Deliberate self-harm in adolescents in Oxford, 1985-1995

Early adult outcomes of adolescents who deliberately poisoned themselves

OBJECTIVE

To describe the early adult psychopathological and social outcomes of adolescents who deliberately poisoned themselves.

METHOD

Prospective cohort study with a 6-year follow-up of 132 of 158 (84%) adolescents who, between ages 11 and 16 years, had taken part in a randomized trial of a brief family intervention after deliberate self-poisoning. Comparisons were made with a sample of participants matched for age, gender, and childhood social class. Both groups were assessed using standardized measures of psychopathology and social functioning.

RESULTS

In most cases (93/132 or 70%) self-harm stopped within 3 years. Psychiatric disorders, particularly depression (74/132 or 56%), were prevalent, and self-harm in adulthood was restricted to this subgroup. There was a strong association between childhood adversity, in particular childhood sexual abuse, and self-harming risk in adulthood. Adulthood adversity also added to the risk, especially for those who had experienced index episode major depression. These associations were not mediated by childhood problem solving and hopelessness.

CONCLUSIONS

For some young people, deliberate self-poisoning in adolescence seems to be part of a complex and continuing network of problems, marked by high rates of psychopathology, comorbidity, with other disorders and high psychosocial adversity.

Prevalence of and risk factors for suicide attempts versus suicide gestures: Analysis of the National Comorbidity Survey

Definitions and classification schemes for suicide attempts vary widely among studies, introducing conceptual, methodological, and clinical problems. We tested the importance of the intent to die criterion by comparing self-injurers with intent to die, suicide attempters, and those who self-injured not to die but to communicate with others, suicide gesturers, using data from the National Comorbidity Survey (n = 5,877). Suicide attempters (prevalence = 2.7%) differed from suicide gesturers (prevalence = 1.9%) and were characterized by male gender, fewer years of education, residence in the southern and western United States; psychiatric diagnoses including depressive, impulsive, and aggressive symptoms; comorbidity; and history of multiple physical and sexual assaults. It is possible and useful to distinguish between self-injurers on the basis of intent to die.

Exposure to suicide and suicidal behaviors among Hong Kong adolescents

Suicidal behaviors (deliberate self-injury with the intent to hurt or kill oneself) have been little examined outside the West. The aims of this study were to (a) determine the correlates of suicidal behaviors, and (b) examine whether depression and suicide ideation moderated the effects of exposure to completed and attempted suicide on suicidal behaviors among a community sample of Hong Kong youth ages 12-17. Adolescents responded to questions regarding self-injurious behaviors, and also indicated presence of intention to hurt or kill themselves in the past 12 months. Based on their responses, two groups of interest were formed: 96 youths reported both self-injurious behaviors and the intent to hurt or kill themselves, and formed the "suicidal behaviors" group; and, 1213 adolescents reported neither self-injurious behaviors nor intent to hurt self or die, and formed the control group. The participants also responded to questions about depressive symptoms, anxiety, suicidal ideation and attempt, alcohol/drug use, stressful life events, and family relationships. They indicated whether anyone they knew had attempted or completed suicide in the previous 12 months. Logistic regression indicated that depressive symptoms, stressful life events, suicidal ideation and exposure to suicide attempt (but not completed suicide) contributed unique variance to the presence of suicidal behaviors, after controlling for demographic variables. Depression (and at trend levels, suicidal ideation) moderated the effect of exposure to suicide attempt by others on suicidal behaviors. Our results indicate that completed suicide in the social network increases risk for suicidal behaviors, but not when other risk factors are controlled. By contrast, a suicide attempt independently increases risk for suicidal behaviors. Furthermore, those youths who experience depressive symptoms or suicidal ideation are at particularly high risk for engaging in suicidal behaviors when an exposure to suicide attempt occurs.

Time trends in child and adolescent mental disorders

PURPOSE OF REVIEW

1995 saw the publication of a major review of time trends in psychosocial disorders of youth across the second half of the twentieth century. It found evidence for substantial increases in rates of youth crime, alcohol and drug use, depression and suicide in most industrialized countries in the decades following the Second World War, slowing in some instances in the 1980s. Ten years on, we review findings on more recent trends in rates of these and other indicators of child and adolescent mental health.

