Teen Violence, Substance Use: Same Suicide Risk as Self-harm

Batya Swift Yasgur, MA, LSW

June 02, 2017

The risk for suicide in adolescents who have been hospitalized for alcohol-, drug-, or violence-related injuries is similar to that of teens who self-harm, even 10 years later, new research shows.

Investigators led by Annie Herbert, PhD, research associate, Institute of Epidemiology and Healthcare, University of College, London, United Kingdom, found adversity-related injury almost doubled the 10-year risk for drug- or alcohol-related death, suicide, or homicide in comparison to accident-related injury. Increased risk for suicide was highest in all adolescents in all categories of adversity-related injury but affected 18- and 19-year-old men the most.

"We anticipated that risks of suicide might be increased after injuries related to either self-harm, drugs, alcohol, or violent deaths, as compared to risks related to accidents, but not that suicide risk following self-harm and following drug- or alcohol-related injury would be similar," Dr Herbert told Medscape Medical News.

"This study shows the importance of carrying out a psychosocial assessment in these adolescents with injuries related to drug or alcohol use or violence, not just self-harm," she said.

The study was published online May 25 in the Lancet.

Deeper Research Dive

Previous population-based cohort studies suggest that adversity-related injuries in adolescents (injuries resulting from self-harm, use of drugs or alcohol, or violence) are associated with similar underlying social and psychiatric problems, the authors note.

Despite the overlap between risk factors for these injuries, previous research has not investigated cause-specific death following hospitalization for drug- or alcohol-related injury nor compared risks for cause-specific deaths after discharge following adversity-related injury with deaths following accident-related injury.

"We know that in this group, risks of death are approximately doubled, but our study looked into this more deeply to find out what these adolescents were dying from," Dr Herbert said.

The study "aimed to inform preventive strategies for reducing risks of future harm for adolescents who are discharged from hospital after self-inflicted, drug-related or alcohol-related, or violent injury," the authors state.

The researchers analyzed data from the Hospital Episode Statistics, a database containing all emergency admissions to the National Health Service in England, from April 1, 1997, to March 31, 2012.

They categorized the cohort of 10- to 19-year-olds (n = 1,080,368) as being admitted for an adversity-related injury (consisting of nonmutually exclusive groups of self-inflicted, drug- or alcohol-related, or violent injury) or accident-related injury.

Deaths within the cohort were further categorized into causal groups: suicide, drug-related or alcohol-related, homicide, accidental, or other causes of death. Ten-year risk for death (total and by cause) following discharge from the hospital for adversity-related injury (exposure) was compared to risk after accident-related injury (comparator).

From the initial cohort, the researchers excluded several categories of adolescents (eg, those who did not have a recorded sex). The final cohort consisted of 333,008 (30.8%) adolescents who had at least one adversity-related injury and 649,818 (60.2%) adolescents with at least one accident-related injury but no adversity-related injury (females, 166,462 [25.6%]; males, 483,356 [74.4%]). Of those with adversity-related injury, 36,985 (20.3%) of females and 36,269 (24.0%) of males had an injury that was also accident related.

Older Boys at Higher Risk

In both males and females, the most frequent injuries were drug- or alcohol-related, followed by self-inflicted injury in females and violent injury in males.

By 10 years after discharge, the numbers of deaths between the adversity-related cohort and the accident-related cohort were comparable (2415 vs 2367 deaths, respectively). However, deaths related to suicide, homicide, drug use, or alcohol use after adversity-related index injury were doubled, as compared to deaths following accident-related injury (1543 [63.9%] vs 796 [33.6%] deaths, respectively).

The 10-year cumulative risks of total death after adversity-related index injury were 7.3 per 1000 females (95% confidence interval [CI], 6.8 - 7.8) and 15.6 per 1000 males (95% CI,14.8 - 16.5), both considerably higher than after accident-related index injury (females, 3.8 per 1000 [95% CI, 3.4 - 4.2]; males, 6.0 per 1000 [95% CI, 5.7 - 6.3]) and were due to "substantially higher" risk for suicide.

The 10-year risk for suicide was similar after hospital discharge following self-inflicted index injury, as compared to drug- or alcohol-related index injury (2.9 per 1000 [95% CI, 2.6 - 3.3] vs 2.5 [95% CI, 2.2 - 2.8] per 1000 for females; 9.8 per 1000 [95% CI, 8.7 - 11.0] vs 7.2 per 1000 [95% CI, 6.5 - 8.0] for males). Compared with adolescents discharged after accident-related injury, risk for suicide was increased about five to six times for adolescents discharged after self-inflicted or drug-related or alcohol-related injury.

The highest risk for death due to any cause was in men aged 18 to 19 years who were discharged after self-inflicted injury or drug-related or alcohol-related injury. The increased risk for suicide in females following violent injury vs accident-related injury was not significantly increased (adjusted subhazard ratio, 1.48 [95% CI, 0.73 - 2.98]).

"The risks of suicide and drug- or alcohol-related deaths are higher for boys compared to girls, not only among adolescents hospitalized with adversity-related injuries but also among adolescents hospitalized with accidents and in the general population as well," Dr Herbert observed, noting that the study did not explore the reason for this trend.

The highest risk for death due to any cause was in adolescents with a chronic physical condition (the most common being chronic respiratory disorder).

"An emergency admission to hospital for injury related to self-harm, drug or alcohol use, or violence may indicate underlying psychosocial need, thereby increasing the 10-year risk of suicide," Dr Herbert commented.

Beyond Teen Turmoil

Commenting on the study for Medscape Medical News, George Patton, MD, PhD, of the Center for Adolescent Health, Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia, said the study "challenges any preexisting notion that such presentations represent 'emotional turmoil' of adolescents and that they will grow out of these problems."

"The findings build on earlier community studies of adolescents who self-harm or who have substance use problems during the teens, which have also shown persistent, ongoing problems within this group," said Dr Patton, coauthor of an accompanying editorial.

"We should respond to adolescents presenting in distress with both the short-term and long-term view," he advised. "In the short-term, it is important to link all of these kids into follow-up health service engagement with monitoring, counseling, family engagement, and in some cases, specific treatments."

In the medium to long term, "they are likely to need continued supervision and engagement around their transitions through education into employment and into future relationships. In particular, they are likely to remain vulnerable at times of future adversity," he emphasized.

Dr Herbert said current UK guidelines regarding drug- or alcohol-related presentations in adolescents, unlike those regarding self-harm, do not specifically address the assessment of psychosocial needs, and no guidelines exist for the response to violent injury.

"Psychosocial assessments by specialized child and adolescent professionals should be standard practice not only in self-harm but in adolescents who have experienced other adversity-related injury," she said.

This study was funded by the Policy Research Unit in the Health of Children, Young People and Families, which is funded by the Department of Health Policy Research Programme. The authors and Dr Herbert have disclosed no relevant financial relationships.

Lancet. Published online May 25, 2017. Abstract, Editorial

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