Elsevier

The Lancet

Volume 379, Issue 9834, 23–29 June 2012, Pages 2373-2382
The Lancet

Series
Self-harm and suicide in adolescents

https://doi.org/10.1016/S0140-6736(12)60322-5Get rights and content

Summary

Self-harm and suicide are major public health problems in adolescents, with rates of self-harm being high in the teenage years and suicide being the second most common cause of death in young people worldwide. Important contributors to self-harm and suicide include genetic vulnerability and psychiatric, psychological, familial, social, and cultural factors. The effects of media and contagion are also important, with the internet having an important contemporary role. Prevention of self-harm and suicide needs both universal measures aimed at young people in general and targeted initiatives focused on high-risk groups. There is little evidence of effectiveness of either psychosocial or pharmacological treatment, with particular controversy surrounding the usefulness of antidepressants. Restriction of access to means for suicide is important. Major challenges include the development of greater understanding of the factors that contribute to self-harm and suicide in young people, especially mechanisms underlying contagion and the effect of new media. The identification of successful prevention initiatives aimed at young people and those at especially high risk, and the establishment of effective treatments for those who self-harm, are paramount needs.

Introduction

Adolescent self-harm is a major public health concern. Although suicide is uncommon in adolescents compared with non-fatal self-harm, it is always a tragic outcome, and prevention of suicide in young people is understandably a focus of national strategies for suicide prevention. In this paper, we discuss self-harm and suicide in adolescents in terms of epidemiology (especially international differences); developmental aspects of self-harm, including short-term and long-term outcomes; factors that contribute to the behaviour; and treatment and prevention. This is a selective paper directed at any professional with an interest in adolescent suicide and self-harm. We have two aims: to provide a synthesis of the evidence for adolescent self-harm and suicide and to identify key areas of uncertainty.

Only a small proportion of individuals who self-harm present to hospitals, meaning that this behaviour is largely hidden (at least from clinical services) at the community level (figure 1).

There is no agreed definition of adolescence—chronological age is just one of several ways it can be defined (as opposed to physical characteristics or cognitive development). The upper age limit used to define adolescence in studies varies between 18 years and 25 years. As a result, some of the findings we present in this paper will include those for individuals older than 18 years.

Section snippets

Self-harm

Self-harm refers to intentional self-poisoning or self-injury, irrespective of type of motive or the extent of suicidal intent.1, 2 It is used here in preference to the dichotomous separation of such acts into non-suicidal self-injury (proposed as a new diagnosis for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition) and attempted suicide—now popular in the USA—because suicidal intent is a dimensional phenomenon, the patient's and clinician's view of suicidal intent might

Epidemiology

Suicide in adolescence might be substantially under-recorded by authorities responsible for death verdicts, with possible suicides often being given undetermined or accidental verdicts.53 Such under-reporting might be done to protect families from the perceived stigma of suicide. Thus national rates of suicide in young people should be compared with caution. Also, nationally recorded statistics are only usually available for comparison for individuals aged 10–24 years. Global figures for

Conclusions

Self-harm and suicide are major public health issues in young people worldwide and there are many challenges to their management and prevention (panel 3). Much is now known about their epidemiology and causes but research efforts should focus on the further identification of subtypes of those who self-harm or are at risk of suicide. Indeed, it would be helpful to have a better understanding of the factors associated with different levels of self-harm (eg, ideators vs high lethality attempts).

Search strategy and selection criteria

We searched the following databases for the period January, 2001, to August, 2011: PsycINFO, PubMed, and Web of Knowledge. We used the following search terms: “suicid*”, “self-harm”, “self-injur*”, and “adolescen*”. We used no language restrictions. We selected key papers from the identified publications on the basis of topic covered and quality of research. We supplemented these publications with earlier landmark papers with our knowledge of the area. We modified our reference list on the

References (97)

  • TE Joiner

    Contagion of suicidal symptoms as a function of assortative relating and shared relationship stress in college roommates

    J Adolesc

    (2003)
  • ME Eisenberg et al.

    Suicidality among gay, lesbian and bisexual youth: the role of protective factors

    J Adolesc Health

    (2006)
  • MD Braquehais et al.

    Is impulsivity a link between childhood abuse and suicide?

    Compr Psychiatry

    (2010)
  • I Manor et al.

    Possible association between attention deficit hyperactivity disorder and attempted suicide in adolescents—a pilot study

    Eur Psychiatry

    (2010)
  • MK Nock et al.

    Non-suicidal self-injury among adolescents: diagnostic correlates and relation to suicide attempts

    Psychiatry Res

    (2006)
  • RH Aseltine et al.

