Before deciding upon the most appropriate treatment for a young person who is self-harming or engaging in suicidal behaviours, the management plan should address the young person’s immediate safety, in the context of establishing a therapeutic relationship (1). As part of the development of a safety plan, a decision needs to be made as to whether hospitalisation is required, or if the young person can utilise existing support networks, such as family and friends, in carrying out their safety plan (1). A comprehensive safety plan should cover the following steps:

1. The young person’s early warning signs
2. Coping strategies they could try to feel better
3. People and social settings that provide a distraction
4. People they can contact for help
5. Professionals or agencies they can contact for help, and
6. How they can make the environment safe.

A template of a safety plan is available here.

Currently, there is insufficient research regarding which interventions are most effective for responding to deliberate self-harm behaviours (2). A systematic review evaluated the evidence for interventions with young people at risk of self-harm or suicide and is the only higher-quality evidence available in this area that is youth-specific. While the evidence is extremely limited, cognitive-behavioural interventions (CBT) appeared to show some promise (3). Given that not much is known about the effectiveness of interventions to reduce self-harm (4), it is recommended that any underlying mental health problems, such as depression, are appropriately treated so that the young person may feel more able to cope and therefore less likely to engage in self-harming behaviours (5).

UK Guidelines for Self-Harm (6) suggest the following aims and objectives in the treatment of self-harm:

• Rapid assessment of physical and psychological need
• Effective measures to minimise pain and discomfort
• Timely initiation of treatment, irrespective of the cause of self-harm\
• Harm reduction (from injury and treatment; short-term and longer-term)
• Rapid and supportive psychosocial assessment (including risk assessment and comordibity)
• Prompt referral for further psychological, social and psychiatric assessment and treatment when necessary
• Prompt and effective psychological and psychiatric treatment when necessary
• An integrated and planned approach to the problems of people who self-harm, involving primary and secondary care, mental and physical healthcare personnel and services, and appropriate voluntary organisations
• Ensuring that the special issues that apply to children and young people who have self-harmed are properly addressed, such as child protection issues, confidentiality, consent and competence.

The evidence map provides reference details for studies of prevention and treatment interventions for self harm and suicide behaviours and risk in young people.

Self-harm and suicide are behaviours, not psychiatric disorders, therefore neither is classified in the DSM-IV-TR (1) or the ICD-10 (2). Similarly, suicidal ideation is quite common and in itself is not a psychiatric disorder and therefore, is also not classified in diagnostic systems. However, while self-harm and suicidal behaviour do not constitute psychiatric diagnoses in and of themselves, it is widely recognized that they often occur in the context of a diagnosable mental disorder. Studies consistently report that young people who complete suicide or who make a serious suicide attempt often have a recognisable mental disorder at the time, such as depression, anxiety, conduct disorder and substance misuse (3). Internationally, research suggests that as many as 90% of people who complete suicide have a diagnosable DSM-IV mental disorder at the time of their death (4). Often these disorders are unrecognized and/or untreated.

Assessment Tools

To assess whether a young person is engaging in self-harm or suicidal behaviour, a comprehensive assessment by a mental health professional is required.  As a first step, the assessment involves asking questions about a range of aspects of a person life including their:

• Home and Environment;
• Education and Employment;
• Activities;
• Drugs and Alcohol;
• Relationships and Sexuality;
• Conduct Difficulties and Risk-Taking;
• Anxiety and Eating;
• Depression and Suicide;
• Psychosis and Mania

To assess specifically for the self-harming and suicidal behaviours, a comprehensive assessment by a mental health professional trained in clinical assessment is required. The assessment should comprehensively evaluate the young person’s social, motivational and psychological factors specific to the self-harming behaviour, their current suicidal intent, level of hopelessness, as well as a full assessment of mental health problems (5). The assessment of suicidal risk requires direct questioning of the young person’s wish to die, the frequency and intensity of any suicidal thoughts, if they have any plans to act on these thoughts, if they have access to any means to end their life, and if they have tried previously to end their life (5-7).  Currently, there are no screening tools that are helpful in formulating an assessment of a young person’s level of risk (6).

