Why Is Self-Harm Rising Among Teen Girls?

Why Is Self-Harm Rising Among Teen Girls?
Authors: News Author: Pauline Anderson; CME Author: Laurie Barclay, MD Faculty and Disclosures

Self-harm among children and adolescents carries a major public health burden and is highly associated with risk for suicide, anxiety disorders, and depression, as well as long-lasting psychological issues in childhood that often herald the onset of mental illnesses in adulthood.

The national suicide prevention strategy in the United Kingdom now targets lowering self-harm rates as a common forerunner of suicide. Such strategies require accurate population-level data regarding the frequency and course of self-harm among children and adolescents. The goals of this population-based cohort study were to evaluate temporal trends in sex- and age-specific incidence of self-harm among children and adolescents, as well as clinical management patterns and risk for cause-specific mortality after an index self-harm episode in early life.
Study Synopsis and Perspective

The incidence of self-harm among girls aged 13 to 16 years increased by 68% in the UK during a 4-year period, new research shows.

This apparent marked increase suggests an "urgent need to identify the causes of this phenomenon," the authors, led by Nav Kapur, MD, professor of psychiatry and population health, University of Manchester, United Kingdom, write.

The findings highlight the important role of primary care for early intervention, monitoring, and targeting of at-risk children and adolescents, said Dr Kapur.

"When a young person is in distress and presents with self-harm to services, that's a real marker; that's a real indication that we need to intervene," he told Medscape Medical News.

The investigators also found that primary care practices in more socially deprived areas are less likely to refer children and adolescents who self-harm to specialist mental health services, and that these teenagers are at higher risk of dying after an incident of self-harm compared with their peers without a self-harm history.

The study was published online October 18 in the BMJ.

Suicide Risk

Self-harm in young people is a major public health problem. Worldwide, it is the strongest risk factor for subsequent suicide. Suicide is the second most common cause of death after traffic incidents for those younger than 25 years.

Researchers used the UK-wide Clinical Practice Research Datalink, 1 of the world's largest databases of electronic primary care patient records.

The anonymized database contains more than 4.4 million active patient records from 674 general practices and is broadly representative of the national population in terms of age, sex, and ethnicity.

About 60% of practices participate in the Clinical Practice Research Datalink linkage scheme, which facilitates access to hospital statistics, national mortality data, and information on social deprivation from census figures.

The analysis comprised 3 phases.

In the first phase, researchers identified 16,912 children and adolescents aged 10 to 19 years who experienced at least 1 episode of self-harm for the period 2001 to 2014. Of the index episodes of self-harm, more than 80% were drug overdoses.

In the United Kingdom, self-harm is a "spectrum of behaviors" that captures self-poisoning as well as self-injury, including self-cutting, regardless of intent, said Dr Kapur. He added that it is difficult to distinguish suicide attempts from nonsuicidal episodes of self-harm.

In this new study, the incidence of self-harm among girls was about 3 times higher than among boys (37.4 per 10,000 compared with 12.3 per 10,000).

Depression diagnoses were recorded in more than a third of girls and more than a quarter of boys. Attention-deficit/hyperactivity disorder, autism spectrum disorders, conduct disorder, and schizophrenia spectrum disorders were more common in boys than girls. Eating disorders were more prevalent in girls.

Within 12 months of the index episode, repeat self-harm was more common (about 21.5%) in girls than boys.

Sex Differences

The researchers investigated 5 categories of deprivation. Among children and adolescents registered with healthcare practices in the most deprived areas, the annual incidence per 10,000 was higher than among those registered in practices in the least deprived areas (27.1 vs 19.6).

Among girls aged 13 to 16 years, the age-specific incidence rate per 10,000 jumped by 68% from 2011 to 2014, going from 45.9 (95% confidence interval [CI], 41.7-50.0) to 76.9 (95% CI, 70.7-83.2).

There were no noticeable increases in the incidence in self-harm over time among females in age groups other than those aged 13 to 16 years or among males of any age.

Dr Kapur cautioned that the study was based on databases that might miss some cases and that lack detail in the recording of self-harm.

Although the reasons behind the recent increase of self-harm among young teenage girls are not clear, the authors indicate it may be linked to common mental health problems in female youths, as well as biological factors such as puberty. The increase could simply be related to problems of identification. Youths might be more willing to talk about self-harm, parents more willing to disclose it, and physicians more likely to inquire about it, said Dr Kapur.

