Relations between Nonsuicidal Self-Injury and Suicidal Behavior in Adolescence: A Systematic Review

Self-harm as a predisposition for suicide attempts: A study of adolescents' deliberate self-harm, suicidal ideation, and suicide attempts

The aim of this study was to analyze the predictive risk factors for self-harm in adolescents with and without suicidal ideation. 600 adolescents answered a questionnaire about self-harm and suicidal behaviors. A logistic regression analysis was conducted. Over half of the individuals with deliberate self-harm (DSH) presented significant suicide risk. There was a direct association between DSH and suicide attempts, with almost the totality of the adolescents with suicide attempts also reporting DSH. According to the prediction model, suicidal ideation and diversity of DSH behaviors are significant predictors of suicide attempts, with an augmentation in the diversity of DSH behaviors and suicidal ideation predicting suicide attempts. Depression and anxiety appeared also as significant predictors of suicide attempts in adolescent self-harmers. Considering that the majority of the sample was not from a clinical setting, an alarming finding was that one third of the total sample was at suicide risk. These results place DSH as a key variable for early intervention.

A typology of nonsuicidal self-injury in a clinical sample: A latent class analysis

Nonsuicidal self‐injury(NSSI) is a behavioural concern and can present in diverse ways, varying by method, frequency, severity, function and so forth. The possible combinations of these features of NSSI produce an array of profiles that makes evaluation and management of this behaviour challenging. The aim of this study was to build upon previous work that reduces the heterogeneity of NSSI patterns by using latent class analysis (LCA) to identify a typology of NSSI. Participants consisted of 235 outpatients aged 14–35 years attending a tertiary psychiatric hospital in Singapore who had reported at least one NSSI behaviour within the last year. Eight indicators captured using the Functional Assessment of Self‐Mutilation were used in the LCA: frequency of NSSI, length of contemplation before engaging in NSSI, usage of more than three NSSI methods, suicidal ideation and four psychological functions of NSSI, that is, social‐positive, social‐negative, automatic‐positive and automatic‐negative. The LCA revealed three distinct groups: Class 1—Experimental/Mild NSSI, Class 2—Multiple functions NSSI/Low Suicide Ideation and Class 3—Multiplefunctions NSSI/Possible Suicide Ideation. Multinomial logistic regression analyses were conducted to examine the associations between class membership and sociodemographic variables as well as measures of emotion dysregulation, childhood trauma, depression and quality of life. Females were overrepresented in Class 3. In general, Class 3 had the poorest scores followed by Class 2. Our analyses suggest that different NSSI subtypes require different treatment indications. Profiling patterns of NSSI may be a potentially useful step in guiding treatment plans and strategies.

Sleep problems and suicide risk in youth: A systematic review, developmental framework, and implications for hospital treatment

OBJECTIVE

Sleep problems are transdiagnostic symptoms that confer significant risk for suicidal thoughts and behaviors (STBs) in adults. However, less is known about the sleep-STB association in adolescence-a developmental period when rates of STBs increase drastically, and sleep problems may be particularly pernicious. This article provides a systematic review of research on the sleep-STB association in youth, an overview of changes in sleep regulation during adolescence that may make sleep problems particularly detrimental for youth, and a discussion of the clinical implications of the sleep-STB association for hospitalized youth.

METHOD

The systematic review included all longitudinal studies in which sleep problems were examined as prospective predictors of STBs in adolescents (aged 10-24 years). The search was conducted on December 1, 2017 using PsychINFO, PubMed, and Web of Science databases.

RESULTS

Ten studies qualified for inclusion in this review. Of these, seven studies found at least one type of sleep problem significantly predicted a STB outcome.

CONCLUSIONS

Although findings are mixed, growing research suggests that sleep problems may be a unique risk factor for STBs in youth. Sleep problems may be particularly important intervention target because they are easily assessed across healthcare settings and are amenable to treatment.

A Systematic Review of the Evidence Supporting Mobile- and Internet-Based Psychological Interventions For Self-Harm

OBJECTIVES

Internet- and mobile phone-based psychological interventions have the potential to overcome many of the barriers associated with accessing traditional face-to-face therapy. Self-injurious thoughts and behaviors (STB) are prevalent global health problems that may benefit from Internet- and mobile-based interventions. We provide a systematic review and meta-analysis of studies evaluating mobile- and Internet-based interventions for STB, including nonsuicidal self-injury (NSSI).

METHODS

Online databases (PsycINFO, Web of Science, Medline) were searched up to March 2019 for single-arm and controlled trials of Internet- or mobile-based interventions for STB. The potential for bias was assessed using the Cochrane risk of bias tool.

RESULTS

Twenty-two eligible trials were identified. The research was limited by a lack of controlled designs and small samples. Evidence supports the acceptability of interventions. There is preliminary evidence that these interventions are associated with a decline in STB. A meta-analysis suggested a positive treatment effect on suicidal ideation when compared to treatment as usual, but not when trials with active controls were also considered.

CONCLUSIONS

Overall, Internet- and mobile-based interventions show promise and further controlled trials are warranted, focusing on behavioral outcomes (NSSI, suicidal behavior). This review was preregistered with PROSPERO (CRD42017074065).

The Emergency Assessment and Management of Non-Suicidal Self-Injury in Adolescents

Background and Goals:

Non-suicidal self-injury (NSSI) is a common presenting issue mental health providers experience in all levels of care from outpatient clinics to inpatient units. It is common among adolescents seen in emergency settings, either as a presenting problem or as a covert condition that may not be detected unless specifically assessed for. The presence of NSSI increases the risk of suicide. This article aims to help the clinician develop a better understanding of NSSI – what it may entail, the prevalence, and the motivations for why young people engage in it.

Methods:

We review the reasons adolescents injure themselves, the link between NSSI and psychiatric diagnoses and suicide, the assessment of NSSI, and treatment planning, with emphasis on ways to screen for NSSI and interventions that can be implemented in the Emergency Department. We illustrate the complexity of NSSI with the case of a young patient with a complex psychiatric history and an extensive history of self-injury.

Results and Discussion:

Despite the seeming intractability of NSSI, a number of evidencebased treatments exist. Treatment primarily involves specialized forms of psychotherapy, but interventions can be implemented in the ED that will reduce the immediate risk of NSSI while more definitive intervention is awaited.

Conclusion:

Mental health consultations in the ED should always include screening for NSSI. Mental health professionals in the ED can play an important role in the detection and treatment of this condition.

