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When Self Harm Predicts Suicide in Young People

A study led by Columbia University Irving Medical Center (CUIMC) revealed that young Americans had a sharply higher risk of suicide in the months after surviving a deliberate self-harm attempt. The authors say the findings, published online today in Pediatrics, underscore the need to direct clinical interventions toward youth who survive such attempts during this critical period.

"Our latest study shows that time is of the essence in preventing a nonfatal self-harm event from leading to a fatality," said Mark Olfson, MD, MPH, professor of psychiatry at Columbia University Vagelos College of Physicians and Surgeons and lead author of the study. "Although young adults compared to adolescents had a higher risk of suicide over the year after self-harm, adolescents had a particularly high risk during the first few weeks."

Nonfatal self-harm -- meaning self-poisoning or self-injury (e.g., cutting) with or without suicidal intent -- is common among young people. Although around one-third of young people who die of suicide have nonfatal self-harm events in the last three months of life, little is known about which young people with self-harm are at the highest short-term risk of suicide.

The researchers analyzed Medicaid data from 45 states to determine the 1-year suicide risk in 32,395 adolescents and young adults (age 12 to 24 years) who had been clinically diagnosed with deliberate self-harm. The data were linked to the U.S. National Death Index to confirm dates and cause of death. The researchers looked at many risk factors, such as demographic characteristics, recent treatment for a psychiatric disorder, and method of self-harm. They compared among young people with self-harm their risks of repeated nonfatal self-harm and suicide and they compared their risk of suicide in relation to the general population of young people who had similar age and demographic characteristics.

Approximately 17 percent had a repeated nonfatal self-harm episode in the first year, and 0.15% percent died of suicide. Adolescents were 46 times more likely than the controls to die of suicide in the 12 months after a nonfatal self-harm attempt. The risk of suicide was especially high after self-harm events using violent methods such as firearms or hanging. Although only about 4% of young people with non-fatal self-harm used violent methods, they accounted for approximately 40 percent of the suicide deaths. In a previous study, Olfson found that adults also had an elevated risk of suicide in the year after a self-harm episode, especially after self-harm involving violent methods.

"For many people, young and old, the same problems that led them to harm themselves in the first place -- such as depression, substance use, and anxiety disorders -- may continue to put them at risk of suicide," said Olfson. Following nonfatal self-harm, males were four times more likely to complete suicide than females, and Native Americans were five times more likely than white non-Hispanic individuals. "We suspect that lower use of mental health services among males and Native Americans may partially explain the higher suicide rates in these groups," said Olfson.

The results suggest that clinical priority should be given to ensuring the safety of young people following self-harm. This may include treating underlying psychiatric disorders, restricting access to lethal means of self-harm, strengthening supportive relationships, and close monitoring for emerging suicidal symptoms.

Jeffrey Lieberman, Chair of Columbia Psychiatry and former President of the American Psychiatric Association added that "this report is a wake-up call to a public mental health problem that has been neglected for too long. It's time to act on these results to provide services that can prevent self-inflicted harm to mentally distressed youth."

The study is titled "Suicide following deliberate self-harm in adolescents and young adults."

This research was funded by a grant from the Agency for Healthcare Research and Quality (U19 HS021112).

Other contributors to this paper are Melanie Wall (CUIMC), Shai Wang (CUIMC), Stephen Crystal (Rutgers University, New Brunswick, NJ), Jeff Bridge (Ohio State University, Columbus, OH), Shang-Min Liu (CUIMC), and Carlos Blanco (National Institute on Drug Abuse, Rockville, MD).

Mark Olfson, Melanie Wall, Shuai Wang, Stephen Crystal, Jeffrey A. Bridge, Shang-Min Liu, Carlos Blanco. Suicide After Deliberate Self-Harm in Adolescents and Young Adults. Pediatrics, 2018; e20173517 DOI: 10.1542/peds.2017-3517

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