knowledge on the issue.
This document (NSPSE) is particularly relevant to our considerations here, as it points out that one reason why little research, at least in the form of intervention studies, has currently been done on the subject, is that any study which has suicide as the main outcome would need a cohort of several million subjects before there would be any hope of achieving a statistically reliable result. For this reason it is important to try to identify groups, such as those who deliberately self harm, in which their behaviour is a good marker for higher suicide rates. (Dew et al. 1987). One of the target goals in the document is “To reduce the risk in key high risk groups.” Another is to produce more studies that have more common outcomes that will act as “a proxy measure” for suicide.
The NSPSE document was, in itself a response to the document “Saving Lives: Our Healthier Nation” (SLOHN) (1999) which effectively started the consultation process going and called for the production of a specific strategy for reducing suicide and related behavioural problems.
There have been a number of authorities who have expressed concern about the possibility of the SSRI group of drugs increasing the risk of deliberate self harm or suicide in the adolescent. (Healy , 2003), (Medawar et al. 2002), (Medawar, 1997). We shall examine the evidence behind these concerns in some greater detail in the Literature Review.
The methodology of this investigation is quite straightforward. This article is primarily to define the factors that influence the phenomenon of deliberate self harm in adolescence. We hope to determine these factors by critical appraisal of the literature on the subject and, having weighed all of the available evidence, then to make an evidence-based judgement on the strength of each intervention found. In addition, it is intended to quantify the size and extent of the problem of adolescent deliberate self harm by the same means.
In a subject which has such a wealth of literature written about it, it is often difficult to find an appropriate place to start. A good place would perhaps be the excellent paper by Hawton (et al. 2002) which was a report on a large cross-section of adolescent school children in 41 schools across England. As can be seen from both the introduction and the reference section, Hawton has been a prolific writer in the field of deliberate self harm and suicide and therefore his opinions must carry a certain amount of intrinsic authority.
This particular investigation was an anonymous self-reporting questionnaire type study in adolescent schoolchildren between the ages of 15-16 yrs. This type of study has tended to yield higher rates of positive reporting than other types of personalised or direct face-to-face interview based surveys (De Wilde EJ, et al. 1994). The target population was reported as over 6,000 students who were aged between 15-16 yrs. old at the time of the survey. They were all asked to report any episodes of any form of deliberate self harm in the preceding year. The authors report a 6.9% positive response rate (n=398) and only 12.6% of these actually presented to a hospital for any reason. In common with the vast majority of other studies in this area, it was found that deliberate self harm was predominantly a female problem with the sex ratio being 11 : 3.
The authors also analysed the factors that were offered (or appeared to be relevant) to the actual reported incident, and also found a significant sex bias in these trigger factors.
Suicidal behaviour patterns (or self-harm behaviour patterns) in friends and family members, drug use and low self-esteem were common to both sexes but girls tended to have an increased incidence of deliberate self harm if any of the following additional factors were present “depression, anxiety, impulsivity,”
We know from other studies (see on) that one of the commoner reasons for an adolescent to present at a casualty department is deliberate self harm episodes. Because this study suggests that only about 12% of such episodes do involve the hospital, it is not a surprise that studies in the community tend to show results that indicate a greater preponderance of deliberate self harm episodes in the community.
One of the reasons for highlighting this particular paper, is the fact that a comparatively few of the published papers actually deal specifically with the incidence of deliberate self harm in the community (Meltzer et al. 2001). Clearly it is of great importance to try to determine the sort of factors that may trigger particular appropriate caring strategies in healthcare professionals, if they are recognised, so that appropriate therapeutic and caring measures can be implemented.
The lengths that the authors went to in order to ensure that their study was an accurate cross section of the community as a whole is commendable. They spread their enquiries geographically - trying to ensure that they covered a representative sample of ethnic minorities, deprived and affluent areas, single sex and coeducational schools, and that they were all included in representative proportions.
One of the difficulties of setting up a prospective anonymous study of this nature is the concerns faced by the authors if their questionnaire were to trigger off some form of deliberate self harm reaction in a susceptible youngster who may have no support network in place. Although this point is not directly addressed in their paper, it clearly is an issue that has been considered, as the authors inform us that parents and teachers were informed of the proposed questionnaire two weeks before that actual date set for the event. The questionnaire itself was refined by “extensive piloting” in other schools and adolescent psychiatric hospitals.