Experts by Experience: Qualitative Evaluation of Adolescent Participation in the Development of a Technological Intervention to Prevent Youth Suicide in Chile

Adolescent suicide is a pressing problem in Chile that has not yet been sufficiently addressed, as suicide rates have stagnated in recent years. One possible explanation could be linked to the adult-centered paradigm that continues to prevail in relation to adolescent health initiatives. In light of this, programs that seek to promote youth mental health should consider incorporating adolescents in the design process using participatory methodologies, to ensure that these initiatives are well-suited for the population. In line with this recommendation, a group of seven adolescents, 13 to 20 years of age, were incorporated into a research team to actively guide the design, development, and validation of a technology-based intervention, known as Project Clan, which was piloted to reduce adolescent suicide in schools in Chile. This group was known as the "Group of Experts," in acknowledgment of their role as experts by experience on adolescence. A qualitative case study was conducted to explore their lived experiences, through semistructured individual in-depth interviews with six members of the group. Results showed that the adolescents had a high level of interest in mental health and had experienced problems of their own or accompanied friends who were struggling, which motivated their participation in the study. They had a critical view of the previous interventions they had received through educational institutions and valued their role in the promotion of their peers' mental health through the Group of Experts. They also highlighted the importance of creating tools that complement their daily lives and provide an alternative to existing social networks, by respecting their anonymity, providing a secure place for divulgation and self-expression, and facilitating access to professional support. We conclude that programs that address issues that affect adolescents should incorporate adolescents in the decision-making and design processes to ensure the acceptability and effectivity of their interventions.

Nonsuicidal Self-Injury and Suicide: The Role of Life Events in Clinical and Non-Clinical Populations of Adolescents

BACKGROUND

Nonsuicidal self-injury (NSSI) is highly prevalent in clinical and non-clinical populations of adolescents. Several studies have supported both the distinction and the strong association between NSSI and suicidal behavior. Although there is a great deal of data on the role of life events in both suicidal behavior and NSSI, few studies have assessed the role of life events in the NSSI-suicidal behavior relationship. Our aims were to explore the relationship between NSSI and suicidal behavior, and the possible moderating role of stressful life events in a clinical and non-clinical adolescent population.

METHOD

A clinical (n = 202) and a nonclinical (n = 161) population of adolescents, aged 13-18 years were assessed. The Mini International Neuropsychiatric Interview Kid, Deliberate Self-Harm Inventory and the Life Events List were used. Group differences related to suicidal behavior, NSSI, and life events were tested with Wilcoxon tests. Two- and three-way interactions were tested with negative binomial regression models including zero-inflation parameter.

RESULTS

The prevalence of suicidal behavior (W = 7,306, p < .001), NSSI (W = 9,652, p < .001) and life events (W = 10,410 p < .001) were significantly higher in the clinical than in the non-clinical group. Between number of life events and NSSI, a moderate effect size (.38, 95%CI [.28,.46]) was found. The main effect of NSSI (χ² (1) = 109.65, p < .001) and group membership (χ² (1) = 39.13, p < .001) predicted suicidal behavior; the main effect of quantity of life events did not explain suicidal behavior. The interaction between NSSI and number of life events (χ² (1) = 10.49, p < .01) was associated with suicidal behavior. Among interpersonal, non-interpersonal events and adverse childhood circumstances, only interpersonal events were associated with both suicidal behavior (χ² (1) = 6.08, p < .05) and had a moderating effect (χ² (1) = 8.59, p < .01) on the NSSI-suicidal behavior relationship. Patterns of the effects of life events on the NSSI-suicidal behavior relationship did not differ in the two groups.

CONCLUSION

Our results confirm the importance of prevention and intervention of NSSI, considering its high prevalence and frequent co-occurrence with suicidal behavior in both clinical and non-clinical adolescent populations. Moreover, to support NSSI and suicide prevention, we would like to highlight the importance of stressful life events, especially those associated with interpersonal conflicts, require special attention.

Anti-Suicide Function of Nonsuicidal Self-Injury in Female Inpatient Adolescents

BACKGROUND

There have been numerous studies investigating the relationship between nonsuicidal self-injury (NSSI) and suicidality. On the one side, NSSI is an important risk factor for suicidality, including suicidal thoughts and behaviors. On the other side, it has been suggested that one function of NSSI might be as a coping mechanism that can help individuals in the short term avoid suicide. The present study investigated the relationship between suicidality and NSSI in female inpatient adolescents, focusing on NSSI as an anti-suicide strategy.

METHODS

Subjects were 56 female adolescents, aged 12-18 years (M = 15.95 years, SD = 1.27), recruited from different inpatient child and adolescent psychiatric units. All participants fulfilled the DSM-5 research criteria for nonsuicidal self-injury disorder (NSSI-D). To assess suicidality, NSSI-D, and current and past diagnoses, a structured clinical interview was conducted.

RESULTS

NSSI as a short-term coping strategy for avoiding suicide was indicated by one third (32.1%) of the participants. Before participants engaged in NSSI, the anti-suicide function was reported more frequently than reducing interpersonal problems (d = -.59). Getting relief from negative emotions and inducing positive feelings were reported at the same frequency as avoiding suicide before NSSI. Participants engaging in NSSI to avoid suicide and those reporting other functions did not significantly differ regarding other NSSI characteristics, suicidality, or psychopathology. Results indicate that the anti-suicide function significantly predicts the duration of current suicidal ideation (β = .557).

CONCLUSION

This study provides preliminary support for the idea that NSSI is frequently used by female adolescents with NSSI-D to avoid suicide. Given the high co-occurrence of NSSI and suicidality, our results underline the importance of clinical assessment of suicidality and several NSSI functions, including the anti-suicide function, in adolescents with NSSI.

Role of Gender in Phemenon of Non-Suicidal Self-Injuries and Suicide Attempt Among Clinical Population of Adolescents

Non suicidal self-injury is defined as intentional self-inflicted injury without the intent to die. Suicide attempt is defined as a non-fatal, self-directed, potentially injurious behavior with the intent to die. Although distinct behaviors, they are frequently associated and possibly clinically related. The aims of this study are to explore demographic data, social-demographic differences between genders, co-occurrence of non-suicidal self-injuries with suicide attempt, their association with gender and clinical variables. Retrospective cohort study on 143 patient admitted in Clinic for mental disorders „Dr Laza Lazarevic“, aged 14 to 18 years, between January 2015 and January 2016. Information were obtained from database and included two categories of variables: socio-demographic (age, gender, education level, current living situation) and clinical variables (abuse, neglect, peer violence, aggressive behavior, non-suicidal self-injuries, suicide attempt and others). The mean age of adolescents was 15.8 years, with female being more frequent in the sample (51.4%). The incidence of Mood disorders was significantly higher (p<0.05) in female compared to male (χ2꞊3,96, df꞊1, rC꞊0.16, p꞊0.04). A significantly higher incidence (p<0.05) of non-suicidal self-injury (χ2꞊11.15, df꞊1, rC꞊0.27, p꞊0.001) and suicide attempt was found in female compared to male (χ2꞊5.38, df꞊1, rC꞊0.19, p꞊0.02). No statistically significant difference was found in their simultaneous occurrence compared to total population of hospitalized adolescents. The findings of the present study demonstrated that non-suicidal self-injury and suicide attempt occur in clinical population of adolescent more often among female then in male adolescents.

Suicide prevention using self-guided digital interventions: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Digital interventions that deliver psychological self-help provide the opportunity to reach individuals at risk of suicide who do not access traditional health services. Our primary objective was to test whether direct (targeting suicidality) and indirect (targeting depression) digital interventions are effective in reducing suicidal ideation and behaviours, and our secondary analyses assessed whether direct interventions were more effective than indirect interventions.