RECENT FINDINGS

Prevalence estimates for autism spectrum disorders have increased in recent decades, as has public and professional awareness of hyperactivity and attention deficits. Trends in adolescent conduct problems, and in alcohol and drug use, appear to reflect culture-specific influences. Rates of suicide among young males, and self-harm among females have risen in many countries in recent years; trends in emotional disorders are more varied, but there is little evidence for any rise in rates of anorexia nervosa. Although some contributors to these trends have been identified, much remains to be learned about the key risks involved.

SUMMARY

Monitoring time trends in child and adolescent mental health is essential for service planning; knowledge of changing trends can also provide important pointers to potential risk factors. Current data sources allow relatively reliable tracking of trends in some areas, but remain severely limited in others. Further research is needed to understand the mechanisms underlying recently identified trends in child and adolescent mental health.

A 20-year review of trends in deliberate self-harm in a British town, 1981-2000

BACKGROUND

It is important to identify trends in deliberate self-harm because of potential links both with complex mental health problems and with suicide itself, and because of its significant impact on resources in both mental health and acute health services.

METHOD

Patients presenting at the A&E department at Kidderminster General Hospital following an act of deliberate self-harm between the years 1981 and 2000 were assessed by the Parasuicide Counselling Group. These data were used to examine trends in deliberate self-harm and patient characteristics.

RESULTS

The 20-year study examined 4,474 episodes of deliberate self-harm in the Kidderminster district. Rates of deliberate self-harm were higher in females throughout, although the difference between the genders narrowed in the second half of the 1990s. In both males and females, the rate of deliberate self-harm was highest in those aged 15-24. Since the mid-1990s, there have been increases in the rate of deliberate self-harm in males aged 45-54 and in females aged 25-44. Rates were highest in males and females who were separated. Although the most common method of deliberate self-harm in both males and females was overdose, males used cutting and other methods of deliberate self-harm proportionally more than females. There was a relentless rise in paracetamol use until a decline at the end of the study period following the introduction of a restriction on sales. Alcohol use at the time of deliberate self-harm rose markedly in both genders. There was a significant increase in deliberate self-harm repetition in both males and females over the study period. In males and females, psychiatric involvement or admission increased in the 1990s compared to the 1980s.

CONCLUSIONS

Higher levels of deliberate self-harm repetition and psychiatric involvement suggest increasing pressures on health services and a continuing need to develop understanding of deliberate self-harm.

Social predictors of suicidal behaviour in adolescents in Trinidad and Tobago

BACKGROUND

Previous research in Trinidad and Tobago has been limited in examining suicidal behaviours through psychological autopsy, secondary data and psychiatric populations. To date, there has been no community survey with an emphasis on causation and prevention.

METHODS

A total of 1,845 respondents aged 14-20 were selected in 24 schools across the country. Data were collected on socio-demographic variables and suicidal behaviour.

RESULTS

Gender differences existed for both suicidal ideation and attempts (p<0.001). Respondents from reconstituted families had higher suicidal ideation compared to other family structures (p<0.001), while intact families had the lowest rate for suicide attempts (p<0.01). Attendance to a religious institution lowered only suicidal ideation (p<0.05), while prayer with the family lowered both suicidal ideation (p<0.01) and suicide attempts (p<0.001). Individuals with alcohol abuse in the family had higher suicidal ideation (p<0.001) and attempts (p<0.001).

CONCLUSIONS

Significant social predictors of suicidal behaviour in Trinidad and Tobago are gender, attendance to a religious institution, prayer with the family, family structure and alcohol abuse in the family. It is essential to consider these predictors in planning public health policies.

Clinical correlates and repetition of self-harming behaviors among female adolescent victims of sexual abuse

This study investigated self-harming behaviors in 149 female adolescent victims of sexual abuse, first, by determining the rates of nine types of self-mutilating behavior at intake and nine months later and, second, by investigating comorbidity of clinical correlates associated with these behaviors. The adolescents were divided into three groups according to level of self-mutilating behavior and then compared on symptom self-reports; 62.1% of the adolescents engaged in at least one self-mutilating behavior. A graded relation was observed between level of self-mutilating behavior and rate, and total number of clinical disorders. At nine month follow-up, one in four teenagers still reported a moderate or high level of self-harm. The need for systematic assessment and intervention of self-mutilating behaviors is discussed.

Self-harm in young people: a perspective for mental health nursing care

AIMS

This paper addresses the assessment and management of self-harm in young people by a nurse consultant-led self-harm service in the UK. The purpose of the paper is to present some of the theoretical perspectives of the service and how these have influenced current practice with this group of young people.

