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Deliberate self-harm in adolescents: A review of literature

 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

Date of Submission14-Oct-2021
Date of Acceptance17-Jan-2022
Date of Web Publication10-Nov-2022

Correspondence Address:
Mahadev Singh Sen,
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipj.ipj_215_21


Deliberate self-harm is a rising epidemic in the youth. This review examined the different self-harm behavior, approach to treatment, and the implication of such behaviors in the adolescent population in the academic literature. Using the PubMed database, we searched for specific terms related to different self-harm behaviors in Adolescents. The bibliography of the articles found relevant for the review was also screened. Each study's findings were taken with reference to our topic and findings were summarized. After reviewing the literature, we found that the prevalence of suicidal attempts was as high as 18% in the past year While the nonsuicidal attempts were as high as 31%. Risk factors associated with higher levels of suicide were bullying, loneliness and anxiety, tobacco and alcohol use, and weak family and social relationships. While the factors playing a protective role are being connected to school, having good social support, and attending school. There are very few studies focused on interventions related to suicide prevention in Adolescent and postvention programs. Out of the evidence available, the interventions are not focused on the target individuals and lack replicability. Self-harm is a major public health concern which needs to be understood holistically. The interventions aimed at preventing and managing self-harm behavior still need to be more targeted and precise. Other targets may include interventions suited to different phases of development, stopping the progression of the behavior to adulthood, including the varied population in such intervention, etc.

Keywords: Adolescent, deliberate self-harm, self-harm, self-injury, suicide

How to cite this URL:
Patra BN, Sen MS, Sagar R, Bhargava R. Deliberate self-harm in adolescents: A review of literature. Ind Psychiatry J [Epub ahead of print] [cited 2023 Jan 27]. Available from: https://www.industrialpsychiatry.org/preprintarticle.asp?id=360857

India has 243 million children aged between 0 and 14 years, a group which consists of 30.9% of the total population.[1] They are at the crossroads between losing out on the potential of a generation or nurturing them to transform society. 65% of the Indian population is below 35 years and on the other hand, it has one of the highest suicidal rates for age range 15–29.[2] Adolescent self-harm and suicide is major public health concern and with adequate risk prediction the shifting of on individual from one stage to other can be stopped.

   Search Strategy Top

The search was done using PubMed database which included the term “(Adolescent) OR (Children) AND (((((((suicide attempt) OR (Self harm)) OR (deliberate self-harm)) OR (intentional self-harm)) OR (suicide)) OR (suicidal behavior)) OR (nonsuicidal self-injury))” till October 2019. The bibliography of the articles found relevant for the review was also screened.

   Deliberate Self Harm Top

Deliberate self-harm (DSH) is defined as “intentional self-poisoning or self-injury irrespective of the type of motive or the extent of suicidal intent, is one important predictor of completed suicide.”[3] A similar term nonsuicidal self-injury (NSSI) which simply refers to self-injury without the intent of suicide.[4] The term NSSI is used more in the American subcontinent and is included as conditions for further study in the Diagnostic and Statistical Manual of Mental Disorders-5th Edition. This has also led to different assessments and interpretations resulting in difficulty in comparing international data. Similar problems in defining and assessing are seen in the Indian context. Though the prevalence of NSSI is more than DSH, the difference is not significant (NSSI 18.0% vs. DSH 16.1%).[5] DSH has been seen in adolescents and young adults with an increased frequency and it is an important risk factor for suicide attempts (SA) which poses a huge public health burden. In recent years India has undergone rapid sociocultural changes due to the technological revolution. This causes easy access of young people to Internet, social media through smart phones which exposes them to violent content and creates peer pressure which affect their mental health. A review by Castellví et al. reported significant overlap between NSSI and SAs where they also concluded that self-injurious behaviors are risk factors for future for up to 26% of SAs in adolescents and young adults.[6] This review included studies with data on self-injurious thoughts and behavior, with either case-control and cohort studies of subjects between ages 12–26.

