Self-harm is a term used to span a spectrum of suicidal and non-suicidal behaviour, with a range of underlying motivations (Skegg, 2005).
It is relatively common in adolescence and is practised by approximately 1 in 5 to 1 in 10 young people (Doyle et al, 2015). It is estimated that every year there are approximately 220,000 presentations to British emergency departments by people who have self-harmed (Hawton et al, 2007). Of course, this is only the tip of the clinical iceberg, and the incidence of hospital-presenting non-fatal self-harm in England is much lower than that of community-occurring non-fatal self-harm, at least in adolescents (Geulayov et al, 2018).
There are a range of reasons why people self-harm including:
- to cope with feeling overwhelmed
- to release tension or experience emotion
- to achieve a sense of control over life
- to reach out to others or to signal that they need help – understood as a 'cry of pain' rather than a 'cry for help'
- to achieve any of the above without the wish to die
- to achieve any of the above without caring whether the outcome is death or not
- a specific wish to die by suicide.
Self-harm may be common, and may help many people cope with unbearable distress, but it also carries substantial risks. Patients who present to hospital having self-harmed have been shown to have an elevated risk of subsequent suicide (Carroll et al, 2014) and risk is particularly high for those who repeat self-harm (Zahl & Hawton, 2004). Risk appears to be highest in the month (and year) immediately following hospital presentation (Geulayov et al, 2019). Children who self-harm are approximately nine times more likely to die from unnatural causes over a 15-year follow-up period (Morgan et al, 2017). Approximately 0.6% of young people who self-harm go on to die by suicide, and this risk is greatest for males, older adolescents, and those who repeatedly self-harm (Hawton et al, 2020).
Risk factors for suicide in those who present to hospital having self-harmed include male gender, increasing age and area-level socio-economic deprivation (Geulayov et al, 2019). Presentations involving self-poisoning alone are associated with the lowest risk of suicide (Geulayov et al, 2019) compared with those who cut or use more than one method.
Beyond these broad risk factors, there is little that helps clinicians distinguish those who eventually take their own lives from those who do not (Mulder et al, 2016). Risk assessment instruments are now understood to have poor predictive ability (Carter et al, 2017). This may leave clinicians unsure how to approach the assessment and management of self-harm, and indeed anxious about a perceived responsibility to predict and prevent suicide.
However, whilst a reduction in suicide risk is a theoretical goal of interventions for people who self-harm, there are other secondary goals such as reduction in associated distress, and a reduction in the risk of repetition.
A range of treatments for self-harm have been investigated, yet evidence for their effectiveness remains weak or uncertain due to the relatively small number of trials and the poor methodological quality of some of these studies (Hawton et al, 2016a).
This module will present:
- the results of individual studies evaluating such treatments for their impact on several outcome measures
- the results of meta-analyses of studies addressing several outcome measures.