METHODS

In this systematic review and meta-analysis, we searched online databases MEDLINE, PubMed, PsycINFO, and Cochrane CENTRAL for randomised controlled trials published between database inception to May 21, 2019. Superiority randomised controlled trials of self-guided digital interventions (app or web based, which delivered theory-based therapeutic content) were included if they reported suicidal ideation, suicidal plans, or suicide attempts as an outcome. Non-inferiority randomised controlled trials were excluded to ensure comparability of the effect. Data were extracted from published reports, and intention-to-treat data were used if available. The primary outcome was the difference in mean scores of validated suicidal ideation measures (Hedges'g) with the associated 95% CI for the analysis of digital intervention effectiveness on suicidal ideation. We also present funnel plots of the primary outcome measure (suicidal ideation) for direct and indirect interventions to assess for publication bias. We calculated I² (with I² CI) values to test heterogeneity. We used random-effects modelling for the meta-analyses to assess the primary and secondary outcomes. This study is registered with PROSPERO, CRD42018102084.

FINDINGS

The literature search yielded 739 articles (including manual searching) for suicidality and 8842 articles for depression. After screening, 14 papers reporting on 16 studies were included in the narrative review and meta-analysis. The 16 studies (ten on direct interventions and six on indirect interventions) provided baseline data for 4398 participants. The primary outcome of overall post-intervention effect for suicidal ideation was small but significant immediately following the active intervention phase (Hedges'g -0·18, 95% CI -0·27 to -0·10, p<0·0001; I²=0%, I² CI 0·0-47·9). The secondary objective, comparing direct and indirect interventions, showed that direct interventions (targeting suicidality) significantly reduced suicidal ideation at post-intervention (g -0·23, 95% CI -0·35 to -0·11, p<0·0001; I²=17·6%, I² CI 0·0-58·6), but indirect interventions (targeting depression) failed to reach significance (g -0·12, 95% CI -0·25 to 0·01, p=0·071; I²=0%, I² CI 0·0-30·7).

INTERPRETATION

Self-guided digital interventions directly targeting suicidal ideation are effective immediately post-intervention. Indirect interventions were not significant for reducing suicidal ideation. Our findings suggest that digital interventions should be promoted and disseminated widely, especially where there is a lack of, or minimal access to, health services.

FUNDING

Australian National Health and Medical Research Council.

Daily patterns in nonsuicidal self-injury and coping among recently hospitalized youth at risk for suicide

Among adolescents at high suicide risk, using a daily diary design, this study examined: (1) the co-occurrence between nonsuicidal self-injury (NSSI) and suicidal ideation, (2) the link between NSSI and coping, and (3) endorsement of using NSSI to cope with suicidal ideation (anti-suicide function). Thirty-four adolescents hospitalized due to suicide risk (76% female; ages 13-17) responded to daily surveys for four weeks after discharge (n = 650 observations). NSSI was positively associated with suicidal ideation at the between- (i.e. relative to others) and within-person (relative to adolescents' own average) levels of analysis. When NSSI and suicidal thoughts co-occurred, adolescents used NSSI to cope with thoughts of suicide on nearly all occasions. While adolescents did not use less adaptive coping when they engaged in NSSI (i.e. within-person), youth who utilized more coping strategies in general (i.e. between-person) had lower probability of NSSI. The probability of NSSI also decreased when adolescents perceived coping to be helpful and for youth who generally tended to perceive coping as helpful. Findings offer fine-grained insights about the intersection of NSSI, suicidal thoughts, and coping among high-risk adolescents, adding to the body of research highlighting the benefit of broadening adolescents' coping strategies as well as assessing their perceived utility.

Negative self-evaluation and the genesis of internal threat: beyond a continuum of suicidal thought and behaviour

BACKGROUND

Death by suicide is often preceded by attempted suicide, suicidal ideation and non-suicidal self-injury. These extreme thoughts and behaviours have been considered in terms of a continuum of suicidality. Little known research, however, has considered a suicide continuum that extends beyond these extreme thoughts and behaviours and incorporates a much wider array of phenomena that may vary in severity and may constitute a broader negative self-evaluation (NSE) continuum.

METHOD

Harvesting key indicators of NSE from a British epidemiological survey (N = 8580), the current study used exploratory factor analysis, confirmatory factor analysis and factor mixture modelling to (i) identify the dimensional structure of NSE in the general population and (ii) profile the distribution of the resultant NSE dimensions. Multinomial logistic regression was then used to differentiate between classes using an array of risk variables, psychopathology outcome variables and a suicide attempt indicator.

RESULTS

A 4-factor model that reflected graded levels of NSE was identified; (F1) Low self-worth & subordination (F2) depression, (F3) suicidal thoughts, (F4) self-harm (SH). Seven classes suggested a clear pattern of NSE severity. Classes characterised by higher levels across the dimensions exhibited greater risk and poorer outcomes. The greatest risk for suicide attempt was associated with a class characterised by engagement in SH behaviour.

CONCLUSIONS

Low self-worth, subordination and depression, while representative of distinct groups in the population are also highly prevalent in those who entertain suicidal thoughts and engage in SH behaviour. The findings promote further investigation into the genesis and evolution of suicidality and internal threat.

Assessment tools of non-suicidal self-injury in adolescents 1990-2016: a systematic review

The purpose of this systematic review was to identify the instruments created or adapted to assess non-suicidal self-injury (NSSI) among adolescents. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) methodology was used. Two individual reviewers analyzed the psychometric properties of instruments published in English or Spanish from 1990 to 2016 considering standardized quality criteria. The PsycINFO, PubMed, ISI Web of Knowledge, Scopus, SciELO, ScienceDirect, and EBSCO databases were consulted. Eighteen studies that created or adapted 11 instruments were selected. Most were developed in the United States or Canada, and none were developed in Latin America. Several studies presented no evidence of the psychometric properties of their instruments. Seven of the 18 studies obtained at least one positive score. The Alexian Brothers Urge to Self-Injure Scale (ABUSI) and the Impulse, Self-harm, and Suicide Ideation Questionnaire for Adolescents (ISSIQ-A) obtained the highest positive scores. The limitation of this study is that only seven databases were employed for the literature search in English and Spanish. The reporting of the psychometric properties of NSSI instruments among adolescents should be improved, and adaptations to Latin American countries should be developed for international comparisons.

Peer Victimization and Suicidal Thoughts and Behaviors in Depressed Adolescents

Suicide is a leading cause of death among youth worldwide, and depressed adolescents are at a significantly elevated risk to report suicidal ideation, planning, and attempts. Peer victimization is a robust predictor of adolescent suicidal thoughts and behaviors (STBs), but little research has focused on why bullying leads to suicidal thoughts and behaviors. To address this empirical gap, we recruited 340 (246 female) depressed adolescents ages 13-19 (M = 15.59, SD = 1.41) within 48 h of admission for acute psychiatric treatment. At the initial assessment, participants were administered clinical interviews characterizing psychopathology, nonsuicidal self-injury, and STBs (ideation, plans, and attempts). Further, they completed questionnaires assessing 3 forms of victimization (overt, relational, and reputational), recent risky behavior engagement, and psychiatric symptom severity. Controlling for internalizing symptoms and age, overt and reputational bullying were associated with more frequent past month suicide attempts, but not suicide ideation. Past month risky behavior engagement, but not NSSI, mediated the relation between victimization and attempts. However, sex differences revealed that this effect only held for males whereas bullying was directly associated with suicide attempts among females. In contrast, overt and relational bullying were non-linearly associated with suicide plans, and these relations were not mediated by risky behaviors or NSSI. Results highlight the complex network of factors that lead victimized adolescents to engage in STBs and may inform targeted suicide prevention and intervention programs.