BACKGROUND

Self-harm in young people continues to be a serious concern for health services globally. Rates of self-harm in teenagers in the UK are among the highest in Europe. The current literature offers information on the nature of self-harm and some evidence of specific interventions mainly from a 'psychiatric perspective'. This paper examines the development of a locally based nurse-led self-harm team involved in the care of this group of young people. A sociological view of children and young people is applied in examining the way society construes self-harm and the formation of the behaviour as a deviant act. Self-harm is considered in the context of transition through adolescence and the growth of self-identity.

CONCLUSION

The locally based child and adolescent mental health service has drawn together the evolving nurse consultant role, mental health nursing and medical sociology. This integration of people and theory will enhance the services understanding of self-harm in young people. At an international level, there is a need to consider the sociological dimensions of self-harm in young people as a way forward for mental health nurses who are involved in working with this group of people.

Reasons for deliberate self-harm: comparison of self-poisoners and self-cutters in a community sample of adolescents

OBJECTIVE

To compare motives and premeditation between adolescent deliberate self-poisoners and self-cutters.

METHOD

In a sample of 6,020 pupils aged 15 and 16 years who completed a self-report questionnaire, those who had deliberately cut themselves in the previous year (n = 220) were compared with those who had taken overdoses (n = 86).

RESULTS

More adolescents who took overdoses than those who cut themselves said that they had wanted to die (66.7% versus 40.2%, chi2 = 14.94, p <.0001) and had wanted to find out if someone loved them (41.2% versus 27.8%, chi2 = 4.14, p =.042). Female self-cutters were more likely than male self-cutters to say that they had wanted to punish themselves (51.0% versus 25.0%, chi2 = 9.25, p =.002) and had tried to get relief from a terrible state of mind (77.2% versus 60.9%, chi2 = 4.78, p =.029). More self-cutters than self-poisoners had thought about the act of self-harm for less than an hour beforehand (50.9% versus 36.1%, chi2 = 5.25, p =.021).

CONCLUSIONS

There are differences between adolescents' motives for overdoses and for self-cutting, and also gender differences in the reasons for self-cutting. The often impulsive nature of these acts (especially self-cutting) means that prevention should focus on encouraging alternative methods of managing distress, problem-solving, and help-seeking before thoughts of self-harm develop.

Deliberate self-harm in adolescents: a study of characteristics and trends in Oxford, 1990-2000

BACKGROUND

Deliberate self-harm (DSH) is a major healthcare problem in adolescents. Identification of targets for prevention and treatment requires ongoing monitoring of trends and characteristics of those involved.

METHOD

Using data from the Oxford Monitoring System for Attempted Suicide, we have examined trends and characteristics in adolescents aged 12-18 years presenting to a general hospital because of DSH between 1990 and 2000.

RESULTS

The numbers of presentations by females increased during the study period. An association of DSH with school stress was suggested by there being fewer presentations during the school holiday periods, the largest number in term times occurring on Mondays, and study problems being common. Self-poisoning was involved in more than 90% of episodes. Paracetamol overdoses decreased following legislation on pack sizes of analgesics. Antidepressant overdoses increased during the study period, in keeping with the rise in prescriptions. Drug misuse increased markedly in the boys, as did a history of violence to others. Being a victim of violence increased in girls. Suicide intent was higher in males. Problems faced by the adolescents showed marked gender differences, and differed between age groups and between those carrying out their first DSH episode and repeaters.

CONCLUSIONS

Clinical management of DSH in adolescents requires a range of responses, often involving multiservice and multidisciplinary input. Preventive initiatives in schools are also required.

Nurses' and doctors' perceptions of young people who engage in suicidal behaviour: a contemporary grounded theory analysis

Over the past 25 years, suicidal behaviour in young people has continued to be a major concern for health services around the world. Self-harm in individuals aged 13-18 is common and represents a significant reason for admission to accident and emergency departments, paediatric medical services and child and adolescent mental health services. Nurses' and doctors' working in these areas are the first point of contact for young people following an episode of self-harm. This paper presents a study exploring nurses and doctors perceptions of young people who engage in suicidal behaviour. The data presented form part of larger project conducted using both quantitative and qualitative methods, and a contemporary grounded theory approach to analysis. The findings revealed two main categories and associated subcategories: Experiences of frustration in practice (subcategories: non-therapeutic situations, insubstantiality of interventions and value of life) and strategies for relating to young people (sub-categories: specialist skills in care and reflections on own experience). The meanings of these categories highlight barriers in the relationship nurses and doctors have with young people who engage in suicidal behaviour. If suicide prevention policies around the world are to succeed the phenomena impacting on the communication between these professionals and young people needs to be addressed in research, education and in the development of practice.