Interestingly, apart from cataloguing the actual number of deliberate self harm acts, the authors also made space available in the questionnaire for respondents to fill in details of the nature of the acts themselves together with the consequences of their actions.
The paper details the structure of the sample and the rationale behind the questionnaire which is not appropriate to discuss here. The results however, make interesting reading. Some have already been outlined above. Some other significant findings include the fact that although they noted a deliberate self harm rate of 6.9% in the preceding year, 13.2% reported episodes at sometime in their lives. A very significant 45% stated that, at the time of the episode that had experienced a wish to die. The two commonest methods employed by this group were reported as cutting in some way (65%) and poisoning (30%)
In addition to asking about actual episodes of deliberate self harm, the study also took the opportunity to ask about the possibility of suicidal ideation. This was reported by 15% of the group who did not self harm.
Arguably the most significant part of this paper is the exploration of the associated risk factors. Because of the prime thrust of this article, this section is of such significance that it bears being quoted verbatim:
“Deliberate self harm was less common in Asian than white females. Females living with one parent (whether or not with a step parent) had higher rates of deliberate self harm. For both sexes there was an incremental increase in deliberate self harm with increasing consumption of cigarettes or alcohol and number of times drunk (especially in females). A higher frequency of self harm was associated with all categories of drug use (data not presented). Self harm was more common in pupils who had been bullied and was strongly associated with physical and sexual abuse in both sexes. Although more males than females had been in trouble with the police, an association with deliberate self harm was stronger in females. Awareness of recent self harm by peers was reported more often by females than by males but was associated with self harm in both sexes. A similar association was found with self harm by family members. Pupils of either sex who had recently been worried about their sexual orientation had relatively higher rates of self harm. Levels of depression, anxiety, impulsivity, and self esteem were all associated with self harm in both sexes.”
The authors criticise their own figures and make a very valid point that absentees from school on the day of the questionnaire clearly did not have the opportunity to be entered into the study. This may have a biasing effect as both Hawton (et al. 2000) and Choquet (et al. 1994) observe that truanting is a potent risk factor for deliberate self harm episodes.
The authors contrast their figures with the other major UK study on the incidence of deliberate self harm (Meltzer et al. 2001) which produced a prevalence of 6.9% Their reasoning for the difference was in the design of that first study, which was associated with probable under-reporting as it was interview based with a parent present.
The authors quote Gould (et al. 1989) whose paper on social clustering of suicides has a resonance with the findings of this study, of an increased incidence of deliberate self harm in the presence of a life experience of a friend, sibling or family member who themselves, has a history of deliberate self harm.
Another significant finding in this study was the fact that deliberate self harm episodes seems to be a “transient period of distress” as well as signalling the possibility of overt mental health problems and the possibility of suicide. (Brent et al. 1993)
The significance of this study is also that it calls for appropriate school-based programmes for mental health where adolescents can be targeted for help if they display any of the appropriate warning signs.
A more up to date paper by Sinclair and Green (2005) takes this theme and expands it further. It is a well written paper, although it has a different style and less obvious scientific “vigour” than the Hawton 2002 paper. It is designed to investigate and report on the experiences of patients who have self harmed, survived the experience and then moved on.
The investigation was done in the form of a series of face-to-face interviews of 20 previous patients who had survived an episode of poisoning and not had any further episodes within the preceding two years. The authors were able to determine three recurrent and common themes throughout the interviews namely:
The authors concluded with a perceptive overview that it was common to find that this group of patients would commonly refer to a perceived lack of control over their own lives and destinies.
This paper is well written, but its style is gently investigative with soft conclusions. It certainly does add to the general pool of knowledge on the subject but is not able to offer substantial recommendations as a result if its findings.
The next paper for review is a most unusual one. It is unusual because it is not attributed, being signed “anonymous” (1994). It is even more unusual in so far as it is published in the BMJ in that form. It is clearly written by a consultant psychiatrist who relates her difficulties in dealing with one particularly difficult patient. The patient ended up assaulting her outside the hospital. It is relevant to this piece for two reasons. Firstly it reveals just how destructive episodes of adolescent self-harm can be in their legacy in later life. more subtly and insidiously, it shows the difficulties that the community mental health teams work under in terms of pressure and - in this case - danger from abuse and violence from patients.
