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Risk of Escalation from Self-Harm to Suicide Attempts in Adolescents


Can Self-Harm Lead to Suicide in Teens?

[seriesbox]A Parent’s Guide to Self-Harm and Suicide Risk in Teens
The Association Between Teen Suicidal Ideation and Childhood Depression and Irritability
Insomnia and Sleep Disturbances in Teens Linked to Higher Risk of Suicide
Bullying and Cyberbullying Associated with Higher Risk of Suicide in Teens
Are Brooding, Impulsive Teens at Higher Risk for Suicidality?
Teen Suicide Contagion: Is Suicide Contagious?[/seriesbox]When we write articles about self-harm in teens, we’re careful to distinguish between the act of self-harm and the act of attempting suicide. We do this because the motivations behind the two types of behavior are often different.

In fact, many experts in adolescent mental health describe the motivations as related, but in opposition to one another.

When a person attempts suicide, data shows that in most cases, they intend to die. In contrast, in most cases, when a person engages in self-harm – known clinically as non-suicidal self-injury (NSSI) – they do not want to die. They self-harm in an attempt to process or mitigate the negative effect of overwhelming emotions, stressful events, or disturbing thoughts. In other words, they self-harm as a way of self-soothing.

This implies they anticipate being alive after the self-harm act: it’s not final.

We know this because they tell us. When discussing reasons why they self-harm, we learn that many teens engage in self-harming behaviors like cutting, branding, or burning to communicate emotional distress or pain to parents, friends, or others.

We have data on this:

  • 74% of teens engage in self-injury to process negative emotions
  • 46% of teens engage in self-injury to communicate distress

This is critical information for parents because it means that most of the time, teens who self-harm are in an emotional place where evidence-based treatment can help. They have intense, overwhelming, and powerful emotions. Their coping mechanism is NSSI. If they get professional support, however, their psychiatrist, therapist, or counselor can teach them distress management techniques that help them process their emotions and communicate their difficulties in a productive, life-affirming manner.

That’s important. But it’s not the whole story.
Tuesday, September 8, 2020
11:40 AM

The Relationship Between Self-Harm and Suicide

The whole story is more complex. We hint at it above. The motivations driving the two behaviors may be in opposition to one another, but they are not completely unrelated. While engaging in self-harm does not mean a teen wants to die, evidence shows that engaging in self-harm does significantly increase subsequent suicide risk.

For decades, research on suicide and self-harm among teens focused on identifying risk factors, warning signs, and protective factors. Recently, though, in response to data showing suicide as the second leading cause of death among adolescents and young adults, and data showing an increase in self-harm among teens and young adults – see our article September is National Suicide Prevention Month: #BeThe1To for facts and figures – researchers have focused their efforts on exploring the relationship between self-harm and subsequent suicide attempts.

A Quick Definition: What is Self-Harm?

Before we go any further, let’s get on the same page about exactly what we mean by self-harm or NSSI. Here’s how the  American Psychological Association (APA) defines the behavior:

“The condition…is characterized by deliberate self-inflicted harm that isn’t intended to be suicidal. People who self-harm may carve or cut their skin, burn themselves, bang or punch objects or themselves, embed objects under their skin, or engage in myriad other behaviors that are intended to cause themselves pain but not end their lives.”

Suicide Following Self-Harm in Teens and Young Adults: New Data

Now that we’ve clarified our definitions and terms, let’s have a look at a study published in 2018 called “Suicide After Deliberate Self-Harm in Adolescents and Young Adults.” Here’s how the study authors introduce their research:

“Although nonfatal self-harm is common among young people and suicide is a leading cause of death among adolescents and young adults, little is known about the rate and risks of suicide after nonfatal self-harm in young people.”

In order to learn more about the “rate and risks of suicide after nonfatal self-harm,” they followed a group of 32,395 adolescents (12-17) and young adults (18-24) for one year after a confirmed instance of NSSI. They collected data in three primary categories:

  1. The initial self-harm/NSSI event.
  2. Instances of self-harm/NSSI one year after the initial self-harm/NSSI event.
  3. Instances of suicide one year after the initial self-harm/NSSI event.

Here’s what they learned.

Self-Harm Initial Events: Key Findings

These are the basic facts about the individuals researchers followed from the initial self-harm event to one year following the initial event.

Demographic Information

  • Gender:
    • 67% female
    • 33% male
  • Race/ethnicity:
    • 62% White
    • 9% African American
    • 1% Hispanic
    • 1% Native American/Native Alaskan

Common Disorders Associated With Initial Self-Harm Events

Method of Self-Harm

  • Poisoning: 65%
  • Cutting: 18.4%
  • Firearms: 0.9%
  • Other: 15.7%

One Year Follow Up: Key Findings

This is the data they collected one year after the initial self-harm event. We’ll look at the self-harm data first.