   Epidemiology Top

Studying suicide in the younger population is important as early morbidity results in poor outcomes. Patel et al. reported that in India there is a risk of about 1·3% of dying at 15-years by suicide.[7],[8] Risk of suicide is approximately 50–100 times more within the 1st year in the aftermath of a self-harm episode. The DSH can start as early as 11 years of age.[9] In another study Arun and Chavan, 2104 studied a sample of 2402 of students between VII to XII class reported that 6% of students had suicidal ideas while 0.39% of students reported of suicidal attempts.[10] While in a similar study done using semi-structured questionnaire in a sample of 1029 school-going adolescents of age between 12 and 18 had different figures, i.e., suicidal ideation (lifetime 21.7%; last year 11.7%) and SA (lifetime 8%; last year 3.5%) owing to different methodology and research focus.[11] Data from 40 low- and middle-income countries found the mean 12-month prevalence of SAs in adolescents to be 17.2%. The overall prevalence of SAs and the proportion of SAs with a plan were higher for girls and both the prevalence increased with age.[12]

A systematic review of 38 studies on NSSI from India concluded that the existing data is limited and that the lifetime prevalence may be higher than the international average (19.8% vs. 17.2%). They also discussed that in India the literature on NSSI could be divided into three categories: Case studies, hospital-based studies, and community-based studies. They also asserted that some of the cases reported were in cultural context but there is a genuine need to look at these practices beyond this as pathological NSSI may be masked due to sanctioning of various forms of self-injurious rituals in India. Hospital-based studies were mostly from a tertiary care center of individuals reaching after an episode of self-harm.[5]

There is only one study from India to study the self-harm behavior in adolescents in a school setting from South India. An Indian study on 1571 adolescents and young adults from 19 schools and colleges found the rate of NSSI was 33.8%. Minor forms of self-harm were more common (19.4% vs moderate/severe 14.6%). In this study, any form of self-injury was found to be 40.7%. Around 18.5% of patients reported any suicidal intent.[13] Another study from reported 31.2% of the individuals on college students reported NSSI in the previous year, where the mean age of onset was 15.9 years.[14]

A study from pediatric clinic from south India interviewed 30 children with a history of self-harm reported that three fourth children had a history of acute stressful events. Also, majority of the children had chronic stress or stress in the family. Half of the sample had psychiatric morbidity most common being depression. The commonest means of self-harm was poisoning (rat poison).[15]

A chart review from the consultation psychiatry clinic of a tertiary care center from northern India studied 109 adolescents with age <19 years. They concluded that females (60.4%) were much more than males. Overall, the mean age was 17 years mostly from nuclear families, middle socioeconomic status and Hindu by religion while the most common method being ingestion of insecticides (65%) and one-fifth had psychiatric morbidity. The self-harm behavior was often precipitated by problems with a family context.[16]

Risk factors and identifying at risk

As the DSH attempts start at an early age it is prudent to learn the various risk and protective factors and understand this entity in a broad manner. Suicide has been conceptualized in many ways but to understand the transition between different suicidal states and predicting the risk of suicide an easy biopsychosocial model is chosen. Many authors have also tried to study the self-report of individuals, a systematic review looking into this topic concluded that these youngsters labeled self-harm as a “positive experience” and “defining the self.”[17]

Looking into factors affecting this behavior one inpatient study found that 70% of those engaging in NSSI had any lifetime SA and around 55% with multiple attempts. Those with a long history of NSSI, using more methods, and not reporting physical pain during NSSI were at a greater risk of making a SA. This highlights the significant overlap between NSSI and SAs and thus the relation between the two should be investigated.[18],[19] Suicidal behavior/intention also is a dimensional concept ranging from the wish to die, suicidal ideation, plan, attempt and completed suicide. At times there is disagreement between the patient and the clinician on this issue. In an inpatient adolescent setting where 77% of participants reported NSSI at baseline followed up after discharge in a naturalistic manner. Fifty-six percent had persistence of self-harm behavior after 6 months of discharge. This study found those who endorsed automatic positive reinforcement as the predominant reason for NSSI, were more likely to persist in NSSI. During follow-up, depression also predicted the persistence of self-harm behavior.[20]

Out of 101 adolescents with attempted suicide who are referred to the Psychiatry services in a general hospital over a period of 6 months were studied. Seventy percent of them had Psychiatric disorders but few of them had prior treatment. Some of the sociodemographic risk factors found in this study were lower-income group, urban background, school educated, female sex, younger age, and being unemployed. Some other risk factors were increased family conflicts, marital problems, financial difficulties, and perceived humiliations.[21]