From a critical view point, it is well written and grippingly engaging. It is written with the author not only relating the experiences of the patient for the reader’s benefit, but documenting her own reactions and subsequent mental health difficulties as a result of the episode. It should be required reading for anyone working in the community in the mental health field.
So far we have reviewed papers that look at the analytical side of deliberate self harm. Treatment is clearly the other side of the debate. The next paper that has therefore been chosen is a review of medication that is appropriate for the adolescent. It is generally acknowledged that therapy in this area is a difficult subject. It is difficult because of:
The paper is by Jon Jureidini (et al. 2004). It is an impressive review of the difficulties associated specifically with antidepressant use in this age range. Most experienced healthcare professionals will be aware of the recent rash of papers, review documents, recommendations and guidelines that have been published relating to the use firstly of paroxetine, then venlafaxine and finally virtually all of the other remaining selective serotonin reuptake inhibitors, with the exception of fluoxetine, in the under 18 age group. This culminated in a publication of a “Public Health Advisory” by the FDA in March 2004 which gave advice on the current concerns for the use of antidepressants in children (and adults).
This paper is written in the form of a literature review of the seven most recent published trials on the subject. The results make very interesting reading
The authors present evidence that the conclusions drawn by the original investigators have been exaggerated thereby overstating their value in childhood and adolescent depression. They draw back from stating an obvious conclusion but they do state unequivocally that pharmaceutical companies paid for the trials and directly paid the authors in at least three of the four largest trials. If you add to this the fact that, on critical analysis, it is clear that the improvement in the control groups is great, (see on), this has the effect of actually negating some of the apparent beneficial effects of the drug under investigation (the authors use the phrase “additional benefit from drugs is of doubtful clinical significance”). Their conclusions are (in the circumstances) comparatively professional and modest but their message is clear. “A more critical approach to ensuring the validity of published data is needed”.
One has to conclude that the major source of prescribing information for most prescribing healthcare professionals comes from published papers. This paper clearly underlines the vigilance and critical approach necessary to discern the true value of the message in each research paper.
Closer examination of the papers reviewed by Jureidini shows very worrying - and indeed possibly unprofessional - activities associated with the trials. They quote a total of 477 patients treated with active antidepressants. Of this number, not one of the patients reports actually showed a statistical advantage by being on the medication. The only analysed index of improvement came from the doctor’s own assessment. Given our knowledge (presented above) about deliberate self harm rates, it is highly significant that there is no mention in any of these papers about any measurement (or recording) of any episodes of deliberate self harm during the trials.
Jureidini and his colleagues then applied meta-analysis techniques to the trials of the selective serotonin reuptake inhibitors. The details of the analysis are published, but of particular reference to this article, the overall effects on depression in children was rated as 3-4 on a scale which has a range of 113 points.
This finding is reinforced by the findings of the FDA (2004) who found that only one out of nine published papers showed any statistical advantage of this type of medication over a placebo reaction in this age range.
Some of the reports detailed were frankly misleading. As Jureidini points out, consider the case where, in one trial where 93 patients were treated with paroxetine, (Keller et al. 2001), there were 11 “serious adverse events”, 7 of which were serious enough for hospital admission. Despite this the report, the authors still claimed "paroxetine was generally well tolerated in this adolescent population, and most adverse effects were not serious," This is utterly disgraceful and clearly designed to mislead. There is absolutely no attempt at scientific rigour. It is hardly surprising that papers like that of Herxheimer & Mintzes (2004) make pointed comments about the drug company’s failure of disclosure of potentially (and actual) adverse events.
There are other serious methodological flaws in these studies. Most of them had a high drop-out rate with some groups in excess of 40%. The study design allowed for the “last attendance result” to be carried forward into the final analysis. So, if at the last assessment (before the patient chose to withdraw for whatever reason) the assessment was favourable, then this would be analysed as a favourable outcome even if the withdrawal was possibly for some other adverse event. Again this clearly (is intended and ) leads to potential result bias.
In the Wagner paper (2003) the placebo group response was so high that, in effect, over 87% of the response attributed to sertrailne could have reasonably been attributed to placebo. Jureidini points also to the editorial endorsement of the paper by Varley (2003) which, to the unwary reader, would appear to add credibility to a severely compromised paper.