Repeated Self-Harm: Adolescents and Young Adults

  • 17.1% reported subsequent incidents of self-harm
    • Likelihood of self-harm increased with each day following the initial event.
    • The risk of repeated self-harm during the first follow-up year was over 100 times greater than the risk of suicide
  • Common disorders associated with repeated self-harm events:
    • Personality disorders
    • Anxiety disorders
    • Mood disorders
    • Substance use disorders
    • Schizophrenia
    • Disruptive behavior disorders
  • Risk of repeated self-harm was greater for:
    • Females compared to males
    • Whites compared to African Americans

Now we’ll look at the suicide data.

Suicide: Adolescents and Young Adults

  • Adolescents with an initial self-harm event were 46.0 times more likely to commit suicide than adolescents with no history of self-harm
  • Young adults with an initial self-harm event were 19.2 times more likely to commit suicide than adolescents with no history of self-harm
  • Overall, adolescents and young adults were at 26.7 times higher risk of suicide than adolescents and young adults with an initial self-harm event
  • Suicide risk was higher for:
    • Adolescents, compared to young adults
    • Males, compared to females
    • Native Americans and Native Alaskans compared to all others
    • Individuals whose initial self-harm event involved firearms or hanging

This data clarifies questions many experts in adolescent mental health posed in recent years about the relationship between self-harm and suicide. Based on this nationally representative group of over thirty thousand adolescents and young adults, the message is clear: self-harm increases the risk of subsequent self-harm and suicide.

In the words of the study authors:

“After self-harm, adolescents and young adults were at markedly increased risk of suicide, including especially those who initially used violent self-harm methods or were of American Indian or Alaskan native descent. These risks highlight the importance of close follow-up after self-harm events.”

We’ll repeat that last sentence, because it implies something critical, which we’ll add next: these risks highlight the importance of close follow-up after self-harm events. Here’s the critical thing we’ll add this: evidence-based support and care can reduce instances of self-harm and suicide after an initial self-harm event.

Evidence: Treatment and Support Can Decrease Suicide in At-Risk Youth

We’ve published several articles on an effective treatment approach for adolescents at-risk of suicide and self-harm. The approach is called dialectical behavior therapy (DBT). To learn more about DBT and suicide prevention, please read this article:

DBT the Gold Standard for Treating Adolescent Self-Harm and Suicidal Ideation

Now, however, we want to share the results of a study involving adolescent Native Americans identified as at-risk of suicide because of their participation in a program designed to reduce binge drinking and/or a previous suicide attempt. Data from this study showed a community-based suicide prevention program reduced rates of suicide among the adolescent members of the Apache tribe of Arizona by 23 percent.

That’s significant, which means the program was effective.

Core components of the suicide prevention program included:

  • An intervention (2-4 hours) with a video adapted for local relevance
  • Multisession life skills curriculum with the following components:
    • Mandatory participation of one adult family member
    • Communication skills
    • Psychological and emotional coping skills
    • Problem-solving skills
    • Goal-setting skills
    • Instruction about how to access community support

We include this information to point out four things:

  1. Teens at risk of suicide and self-harm respond positively to proactive treatment and intervention
  2. Support tailored for teens is effective
  3. Support that prioritizes practical skills is effective
  4. Family involvement in adolescent treatment increases chances of treatment success

For parents of teens who self-harm, this data can help mitigate the fear that may arise when they learn that teens who self-harm are at increased risk of suicide.

We encourage parents to find hope in the fact that targeted, skills-based treatment works.

Teens with mental health disorders associated with suicide and self-harm can get effective, evidence-based, professional support. Therapists with experience working with adolescents can teach them the tools they need to process difficult emotions and replace life-interrupting behaviors such as self-harm with life-affirming skills that allow them to live a full and productive life, rather than a life dominated by the symptoms of their mental health disorder.

Suicide and Self Harm Hotlines

  • Teens who need help can call or text the following numbers:
    • The National Suicide Prevention Lifeline (24/7/365): 1-800-273-8255
    • The Trevor Project Phone (24/7/365): 1-866-488-7386
    • Trevor Project Text (7 days/wk, 6am-am ET, 3am-10pm PT): Text START to 678678
    • The Trevor Project Chat: CLICK HERE
    • Youth Crisis Text Line (24/7/365): Text CONNECT to 741741
    • The Youth Yellow Pages TEEN LINE (6pm-10pm PT) 310-855-4673
    • The Youth Yellow Pages TEXT: Text TEEN to 839863

Finding Help: Resources

If you’re seeking depression treatment for your teen, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.

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