Correlates of youth suicide attempters in Australian community and clinical samples

OBJECTIVE

This study (i) explores differences between a clinical sample of deliberate self-poisoning (DSP) patients and a community sample who reported previous attempted suicide (AS); and (ii) examines correlates of suicidal behaviour in these groups compared with a community control group (CC) with no suicidal behaviour.

METHOD

The study design was: case-case, case-control and cross-sectional population studies. A clinical sample of DSP (n = 51), a community sample of AS (n = 31) and a community sample with no suicidal behaviour (n = 842) were used, all aged 18-24 years. The DSP and AS groups were compared on several variables and two logistic regression models were developed for risk of (i) DSP and (ii) AS compared to community controls.

RESULTS

The adjusted odds ratios for DSP were: female gender (OR = 5.7, CI = 1.7-19.4), anxiety (OR = 7.4, CI = 2.2-25.1), affective (OR = 23.0, CI = 6.9-76.5), or substance-use disorder (OR = 19.2, CI = 5.6-65.4) and greater mental health related disability (OR = 0.5, CI = 0.3-0.7 for 1 SD decrease). For AS the results were: anxiety (OR = 9.4, CI = 1.7-52.8) or substance-use disorder (OR = 3.0, CI = 1.1-8.7) and greater mental health disability (OR = 0.5, CI = 0.4-0.7). Affective disorder was close to significant for the AS group (OR = 4.0, CI = 0.9-17.1).

CONCLUSIONS

Correlates of DSP/AS were usually more powerful in the clinical group, but showed a similar pattern of psychiatric disorder and disability factors in both groups, supporting a continuum of risk factors across these groups. Interventions based on modifiable risk factors could target the same factors for public health, primary care or hospital populations: anxiety, depression and substance use disorders and mental health related disability.

Repetition risk for adolescent self-poisoning: a multiple event survival analysis

OBJECTIVES

To examine risk factors associated with re-presentation (event rates) following an initial episode of hospital treated self-poisoning.

METHOD

A longitudinal cohort study using the Hunter Area Toxicology Service (HATS) database of all presentations to hospital of self-poisoned patients aged 10-19 in Newcastle and Lake Macquarie Regions of New South Wales from January 1991 to December 1995. The study factors were: age, gender, employment status, 'substance abuse' and psychiatric diagnosis at index (first documented episode during the study time-period) admission. The main outcome measure was re-presentations per unit time. Time-event analysis (multivariate) was used to compare re-presentation rates per person-year exposure to the study factors.

RESULTS

There were 450 patients who presented on a total of 551 occasions. The median and modal age at initial presentation was 17. Three hundred and nine (69%) were female and 141 (31%) were male. The probability (95% CI) of a patient re-presenting within one year of an index admission with self poisoning was 0.09 (0.07-0.12) and within 5 years was 0.16 (0.12-0.21). The adjusted rate ratios for episodes of re-presentation were: any 'substance abuse (ever)' 3.87 (2.08-7.21), 'alcohol abuse' 2.32 (1.15-4.68),'benzodiazepine abuse' 4.89 (1.63-14.62), schizophrenia and other psychotic disorders (DSM-IV) 2.85 (1.2-6.79), and any personality disorder (DSM-IV) 2.68 (1.73-4.16).

CONCLUSIONS

Interventions to decrease recurrence rates for adolescent self poisoning should be directed towards substance (particularly alcohol or benzodiazepine) abuse, non-affective psychoses and personality disorder.

United Kingdom legislation on pack sizes of analgesics: background, rationale, and effects on suicide and deliberate self-harm

Following increasing concern in the UK about the mortality and morbidity associated with self-poisoning with analgesics, especially paracetamol (Tylenol, acetaminophen), legislation was introduced in 1998 to modify packs sold over-the-counter. The most important change was a reduction in the maximum size of packs. In this paper the background to the legislation, the rationale behind it, and its early impact are reviewed. The changes have had significant positive initial benefits on the mortality and morbidity associated with self-poisoning with analgesics.

Deliberate self harm in adolescents: self report survey in schools in England

OBJECTIVE

To determine the prevalence of deliberate self harm in adolescents and the factors associated with it.

DESIGN

Cross sectional survey using anonymous self report questionnaire.