We have clearly spent a considerable amount of time critically reviewing this paper, but equally make no apology for it, as it highlights the problems that can arise if healthcare professionals read literary articles in an uncritical way. The authors conclusions are to the point and again, are worth quoting (in part) verbatim:
“In discussing their own data, the authors of all of the four larger studies have exaggerated the benefits, downplayed the harms, or both. This raises the question of whether the journals that published the research reviewed the studies with a sufficient degree of scrutiny, given the importance of the subject. Despite the authors' initial claims, data reported by Keller et al showed no statistically significant advantage of drug over placebo……….. Altering this definition (quoted) enabled the authors to claim significance on a primary endpoint. The authors have subsequently modified that claim to having shown a "signal for efficacy.
The paper continues with a catalogue of criticisms, all of which appear to be based in sound science. There is no merit in recording them all here, as the initial point of the paper has clearly been made. The concerns for all healthcare professionals must be the extent to which agencies such as the Food and Drug administration in the US. Ever gave the drugs approval (or indeed subsequently exempted fluoxitine from criticisms applied to the rest of the group) in the first place.
The sum total of the effects of misleading trials such as the ones reviewed in this paper, is that such inaccurate, and frankly biased trials will mislead not only healthcare professionals but also patients or their families who may research these papers for their own information. One should not forget that many non-drug treatments may be considered both safer and possibly more effective, but when compared to the false claims in these papers, may then be discounted.
In conclusion we must judge this paper to be a brave attempt to unmask the shameless propaganda that is sponsored by some of the pharmaceutical companies.
The next paper has been chosen for review because it follows on from the thrust of the last paper. Martinez (et al. 2005) has recently tackled the problem of trying to decide an appropriate treatment regime in adolescents who repeatedly deliberate self harm as a result of underlying depression. After considering the last paper, one could be forgiven for treating all peer-reviewed papers with a very healthy scepticism. Although it is, of course important to be alert to shortcomings in academic papers, one must not loose a sense of perspective. This paper is particularly well written and tackles the practical problems head-on, which is refreshing.
It has been a therapeutic problem since the introduction of the SSRI’s (selective serotonin reuptake inhibitors), and indeed since the advent of the tricyclic antidepressants, just how best to help a depressed adolescent patient who has a history of deliberate self harm. We know, from previous studies (see above) that about 60% of cases of deliberate self harm are as a result of some from of self poisoning. Equally we know (from the same study and others) that untreated depression is one of the major risk factors in determining the incidence of further episodes of deliberate self harm (Zahl & Hawton 2004). The dilemma then arises, is it safe to give a depressed patient potentially dangerous drugs (if taken in overdose) in order to try to reduce their depression and therefore reduce the apparent risk of deliberate self harm or suicide?
Martinez and his colleagues looked at the problem by comparing the response rates between different SSRI’s and different tricyclic antidepressants. The study was absolutely enormous, and well constructed. The entry cohort was 146,000 patients and the criteria for entry was a first prescription for depression. The outcome measures were either suicide or non-fatal deliberate self harm. In that group nearly 2000 cases of deliberate self harm were recorded and 69 successful suicides were seen. So the statistical validity of the results can hardly be questioned.
As we have outlined in the introduction to this article, a number of authors have written about the possibility of the SSRI’s being associated with an increase in the rates of both suicide and deliberate self harm in therefore adolescent age range.
(Healy , 2003), (Medawar et al. 2002), (Medawar, 1997) there appears to also be some evidence to support the hypothesis that suicidal ideation and deliberate self harm may be increased with the use of SSRI’s (Whittington et al. 2004).
Significantly (for our considerations here) there was a significant difference in response related to age group. Those in the adolescent age range had a (incidence adjusted) higher rate of deliberate self harm on SSRI’s than they did on tricyclic antidepressants. Also there was no increased incidence of suicide in either group
The situation is complicated by a number of less than obvious biasing factors. The authors point to the fact that one of the reasons that fluoxitine was found to have been used in a disproportionate number of deliberate self poisoning episodes in adolescent patients could well be because of the drugs excellent therapeutic / toxic ratio, healthcare professionals may have selectively prescribed it to patients who were adjudged to be of greater than normal risk of deliberate self harm. (Jick et al. 1995)
The methodological details of the study take up a lot of the paper and again, they need not concern us here other than to observe that the authors have been both diligent and meticulous in their study design. The conclusions are, however, of great significance to our considerations here. As we have commented earlier, the cohort size was enormous so it is very unlikely that any statistical quirks would skew the figures. The authors found no increase in suicide risk or risk of deliberate self harm when any SSRI was compared to any tricyclic antidepressant. They did, however find evidence that there was an increased risk of non-fatal deliberate self harm in the under 18 age group, which was not present in the older age groups. It was at it’s greatest risk with paroxitene use.