A meta-analysis of 29 studies on 1,122,054 individuals aged 12–26 years found the suicide death to be very strongly associated with any previous self-injurious thoughts or behaviors. A history of previous self-injurious behaviors predicted SAs. The population attributable risk of previous self-injurious thoughts or behaviors to SAs is 26%.[6] A study from Korea retrospectively reviewed 5 years of nationwide prospective registry of all injured patients younger than 29 years and admitted to tertiary care emergency departments. 8,400 out of 588,549 injury patients reported DSH. The rate began to rise at age 11 years and the highest risk of DSH rate was observed at age 20 years. Females outnumbered males in attempting self-harm, the most commonplace of injury was home and the most common method of poisoning was poisoning or overdose.[9] Various factors associated with self-harm are the presence of psychiatric illness particularly depression, alcohol abuse, impulsivity, exposure to a negative life event, bullying, and history of physical and sexual abuse.[22]

Factors associated with SAs were poor socioeconomic status, history of bullying, loneliness and anxiety, tobacco and alcohol use, and weak family and social relationships.[12] Other factors associated with suicidal behavior are poor attendance in school, educational attainment, feeling of not being connected, having negative experiences or attitude toward school. Young adults with poor school performance have a higher risk of SAs in young adults but the risk in lower if they attended school.[23]

A study from China on 2131 students from middle school reported that the prevalence of lifetime NSSI and SA were 23.2% and 3.2%, respectively. The authors also observed a co-occurrence of up to 2.3%. Females, having a single parent, depressive symptoms, and impulsivity differentiated attempted suicide from NSSI.[24] Another recent study from China on 11,831 adolescents reported adolescents with either NSSI or SA scored significantly higher on hopelessness, internalizing and externalizing problems, trait anger, impulsiveness.[12] A retrospective study of adolescent patients presenting to the emergency department found that self-harm patients had prior histories of the emergency visit, for mental health problems, substance abuse, and injuries as compared to control. The cumulative incidence of recurrent self-harm for 5 years was 19.3%. Admission as an inpatient at index visit and prior psychiatric emergency visit increased the risk of recurrent self-harm risk.[25]

A review focusing on risk and protective factors of self-harm behaviors in Low- and Middle-income countries showed that the 12-month prevalence of NSSI varied from 15.5% to 31.3%, as high as compared to the suicidal behavior rates which varied from 3.2% to 4.7%. In hospital studies, poisoning was the commonest method against the community sample where Banging and hitting were more common. It was seen that many factors were associated with self-harm which included having a conflict within the family, having similar behavior in peers, the incidence of truancy, or absenteeism at school. However, having understanding members in the family, friends in general, higher school competence were protective in nature. The absence of close friend and a history of suicide in a peer increased suicidal thought in the subjects.[26]

   Prevention and Management Top

Coupled with low resources, the slow progress of child and adolescent psychiatry in a country like India makes it difficult to handle such a huge burden. India is far from developing a child and adolescent mental health program which has been recommended by the WHO since 1977 to every country. Though scales are helpful, authors have reported that they should not be over-relied upon while assessing such a sensitive issue. Rather a comprehensive psychosocial analysis of risk and protective factors is irreplaceable.

Various public health measures can also be devised for its possible application at the school level or community level to prevent the emergence of risk factors of DSH. The interventions for suicide prevention range from general interventions to specific targeted interventions for high-risk individuals. The general interventions target all the students in Institute and include activities which promote mental health in general. Then there are selective prevention strategies for children at a high risk of self-harm and those who have demonstrated suicidal behavior [Figure 1].
Figure 1: Levels of prevention

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A nonjudgemental attitude helps the youngster to easily open about their problems. There is already difficult to access to services for them so those coming should be encouraged with a nonjudgemental attitude. Although a detailed assessment may not be possible at educational setting issues like bullying, abuse or any mental health issues should be adequately addressed. At educational institute certain screening tools/questionnaires may be used to compliment the verbal interview in identifying risk factors.

Screening of the adolescent population is a crucial step as a part of the secondary prevention strategy. Using available resources and understanding risk and protective factors including a history of mental illness, ongoing stressors, and substance use are also key factors to be screened. Evidence for use of screening tools though not very strong and some authors have also questioned its financial burden on Educational Institutes and overreporting of cases, but overall literature favors the use. In recent times integration of technology by using web and mobile app-based screening tools have also been tried and show promising results in encouraging students to turn up. There are various strategies recommended for the prevention of self-harm behavior which includes general awareness program focusing on the extent and burden of the problem, decreasing stigma, and increasing case finding. Reducing access to methods of suicide is another widely used public measure.

