Rates of Self-Harm Soar, Especially Among Girls, Young Women

Batya Swift Yasgur, MA, LSW

June 11, 2019

Rates of nonsuicidal self-harm (NSSH) are rising, especially among adolescent girls and young adult women. Few of these people receive medical or psychological help, new research suggests.

Researchers analyzed data regarding NSSH from a series of surveys of adults aged 16–74 years living in England during 2000, 2007, and 2014. They found that the lifetime prevalence of NSSH in the British population tripled during that time, rising from 2.4% in 2000 to 3.8% in 2007 and to 6.4% in 2014.

Although prevalence increased across age groups and among both sexes, the group most affected were women and girls aged 16–24 years. For these persons, rates increased from 6.5% in 2000 to almost 20% in 2014.

In 2000 and 2007, roughly 51% of participants who had engaged in NSSH reported receiving no medical or psychological help. This percentage rose to 59% in 2014.

"We found a nearly threefold increase in NSSH in both men and women and in different age groups, but the most pronounced rates were in young women, where nearly one fifth reported engaging in NSSH at some point in their lives," lead author Sally McManus, MSc, of the National Center for Social Research, London, United Kingdom, told Medscape Medical News.

"One of the things we want to see come out of our study is positive emphasis in healthcare, education, social services, and criminal justice on developing emotionally health and positive coping strategies," McManus said.

The study was published online June 4 in Lancet Psychiatry.

Temporal Study

An increasing number of studies have investigated NSSH, which has led to "improved recognition and informed prevention programmes," the authors write.

However, it is "unclear" whether the prevalence or nature of NSSH is changing, because "studies of temporal trends are rare and their findings inconsistent."

To investigate the question, the researchers conducted a secondary analysis of data from the Adult Psychiatric Morbidity Surveys for 2000, 2007, and 2014 regarding individuals aged 16–74 years (n = 7243, 6477, and 6477, respectively).

The amount of missing data was "minimal," the researchers state. In the 2014 survey, data were missing from 4.3% of participants who did not provide responses for self-completion. The self-completion component was conducted via a laptop for enhanced privacy, whereas the remainder of the survey was conducted through face-to-face interviews.

There was a steady overall increase in lifetime prevalence of NSSH, from 2.4 (95% confidence interval [CI], 2.0–2.8) in 2000 to 3.8 (95% CI, 3.3–4.3) in 2007 to 6.4 (95% CI, 5.8–7.2) in 2014.

Although the profile of participants in all three waves remained stable in terms of age and sex, the proportion of respondents who were white declined. The prevalence of NSSH did not significantly differ between ethnic groups during any wave.

What remained steady during all three waves was that NSSH was most prevalent in the youngest age groups and was least prevalent in the oldest age groups.

Although prevalence was similar among male and female participants in 2000 and 2007, it was significantly higher in women and girls (7.9%; 95% CI, 6.9–9.0) vs men and boys in 2014 (5.0%; 95% CI, 4.0–6.1; P = .0002).

Moreover, although prevalence increased in both sexes and in all age groups, the increase in absolute terms was greatest in girls and young women: in 2014, 19.7% of female 16- to 24-year-olds reported NSSH in face-to-face interviews (95% CI, 15.7–24.5), up from 6.5% in 2000 (95% CI, 4.2–10.0) and 11.7% in 2007 (95% CI, 8.4–16.0).

The prevalence was even higher when self-completion reports were included: a quarter (25.7%) of women and girls aged 16–24 years reported engaging in NSSH.

Changing Means, Motives

In each survey wave, around two thirds of participants who reported NSSH had engaged in self-cutting.

However, as NSSH became more common, the overall population prevalence of self-cutting from 2000 to 2014 rose from 1.5% (95% CI, 1.2–1.8) to 3.9% (95% CI, 3.5–4.5). The increase in prevalence was especially pronounced in women and girls.

In 2000 and 2007, the prevalence of self-cutting did not differ significantly by sex, but in 2014, it was higher among women and girls than among men and boys (P < .0001).

On the other hand, the prevalence of self-burning in men and boys increased slightly, from 0.0% (95% CI, 0.0–0.1) in 2000 to 0.6% (95% CI, 0.4–1.1) in 2007 and 0.7% (95% CI, 0.4–1.3) in 2014.

In both sexes, the proportion of the population who reported that they engaged in NSSH to relieve unpleasant feelings (anger, tension, anxiety, or depression) roughly tripled in prevalence from 2000 to 2014, from 1.4% (95% CI, 1.0–2.0) to 4.0% (95% CI, 3.2–5.0) in men and boys, and from 2.1% (95% CI, 1.6–2.7) to 6.8% (95% CI, 6.0–7.8) in women and girls.

In 2000 and 2007, the prevalence of the use of NSSH to cope with these feelings did not differ significantly by sex, but in 2014, it was significantly more common in women and girls than in men and boys, with the highest prevalence in women and girls aged 16–24 years.

When those who reported NSSH in the self-completion section in 2014 were included, close to one quarter (22.4%) female 16- to 24-year-olds reported engaging in NSSH as a mean of coping.

