Serious self-harm is one of the top five causes of acute medical admission to hospital. The age group with the highest admission rate is 16-24 year olds, but those seen in hospitals represent only the tip of the iceberg. Most young people who self-harm do not contact health services. And when they do make contact, typically with accident and emergency clinics, underlying psychological problems may be ignored and vital follow-up services not provided.

Researchers at the Thomas Coram Research Unit at the Institute of Education, University of London, with colleagues at the University of Leeds, have been conducting a study for the Department of Health to follow 16- to 22-year-olds who make repeat presentations at A&E with self-inflicted injuries or overdoses.

A&E departments concern themselves mainly with the physical consequences of self-harm, and the psychological elements most likely to receive attention are the short-term risk of repetition and clear evidence of depression or serious mental illness. As an emergency service, A&E is not designed to provide a sustained response to these young people's needs. So continued support must come from elsewhere, and follow-up is offered usually through mental health services.

The current study has looked at how the longer-term needs of this patient group could be better served by a multi-agency approach. It followed patients for a year to get their views of the services offered.

One of the difficulties in treating self-harm is that it is more of an action than an illness. It is important to understand whether it comes as a response to one particular event, or is symptomatic of deeper problems. The study looked at other aspects of the young people's lives, and found that issues such as employment, housing and relationships should be taken into account. These all have important implications for treatment, yet commonly receive less attention than the presence of a medical condition such as depression.

An earlier study, which audited case notes in 18 A&E departments, provided valuable details of this patient group.¹ But there were significant gaps. The brevity of many notes meant the recording of living arrangements and employment, education, drug and alcohol use were limited.

However, a picture emerged of a marginalised and often socially excluded group. Many young people who self-harm come from difficult or fragmented home backgrounds: 52 per cent of the 16- to 19-year- olds and 31 per cent of the 20- to 24-year-olds lived with their parents. These figures are considerably lower than the national average. Half of them reported problems in living with parents and were actively looking for somewhere else to live. Tracking the young people over the course of a year revealed that many had moved several times and a high proportion lived alone in hostels, supported lodgings or bed-and-breakfast accommodation.

High levels of unemployment were found among this group: 44 per cent were not working or in education while 40 per cent had no formal qualifications. These figures, too, were well above the norm. Alcohol use featured in 40 per cent of presentations, with young men more likely than women to have been drinking before presenting at A&E. The use of street drugs was poorly recorded but it was implicated in 22 per cent of cases. However, excessive use of drugs and rates of alcohol dependency were fairly low.

The young people taking part in the study described repeated incidents of self-harm that did not attract medical attention or went unreported. This pattern obscures the true figures, and the picture is muddied further by the fact that information on previous episodes of self-harm was missing in almost half of the case notes examined.

The research suggested that the lack of recording stemmed from a failure to elicit the relevant information rather than from careless note-making. Establishing any previous history of self-harm is the most reliable way to identify whether there are underlying and potentially chronic psychological problems. Repeated episodes, as distinct from a "one-off" impulsive response to an upsetting event, are a major risk factor for future serious self-harm and suicide. More than two-thirds of the young people interviewed in the study had previously presented as a result of self-harm, with 40 per cent reporting at least seven incidents.

A strong gender bias appeared in the way problems were precipitated. Young men were more likely to present with mental health problems or drink and drug misuse, while young women were more likely to talk about problems with relationships. But not all of them could explain why they had self-harmed, nor relate it to a specific event.

As to why information was missing from case notes, light was shed on these omissions when patients were interviewed. Young people described being confused, disorientated by their situation, in an emotional state, and unable or unwilling to talk about what had happened to them. Some were reluctant to seek medical treatment and were brought in by friends or family; some were hostile to any questioning and, often, a busy A&E department militated against any in-depth examination.

Self-harm included cutting and burning themselves over long periods of time, or punching walls and windows which often resulted in cuts and broken bones. The young people interviewed acknowledged that when they visited their GP or the hospital they had rarely mentioned deliberately injuring themselves. Others described small overdoses for which they had not sought medical help and which they had failed to mention at their first time in A&E.

Young people often mentioned guilt about attending A&E departments. They felt that they didn't deserve to be there, as they had brought the situation on themselves, and perceived staff to be judgmental. While some interviewees were able to give positive accounts of interaction with medical staff, for most the difficulties in communicating their problems were compounded by overstretched medical services and their perception of the stigma attached to self-harm.

Young people who self-harm fall between the gaps. Since more than 80 per cent of the sample had a history of self-harm going back over two years or more, the research suggests that it may be necessary to view self-harm not as an event, but as a syndrome. As such, it requires a multi-agency approach to respond to the factors that precipitate episodes.

Most of the young people interviewed reported inadequate follow-up treatment. And while many had refused treatment, others had hoped for a response from service providers but had fallen through the net. Even where services such as a mental health liaison team based in the A&E department existed, subsequent referrals - such as alcohol and drug counselling - often did not take place.

However, mental health services are not the only source of professional help needed. With unemployment being a risk factor for repeated self-harm and suicide, the level of non-participation in the workforce and in education is worrying. Only half of the unemployed young people received any professional help with finding work or training. Some found low-paid work in supermarkets, call-centres and warehouses, usually on shifts, which further disrupted their already fragmented lives.

These young people are dealing with a range of intertwined problems, some psychological and some practical. This complexity has implications for both assessment and treatment. Young people who self-harm are often unable to negotiate access to services for themselves. They may find that an A&E department is their first resort, but it should not be their last.

Key points

• Most people who self-harm do not contact health services.
• Most young people interviewed in the study reported inadequate follow-up services.
• Young men's problems were more likely to be linked to drug or drink problems. Young women were more likely to talk about relationship problems. But not all of them could explain why they had self harmed.
• Nearly half of the self-harmers interviewed were unemployed. Many reported accommodation problems and family difficulties.
• Case notes were frequently deficient, often because of the state of mind of the young person, but also because A&E is too busy.
• Self-harm is more of a syndrome than an event and requires a multi-agency response.

Pamela Storey and Jane Hurry are researchers for, and Cathy Brownjohn is communications officer at, the Thomas Coram Research Unit. 

Reference  

¹ J Hurry and P Storey, "Assessing young people who deliberately harm themselves", British Journal of Psychiatry Vol 176, 2000  For further information, contact Pamela Storey, Thomas Coram Research Unit; tel 020 7612 6566; e-mail p.storey@ioe.ac.uk