Non-suicidal self-injury and co-occurring suicide attempt in male prisoners

High rates of non-suicidal self-injury (NSSI) and suicide attempts (SA) are well documented in prisoners, however, few studies examined their co-occurrence in this high-risk population. Study participants were 1203 adult men randomly selected from 15 Belgian prisons, representing 12% of the national male prison population. Lifetime prevalence rates for NSSI and SA are 17% and 20% respectively, with half (55%) of self-injurers reporting a SA history. Bivariate analyses show that NSSI and SA are significantly related to one another, and many risk factors are common to both. Multivariate analysis comparing prisoners who engaged in NSSI with (n = 109) and without (n = 90) co-occurring SA indicates that suicidal ideation is the strongest independent correlate of SA among self-injurers. Additionally, relative to those with a history of NSSI only, prisoners with co-occurring NSSI and SA are significantly more likely to be violent offenders, being prescribed psychotropic medication, and report a psychiatric diagnosis; suggesting that they constitute a more clinically severe subgroup. Collectively, these findings highlight the marked overlap between NSSI and SA in prisoners, both in terms of prevalence and correlates, with suicidal ideation being an important predictor of suicide risk among self-injurers.

Evidence Base Update of Psychosocial Treatments for Self-Injurious Thoughts and Behaviors in Youth

The current review provides an evidence base update of psychosocial treatments for self-injurious thoughts and behaviors (SITBs) in youth. A systematic search was conducted of 2 major scientific databases (PsycInfo and PubMed) and ClinicalTrials.gov for relevant randomized controlled trials (RCTs) published prior to June 2018. The search identified 26 RCTs examining interventions for SITBs in youth: 17 were included in the 2015 review and 9 trials were new to this update. The biggest change since the prior review was the evaluation of Dialectical Behavior Therapy for adolescents (DBT-A) as the first Level 1: Well-established intervention for reducing deliberate self-harm (composite of nonsuicidal and suicidal self-injury) and suicide ideation in youth and Level 2: Probably efficacious for reducing nonsuicidal self-injury and suicide attempts. Five other interventions were rated as Level 2: Probably efficacious for reducing SITBs in youth, with the new addition of Integrated Family Therapy. This evidence base update indicates that there are a few promising treatments for reducing SITBs in youth. Efficacious interventions typically include a significant family or parent training component as well as skills training (e.g., emotion regulation skills). Aside from DBT-A, few treatments have been examined in more than one RCT. Given that replication by independent research groups is needed to evaluate an intervention as Well-established, future research should focus on replicating the five promising interventions currently evaluated as Probably efficacious. In addition, an important future direction is to develop brief efficacious interventions that may be scalable to reach large numbers of youth.

Non-suicidal Self-Injury in Clinical Practice

Background: Non-suicidal self-injury (NSSI) among adolescents is a major public health concern and a common problem in clinical practice. The aim of this study was to examine different aspects of NSSI in a high-risk adolescent sample in clinical practice in association with personality disorders, symptoms, and coping skills to enhance the understanding of NSSI and improve treatment interventions.

Methods: In a sample of 140 adolescent inpatients treated for personality disorders, assessments were performed pre-treatment and post-treatment using a questionnaire on NSSI developed for clinical practice, the Structured Clinical Interview for DSM personality disorders, the Symptom Check List 90, and the Cognitive Emotion Regulation Questionnaire.

Results: NSSI was common (66.4%) among the inpatient adolescents. Of those without NSSI behaviour (n = 47), 10 (21.3%) started NSSI during treatment. NSSI was related to number of personality disorders and not to one specific. Participants who experienced NSSI (n = 93) reported significantly more symptoms and the negative coping strategy self-blame. They scored lower on the positive coping strategies of refocusing and reappraisal.

Conclusion: NSSI in adolescent clinical practice is common, not exclusive to borderline personality disorder and could be contagious. Reducing self-blame and enhancing positive refocusing and positive reappraisal seem important treatment targets.

Patterns of self-harm methods over time and the association with methods used at repeat episodes of non-fatal self-harm and suicide: A systematic review

BACKGROUND

The risk of self-harm repetition and suicide may be influenced by self-harm method choice. However, there are mixed findings regarding whether there is a discernible pattern in self-harm methods over successive episodes of non-fatal self-harm, and if so, how these may be associated with self-harm repetition and/or suicide.

METHODS

A systematic review of five electronic databases was undertaken until 31 May 2018 to identify cohort studies on patterns of self-harm methods and their association with methods used either at repeat self-harm episodes and/or suicide.

RESULTS

15 studies were included reporting data on of 127,371 participants. Over an average follow-up period of 2.8 years, one-third (33.3%) switched methods between episodes of self-harm, most commonly from self-injury to self-poisoning. For suicide, almost one-half (42.1%) switched methods over an average follow-up period of 11.2 years.

LIMITATIONS

Studies were characterised by a moderate study quality. Studies tended to group all methods into self-injury and/or self-poisoning with little consideration as to the diverse range of self-harm methods included within these broad categories and the likely differences in potential lethality between these methods. Few investigated the role of alcohol and/or drug dependence and mental illness on self-harm method choice.

CONCLUSIONS

Given the frequency of method switching observed, and the lack of discernible patterns over time, all patients should be routinely assessed for risk and needs irrespective of the method used at the index episode of non-fatal self-harm.

Insight and risk of suicidal behaviour in two first-episode psychosis cohorts: Effects of previous suicide attempts and depression

BACKGROUND

The role of insight dimensions - illness recognition (IR), symptoms relabelling (SR), treatment compliance (TC) - in suicide risk in first-episode psychosis (FEP) remains unclear.

METHOD

The AESOP (n = 181) and GAP (n = 112) FEP cohorts were followed-up over 10- and 5 years. Survival analysis modelled time to first suicidal event in relation to baseline scores on the Schedule for the Assessment of Insight, whilst adjusting for demographic, clinical, psychopathological and neuropsychological variables.

