Time to take self-harm in young people seriously
Authors: Ellen Townsend
Journal: The Lancet Psychiatry (2019)

Self-harm and suicide research are currently having a serious moment. At no time in the past 20 years has there been such policy and public interest in self-harm and suicide, at least in the UK. We have a Minister for Suicide Prevention, money has been allocated specifically to suicide prevention efforts, and self-harm prevention has been included as a priority in the National Suicide Prevention Strategy for England.1UK GovernmentPreventing suicide in England: third progress report on the cross-government outcomes strategy to save lives.https://www.gov.uk/government/publications/suicide-prevention-third-annual-reportDate: January, 2017Date accessed: February 27, 2019Google Scholar Thus, the excellent study in The Lancet Psychiatry by Becky Mars and colleagues2Mars B Heron J Klonsky ED et al.Predictors of future suicide attempt among adolescents with suicidal thoughts or non-suicidal self-harm: a population-based birth cohort study.Lancet Psychiatry. 2019; (published online March 14.)http://dx.doi.org/10.1016/S2215-0366(19)30030-6Summary Full Text Full Text PDF PubMed Scopus (173) Google Scholar on predicting suicide attempts in young people who have had previous suicidal thoughts or non-suicidal self-harm is extremely welcome and timely. A considerable strength of this large exploratory study, which is based on responses from participants in the Avon Longitudinal Study of Parents and Children (a population-based birth cohort study in the UK), is that it is prospective. Risk factors measured at age 15–16 years were used to predict suicide attempts at 21 years of age. These exploratory findings now require replication—especially in studies with shorter timeframes between baseline measurement of risk factors and outcomes. A key finding from this work is that self-harm (here dubbed non-suicidal self-harm to distinguish it from suicide attempts where specific intent to die was articulated) significantly predicts the transition from suicidal thoughts to suicide attempts (odds ratio [OR] 2·78, 95% CI 1·35–5·74; p=0·0059). This finding bolsters an already robust evidence base signalling that self-harm (regardless of the intent underpinning it) is an extraordinarily important risk factor for future self-harm and suicide3Suicide by children and young people in England. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). University of Manchester, Manchester2017Google Scholar and early mortality from all causes of death (with a mean of 40 years of life lost to external causes in those who self-harm).4Bergen H Hawton K Waters K et al.Premature death after self-harm: a multicentre cohort study.Lancet. 2012; 380: 1568-1574Summary Full Text Full Text PDF PubMed Scopus (186) Google Scholar Given this ever-increasing evidence base, why is self-harm still not taken seriously, even stigmatised by front-line staff with negative attitudes?5Saunders KEA Hawton K Fortune S Farrell S Attitudes and knowledge of clinical staff regarding people who self-harm: a systematic review.J Affect Disord. 2012; 139: 205-216Crossref PubMed Scopus (233) Google Scholar Partly, insufficient knowledge and training is responsible, and evidence points to significant positive shifts in attitudes when staff undergo effective training in self-harm and suicide prevention awareness.6Appleby L Morriss R Gask L et al.An educational intervention for front-line health professionals in the assessment and management of suicidal patients (The STORM Project).Psychol Med. 2000; 30: 805-812Crossref PubMed Scopus (106) Google Scholar Another important issue is that, for myriad reasons, young people are often not taken seriously in their teenage years. This point comes across strongly in accounts of young people reflecting on why they started self-harming, what keeps them self-harming, and what might help them to stop self-harming; they feel patronised and not listened to.7Wadman R Armstrong M Clarke D et al.Experience of self-harm and its treatment in looked-after young people: an interpretative phenomenological analysis.Arch Suicide Res. 2018; 22: 365-379Crossref PubMed Scopus (12) Google Scholar It is also important to note that such attitudes in society in general have probably affected the range, depth, and quality of health-related research on any topic in adolescence.8Patton GC Sawyer SM Santelli JS et al.Our future: a Lancet commission on adolescent health and wellbeing.Lancet. 2016; 387: 2423-2478Summary Full Text Full Text PDF PubMed Scopus (1543) Google Scholar We now face the situation in the UK in which self-harm is on the increase in young people,9McManus S Bebbington P Jenkins R Brugha T Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. NHS Digital, Leeds2016Google Scholar and suicide is the leading cause of death in people aged 5–19 in England and Wales.10Office for National StatisticsDeaths registered in England and Wales (series DR).https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregisteredinenglandandwalesseriesdr/2016Date: 2016Date accessed: February 27, 2019Google Scholar At no time in life does the risk of suicide increase as dramatically as it does in the mid-to-late teenage years.3Suicide by children and young people in England. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). University of Manchester, Manchester2017Google Scholar We must act collectively as researchers, clinicians, front-line workers, carers, and people with lived experience to ensure that a clear message is heralded across society, and especially in the health, education, justice, and social care sectors: not only is suicide everyone's business, but so is self-harm. Mars and colleagues' exemplary work emphasises the multidimensional and complex nature of self-harmful thoughts and behaviours. Embracing this complexity allows us to consider the wide range of opportunities at our disposal to help a young person who is at risk of attempting suicide. The work here suggests that non-suicidal self-harm, substance use (especially cannabis), sleep, personality traits, and exposure to self-harm in others could help clinicians to identify individuals at risk of future suicide attempts. However, it must be stressed that the meaning of these factors must be explored in depth with the young person being assessed, in order to glean a full understanding from the perspective of the person facing these issues. We have a strengthening evidence base that talking therapy interventions help to facilitate recovery from suicidal thoughts and self-harm.11Hawton K Witt K Salisbury TLT et al.Psychosocial interventions following self-harm in adults: a systematic review and meta-analysis.Lancet Psychiatry. 2016; 3: 740-750Summary Full Text Full Text PDF PubMed Scopus (130) Google Scholar, 12Hawton K Witt KG Salisbury TL et al.Interventions for self-harm in children and adolescents.Cochrane Database Syst Rev. 2015; 12 (CD012013.)Google Scholar It is vital that young people who are struggling with suicide ideation and self-harm are taken seriously and offered psychological therapies to help them to deal with the distress that underpins such thoughts and behaviours. Crucially, policy makers will need to review and improve the service provision for young people who are experiencing suicidal thoughts and self-harm. Given that many people who die by suicide have been assessed as low risk, this means taking all self-harmful thoughts and behaviours seriously and offering compassionate, evidence-based services in response. I declare no competing interests. Predictors of future suicide attempt among adolescents with suicidal thoughts or non-suicidal self-harm: a population-based birth cohort studyMost adolescents who think about suicide or engage in non-suicidal self-harm will not make an attempt on their life. Many commonly cited risk factors were not associated with transition to suicide attempt among these high-risk groups. Our findings suggest that asking about substance use, non-suicidal self-harm, sleep, personality traits, and exposure to self-harm could inform risk assessments, and might help clinicians to identify which adolescents are at greatest risk of attempting suicide in the future. Full-Text PDF Open Access