Suicide and Deliberate Self-harm 121adaptive way. Occasionally this sort of crisis intervention will lead on to
longer-term psychotherapy. Individuals and families are more likely to
accept treatment when there is continuity of care between the assessment
and treatment phases. Engagement is more likely if the initial assessment
includes some time exploring what the child or adolescent would find
helpful – and ideally provides an immediate advance instalment so as to
make it seem worth returning.
Since selective serotonin reuptake inhibitors (SSRIs) may be prescribed
when a child or adolescent has deliberately harmed themselves in the
context of low mood, it is important to note two points covered in Chapter
- Firstly, the evidence for the efficacy of SSRIs in adolescent depression
is weak as far as mild or moderate depression is concerned, but is stronger
for severe depression. Secondly, there is some evidence that SSRIs can
increase suicidal ideation. The case for giving rather than withholding
SSRIs clearly needs careful reflection.
A number of trials of preventive programmes are emerging, usually
delivered in secondary schools, but so far results have been disappointing.
While some show a reduction inideasof self-harm, none has yet proven
to reduceactsof self harm.
Prognosis
There are relatively few high-quality follow-up studies of young people
who have harmed themselves, in large part because of the difficulties
involved in tracing and recruiting subjects. One month later, the overall
adjustment is generally better than at the time of DSH, but a substantial
minority are still experiencing considerable adjustment problems a year
later. Continuing difficulties are predicted by co-existent antisocial traits.
Individuals who harm themselves during an acute crisis but who were
previously well adjusted have a particularly good prognosis. Roughly 10%
of young people who harm themselves do so again within the next year.
Predictors of repetition include male sex, more than one previous episode
of DSH, extensive family psychopathology, poor social adjustment and
a psychiatric disorder (including substance abuse). Subsequent episodes
may be fatal, either by design or because the individual underestimates
the lethality of what was intended to be a non-fatal overdose or injury.
Roughly 1% of young people who harm themselves do subsequently
kill themselves, usually within the next two years. Factors that increase
the risk of eventual suicide are male sex, being an older adolescent, the
presence of a psychiatric disorder and use in the initial episode of active
rather than passive means (for example, hanging rather than an overdose).
Subject review
Hawton K, Fortune S. (2008) Suicidal behavior and deliberate self-harm.
In: Rutter Met al.(eds)Rutter’s Child and Adolescent Psychiatry,5thedn.
Wiley-Blackwell, Chichester, pp. 648–669.