RESULTS

AESOP: those with previous suicide attempts scored higher on IR (7.6 ± 1.9 vs. 5.9 ± 3.0, p < 0.01) and total insight scores (TIS) (17.2 ± 5.0 vs. 13.4 ± 6.7, p = 0.03). IR (r = 0.23, p < 0.01), SR (r = 0.18, p = 0.04) and TC (r = 0.26, p < 0.01) correlated with depression. Univariable analyses: IR (HR = 1.14, 95% CI = 0.98-1.34, p = 0.09), TC (HR = 1.30, 95% CI = 0.99-1.71, p = 0.06) and TIS (HR = 1.06, 95% CI = 0.99-1.13, p = 0.08) were linked with suicidal behaviour. Multivariable regression models: depression (HR = 1.55, 95% CI = 1.22-1.97, p < 0.01) predicted suicidal behaviour. GAP: SR (6.4 ± 3.1 vs. 4.5 ± 3.4, p = 0.03) and TIS (16.8 ± 6.4 vs. 12.8 ± 7.4, p = 0.03) were higher in those with suicidal antecedents. IR (r = 0.32, p < 0.01) and SR (r = 0.27, p = 0.01) correlated with depression. Univariable analyses: TC (HR = 1.36, 95% CI = 1.01-1.83, p = 0.04) and TIS (HR = 1.06, 95% CI = 0.99-1.14, p = 0.08) were associated with suicidal behaviour. Multivariable regression models: previous suicide attempts (HR 5.17, 95% CI 1.32-20.29, p = 0.02) and depression (HR 1.16, 95% CI = 1.00-1.35, p = 0.04) predicted suicidal behaviour.

CONCLUSIONS

Suicide attempts prior to FEP and depression at that point were associated with baseline insight levels and predicted risk of suicidal behaviour over the follow-up, which was not linked with insight. This may explain the apparent association of insight with suicidality in FEP.

[Suicidological research in epilepsy: problems of methodology]

The review highlights contemporary views on the problem of suicide in patients with epilepsy. The most relevant theories are presented that describe the emergence of suicidal thoughts and the transition to suicidal attempts. Along with a description of risk factors, protective factors, as well as the possible impact of comorbidity, a description of methodological deficiencies in papers on suicide in patients with epilepsy is given. Recommendations for studies related to suicidal behaviour in patients with epilepsy are discussed.

The Quest for Meaning Around Self-Injurious and Suicidal Acts: A Qualitative Study Among Adolescent Girls

Introduction: Suicide and non-suicidal self-injury (NSSI) are major problems in adolescent psychiatry and share numerous clinical characteristics. The principal objective of this study is to describe the subjective experience of adolescent girls and young women who present NSSI and/or suicidal behaviors and to determine the common aspects and the specificities of each experience. Method: This exploratory study is based on a procedure that is qualitative, phenomenological, and inductive. The data were collected from two semi-structured interviews each of 18 girls and young women aged 12-21 years, who were receiving care from a psychiatrist specializing in adolescents and who at least once had harmed themselves by NSSI or attempted suicide, or both. The thematic data analysis was performed by applying the methods of interpretative phenomenological analysis. Results: The results are described around four superordinate themes: relationships with the self, with others/otherness, with the body, and with death; they are then subdivided into 13 themes. Several themes appeared common to both types of behavior, especially the relational dimension of self-harming acts. The process of separation-individuation seems complex for these youth. Conclusion: The results underline the relational aspects of the self-harming behavior (NSSI or suicidal) among adolescent girls. These aspects also appear to be expressed in the family sphere, the social sphere, in contact with peers, and also at a societal level when the community no longer addresses adolescents' difficulties. When the process of subjectification does not appear to reach completion, self-aggressive behavior is seen as an ultimate attempt to regain a feeling of autonomy.

Regional grey matter volume reduction in adolescents engaging in non-suicidal self-injury

There is a high prevalence of non-suicidal self-injury (NSSI) amongst adolescents worldwide and therefore an urgency to investigate the underlying mechanisms that may facilitate such behaviours. This study aimed to investigate neurobiological alterations, specifically in regional brain volumes of the frontolimbic system, in adolescents engaging in NSSI in comparison to healthy controls. Regional grey matter volumes were compared between 29 adolescent female patients who presented with incidents of NSSI on ≥5 days within the last 12 months (DSM-5 criteria for NSSI) and 21 healthy age, gender and education matched controls who had never received any psychiatric diagnosis/treatment, or engaged in NSSI. Significant group effects in regional brain volumes were observed in insula, and a suggested change in the anterior cingulate cortex (ACC), while controlling for total segmented volume. Additionally, ACC volume showed a significant association with past suicide attempts, where estimated marginal means showed even smaller ACC volume in adolescents engaging in NSSI with a history of suicide attempt in comparison to those with no history of suicide attempt, including healthy controls. This study provides the first evidence of volumetric changes in adolescents engaging in NSSI and a potential neurobiological link between NSSI and suicide attempt.

The associations between non-suicidal self-injury and first onset suicidal thoughts and behaviors

BACKGROUND

Theoretical and empirical literature suggests that non-suicidal self-injury (NSSI) is an important correlate of suicide risk. The present study was designed to evaluate: (a) whether NSSI is associated with increased odds of subsequent onsets of suicidal thoughts and behaviors (STB) independent of common mental disorders, (b) whether NSSI is associated with increased risk of transitioning from suicide ideation to attempt, and (c) which NSSI characteristics are associated with STB after NSSI.

METHOD

Using discrete-time survival models, based on retrospective age of onset reports from college students (n = 6,393, 56.8% female), we examined associations of temporally prior NSSI with subsequent STB (i.e., suicide ideation, plan, and attempt) controlling mental disorders (i.e., MDD, Broad Mania, GAD, Panic Disorder, and risk for Alcohol Dependence). NSSI characteristics associated with subsequent STB were examined using logistic regressions.

RESULTS

NSSI was associated with increased odds of subsequent suicide ideation (OR = 2.8), plan (OR = 3.0), and attempt (OR = 5.5) in models that controlled for the distribution of mental disorders. Further analyses revealed that NSSI was associated with increased risk of transitioning to a plan among those with ideation, as well as attempt among those with a plan (ORs = 1.7-2.1). Several NSSI characteristics (e.g., automatic positive reinforcement, earlier onset NSSI) were associated with increased odds of experiencing STB.

LIMITATIONS

Surveys relied on self-report, and thus, there is the potential for recall bias.

CONCLUSIONS

This study provides support for the conceptualization of NSSI as a risk factor for STB. Investigation of the underlying pathways accounting for these time-ordered associations is an important avenue for future research.

[An overview of suicide risk in adolescence]

Suicidal behaviour in adolescence is a major public health issue. It is the consequence of a sum of individual, relational and environmental difficulties that weaken the subject in a period of great vulnerability. The main aspects of their care consist in developing a good therapeutic link and adapting the adolescent's environment. Prevention is the concern of everyone, especially healthcare professionals who are regularly consulted before suicidal acts.

Why are psychotic experiences associated with self-injurious thoughts and behaviours? A systematic review and critical appraisal of potential confounding and mediating factors

Psychotic experiences (PEs), including hallucination- and delusion-like experiences, are robustly associated with self-injurious thoughts and behaviours (SITB) in the general population. However, it remains unclear as to why there is an association. The purpose of this systematic review was to elucidate the role of other factors that influence the association between PEs and SITB and, in doing so, highlight potential mechanisms underlying the relationship. A search of electronic international databases was undertaken, including PubMed, PsycINFO and EMBASE, and eligible studies were grouped according to seven confounder categories: sociodemographics, mental disorders, alcohol and substance use, environmental, psychological, intervention and family history/genetic factors. The systematic search strategy identified 41 publications reporting on 1 39 427 participants from 16 different countries. In the majority of studies, where adjustment for other variables occurred, the association between PEs and SITB persisted, suggesting PEs have an independent role. Common mental disorders, psychological distress and negative environmental exposures explained a substantial amount of the variance and therefore need to be considered as potential underlying mechanisms. There was high variability in the variables adjusted for in these studies, and so the question still remains as to whether the association between PEs and self-harm/suicidality can be attributed (fully or in part) to confounding and mediating factors or directly causal mechanisms. Regardless of causality, the now extensive literature reporting an association between these two clinical phenomena supports the broad usefulness of PEs as an indicator of risk for SITB.

