COMMENTARY

Pay Attention to Self-harm: It Is a Precursor to Suicide

William T. Basco, Jr., MD, MS

Disclosures

July 05, 2018

Self-harm and Suicide

Among teens and young adults aged 15 to 24 years, suicide is the second-leading cause of death. A recent study[1] sought to determine whether self-harm (a nonfatal self-injury or self-poisoning that occurred with or without suicidal intent) predicted future suicide. Other cohort studies have shown that the frequency of suicide in the first year after self-harm was less than 1%. Olfson and colleagues add to what is known by looking at expanded covariates, including gender, age, race, and ethnicity, as well as clinical diagnoses that might alter the risk for suicide after self-harm.

They analyzed 2001-2007 Medicaid data from 45 states, matched to the National Death Index, to identify persons aged 12-24 years who had a diagnosis of deliberate self-harm in the Medicaid data. The first instance of self-harm that appeared for any patient was assessed, and each person's subsequent 365-day history after the self-harm event was evaluated. Those who died at the time of the initial self-harm event were excluded. Most persons with nonfatal initial self-harm were white, female adolescents. Other demographics of the cohort are shown in the table.

Table. Demographic Composition of Cohort.

Race Proportion of Cohort
Non-Hispanic white 62.3%
Non-Hispanic black 27%
Hispanic 13.1%
American Indian/Alaska Native 5.1%
Other Characteristics
Female 67.6%
Male 32.4%
Depressive disorder 35.6%
Anxiety disorder 15.4%
Substance-use disorder 23.3%
Schizophrenia 10%
Attention-deficit/hyperactivity disorder 8.9%
Two or more mental health diagnoses 21%

Among more than 32,000 self-harm events, the method was classified as violent in 4.5% of the episodes and nonviolent in 83.4% of the episodes (two-thirds of which were poisoning and 18% of which were cutting).

About 17% of the young people who harmed themselves had at least one repeat nonfatal self-harm event during the following year. Several factors were positively associated with repeated self-harm, including female sex, bipolar or anxiety disorder, substance use disorder, personality disorder, and two or more clinical mental health diagnoses.

The overall standardized mortality ratio (SMR) was 26.7 (95% confidence interval [CI], 19.9-305.1) when the children were compared with a matched cohort in the general US population. The SMR of 46 was particularly high for adolescents (aged 12-17 years) compared with 19.2 among young adults (aged 18-24 years).

A self-harm episode that involved a firearm had a much greater hazard ratio (33.45; 95% CI, 13.3-84.1) for suicide after controlling for covariates.

These findings are consistent with previous research, which found that being male, being an American Indian or Alaskan native, or use of a violent method at initial presentation was a risk factor for suicide.

The investigators conclude that risk for suicide in a teen or young adult is increased after nonfatal self-harm. They suggest that knowing the demographic and clinical correlations with self-harm and later suicide can help prioritize populations for care and follow-up.

Viewpoint

Many of these findings will not surprise practitioners in emergency departments or inpatient or other settings where suicidal patients are seen frequently. Still, it's worth reiterating the results for other frontline providers who may see patients will self-harm at much lower frequencies.

These data point out that any self-harm, including cutting, which has the same hazard ratio as poisoning, is a risk factor. The magnitude of increase in standardized mortality or hazard ratio is also worth emphasizing and not forgetting.

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