In the conclusions section, the authors also comment on the fact that they found a much higher incidence of deliberate self harm (as one could expect), in patients taking anti depressive medication as they were clearly depressed. Their rate of 62 per 100,000 patient years, contrasts to that of the general population - 9 per 100,000 patient years (National Statistics 2001). There were no suicides recorded in the under 19 age range. Previous evidence from other trials which showed that there may have been an increased risk of deliberate self harm with the SSRI’s in adolescents was not substantiated in this study, indeed there was no detectable difference between deliberate self harm and suicide risk in those taking SSRI’s when compared to those taking tricyclic antidepressants.
A logical extension of our investigation here must take us to the area of investigating just which treatments or interventions are useful in cases of deliberate self harm in the adolescent age range (Linehan et al.1993). Hawton (et al. 1998) considered this problem and therefore we shall examine their results in a degree of detail. They looked at all of the recently published literature in the area and performed a meta-analysis. This gave them an effective cohort of nearly 2,500 patients, all of whom had deliberate self harm in the recent past. The most substantial finding that came from this study was that the biggest reduction in the rates of repeat acts of deliberate self harm came with the use of depot flupenthixol when compared to a matched placebo group. This was particularly marked in the repeat group of deliberate self harmers.
The authors also reported “promising results” (although the numbers involved were to small for proper and meaningful statistical analysis) with interventions such as problem solving therapy and the provision of an “emergency card” which allowed the respondents quick access to mental health team services. The adolescent female patients who had a history of deliberate self harm appeared to fare better with long term psychological therapy.
As we have discussed earlier, deliberate self harm has a distinct correlation with suicide particularly in the young adult and adolescent (Hawton et al. 1997) (Schmidtke et al. 1996)
The paper highlights the recent increases in deliberate self harm rates in the UK
(Bilas et al. 1996) and also the increased associated healthcare costs (McLoone & Crombie 1996) and therefore calls for a review of appropriate aftercare policies.
One interesting, and possibly unexpected, finding came in the fact that the repetition rate in the deliberate self harm group that had aftercare from the same person who first assessed them in hospital, was significantly higher than those patients who had a change of clinician. No explanation is given for this finding.
When the results for antidepressants were compared against placebo there was no demonstrable benefit (in terms of incidence of repeated deliberate self harm ), and equally longer courses showed no more benefit than did short term courses.
The very worrying conclusion that the authors present us with is that there simply is not enough evidence to recommend any particular form of therapeutic intervention in the recent deliberate self harm group of adolescents. Clearly this is a serious situation given the numbers of people that are involved in this type of behaviour and the sequel of potential suicide (Gunnell & Frankel 1994). This seems a curious conclusion to come to after a fairly extensive meta-analysis of the situation but the authors comment that part of the reason for this is the fact that each individual study was not really large enough to have valid statistical outcomes and because there was not a uniformity of endpoint on even uniformity of entry criteria, direct comparison between studies simply was not possible.
Although not statistically significant (for the reasons set out above) the authors were able to conclude that the teaching of problem solving strategies did appear to produce a degree of benefit and it was simple, cheap and easy to teach. (Hawton & Kirk 1989) (Liberman & Eckman 1981)
The authors call for a more substantial study into the one area where a positive degree of benefit was demonstrated - that of neuroleptic medication (Montgomery et al.1979) the trial was not big enough for high grade statistical analysis but trends could be discerned from the figures available. The only real difficulty is that, as a general rule, depo medications tend not to be particularly popular with patients as the incidence of comparatively intractable side effects is quite high. (Cotgrove et al. 1997)
It should be noted that this study was designed to specifically look at the therapeutic effect of various interventions on their ability to reduce the frequency of deliberate self harm. The fact that that authors have stated that they could find no response should not be interpreted as there was no response in an unrelated modality. They are not saying that antidepressants don’t work in depression, they are simply saying that there is no benefit to be found in repeated deliberate self harm.