People who engage in self-harm deliberately hurt their bodies. The term ‘self-harm’ (also referred to as ‘deliberate self-harm’ or DSH) refers to a range of behaviours, not a mental disorder or illness (1).  At the milder end of the spectrum, these behaviours include mild to moderate self-injury as a response to emotional pain and, at the more extreme end, attempted suicide (1, 2). The most common methods of self-harm among young people are cutting and deliberately overdosing on medication. Other methods include burning or scalding the body, pinching and scratching oneself, self-hitting and hanging(2).

In many cases self-harm is not intended to be fatal (2). It is estimated that the number of young people who have engaged in self-harm is 40-100 times greater than those who have actually ended their lives (3). For many young people self-harm is a coping strategy, however maladaptive and damaging, that allows them to continue to live rather than an attempt to end their life (4).

There is now a general consensus among clinicians and researchers that there is a distinct type of self-harming behaviour, termed non-suicidal self-injury (NSSI) in which the motivation is not intention to die, and that these behaviours should be distinguished from those that are suicidal in nature (5). However research studies typically fail to make this distinction and there is continued debate about terminology and definitions (6). Other terms used to refer to different forms of self-harm include self-injury, cutting, parasuicide and attempted suicide.

Although many young people might try to hide their self-harming behaviour, there are some obvious and less obvious signs that someone might be self-harming (1). These include:

Psychological signs:

• Obvious changes in mood
• Changes in sleeping and eating patterns
• Losing interest and pleasure in activities that were once enjoyed
• Decreased participation and poor communication with friends and family
• Hiding or washing their own clothes and avoiding situations were exposure of arm and legs is required (eg, swimming)
• Problems in social or intimate relationships
• Strange excuses provided for injuries
• Problems with work, school, social or family life

Physical signs:

• Unexplained injuries, such as scratches, cuts or burn marks
• Unexplained physical complaints such as headaches or stomach pains
• Wearing clothes that cover up arms and legs, even in hot weather

Burden of youth suicide and self-harm in young people

The most recent ‘causes of death’ publication from the Australian Bureau of Statistics (ABS) indicates that in 2010, suicide was the leading cause of death for young people aged 15-24, followed closely by road traffic accidents (7). In 2010, 88 males aged 15-19 years and 129 males aged 20-24 years died by suicide (7). For young females, 25 aged 15-19 years and 54 aged 20-24 years died by suicide (7). (These figures should be interpreted with caution as they are subject to an ABS revision process which could see them change, see (8) for further information).

The number of young people who die by suicide in Australia each year is relatively low compared with the number who self-harm. It is difficult to estimate the rate of self harm as evidence suggests that only 10% of young people who self-harm will present for hospital treatment (9). Evidence from Australian studies suggest that 6-7% of Australian youth aged 15-24 years engage in self-harm in any 12-month period (9). Lifetime prevalence rates are higher, with 24% of females and 18% of males aged 20-24 and 17% of females and 12% of males aged 15-19 reporting self-harming at some point in their life (10). While suicide is more common among young men, self-harm is more common among young women.

Taken together, suicide and self-harm account for a considerable portion of the burden of disability and mortality among young Australians. It is estimated that 21% of “years life lost” due to premature death among Australian youth in 2004 was due to suicide and self-inflicted injury (11). In addition, non-fatal suicidal behaviour and self-harm are associated with substantial disability and loss of years of healthy life (11).