Suicide Evaluation in the Pediatric Emergency Setting

Suicide is 1 of the top 3 leading causes of death in the pediatric population and a serious public health concern. There are evidence-based screening tools for suicide in the pediatric population; however, predicting suicide risks can be a difficult task. The emergency department is an essential source of mental health care for youths and can serve as an important opportunity for suicide screening and subsequent targeted interventions and resource management. More research is needed in emergency department-based screening algorithms and evidence-driven interventions in the pediatric population.

Non-Suicidal Self-Injury Elevates Suicide Risk among United States Military Personnel with Lifetime Attempted Suicide

Military psychiatric inpatients with and without a lifetime history of non-suicidal self-injury (NSSI), combined with a history of at least one suicide attempt, were compared on suicide ideation severity, number of suicide attempts, and Interpersonal-Psychological Theory of Suicide variables. Data were derived from baseline assessments performed in a psychotherapy randomized controlled trial. Lifetime history of NSSI and lifetime number of suicide attempts were assessed using the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011 ). Individuals with versus without a combined lifetime history of attempted suicide and NSSI showed significant elevations on thwarted belongingness and acquired capability for suicide. No significant between-group differences were found on perceived burdensomeness, frequency, duration, and controllability of suicide ideation, or number of lifetime suicide attempts. A history of NSSI, above and beyond attempted suicide, appears to increase service members' social alienation and acquired capability for suicide.

[Links between self-harm and suicidal behaviour in adolescents]

Nonsuicidal self-injury (NSSI) and suicidal behaviour (SB) are both important issues in adolescent health care. The fact that they frequently coexist means that it is important to consider the nature of the link between them and the ways they are understood. Suicide and self-injury share the same risk factors. Integrated models envisage NSSI as a gateway enabling teenagers to acquire a capability for suicide. The act short-circuits the thought process and the intention to die underlying the act appears difficult to assess.

Use of Ecological Momentary Assessment (EMA) in Non-Suicidal Self-Injury (NSSI): A systematic review

Conceptualization and assessment of non-suicidal self-injury (NSSI) has evolved substantially in recent years. In both cross-sectional and longitudinal studies, NSSI and its related variables have traditionally been assessed retrospectively, leading to less precise studies of the mechanisms involved in the maintenance, cessation, or aggravation of this behavior. Ecological momentary assessment (EMA) enables real-time collection of patient states, which can be very useful in the study of the mechanisms implied in this behavior. This systematic review aims to elucidate the current status of EMA use in NSSI investigation. An exhaustive search in PubMed and PsycINFO was conducted up to September 2017. All papers included were focused on the study of NSSI using EMA. Studies with methodological diversity were included, which were afterwards organized according to main topic of studies. There were no ineligibility criteria based on age or diagnosis. Twenty-three papers were studied, the majority of which are short-term studies focused on the study of affect dynamics and the emotion-regulation function of NSSI. Implications of these results and recommendations for future research are discussed.

Annual Research Review: Suicide among youth - epidemiology, (potential) etiology, and treatment

BACKGROUND

Suicide is a leading cause of death and a complex clinical outcome. Here, we summarize the current state of research pertaining to suicidal thoughts and behaviors in youth. We review their definitions/measurement and phenomenology, epidemiology, potential etiological mechanisms, and psychological treatment and prevention efforts.

RESULTS

We identify key patterns and gaps in knowledge that should guide future work. Regarding epidemiology, the prevalence of suicidal thoughts and behaviors among youth varies across countries and sociodemographic populations. Despite this, studies are rarely conducted cross-nationally and do not uniformly account for high-risk populations. Regarding etiology, the majority of risk factors have been identified within the realm of environmental and psychological factors (notably negative affect-related processes), and most frequently using self-report measures. Little research has spanned across additional units of analyses including behavior, physiology, molecules, cells, and genes. Finally, there has been growing evidence in support of select psychotherapeutic treatment and prevention strategies, and preliminary evidence for technology-based interventions.

CONCLUSIONS

There is much work to be done to better understand suicidal thoughts and behaviors among youth. We strongly encourage future research to: (1) continue improving the conceptualization and operationalization of suicidal thoughts and behaviors; (2) improve etiological understanding by focusing on individual (preferably malleable) mechanisms; (3) improve etiological understanding also by integrating findings across multiple units of analyses and developing short-term prediction models; (4) demonstrate greater developmental sensitivity overall; and (5) account for diverse high-risk populations via sampling and reporting of sample characteristics. These serve as initial steps to improve the scientific approach, knowledge base, and ultimately prevention of suicidal thoughts and behaviors among youth.

Examining the Course of Suicidal and Nonsuicidal Self-Injurious Thoughts and Behaviors in Outpatient and Inpatient Adolescents

Suicidal and nonsuicidal self-injurious thoughts and behaviors (SITBs) among youth are major public health concerns. Although a growing body of research has focused on the complex association between nonsuicidal and suicidal self-injury, the temporal relationship between these two classes of behaviors is unclear. The current study addresses this empirical gap by examining the course of SITBs in adolescents receiving outpatient (N = 106; 82.1 % female) and inpatient (N = 174; 75.9 % female) treatment. SITBs (co-occurrence, age-of-onset, and time lag between SITBs) and major psychiatric disorders were assessed at a single time point with well-validated structured interviews. Adolescents in both clinical samples reported high co-occurrence of SITBs: most adolescents reported both lifetime nonsuicidal self-injury (NSSI) and suicidal thoughts. A similar temporal pattern of SITBs was reported in the two samples: thoughts of NSSI and suicide ideation had the earliest age-of-onset, followed by NSSI behaviors, suicide plans, and suicide attempts. However, the age-of-onset for each SITB was younger in the inpatient sample than in the outpatient sample. In terms of time lag between SITBs, suicide ideation occurred on average before initial engagement in NSSI, suggesting that pathways to NSSI and suicidal behavior may occur simultaneously rather than in succession from nonsuicidal to suicidal self-injury. Results also indicated that the time to transition between SITBs was relatively fast, and that a key period for intervention and prevention is within the first 6-12 months after the onset of suicidal thinking. Taken together, these findings have important implications for understanding the time-lagged relationship between nonsuicidal and suicidal self-injury.

The Role of Difficulty in Identifying and Describing Feelings in Non-Suicidal Self-Injury Behavior (NSSI): Associations With Perceived Attachment Quality, Stressful Life Events, and Suicidal Ideation

Objective: Core alexithymic features, such as the difficulty in identifying and describing feelings, are associated with poor attachment styles and emotional trauma, which influence the capacity to regulate affect. Additionally, emotional regulation has been found to be the most commonly identified function associated with non-suicidal self-injury behavior (NSSI) in adolescents as they attempt to modulate strong emotions. However, few studies have examined the link between difficulty in identifying and describing feelings (core components of alexithymia), NSSI behaviors, quality of attachment, life stressors and suicidal ideation in healthy early adolescents. Consequently, this study aims to investigate these constructs and the relationship among them in a large non-clinical sample of adolescents.