    Age variability in the association between heavy episodic drinking and adolescent suicide attempts: findings from a large-scale, school-based screening program

    J Am Acad Child Adolesc Psychiatry

    (2009)
  • T Bronisch et al.

    Smoking predicts suicidality: findings from a prospective community study

    J Affect Disord

    (2008)
  • TH Makikyro et al.

    Smoking and suicidality among adolescent psychiatric patients

    J Adolesc Health

    (2004)
  • S Fortune et al.

    Suicide in adolescents: using life charts to understand the suicidal process

    J Affect Disord

    (2007)
  • GC Patton et al.

    Global patterns of mortality in young people: a systematic analysis of population health data

    Lancet

    (2009)
  • A Värnik et al.

    Gender issues in suicide rates, trends and methods among youths aged 15–24 in 15 European countries

    J Affect Disord

    (2009)
  • DA Brent et al.

    Age- and sex-related risk factors for adolescent suicide

    J Am Acad Child Adolesc Psychiatry

    (1999)
  • MJ Marttunen et al.

    Psychosocial stressors more common in adolescent suicides with alcohol abuse compared with depressive adolescent suicides

    J Am Acad Child Adolesc Psychiatry

    (1994)
  • K Houston et al.

    Suicide in young people aged 15–24: a psychological autopsy study

    J Affect Disord

    (2001)
  • MS Gould et al.

    Service use by at-risk youths after school-based suicide screening

    J Am Acad Child Adolesc Psychiatry

    (2009)
  • R Harrington et al.

    Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves

    J Am Acad Child Adolesc Psychiatry

    (1998)
  • A Cotgrove et al.

    Secondary prevention of attempted suicide in adolescence

    J Adolesc

    (1995)
  • D Donaldson et al.

    Treatment for adolescents following a suicide attempt: results of a pilot trial

    J Am Acad Child Adolesc Psychiatry

    (2005)
  • A Wood et al.

    Randomized trial of group therapy for repeated deliberate self-harm in adolescents

    J Am Acad Child Adolesc Psychiatry

    (2001)
  • PL Hazell et al.

    Group therapy for repeated deliberate self-harm in adolescents: failure of replication of a randomized trial

    J Am Acad Child Adolesc Psychiatry

    (2009)
  • SJ Huey et al.

    Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies

    J Am Acad Child Adolesc Psychiatry

    (2004)
  • GA Melvin et al.

    A comparison of cognitive-behavioral therapy, sertraline, and their combination for adolescent depression

    J Am Acad Child Adolesc Psychiatry

    (2006)
  • Self-harm: longer term management. NICE clinical guideline 133

    (2011)
  • K Hawton et al.

    Deliberate self-harm in adolescents: a study of characteristics and trends in Oxford, 1990–2000

    J Child Psychol Psychiatry

    (2003)
  • D De Leo et al.

    Who are the kids who self-harm? An Australian self-report school survey

    Med J Aust

    (2004)
  • N Madge et al.

    Deliberate self-harm within an international community sample of young people: comparative findings from the Child and Adolescent Self-harm in Europe (CASE) Study

    J Child Psychol Psychiatry

    (2008)
  • K Hawton et al.

    Deliberate self-harm in adolescents: self report survey in schools in England

    BMJ

    (2002)
  • E Hargus et al.

    Distinguishing between subgroups of adolescents who self-harm

    Suicide Life Threat Behav

    (2009)
  • Youth risk behavior surveillance—United States, 2009

    MMWR Surveill Summ

    (2010)
  • M Olfson et al.

    Emergency treatment of young people following deliberate self-harm

    Arch Gen Psychiatry

    (2005)
  • DK Boeninger et al.

    Sex differences in developmental trends of suicide ideation, plans, and attempts among European American adolescents

    Suicide Life Threat Behav

    (2010)
  • S Burrows et al.

    Socioeconomic disparities and attempted suicide: state of knowledge and implications for research and prevention

    Int J Inj Contr Saf Promot

    (2010)
  • SJ Blakemore

    The social brain in adolescence

    Nat Rev Neurosci

    (2008)
  • K Hawton

    How patients and psychiatrists account for overdoses

  • K Hawton et al.

    Motivational aspects of deliberate self-poisoning in adolescents

    Br J Psychiatry

    (1982)
  • K Hawton et al.

    How adolescents who cut themselves differ from those who take overdoses

    Eur Child Adolesc Psychiatry

    (2010)
  • RC O’Connor et al.

    Self-harm in adolescents: self-report survey in schools in Scotland

    Br J Psychiatry

    (2009)
  • RC O’Connor et al.

    Predicting deliberate self-harm in adolescents: a six month prospective study

    Suicide Life Threat Behav

    (2009)
  • Cited by (1398)

    View all citing articles on Scopus
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