Risk factors
Common risk factors or characteristics for those self-harm are similar to those who complete suicide (12). These include (13):

• History of self-harm and/or previous suicide attempt
• Mental or substance use disorders, especially depression
• Physical illness: terminal, painful or debilitating illness
• Family history of suicide, substance abuse and/or other psychiatric disorders
• History of sexual, physical or emotional abuse
• Socially isolated and/or living alone
• Bereavement in childhood
• Family disturbances
• Unemployment, change in occupational or financial status
• Rejection by a significant person eg, relationship breakup
• Recent discharge from a psychiatric hospital

Experiencing a mental health problem is a risk factor for both self-harm and suicide. Evidence suggests that more than 90% of people who present to hospital with self-harm have a mental disorder, the most common being depression (2). A history of mental illness, in particular depression, as well as the presence of more than one mental disorder are also strong predictors of suicide (14-16).

While not all young people who self-harm or contemplate suicide have a mental health problem, these behaviours do suggest the experience of psychological distress.

“The bravest thing I ever did was continuing my life when I wanted to die.”

— Juliette Lewis 

 I feel like it’s completely spot on. Now with the way I view suicide, I can see both sides of the spectrum. Some ignorant people say that committing suicide is cowardly. I disagree. Speaking from someone who has been there a million times, I know what it’s like to fight for so long and so hard that you no longer have the energy to fight anymore. People who are suicidal and those who succeed, they have so much pain inside that living becomes the last thing they want to do, and the saying “People who are suicidal don’t want to die, they just want the pain to stop.” is completely accurate. When you’re in that state it’s like you have blinders on, you can’t see that someday the pain will subside, you feel like you’re going to be in that pain forever and that is unbearable. I don’t necessarily think that people who want to kill themselves or people who do kill themselves are brave, I just think that they can’t stand the pain anymore. Most people spend so much time running from their problems that they never think that they can face them. I’ve been there, running from all the fear, the pain, the sadness, and for people like me, running from the past. This is why I like that quote so much, it takes incredible bravery to stop running and face your problems instead of continuing to run from them. And I truly believe that facing the problems is the only way to get through them, you can’t keep running from them and expect that one day they will all disappear. It just doesn’t work that way. To face them, work through them, and someday be able to look beyond them and find contentedness is the bravest thing you can do. I’ve spend the better part of my life running, but now I’ve finally stopped and basically said “Bring it on”. I’ve been lucky though, if I wasn’t in therapy, and especially if I never met my current therapist, I don’t think I would be at the same place that I am. A lot of hurting people don’t have peoples’ guidance, they don’t  have the opportunity to know the things that I have learned on my journey. I try to put in my two cents on my blogs but I have no way in knowing if I’m actually getting through to people. Sometime I feel like I want to do so much to help people but I can’t do it by myself, there will always be people like the old me, and that is frustrating to me. 

Self-reported nightmares among patients seeking emergency psychiatric evaluation appear to be an excellent forecaster of elevated suicidal symptoms.

Results indicate that severe nightmares were independently associated with elevated suicidal symptoms after accounting for the influence of depression, whereas symptoms of insomnia were not.

These findings suggest that nightmares stand alone as a suicide risk factor.

The sample included 82 men and women between the ages of 18 and 66, who were in a community mental health hospital admissions unit awaiting an emergency psychiatric evaluation. Evaluations determined eligibility for crisis stabilization inpatient admittance.

Patients’ nightmares, insomnia, depression and suicidal tendencies were assessed through several questionnaires, including the Disturbing Dreams and Nightmare Severity Index, Insomnia Severity Index (ISI), Beck Depression Inventory (BDI), and the Beck Scale for Suicide Ideation (BSS).

According to principal investigator Rebecca Bernert, doctoral candidate in clinical psychology at Florida State University, findings of the study emphasize the need for a more thorough assessment ofsleep among acutely ill patients, as it may be an important opportunity for intervention.

“Sleep disturbances, especially nightmares, appear to be an acute warning sign and risk factor for suicide,” said Bernert.

“Given that poor sleep is amenable to treatment, and less stigmatized than depression and suicide, our findings could impact standardized suicide risk assessment and prevention efforts.”

The study states that sleep complaints are now listed among the top 10 warning signs of suicide by the Substance Abuse and Mental Health Services Administration (SAMHSA).