SETTING

41 schools in England.

PARTICIPANTS

6020 pupils aged 15 and 16 years.

MAIN OUTCOME MEASURE

Deliberate self harm.

RESULTS

398 (6.9%) participants reported an act of deliberate self harm in the previous year that met study criteria. Only 12.6% of episodes had resulted in presentation to hospital. Deliberate self harm was more common in females than it was in males (11.2% v 3.2%; odds ratio 3.9, 95% confidence interval 3.1 to 4.9). In females the factors included in a multivariate logistic regression for deliberate self harm were recent self harm by friends, self harm by family members, drug misuse, depression, anxiety, impulsivity, and low self esteem. In males the factors were suicidal behaviour in friends and family members, drug use, and low self esteem.

CONCLUSIONS

Deliberate self harm is common in adolescents, especially females. School based mental health initiatives are needed. These could include approaches aimed at educating school pupils about mental health problems and screening for those at risk.

Annotation: randomised trials

BACKGROUND

This annotation describes the uses of randomised controlled trials (RCTs) in clinical child psychology and psychiatry.

METHOD

It explores the scientific basis for randomised designs, the conceptual and methodological issues that can arise when using them, alternative methods, and future directions.

RESULTS

There are many issues that have to be tackled when using randomised trials to answer questions about the effectiveness of interventions used by child mental health professionals. The most important are conceptual issues concerning the design of these studies, practical issues, and issues about the interpretation of the results. There are some situations in which randomised trials are not possible or ideal and alternative strategies may therefore be needed. Future RCTs should be more explicit about whether their primary purpose is to further scientific knowledge or to evaluate the benefit of a treatment in routine clinical practice. Future trials should also have outcomes of unequivocal significance and be reported in accordance with standardised guidelines.

CONCLUSIONS

Well-designed and unambiguously reported RCTs usually provide the best possible evidence about the effectiveness of an intervention. RCTs are not, however, the only way of establishing cause and effect and their results should always be interpreted in the light of other evidence.

Treatment strategies for early presenting acetaminophen overdose: a survey of medical directors of poison centers in North America and Europe

BACKGROUND

Acetaminophen is frequently used in self-poisoning in Western countries. Although treatment with N-acetylcysteine (NAC) reduces liver injury, no consensus exists on the preferred management of acetaminophen toxicity.

OBJECTIVES

To describe the approach taken by toxicologists in North America and Europe toward the management of acetaminophen toxicity.

METHODS

Medical directors of poison centers in the US, Canada, and Europe were surveyed by means of a questionnaire presenting two clinical scenarios of acetaminophen overdose: a healthy adolescent with no risk factors who had an acute ingestion of acetaminophen, and an adult with both acute ingestion and possible risk factors. For each case, several questions about the management of these patients were asked.

RESULTS

Questionnaires were sent to medical directors of 76 poison centers in North America and 48 in Europe, with response rates of 62% and 44%, respectively. Forty percent of responders suggested using charcoal 4 hours after ingestion of a potential toxic dose of acetaminophen, and 90% recommended treatment with NAC when levels were above 150 microg/mL but below 200 microg/mL 4 hours after ingestion. Duration of treatment with oral NAC ranged from 24 to 96 hours; 38 responders suggested a duration of 72 hours. Of 49 centers recommending oral NAC, 18 (36.7%) said they might consider treatment for less than 72 hours. Eleven of 29 (37.9%) responders suggested treatment with intravenous NAC for more than 20 hours as their usual protocol or a protocol for specific circumstances.

CONCLUSIONS

Our study showed large variability in the management of acetaminophen overdose. Variations in treatment protocols should be addressed in clinical trials to optimize the treatment for this common problem.