Methods: Seven hundred and nine middle school students (50.4% males), aged 10–15 years (M = 12.6; SD = 1.06) were involved in this study. In order to investigate the variables considered in the study, the following measures were administered: the Deliberate Self-Harm Inventory exploring non-suicidal self-injurious behaviors; the Alexithymia Questionnaire for Children examining difficulty in identifying and describing feelings; the Inventory of Parent and Peer Attachment assessing the quality of parental and peer attachment; the Life Stressor Checklist-Revised outlining stressful/traumatic events and the Children’s Depression Inventory evaluating suicidal ideation.

Results: We found significantly positive relationships among difficulty in identifying and describing feelings, NSSI behaviors, stressful events, and suicidal ideation. Data indicated a significant negative association of difficulty in identifying and describing feelings with quality of attachment to parents and peers. Further findings highlighted that difficulty in identifying and describing feelings significantly mediated the effect of quality of attachment (parent and peer) on NSSI and suicidal ideation.

Conclusion: The ability to identify and describing feelings is important to managing emotional expression and understanding the feelings of others, both crucial in attaining successful interpersonal relationships. Our data revealed that, while controlling for stressful life events, low levels of attachment may increase adolescents’ difficulty in identifying and describing their own feelings, which in turn may increase the risk of both NSSI and suicidal ideation.

Prevalence of and risk factors for non-suicidal self-injury in rural China: Results from a nationwide survey in China

BACKGROUND

Non-suicidal self-injury (NSSI) is a highly prevalent and serious public health problem among adolescents worldwide. However, to date there were no studies assessing the prevalence of NSSI defined by suggested DSM-5 criteria among Chinese adolescents. We aimed to conduct a nationwide survey to explore the prevalence of and risk factors for NSSI among school-based adolescents in rural China.

METHODS

A total sample of 15,623 adolescents in rural China were enrolled by using a multistage sampling method. Data was collected by self-report questionnaires including demographic characteristics, neglect, maltreatment, loneliness, resilience, social support and emotional management ability. NSSI was defined by suggested DSM-5 criteria, according to which the engagement in self-injury took place more than 5 times a year. Multinomial logistic regression models were used to estimate the association between risk factors and NSSI.

RESULTS

There were 12.2% of adolescents (n = 1908) met the suggested DSM-5 criteria. Approximately 29% reported a history of NSSI at least once during the last year. Significant differences were found in several demographic factors including gender, ethnicity, grade, and family structure between adolescents with and without experiencing NSSI. The top three NSSI behaviors among adolescents with NSSI experience were hitting self, pinching, and pulling hair, with a prevalence rate of 16.7%, 14.1% and 11.2%, respectively. Female, Han ethnicity, fathers' education level, neglect, maltreatment, loneliness, social support, suicidal behaviors and emotional management ability were significantly associated with NSSI by multivariate analysis. No significant relationship was found between resilience and risk of NSSI.

LIMITATION

The DSM-5 has proposed 6 groups of criteria for NSSI, we only used criteria on frequency given its more accepted feasibility and pragmatic application. Consequently, it may different from other prevalence that estimated by other criteria.

CONCLUSION

To the best of our knowledge, this is the first study reporting prevalence of NSSI defined by suggested DSM-5 criteria among adolescent in rural China. In comparison to finding from the similar samples of adolescents, Chinese rural adolescents seem to have a relative higher prevalence. The potential risk factors for NSSI include female, father's education, Han ethnicity, psychosocial factors and suicide behaviors. More evidence for further understanding of context of the occurrence, improving access to health care utilization, and identifying the role of psychosocial factors and family relationship, is needed for the prevention and management of NSSI.

Non-suicidal self-injury and suicide attempts in a New Zealand birth cohort

BACKGROUND

Non-suicidal self-injury (NSSI) and suicide attempts are related, but distinct behaviors. The primary aim of the current study was to identify factors that distinguish those with different lifetime histories of self-injury. A secondary aim was to test whether lifetime history of self-injury at age 26 predicted current suicide ideation at age 32.

METHODS

Participants were 26 year olds from a large birth cohort with a lifetime history of no self-injury (n = 466), a lifetime history of NSSI (n = 191), or a lifetime history of NSSI and a suicide attempt (NSSI+SA; n = 52). They were compared on a history of psychiatric disorders, 12-month suicide ideation, lifetime history of childhood sexual abuse, and lifetime exposure to suicide.

RESULTS

An anxiety disorder, a substance dependence disorder, suicide ideation, and a history of childhood sexual abuse distinguished the NSSI+SA and NSSI only groups. Longitudinal results demonstrated that a history of NSSI predicted future suicide ideation after adjusting for other selected risk factors.

LIMITATIONS

The majority of analyses are cross-sectional which limits inferences about causality. The retrospective self-report for lifetime behavior could be subject to reporting biases.

CONCLUSIONS

Adults with a history of NSSI and adults with a history of NSSI and a suicide attempt are clinically distinct groups that are both at risk of future suicide ideation. Identifying and treating NSSI could be a key preventive factor in reducing subsequent suicide risk.

Predictors of non-suicidal and suicidal self-injurious behaviours, among adolescents and young adults in urban India

BACKGROUND

The complex intersections between non-suicidal self-injurious (NSSI) behaviours; like cutting, burning or self-hitting, and suicide attempts, are an important domain of enquiry among vulnerable adolescents and young adults. A cross-sectional survey in urban schools and colleges assessed the rates of self-injurious behaviour among Indian adolescents and young adults. Predictors of NSSI and of self-injurious behaviours with associated suicidal intent, were also examined.

PARTICIPANTS AND METHODS

The sample comprised 1571 male and female students, from 19 private and government aided high schools, pre-university colleges and undergraduate colleges in an urban city in South India. Participants completed the Functional Assessment of Self-Mutilation which assesses the methods, characteristics and functions of self-injurious acts in the past 12 months. The measures of psychopathology included the Youth Self-Report and the Young-Adult Self-Report.

RESULTS AND CONCLUSION

The results indicated that rate of NSSI was 33.8%, with minor forms of self-injury reported more often (19.4%) than the moderate/severe forms (14.6%). A smaller proportion (6.8%) reported self-injurious acts with associated suicidal intent. Certain self-injury characteristics and levels of internalizing and externalizing problems differentiated self-injuring youth with and without suicidal intent. Logistic regression analyses identified predictors of any self-injurious behaviour and of self-injury associated with suicidal intent. The implications for assessment and intervention frameworks for self-injuring youth are discussed.

Combination of self-harm methods and fatal and non-fatal repetition: A cohort study

BACKGROUND

Assessment and aftercare for people who self-harm needs to be related to an understanding of risks of adverse outcomes. We aimed to determine whether self-harm by a combination of methods and its early repetition are associated with adverse outcomes - especially non-fatal repetition and suicide.