Use of crises center or hotline has been tried which includes personnel with basic training of crisis management and identification and timely referral of high-risk individuals. Evidence for some other sources on the Internet for self-help and various other self-help books/apps are is upcoming. Efforts should also be made to reintegrate those children who have attempted suicide in society and school on the other hand social isolation should be avoided. Developing healthy skills like improved problem solving, better coping with stress in general, etc., are promising in improving in the way individual deals with stress and reduction in suicidal ideation.

Specific interventions

Although interventions in Adolescent and child is not well researched and clear, recently the number of trials and published literature has gained pace. Now in addition to nonrandomized controlled trials (non-RCT) now researchers are including RCT. Although few reviews are available till date, the case may not be so in a few years [Table 1].
Table 1: Interventions for suicide prevention in children and adolescent

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Gatekeeper training interventions have been used in school settings. In this regard a program developed called Gatekeeper training where the term “Gatekeeper” has been defined as “individuals in a community who have face-to-face contact with large numbers of community members as part of their usual routine, and who are trained to identify persons at risk of suicide and refer them to treatment or supporting services as appropriate.” Apart from general training of the educators they are trained on topics including suicide warning signs, risk/protective factors, healthy relationships, etc., and to identify and refer students with self-harm/suicidal behavior.[27],[28]

Peer-based intervention has been theoretically presumed to have a better influence as adolescents discuss their problems usually with their nondistressed peers and thus have a better outcome.[29] Trust issues with adults are also a concern. Starting from awareness training in general specific interventions have also been taken up peers getting trained to identify others with suicide risk or help in building support, or just act as a bridge between the gatekeeper and the concerned individual.

Universal interventions: structured psychoeducation workshops have been shown to report less suicidal ideations compared to treatment as usual in a large study of high school students.[30] Similarly, an online-based CBT module was found to be effective in reducing suicidal ideations compared to attention control (where an informative E-mail was sent at the similar frequency).[31] Psychoeducation programs depicting signs of suicide using video tools also beneficial.[32]

Indicated interventions

Interventions like suicide-specific counseling and suicide-based psychoeducation have been seen to reduce suicidal ideation and behavior in young people. Challenges remain in a country like India where these resources are scant and the patient burden is immense. Some of these challenges may be overcome by the use of web-based CBT module Group interventions for coping with stress.[33],[34] The main advantage is the time and capital saved at no added cost. These interventions have also shown significant improvement over patients on Treatment as usual. Regular monthly sessions with counselors and parents result in decreased suicidal risk factors.[35]

Curriculum changes

Changes in the curriculum like including lectures and student handbook have also shown a reduction in suicidal ideation and even depressive symptoms postintervention in medical students. Although the concern remains between teachers and students regarding the changes in the curriculum, further studies are required to establish the facts.[36]

Last but not the least for adolescent at-risk interventions like psychosocial interventions with/without Pharmacotherapeutic interventions should be used. The treatment of underlying illness/psychiatric morbidity, if is of great help. The highest evidence has been associated with Lithium, clozapine, and electroconvulsive therapy with anti-suicidal properties. Combination with psychotherapy (incl. CBT, DBT, IPT, problem-solving therapy) is recommended, especially in the case of adolescents.

   Conclusion Top

Predicting and preventing a SA is a need of further research in this area. Though the evidence is upcoming, still a lot of work is needed in this area. At present interventions as well as policy from this part of the world are lacking. The possibility of implementing the already existing interventions like Gatekeeper training or curriculum changes should be explored. In addition, the development of targeted interventions should be developed specifically to Indian adolescents taking into consideration the sociocultural variations across the country. Such interventions should be suited to different phases of development and the aim of such interventions should be to stop the progression. There is a need of national policy and guidelines which should include programs targeting community as well as educational institutes.

Financial support and sponsorship

Review was done as a part of Indian Council of Medical Research (ICMR) project “Deliberate self-harm in Adolescents: A School Based Study” (Proposal ID – 2019-0867), funding as a part of extramural project from ICMR, has been received by BNP.

Conflicts of interest

There are no conflicts of interest.

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