Rohan Borschmann, Denise Becker, Carolyn Coffey, Elizabeth Spry, Margarita Moreno-Betancur, Paul Moran, George C Patton

Abstract

Background Little is known about the long-term psychosocial outcomes associated with self-harm during adolescence. We aimed to determine whether adolescents who self-harm are at increased risk of adverse psychosocial outcomes in the fourth decade of life, using data from the Victorian Adolescent Health Cohort Study.

Methods We recruited a stratified, random sample of 1943 adolescents from 44 schools across the state of Victoria, Australia. The study started on Aug 20, 1992, and finished on March 4, 2014. We obtained data relating to self-harm from questionnaires and telephone interviews at eight waves of follow-up, commencing at mean age 15·9 years (SD 0·5; waves 3–6 during adolescence, 6 months apart) and ending at mean age 35·1 years (SD 0·6; wave 10). The outcome measures at age 35 years were social disadvantage (divorced or separated, not in a relationship, not earning money, receipt of government welfare, and experiencing financial hardship), common mental disorders such as depression and anxiety, and substance use. We assessed the associations between self-harm during adolescence and the outcome measures at 35 years (wave 10) using logistic regression models, with progressive adjustment: (1) adjustment for sex and age; (2) further adjustment for background social factors; (3) additional adjustment for common mental disorder in adolescence; and (4) final additional adjustment for adolescent antisocial behaviour and substance use measures.

Findings From the total cohort of 1943 participants, 1802 participants were assessed for self-harm during adolescence (between waves 3 and 6). Of these, 1671 were included in the analysis sample. 135 (8%) reported having self-harmed at least once during adolescence. At 35 years (wave 10), mental health problems, daily tobacco smoking, illicit drug use, and dependence were all more common in participants who had reported self-harm during the adolescent phase of the study (n=135) than in those who had not (n=1536): for social disadvantage odds ratios [ORs] ranged from 1·34 (95% CI 1·25–1·43) for unemployment to 1·88 (1·78–1·98) for financial hardship; for mental health they ranged from 1·61 (1·51–1·72) for depression to 1·92 (1·79–2·04) for anxiety; for illicit drug use they ranged from 1·36 (1·25–1·49) for any amphetamine use to 3·39 (3·12–3·67) for weekly cannabis use; for dependence syndrome they were 1·72 (1·57–1·87) for nicotine dependence, 2·67 (2·38–2·99) for cannabis dependence, and 1·74 (1·62–1·86) for any dependence; and the OR for daily smoking was 2·00 (1·89–2·12). Adjustment for socio-demographic factors made little difference to these associations but a further adjustment for adolescent common mental disorders substantially attenuated most associations, with the exception of daily tobacco smoking (adjusted OR 1·74, 95% CI 1·08–2·81), any illicit drug use (1·72, 1·07–2·79) and weekly cannabis use (3·18, 1·58–6·42). Further adjustment for adolescent risky substance use and antisocial behaviour attenuated the remaining associations, with the exception of weekly cannabis use at age 35 years, which remained independently associated with self-harm during adolescence (2·27, 1·09–4·69).

Interpretation Adolescents who self-harm are more likely to experience a wide range of psychosocial problems later in life. With the notable exception of heavy cannabis use, these problems appear to be largely accounted for by concurrent adolescent mental health disorders and substance use. Complex interventions addressing the domains of mental state, behaviour, and substance use are likely to be most successful in helping this susceptible group adjust to adult life.

Summary

My second H&P was about a 12 year old who was brought in about concern for self cutting behaviors. Even though we did not suspect that this patient was self cutting, I was still interested in learning more about the long term effects of this behavior. I came across this cohort study that followed nearly 2000 adolescents from 44 schools in Victoria, Australia for 22 years from 1992 through 2014 to determine the long term psychosocial outcomes of self-harm during adolescents. The average age at enrollment was 15.9 years, and ending at 35.1 years. Questionnaires and telephone interviews were used at 8 waves of follow up. Outcomes measured at age 35 included social disadvantage (divorced/separated, not in a relationship, not earning money, receiving government welfare, financial hardship), common mental disorders (depression, anxiety) and substance use. Of 1943 participants, 1671 were included in analysis of which 135 (8%) reported at least 1 episode of self harm during adolescence. Mental health problems, daily tobacco smoking, illicit drug use, and dependence were more commonly seen in those who reported self harm during adolescence than those who did not. These problems persisted into mid-thirties and this population also reported greater financial hardship, daily tobacco smoking, and weekly cannabis use, higher rates of divorce or separation. Risk was only marginally reduced after adjusting for socio-economic factors. Concluded that adolescents who self harm are more likely to experience a wide range of psychosocial problems later in life including mental health disorders, antisocial behavior, and drug use. Recommend complex interventions to address mental state, behavior, and substance use in order to help adolescents who self harm adjust to adult life. (CBT, dialectical behavior therapy, mentalisation based therapy) however there is limited evidence for their effectiveness at this time. There is a need for further trials to determine the effectiveness of these therapies and optimal therapy for this at risk population. Strengths of the study included large sample size, high retention rates, long term follow up. Study was limited by methodology, self harm behaviors were not differentiated between with or without suicidal intent and type of self harm was not specified. Also, follow up was based on self reporting and was not checked with hospital records. There has been some research showing discrepancies between self-reported self harm and hospital admissions/ED presentations (20% go undisclosed). Authors surmised that self-harm events were likely underreported. While retention rates were high the authors believe that those with chaotic lives were more likely to refuse participation