METHOD

10,829 consecutive general hospital attendances due to self-harm in one large English city were monitored, through scrutiny of Emergency Department attendances, over three years and followed up to determine the incidence of non-fatal repetition. Subsequent deaths, by any cause and by suicide, were determined from national statistical records.

RESULTS

6155 patients accounted for the 10,829 episodes: 72% by self-poisoning, 21% self-injury, and 746 episodes (7%) due to a combination of methods. After a combined-methods index episode, non-fatal repetition (P=0.001) and suicide (P=0.002) occurred sooner and more frequently than it did among those who had self-poisoned. Further hospital attendance due to self-harm within a month was associated with a 3.7-fold (95% CI 2.1-6.4) risk of subsequent suicide.

LIMITATIONS

The data exclude self-harm episodes that do not result in a hospital attendance. Index episodes in the study are not generally life-time first episodes so follow-up data are based on an arbitrary start-point. Both of these limitations are common to all studies of this kind.

CONCLUSIONS

At psychosocial assessment and the making of aftercare arrangements, combined methods of self-harm or another recent episode should be considered 'red-flag' indicators for attention to care.

Self-injury and externalizing pathology: a systematic literature review

BACKGROUND

During the last decade there is a growing scientific interest in nonsuicidal self-injury (NSSI). The aim of the current paper was to review systematically the literature with a special focus on the associations between self-injurious behaviours and externalizing psychopathology. An additional aim was to review terminology and measurements of self-injurious behaviour and the connection between self-injurious behaviours and suicide in the included publications.

METHODS

A systematic literature search was conducted on 31st December 2016 in five databases (PubMed, OVID Medline, OVID PsycINFO, Scopus, Web of Science) with two categories of search terms (1. nonsuicidal self-injury, non-suicidal self-injury, NSSI, self-injurious behaviour, SIB, deliberate self-harm, DSH, self-injury; 2. externalizing disorder, attention deficit hyperactivity disorder, ADHD, conduct disorder, CD, oppositional defiant disorder, OD, ODD).

RESULTS

Finally 35 papers were included. Eleven different terms were found for describing self-injurious behaviours and 20 methods for measuring it. NSSI has the clearest definition. All the examined externalizing psychopathologies had strong associations with self-injurious behaviours according to: higher prevalence rates in externalizing groups than in control groups, higher externalizing scores on the externalizing scales of questionnaires, higher symptom severity in self-injurious groups. Eight studies investigated the relationship between suicide and self-injurious behaviours and found high overlap between the two phenomena and similar risk factors.

CONCLUSIONS

Based on the current findings the association between externalizing psychopathology and self-injurious behaviours has been proven by the scientific literature. Similarly to other reviews on self-injurious behaviours the confusion in terminology and methodology was noticed. NSSI is suggested for use as a distinct term. Further studies should investigate the role of comorbid conditions in NSSI, especially when internalizing and externalizing pathologies are both presented.

Social support buffers the effect of interpersonal life stress on suicidal ideation and self-injury during adolescence

BACKGROUND

The effect of life stress on suicidal symptoms during adolescence is well documented. Stressful life events can trigger suicidality, but most adolescents are resilient and it is unclear which factors protect against the deleterious impact of stress. Social support is thought to be one such factor. Therefore, we investigated the buffering effect of specific sources of social support (parental and peer) on life stress (interpersonal and non-interpersonal) in predicting suicidal symptoms during adolescence. In order to test the specificity of this stress buffering, we also examined it with regard to dysphoric mood.

METHOD

Data come from the Adolescent Development of Emotions and Personality Traits (ADEPT) Project, a cohort of 550 adolescent females aged 13.5-15.5 recruited from Long Island. Self-reported social support, suicidality, and dysphoria were assessed at baseline and suicidality and dysphoria were assessed again at 9-month follow-up. Life stress was assessed by interview at the follow-up.

RESULTS

High levels of parental support protected adolescent girls from developing suicidal symptoms following a stressor. This effect was less pronounced for peer support. Also, social support did not buffer the pathogenic effects of non-interpersonal stress. Finally, social support did not buffer the effect of life stress on dysphoric symptoms.

CONCLUSIONS

Altogether, our results highlight a distinct developmental pathway for the development of suicidal symptoms involving parental support that differs from the development of dysphoria, and signifies the importance and specificity of social support in protecting against suicidality in adolescent girls.

Adolescent self-injurers: Comparing non-ideators, suicide ideators, and suicide attempters

Adolescent non-suicidal self-injury (NSSI) and suicidality are serious health concerns; however, factors that contribute to the transition from NSSI to suicide ideation and suicide attempts are unclear. To address this gap, we investigated whether demographic characteristics, child maltreatment, and psychiatric factors are associated with the level suicidality among adolescents with a history of self-injury. Participants were three groups of adolescent inpatient self-injurers (n = 397, 317 female), aged 13-18 years (M = 15.44, SD = 1.36): (a) non-ideators (n = 96; no current suicide ideation and no lifetime suicide attempts), (b) suicide ideators (n = 149; current ideation and no lifetime attempts), and (c) suicide attempters (n = 152; current ideation and at least one lifetime attempt). Participants completed interviews assessing psychiatric diagnoses, suicidality, and NSSI characteristics, as well as questionnaires on childhood trauma, psychiatric symptoms, and risky behavior engagement. Depression severity was associated with greater odds being a suicide ideator (p < 0.001, OR = 1.04) and an attempter (p < 0.001, OR = 1.05) compared to a non-ideator. Suicide attempters used more NSSI methods and reported greater risky behavior engagement than non-ideators (p = 0.03, OR = 1.29 and p = 0.03, OR = 1.06, respectively) and ideators (p = 0.015, OR = 1.25 and p = 0.04, OR = 1.05, respectively); attempters used more severe NSSI methods (e.g., burning). Our results identify a wide range of risk markers for increasing lethality in a sample at high risk for suicide mortality; future research is needed to refine risk assessments for adolescent self-injurers and determine the clinical utility of using risk markers for screening and intervention.

The Relationship between Childhood Maltreatment and Non-Suicidal Self-Injury: A Systematic Review

INTRODUCTION

Childhood maltreatment (CM) has been associated with an increased risk of non-suicidal self-injury (NSSI) and suicidal behaviors. However, the exact nature of the association between CM and NSSI is currently unclear. The present review aimed to systematically investigate the association between CM and NSSI in adolescence and early adulthood.

METHODS

A systematic search of four major electronic databases covering both medical and social science research (PubMed, Scopus, Science Direct, and PsycINFO) was conducted.

RESULTS

Overall, 20 cross-sectional studies including a total of 22,517 individuals, 3 longitudinal follow-up studies including 1,728 individuals, and 3 retrospective studies including 62,089 individuals were selected. It appears that CM is a significant risk factor for both NSSI and suicide attempts. The increased vulnerability to NSSI seems to be related to experiences of CM, particularly sexual abuse. Gender differences were also found. Generally, when compared to males, females who experienced CM seem to be more vulnerable to presenting with NSSI and suicidal behaviors.

CONCLUSION

There is a positive association between CM and NSSI. The importance of early detection and risk reduction of self-injurious behavior for adolescents is discussed.