Responding to the rising prevalence of self-harm
Authors: Rohan Borschmann, Stuart A Kinner
Journal: The Lancet Psychiatry (2019)

Young people who self-harm have substantially increased risk of adverse non-fatal and fatal outcomes, including suicide, compared with those who do not self-harm.1Borschmann R Becker D Coffey C et al.20-year outcomes in adolescents who self-harm: a population-based cohort study.Lancet Child Adolesc Health. 2017; 1: 195-202Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 2Hawton K Harriss L Zahl D Deaths from all causes in a long-term follow-up study of 11583 deliberate self-harm patients.Psychol Med. 2006; 36: 397-405Crossref PubMed Scopus (93) Google Scholar The frequency of young people presenting to general practices and emergency departments after self-harm has increased in the past 20 years in England3Morgan C Webb RT Carr MJ et al.Incidence, clinical management, and mortality risk following self harm among children and adolescents: cohort study in primary care.BMJ. 2017; 359: j4351Crossref PubMed Scopus (183) Google Scholar and Australia.4Hiscock H Neely RJ Lei S Freed G Paediatric mental and physical health presentations to emergency departments, Victoria, 2008–15.Med J Aust. 2018; 208: 343-348Crossref PubMed Scopus (68) Google Scholar However, people who present to medical services after self-harm differ from those who do not,5Geulayov G Casey D McDonald KC et al.Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): a retrospective study.Lancet Psychiatry. 2018; 5: 167-174Summary Full Text Full Text PDF PubMed Scopus (135) Google Scholar and most people who self-harm do not seek medical attention.5Geulayov G Casey D McDonald KC et al.Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): a retrospective study.Lancet Psychiatry. 2018; 5: 167-174Summary Full Text Full Text PDF PubMed Scopus (135) Google Scholar Thus, whether this increase in presentation reflects a true rise in the prevalence of self-harm remains unclear. In The Lancet Psychiatry, Sally McManus and colleagues6McManus S Gunnell D Cooper C et al.Prevalence of non-suicidal self-harm and service contact in England, 2000–14: repeated cross-sectional surveys of the general population.Lancet Psychiatry. 2019; (published online June 4.)http://dx.doi.org/10.1016/S2215-0366(19)30188-9Summary Full Text Full Text PDF PubMed Scopus (152) Google Scholar address this uncertainty. The authors analysed data for non-suicidal self-harm (NSSH) from three waves of the Adult Psychiatric Morbidity Survey administered to people aged 16 years or older in the general population of England, Scotland, and Wales in 2000, 2007, and 2014. To maximise comparability between waves (which differed slightly in terms of locations and the age range of participants included), they focused on data for people aged 16–74 years who lived in England. Notable strengths of the study include the repeat probability-sample survey design, the population sampling frame, and the inclusion of respondents not in contact with mental health services (who are often excluded from studies of NSSH). McManus and colleagues' report that the prevalence of lifetime NSSH increased from 2·4% (95% CI 2·0–2·8) to 6·4% (5·8–7·2) between 2000 and 2014, with rises noted in both male and female participants and across all age groups. The largest increase was in women and girls aged 16–24 years (from 6·5% [95% CI 4·2–10·0] to 19·7% [15·7–24·5] in 2014). Data from the 2014 survey7McManus S Bebbington P Jenkins R Brugha T Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. NHS Digital, Leeds2016Google Scholar suggest a concurrent rise in anxiety and depression in girls and young women, which could partly explain the increase in NSSH. With one in five female 16–24-year-olds in England reporting lifetime NSSH in 2014—a proportion higher than the pooled global prevalence estimate of past-year common mental disorder (17·6%)8Steel Z Marnane C Iranpour C et al.The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013.Int J Epidemiol. 2014; 43: 476-493Crossref PubMed Scopus (1385) Google Scholar—NSSH in young people is clearly an important public health issue. Despite the increased prevalence of NSSH, McManus and colleagues noted no significant change in the proportion of respondents who subsequently sought support from health services. At each wave, more than 50% of respondents who reported lifetime NSSH sought no medical or psychological treatment and, in 2014, such help-seeking was even less likely in male respondents and people younger than 35 years. Coupled with the rise in NSSH, these findings underscore the importance of both population-level and targeted prevention strategies to reduce the incidence of NSSH, complemented by efforts to promote help-seeking from low-threshold mental health services for people who engage in NSSH. NSSH is a complex, multifaceted behaviour with myriad precipitants and functions. McManus and colleagues also provided informative data about the motivations driving NSSH. The prevalence of NSSH to cope with unpleasant emotions (including anger, tension, anxiety, and depression) roughly tripled in both sexes between 2000 and 2014. This was the most common reason provided for engaging in NSSH, and was reported by 17·7% ([95% CI 13·9–22·3]) of women and girls aged 16–24 years in the 2014 survey. Because most NSSH does not lead to help-seeking,5Geulayov G Casey D McDonald KC et al.Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): a retrospective study.Lancet Psychiatry. 