Non suicidal self injury and suicidal behavior among adolescents: co-occurrence and associated risk factors
Authors: Poudel Anju , Lamichhane Anjana , Magar Kamala Rana , Khanal Gopal Prasad 
Published: February 2022

Abstract
Background
Non-suicidal self-injury (NSSI) and suicidal behavior (SB) are the major public health problems in adolescents. Despite the increased focus on these phenomena, there exist no reliable data in Nepal. This study aimed to determine the prevalence of NSSI and SB among adolescents. Furthermore the study identified the relationship between these two behaviors and assessed demographic, behavioral, and psychological risk factors of NSSI and SB in Nepalese adolescents in a representative sample of the general population.

Methods
The study was conducted among 730 adolescents studying in grade 9 to 12 of public and private schools of Pokhara Metropolitan city, Nepal. Data were collected through self administered standard tools- Functional Assessment of Self Mutilation (FASM) tool, Suicidal Behaviors Questionnaire-Revised (SBQ-R), Rosenberg self-esteem scale (RSES) and Beck Depression Inventory (BDI). Descriptive statistical measures such as frequency, percentage, mean, standard deviation, range were used to assess demographic characteristics and adolescent’s behavior regarding NSSI and suicide. For inferential analysis chi-square and one way ANOVA test was used. Furthermore, to determine the predictors of NSSI and SB, multiple logistic regression analysis was used.

Results
Regarding behavioral characteristics, nearly half of the sample 327 (44.8%) reported a history of NSSI in past 1 year. Furthermore, 25.8% (n = 188) of the overall sample engaged in minor NSSI only and 3.42% (n = 25) engaged in at least one act of moderate/severe NSSI. The mean number of type of NSSI performed was 2.63 ± 1.71. The most common type of NSSI method used were picking at wound (27.3%), biting self (20.3%), pulling hair out (11.8%), cutting self (11.1%). Boys (52.6%) were more likely to be engaged in NSSI than girls (47.4%) (χ2  =  10.298, p  =  0.002). Furthermore, among 730 adolescents who completed the SBQ-R questionnaire, 131 (17.9%) had suicidal behaviors (SB) (as defined by SBQ-R a total score ≥ 7). Regarding sex differences female were significantly higher in life time prevalence of suicidal behavior than male (χ2 = 30.26, p = 0.001). Simple Chi-square tests indicated that NSSI was significantly associated with SB (χ2 = 58.16, P < .001). Logistic regressions identified the four significant predictors of NSSI behavior: male, low-level of self-esteem (SE), moderate to severe form of depression and SB. Similarly, significant predictors of SB were: female, low-level of SE, moderate to severe form of depression and NSSI behavior.

Conclusion
The prevalence of both NSSI and SB is high in adolescents. Despite the differences between NSSI and SB a significant number of adolescents reported a history of both behaviors. Lower level of SE and moderate to severe depression were the significant predictors of both NSSI and SB. Furthermore, male and adolescents with the history of SB were at risk of NSSI behavior whereas female sex and adolescents with the history of NSSI were at risk of SB.