The final paper that we shall consider here, is something of an overview. Beautrais (2003) looked at the factors which were present during a lifetime that could be associated with severe deliberate self harm or suicide. His particular paper covered all age ranges, and is therefore not wholly applicable to our consideration here. We shall therefore restrict ourselves to comment on those factors which he found to be relevant to the adolescent age group. This is one of the very few papers that we have seen that raises the question of the possibility of genetic factors in the deliberate self harm group. Having made that observation, it leaves the question unanswered and calls for more research on the subject.
The paper is significant as it highlights the changing emphasis that needs to be placed on the various risk factors that may be identified in an individual patient as they progress through life. Issues that may be potent triggers in the adolescent such as police involvement, are of lesser significance in later life when factors such as depression are of greater consequence. The major conclusion from this paper is that the incidences of suicide or deliberate self harm should not be viewed in isolation, but as the “culmination of adverse life course sequences that involve multiple risk factors.”
The discussion of this subject must inevitably take us through several different areas. We started by trying to define the size of the overall problem together with it’s particular demographic features. Hawton (1999,2000,2002) proved to be a reliable reference for the majority of the statistical detail quoted throughout the piece. We have already commented on the expertise that he has built up over the years with a considerable number of erudite and authoritative papers to his credit. We can point to evidence that tells us the size of the overall problem with 25,000 presentations to hospital with a specific diagnosis of deliberate self harm and that this represents about 12% of the total load of this type of problem in the UK.
We can also point to discernible patterns of behaviour such as the repeat deliberate self harm patient being less likely to attend at a hospital than the first time deliberate self harm patient. We have also pointed to evidence that a pattern of deliberate self harm can actually be a harbinger of more serious psychopathology in terms of suicidal ideation and suicide acts. (Gould et al. 1989)
We can also find evidence to suggest that the true incidence of suicide is probably not recorded due to the institutional reluctance of coroners to accept the possibility of suicide in the young adolescent age group. (Hawton 2005)
All these factors should be weighed within the context and strategy of the National Suicide Prevention Strategy for England (2002) document which has been discussed above. It is clear that although this article is primarily about factors relating to deliberate self harm in adolescents suicide is unfortunately represented in a higher frequency in this group (Foster et al. 1997) and (Bancroft & Marsack 1977), a fact that was also recognised in the preliminary document “Saving lives: Our Healthier Nation” (1999).
The aims set out in the introduction and method sections of this article, were to try to identify the factors which led to deliberate self harm in adolescents. Having carried out a critical review of the literature, we now feel confident in being able to identify some of these factors with a degree of evidence-based confidence.
Hawton ‘s (et al. 2002) paper sets out evidence for a number of related behaviour patterns. He tells us that the most statistically significant trend is the sex bias. Females outnumber males in episodes of deliberate self harm in a ratio of 11:3. Other trends and factors are obviously relevant but none are as pronounced as this.
An awareness of a history of family, friends, peer group having indulged in deliberate self harm is another potent trigger factor which was found to be of greater significance in females than males (Hawton et al. 2002), together with drug use and low self esteem. These factors were independent significant variables common to both sexes but in addition, female adolescents were also found to have an increased incidence of deliberate self harm if they had a current or recent episode of depression or anxiety. Impulsive behaviour was also and independent variable risk factor for female adolescents although it did not appear to be statistically significant for males.
We know that deliberate self harm is an independent variable for suicide prediction and that 65% of suicide attempts are related to some form of cutting and a further 30% are due to poisoning. In many respects, some authors claim that suicide is one end of a continuous spectrum that includes other aspects of deliberate self harm. Also they assert that the suicide act can be viewed as a severe form of the same impulses that are manifest as the clinical spectrum of deliberate self harm. (Davis & Kosky 1991)
It should be remembered, when considering the significance of this statement, that Hawton (2000) also records that suicidal ideation in the preceding year was reported by 15% of the respondents in his study who did not self harm.
Other risk factors for deliberate self harm that have been identified are Caucasian rather than Asian ethnicity and being female and living with one parent or step-parent. (Hawton 2000). The incidence of deliberate self harm rises in a linear fashion independently with the consumption of both tobacco and alcohol. Another potent predictor is the frequency of being clinically drunk - this trend is more pronounced in the female population.
Although the paper did not actually present the data to support the assertion, Hawton (2000) also stated that varying degrees of increased incidence of deliberate self harm was associated with all categories of illicit drug use.
