Self-harm among adolescents: A primary care perspective on incidence, clinical-management and mortality risk
Self-harm is a significant problem in young people. It is the strongest risk factor for suicide - the second most frequent cause of death in adolescents globally. One of the priorities of the Suicide Prevention Strategy for England concerns improving mental health and lowering the increasing suicide rate among 15-19 year olds. Primary care is most often the first point of contact for mental health problems. However, available epidemiological evidence on self-harm is largely based on secondary care presentations. It is therefore important to gain an understanding of adolescent self-harm among primary care patients.
Using the Clinical Practice Research Datalink (CPRD), a large database of electronic GP health records in the UK, we estimated the incidence of self-harm among adolescents aged 10-19 years. We investigated temporal trends of self-harm incidence over the period 2001 to 2014, stratified by gender, age and level of deprivation for the practice locality. Clinical management during the 12 months following the initial self-harm episode was profiled by referral rates to mental health services and frequency of psychotropic prescribing. Using survival analysis, we also estimated all-cause and cause-specific mortality risks among adolescents following self-harm versus unaffected individuals of the same age and gender.
We identified 16,912 adolescents aged 10-19 years, with an initial self-harm record between 1st January 2001 and 31st December 2014. Among girls, we observed an elevated standardised annual incidence rate of 37·4 per 10,000 (95% CI 36·8, 38·1) versus 12·3 per 10,000 (95% CI 11·9, 12·6) in boys. There was a sharp increase in incidence among girls aged 13-16 years from 2011 (45·9 95% CI 41·7, 50·0 per 10,000) to 2014 (77·0 95 % CI 70·7, 83·3 per 10,000). Approximately one in six adolescents was referred to mental health services during the 12 months following their initial self-harm episode. Adolescents from GP practices located in more deprived areas were 23% less likely to be referred within this 12 month period. Adolescents who self-harmed died from unnatural causes an estimated nine times more frequently, than adolescents without self-harm history, with large elevations in risks for suicide (hazard ratio 17·5, 95% CI 7·6-40·5) and death by acute alcohol/drug poisoning (hazard ratio 34.3, 95% CI 10.2-115.7).
This study of a large cohort of adolescents provides a unique primary care focus on self-harm at a young age. The marked increase in self-harm episodes observed among girls aged 13-16 years prompts the urgent need to identify the reasons for this rise to ensure their future mental wellbeing. Our findings highlight the important role of primary care in increasing opportunistic enquiry, monitoring, support or referral for younger adolescents and should inform healthcare policy and commissioning decisions about services for adolescents with mental health problems.