The proportion of participants who reported that they engaged in NSSH to change their situation increased overall, but less sharply than the proportion who used NSSH as a coping mechanism, and the proportion did not differ by sex in any of the three waves.

The proportion of people who engaged in NSSH and who reported receiving no subsequent medical or psychological services remained stable from 2000 to 2007 (51.2% [95% CI, 42.2–60.0] and 51.8% [95% CI, 47.3–56.40], respectively), but it nonsignificantly increased in 2014 (59.4%; 95% CI, 54.7–63.9).

Low Rates of Help-Seeking

When participants in 2014 who reported NSSH only in the self-completion section were included, a larger proportion (62.6%; 95% CI, 58.9–66.1) reported having no contact with medical or psychological services after engaging in NSSH.

Compared to men and boys, women and girls who engaged in NSSH had roughly twice the odds of contacting medical or psychological services.

Service contact after NSSH was also higher in people aged 35–74 years, compared to those aged 16–34 years.

Moreover, the odds of reporting service contact after engaging in NSSH were increased in people who had also made a suicide attempt at some point.

"We are aware that this story could be picked up widely, and we don't want it to contribute to normalizing self-harming behavior and seeing it as a way of coping," said McManus.

"Rather, we want the findings to alert people to look for alternatives that are more positive ways of coping," she added.

She suggested that the fact that the number of people who sought professional help was low might be attributable to stigma.

Moreover, "the high prevalence among younger people may be that they feel less empowered to access such support," she said.

Behind Closed Doors

Commenting on the study for Medscape Medical News, Rohan Borschmann, PhD, DClinPsych, psychologist and senior research fellow, Melbourne School of Population and Global Health, University of Melbourne, Australia, who was not involved with the study, called it "a very welcome addition to the literature."

He commended the researchers on including respondents who had not been in contact with mental health services, because this subgroup is often excluded from studies of self-harm.

Borschmann, who is the coauthor of an accompanying comment, suggested that self-harm is "typically a very private behavior and still carries with it a considerable stigma, often done behind closed doors and kept hidden from others, including close friends and family members."

Often, it is "only when a young person accidentally 'goes too far' that medical assistance is sought," he observed.

He emphasized that self-harm in young people "is often a marker for other risk behaviors that pose considerable hazards for social and emotional development throughout young adulthood and beyond and should never be considered as just a passing phase."

Also commenting on the study for Medscape Medical News, E. David Klonsky, PhD, professor, Department of Psychology, University of British Columbia, Canada, who was not involved with the research, called it a "well-done study by an experienced and thoughtful team."

Because the study distinguished between NSSH and other forms of self-harm with suicidal intent, it is a "step in the right direction toward understanding the scope of self-harm with better specificity," he said.

He noted that the rates reported in the study are "roughly in line with rates reported in other Western countries, such as the USA and Germany."

However, he pointed out, "unique to the USA is a 15-year-long trend of increasing suicide rates."

Some Reservations

Igor Galynker MD, PhD, professor of psychiatry, Icahn School of Medicine, and director, MSBI Suicide Research Laboratory, Mount Sinai Beth Israel, New York City, also commented on the study, describing it as "very solid methodologically."

He did, however, express reservations.

"My main issue with the study is that NSSH is nonfatal, and its main relevance in the US in seriousness is to what extent it's related to suicide and suicidal behavior," said Galynker, who was not involved with the study.

"It is interesting that in England, although NSSH increased three- to fivefold, suicidal behavior did not increase, which is a striking finding," he noted.

On the other hand, in the United States, "the suicide rate is going up — not only attempts but also completed suicide rates — and is escalating, especially in adolescents and in children younger than 15 years," he pointed out.

"The most obvious reason [for this increase] is access to firearms in the US, where 50% of people kill themselves using firearms, compared to 5% in Europe," he suggested.

"Someone in the US who might want to relieve terrible mental pain might get a gun and shoot themselves, but when they don't have a gun, they may cut themselves, using NSSH to feel better," he said.

He noted that in the United States as well as the United Kingdom, people who engage in NSSH are not getting sufficient help.

"Some people are embarrassed, and some don't want to get help because it is a coping skill for them, so they most frequently cut their inner or outer thigh, where the cuts are not visible," he said.

Moreover, social media may be a culprit in normalizing this behavior, he speculated.

McManus said that clinicians who work with young people should be aware that NSSH is prevalent and acknowledge that it could be happening, but they should talk about it in a way that does not normalize it.

She encouraged clinicians to inquire whether patients are engaging in NSSH and "to have available, when asked, positive alternative coping strategies instead for dealing with distress."

The English Department of Health and Social Care is the primary funder of the Adult Psychiatric Morbidity Surveys, which were commissioned by NHS Digital. The analyses were independent research funded by the National Institute for Health Research Policy Research Programme. Other sources of funding are listed on the original article. McManus and coauthors, Borschmann and coauthor, Klonsky, and Galynker have disclosed no relevant financial relationships.

Lancet Psychiatry. Published online June 4, 2019. Full text, Comment

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