However, the sharp increase that is restricted to a specific age and sex suggests otherwise.

"If it was just an identification issue, we would expect to see it across all age groups, and we would expect to see it in boys as well as girls," said Dr Kapur.

Responsible Use of Social Media

He noted "converging evidence" from various sources, including recent surveys, that suggests that the rise is "real," and that self-harm rates "might actually be going up," said Dr Kapur.

On the assumption that the increase is real, Dr Kapur suggested some possible causes for such an increase.

Higher levels of stress could play a role, said Dr Kapur. Young girls might be experiencing the same level of stress as boys but are responding to it differently. Boys, for example, might drink alcohol, whereas girls might start cutting themselves.

Digital media might also contribute to the recent rise in self-harm among teenaged girls.

"Social media and the Internet can be helpful to some people, as well as harmful," said Dr Kapur. For example, some websites might connect kids to useful resources, whereas others might encourage self-harm or present it as a normal reaction to a stressful event.

"The solution there, I think, is about educating and training young people to use social media responsibly," said Dr Kapur.

In the second analytic phase, researchers assessed clinical management during the 12 months after self-harm. A total of 2395 persons (17.7%) were referred to mental health services in this time frame. Of those, 18.2% were girls and 16.5% were boys.

The study showed that children and adolescents from general practices that were located in the most deprived areas were 23% less likely to be referred compared with practices in the least deprived areas.

This, said Dr Kapur, is an example of the "so-called inverse care law," according to which people who have the most complex needs (more mental illness and economic adversity, for example) "paradoxically" have the least access to healthcare. This could be partly a result of geographical barriers to accessing care.

Not Just a Clinical Problem

Overall, 22.2% of patients were prescribed antidepressants in the year after the index self-harm episode. More girls were given these drugs than boys. Conversely, boys were more likely to be prescribed hypnotics, anxiolytics, and antipsychotics than girls.

In the third analytic phase, each person with an incident episode was matched by age, sex, and registered practice, with up to 20 comparison individuals for whom there was no record of self-harm.

The researchers compared mortality data from 8638 youth in the self-harm cohort with those of 170,274 unaffected children. There were 43 deaths in the former group and 176 in the latter cohort.

Children and adolescents who engaged in self-harm were more than 9 times more likely to die an "unnatural" death during the follow-up period than their unaffected peers (hazard ratio [HR], 9.35; 95% CI, 5.84-14.97 after adjusting for deprivation level).

They were 17 times more likely to die by suicide (adjusted HR, 17.48; 95% CI, 7.55-40.46).

"This is an important reminder that self-harm is a behavior that needs to be taken very seriously," said Dr Kapur. He added that it is clear that self-harm is "linked to suicide" and is not always merely an act of attention seeking.

In addition to assessing young patients for self-harm risk, clinicians should ensure these patients have access to good psychiatric treatments, including "talk therapies," said Dr Kapur.

He noted the importance of involving others in the community to help tackle the problem of self-harm among young people.

"This is not just a clinical responsibility; we need to be working with schools, families, and others."

Calling Attention

Commenting on the study for Medscape Medical News, R. Scott Benson, MD, a child and adolescent psychiatrist in Pensacola, Florida, who is a member of the practice guideline committee of the American Psychiatric Association, praised the authors for "calling attention to this problem."

However, the data showing a 68% rise in the incidence of self-harm in young teenaged girls are "a little bit inflammatory," said Dr Benson.

"You have to look at the relative incidence, which is still fairly low, although it's more than it used to be, and it's more than it should be."

The vast majority of teenagers "are doing just fine," said Dr Benson. He added that the group of teenagers who are having trouble is small, and a group in the middle are "kind of wobbling," noting: "It's in the group who are wobbling where we can really make a difference."

The study results "are pretty consistent with what our clinical experience has been," noted Dr Benson, who said he characterizes self-cutting and self-harm as "tension-discharge behaviors."

"It just tells me that someone is under enormous stress and tension and doesn't feel they're getting the kind of support they need," said Dr Benson.

"Our job is to identify those children who are experiencing all that stress and make sure they get care."

Dr Benson commented that the fact that the most deprived regions have the least access to mental health services might reflect a degree of family instability.

"If the kids are under more stress, their parents may also be suffering stress, and because of that stress, may be less able to come up with a plan for accessing services for their children."