2018; 5: 167-174Summary Full Text Full Text PDF PubMed Scopus (135) Google Scholar population-level interventions to enhance emotion regulation and resilience in young people, including through school-based initiatives, could help to reduce the incidence of NSSH. NSSH is difficult to assess accurately. In addition to the limitations associated with assessing NSSH via self-report, the lifetime measure of NSSH used by McManus and colleagues did not take into account the frequency or recency of NSSH, meaning that the temporal variability of NSSH during adolescence9Moran P Coffey C Romaniuk H et al.The natural history of self-harm during adolescence and young adulthood: population-based cohort study.Lancet. 2012; 379: 236-243Summary Full Text Full Text PDF PubMed Scopus (352) Google Scholar was not captured. Additionally, despite the purported population sampling frame, people living in institutional settings, such as prisons, youth detention centres, and psychiatric hospitals, were excluded. Thus, the prevalences reported by McManus and colleagues are probably underestimates, because NSSH is common in institutional settings.10Skegg K Self-harm.Lancet. 2005; 366: 1471-1483Summary Full Text Full Text PDF PubMed Scopus (522) Google Scholar Young people in such settings are typically excluded from whole population studies, despite the high mental health burden. Inclusion of these highly vulnerable young people in research and policy responses needs to form part of a comprehensive strategy to prevent NSSH at the population level. Finally, the small numbers of people who self-harmed did not permit robust analysis by ethnic group. In view of the reported differences between ethnic groups in the prevalence and characteristics of NSSH, and in the frequency of subsequent service use,11Cooper J Murphy E Webb R et al.Ethnic differences in self-harm, rates, characteristics and service provision: three-city cohort study.The British Journal of Psychiatry. 2010; 197: 212-218Crossref PubMed Scopus (57) Google Scholar complementary use of data-linkage methods—which are effective for studying inclusion health populations and stigmatised behaviours such as NSSH—might be beneficial in future studies. Adolescent NSSH is a marker for concurrent risk behaviours that pose substantial hazards for social and emotional development throughout young adulthood and beyond.1Borschmann R Becker D Coffey C et al.20-year outcomes in adolescents who self-harm: a population-based cohort study.Lancet Child Adolesc Health. 2017; 1: 195-202Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar Interventions addressing other key individual-level risk domains—including mental health problems, substance use, and antisocial behaviour—are therefore likely to help to support vulnerable young people as they make their way through life.1Borschmann R Becker D Coffey C et al.20-year outcomes in adolescents who self-harm: a population-based cohort study.Lancet Child Adolesc Health. 2017; 1: 195-202Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar Many of the girls and young women in McManus and colleagues' study who reported NSSH will form part of the next generation of mothers in England. In a population-based intergenerational cohort study12Borschmann R Molyneaux E Spry E et al.Pre-conception self-harm, maternal mental health and mother-infant bonding problems: a 20-year prospective cohort study.Psychol Med. 2018; (published online Dec 18.)DOI:10.1017/S0033291718003689Crossref PubMed Scopus (11) Google Scholar in Australia, new mothers who self-harmed only in young adulthood (ie, when aged 20–29 years) scored twice as high on measures of postpartum depression and mother–infant bonding problems than those who self-harmed only during their teenage years and those with no history of NSSH. This finding suggests that, in addition to the established adverse health and social outcomes associated with NSSH during adolescence,1Borschmann R Becker D Coffey C et al.20-year outcomes in adolescents who self-harm: a population-based cohort study.Lancet Child Adolesc Health. 2017; 1: 195-202Summary Full Text Full Text PDF PubMed Scopus (61) Google Scholar NSSH during young adulthood could also be a marker of future vulnerability to perinatal mental health and mother–infant bonding problems. The longer-term consequences of maternal NSSH for the health and wellbeing of offspring beyond the perinatal period are unknown. Evidence for effective interventions to reduce NSSH in young people is scarce, and key studies require replication.13Ougrin D Tranah T Stahl D Moran P Asarnow JR Therapeutic interventions for suicide attempts and self-harm in adolescents: systematic review and meta-analysis.J Am Acad Child Adolesc Psychiatry. 2015; 54: 97-107Summary Full Text Full Text PDF PubMed Scopus (274) Google Scholar Thus, the increase in the prevalence of NSSH has wide-reaching and potentially lifelong implications. Sequelae of the growing burden of NSSH include a rise in preventable suicide deaths in vulnerable young people and a poorer start in life for the children of young women engaging in self-harm. Unless evidence-based, population-level, and targeted preventive responses are scaled up proportionately to the increase in NSSH, and access to low-threshold mental health services for young people engaging in NSSH is improved, the burden of untreated NSSH will continue to rise. We declare no competing interests. Prevalence of non-suicidal self-harm and service contact in England, 2000–14: repeated cross-sectional surveys of the general populationThe prevalence of NSSH has increased in England, but resultant service contact remains low. In 2014, about one in five female 16–24-year-olds reported NSSH. There are potential lifelong implications of NSSH, such as an increased frequency of suicide, especially if the behaviours are adopted as a long-term coping strategy. Self-harm needs to be discussed with young people without normalising it. Young people should be offered help by primary care, educational, and other services to find safer ways to deal with emotional stress. Full-Text PDF Open Access