School bullying, both past and present, was associated with a higher incidence of deliberate self harm and physical or sexual abuse showed a strong correlation with multiple self-harm incidents. There was also found to be an association with being in trouble with the police. This was not quite straight forward as more males than females are found to be associated with police intervention but the incidence of deliberate self harm is found to be greater in the female subgroup. (Schmidtke et al. 1996)
Concerns about sexual orientation is also found to be an independent variable trigger for deliberate self harm in both sexes (Gunnell & Frankel 1994). Such events are frequently multiple or repetitive rather than single, one-off episodes.
Depression is also found in association with episodes of deliberate self harm in both sexes, although the incidence in depressed females is greater than in males. (Hawton 2000).
Both Hawton (et al. 2000) and Choquet (et al. 1994) observe that school absenteeism and truanting are potent factors associated with deliberate self harm. Hawton comments on the fact that this is a factor which can skew the figures in any school-based enquiry into deliberate self harm, as clearly, if this is the case, then a high risk sub-group of self-harmers will be under-represented in the sample and can therefore give rise to an inappropriately low estimation of the size of the group.
We have commented on the increased incidence of deliberate self harm in association with other incidences within the peer-group or family, but Gould (1989) also finds an association between deliberate self harm in a person and episodes of suicide in the same distribution of family and friends.
In specific relation to the adolescent population, Brent (et al. 1993) suggests that a comparatively non-specific “period of distress” can be a trigger for deliberate self harm. But he suggests that healthcare professionals should also consider the possibility that it may be an indicator of other, possibly unsuspected mental health problems as well as signalling the possibility of suicidal intent.
Although not specifically a factor which affects deliberate self harm as such, the conclusions in the paper by Sinclair and Green (2005) are certainly of great relevance to the subject. By inference from patients who had survived suicide or serious deliberate self harm and not had any further episodes over the immediately preceding two years, a resolution of turmoil and distress, an understanding of the role of alcohol and an appreciation that deliberate self harm can be an indicator of otherwise sub-clinical mental illness, were all factors that appeared to be associated with a reduction of the factors that may well have triggered the episodes in the first place. By inference therefore, (and from other evidence), the converse may well be relevant in the genesis of episodes of deliberate self harm.
One factor that is ether expressed directly, or often implicit in some of the other factors and explanations, is the perception of a lack of control in a patient’s life together with the feeling that they were not in control of their own destiny.
It follows that, having identified certain factors that can be associated with deliberate self harm, measures that can reduce these factors may well have the effect of reducing deliberate self harm episodes. Some of the studies that we have explored have looked at exactly this hypothesis. We have learned, for example, that teaching problem solving strategies to recurrent deliberate self harmers will reduce the repetition rate (Hawton & Kirk 1989) (Liberman & Eckman 1981). It appears to be a simple strategy to adopt, easy to teach and therefore a comparatively cheap intervention to produce significant benefit.
We have looked at the reputation of tricyclic antidepressants and SSRI’s as possible factors that can affect the incidence of deliberate self harm adversely (Healy , 2003), (Medawar et al. 2002), (Medawar, 1997). Associated with this is the suggestion that suicidal ideation and episodes of deliberate self harm may be increased with medication such as the SSRI group (Whittington et al. 2004).
The paper by Martinez (et al. 2005) seems able to conclusively remove any lingering doubts on that issue. Zahl & Hawton (2004) present us with the dilemma that a depressed patient is more likely to self-harm than one who is not. As healthcare professionals, should we consider trying to treat the underlying depression with therapeutic agents which, if taken irresponsibly, could lead to further damage to the patient?
We have been able to determine a significant body of opinion which suggests that, in specific relation to the adolescent age group under consideration here, that there was a higher rate of deliberate self harm on SSRI’s than on tricyclic antidepressants. We have also determined that in the opinion of Martinez (et al. 2005) that this may be an experimental artefact which can be explained by the fact that a disproportionate number of deliberate self harmers are put on SSRI’s because of their comparatively low toxicity.
Perhaps we should conclude this article with a warning against complacency. Deliberate self harm is a serious problem with potentially lethal consequences. Although we have discussed the relevance of deliberate self harm to suicide when it occurs in the recent past, the figures show that, in terms of overt suicide risk any episode of deliberate self harm during life (even if it is not necessarily recent) will double that incidence of suicide risk.
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