Dr Kapur chaired the National Institute for Health and Care Excellence (NICE) self-harm guidelines, quality standard topic expert group; is current chair of the National Institute for Health and Care Excellence adult depression guidelines, treatment, and management committee; is a topic expert for National Institute for Health and Care Excellence suicide prevention guidelines; and is a member of the Department of Health Suicide Prevention Strategy Advisory Group. Dr Benson has disclosed no relevant financial relationships.

BMJ. Published online October 18, 2017.[1]
Study Highlights

Using the UK Clinical Practice Research Datalink including electronic health records from 674 general practices, investigators identified 16,912 patients aged 10 to 19 years who harmed themselves during 2001 to 2014.
The first phase of analysis evaluated temporal trends in sex- and age-specific annual incidence of self-harm.
Practice-level deprivation was assessed ecologically with the index of multiple deprivation.
The second phase of analysis studied the probability of mental health services referral and psychotropic drug prescribing as measures of clinical management.
To evaluate cause-specific mortality after self-harm, investigators matched 8638 patients who were linked to hospital episode statistics and Office for National Statistics mortality records with up to 20 unaffected children and adolescents (n=170,274), based on age, sex, and general practice.
The third phase of analysis estimated relative risks for all-cause mortality, unnatural death (including suicide and accidental death), and fatal acute alcohol or drug poisoning.
Stratified Cox proportional hazards models for the self-harm cohort compared with the matched unaffected comparison cohort allowed derivation of HRs.
Annual incidence of self-harm increased in girls (37.4 per 10,000) compared with boys (12.3 per 10,000).
Repeat self-harm within 12 months of the index episode was approximately 21.5% more common in girls than in boys.
Among girls aged 13 to 16 years, annual incidence of self-harm increased rapidly and substantially by 68% from 2011 to 2014, from 45.9 per 10,000 to 77.0 per 10,000.
Annual incidence of self-harm did not increase appreciably among younger girls or among boys.
Young patients at the most socially deprived practices had considerably higher incidences of self-harm (27.1 vs 19.6 per 10,000), but were 23% less likely to receive referrals within 12 months of the index self-harm episode.
During follow-up, risks for all-cause and cause-specific mortality were increased, and unnatural death was approximately 9 times more likely among young patients with self-harm.
Risks for suicide were especially elevated, with a deprivation-adjusted HR of 17.5 (95% CI, 7.6-40.5), as were risks for fatal acute alcohol or drug poisoning (HR, 34.3; 95% CI, 10.2-115.7).
On the basis of their findings, the investigators concluded that multiple public agencies should place urgent priorities on clarifying the mechanisms underlying the recent apparent increase in the incidence of self-harm among early- to midteenaged girls, and on coordinated initiatives to address inequalities in health services provision to distressed children and adolescents.
Possible causes for this increase could include higher levels of stress and increased acceptability or even encouragement of self-harm by some social media.
Primary care plays an important role for early intervention and evaluation, monitoring, and targeting of young people who may not openly seek healthcare services for their self-harming behavior.
Given the scant evidence of consistent clinical management strategies for self-harm among children and adolescents, particularly in primary care settings, further development of appropriate interventions is needed.
The need to develop and implement effective interventions is especially crucial for girls in their early- to midteens, as this group had a 68% increase in self-harm incidence from 2011 to 2014.
Practices in the most deprived localities had the highest incidence of self-harm but the lowest likelihood of referral, illustrating the "inverse care law" in which quantity or quality of healthcare service provision is inversely associated with the level of healthcare need.
Increased mortality risks highlight the urgent need for effective interagency collaboration involving families, schools, and healthcare practices to improve safety for these distressed young people in the short term, and to help ensure their future mental health and well-being.
Given the particularly high relative risks for suicide and fatal acute alcohol or drug poisonings, interventions especially need to target prevention of these outcomes.
Study limitations include potential misclassification because of inaccurate code usage in primary care databases, possible lack of generalizability to the overall community, and underestimation of suicide in questionable cases.

Clinical Implications

From 2011 to 2015, the incidence of self-harm among girls aged 13 to 16 years increased by 68%, according to findings of a population-based cohort study.
Multiple public agencies should place urgent priorities on clarifying the mechanisms underlying this increase and on coordinated initiatives to address inequalities in provision of health services to distressed children and adolescents.
Implications for the Healthcare Team: Primary care plays an important role for early intervention and evaluation, monitoring, and targeting of young people who may not openly seek healthcare services for their self-harming behavior.