Management of paracetamol overdose: current controversies

Paracetamol (acetaminophen) is one of the most frequently used analgesics, and is the most commonly used substance in self-poisoning in the US and UK. Paracetamol toxicity is manifested primarily in the liver. Treatment with N-acetyl-cysteine (NAC), if started within 10 hours from ingestion, can prevent hepatic damage in most cases. Pharmacokinetic data relating plasma paracetamol concentration to time after ingestion have been used to generate a 'probable hepatoxicity line' to predict which cases of paracetamol overdose will result in hepatotoxicity and should be treated with NAC. However, later studies use a 25% lower line as their 'possible hepatotoxicity line'. Although adopting the original line may save considerable resources, further studies are needed to determine whether such an approach is safe. On the basis of the metabolism of paracetamol, several risk factors for paracetamol toxicity have been proposed. These risk factors include long term alcohol (ethanol) ingestion, fasting and treatment with drugs that induce the cytochrome P450 2E1 enzyme system. Although some studies have suggested that these risk factors may be associated with worse prognosis, the data are inconclusive. However, until further evidence is available, we suggest that the lower line should be used when risk factors are present. In Canada and the UK, the intravenous regimen for NAC is used almost exclusively; in the US, an oral regimen is used. Both regimens have been shown to be effective. There is no large scale study with direct comparison between these 2 therapeutic protocols and controversy still exists as to which regimen is superior. During the last few years there has been an increase in the number of reports of liver failure associated with prolonged paracetamol administration for therapeutic reasons. The true incidence of this phenomenon is not known. We suggest testing liver enzyme levels if a child has received more than 75 mg/kg/day of paracetamol for more than 24 hours during febrile illness, and to treat with NAC when transaminase levels are elevated. Paracetamol overdose during pregnancy should be treated with either oral or intravenous NAC according to the regular protocols in order to prevent maternal, and potentially fetal, toxicity. Unless severe maternal toxicity develops, paracetamol overdose does not appear to increase the risk for adverse pregnancy outcome.

Randomized trial of group therapy for repeated deliberate self-harm in adolescents

OBJECTIVE

To compare group therapy with routine care in adolescents who had deliberately harmed themselves on at least two occasions within a year.

METHOD

Single-blind pilot study with two randomized parallel groups that took place in Manchester, England. Sixty-three adolescents aged 12 through 16 years were randomly assigned to group therapy and routine care or routine care alone. Outcome data on suicide attempts were obtained without knowledge of treatment allocation on all randomized cases (62/63 by direct interview) on average 29 weeks later. The primary outcomes were depression and suicidal behavior.

RESULTS

In intention-to-treat analyses, adolescents who had group therapy were less likely to be "repeaters" at the end of the study (i.e., to have repeated deliberate self-harm on two or more further occasions) than adolescents who had routine care (2/32 versus 10/31; odds ratio 6.3), but the confidence intervals for this ratio were wide (95% confidence interval 1.4 to 28.7). They were also less likely to use routine care, had better school attendance, and had a lower rate of behavioral disorder than adolescents given routine care alone. The interventions did not differ, however, in their effects on depression or global outcome.

CONCLUSIONS

Group therapy shows promise as a treatment for adolescents who repeatedly harm themselves, but larger studies are required to assess more accurately the efficacy of this intervention.

Suicide in adolescents

In many parts of the world rates of suicidal behaviour are increasing among young people. Community surveys of suicidal ideation have demonstrated that up to 24% of adolescents have experienced suicidal thoughts at some point in their lives. Rates of attempted suicide are highest among young people, and increased occurrence is reported, particularly among young males. A similar picture emerges with regard to completed suicide, and in some countries rates of suicide among young males are higher than those for older age groups. Risk factors can be grouped according to their social/familial, individual, or environmental nature. Based on these findings an explanatory model of suicidal behaviour can be developed, in which three criteria can be discerned: i.e. trait-dependent factors, including those related to serotonin, personality and cognitive psychological dysfunctions; state-dependent characteristics, such as depression and hopelessness; and threshold factors, which may have a risk-enhancing or protective effect, such as social support, contagion effects, the availability of means, and the accessibility of mental health care. Preventive actions need to be developed, targeting the general population (through, for example, educational programmes) or populations at particular risk, such as adolescents attempting suicide. Potential treatment approaches include the treatment of individual psychopathological phenomena, whether or not in school-based clinics, but particular attention has to be given to inducting and keeping young people at risk in treatment.

Depression, suicide and deliberate self-harm in adolescence

The past decade has seen important advances in research into the epidemiology, aetiology and treatment of depression and suicidal behaviour in the young. We are beginning to understand how risk factors combine to precipitate and maintain these problems. There is rarely a linear relationship between causes and outcomes. Rather, the cause is usually a combination of predisposing constitutional factors arising from genetic endowment or earlier experience and precipitating stressful events. These aetiological factors act through biochemical, psychological and social processes to produce the outcome. Progress has also been in the development of a range of effective treatments, such as 'here and now' psychological treatments and antidepressants. All depressed or suicidal young people require careful assessment. Some will require a brief intervention only. Others, however, will require more intensive and lengthy forms of treatment.