A review of the scope of non-suicidal self-injury behavior in adolescents with depressive disorders: an analysis of related influencing factors

Abstract

Background

Non-suicidal self-injury (NSSI) behavior is one of the major causes of death and disability in adolescents with depressive disorders, and this behavior has a high detection rate among adolescents globally, which seriously affects their physical and mental health and quality of life. Given the high prevalence and severity of NSSI behavior, this study provides a reference for the future construction of a risk-grading-based preventive intervention framework for NSSI in adolescents with depressive disorders by systematically sorting out the factors affecting non-suicidal self-injury.

Methods

This study adopted Arksey and O'Malley's methodology and the scoping review framework. The search took place from the creation of the database until November 12, 2024, in professional guideline websites like NICE and GIN and databases like China Knowledge, Wanfang, CINAHL, PubMed, and Web of Science. The topics searched for were adolescent depressive disorder, NSSI and behavioral influencing factors in relevant Chinese and English literature. We identified the research questions, completed the literature screening and quality assessment, extracted the data, summarized it, and analyzed it.

Results

The study included a total of 15 papers, comprising 1 guideline, 3 systematic evaluations, 1 Literature review, and 10 cross-sectional studies. Study topics focused on four categories: individual characteristics and psychological factors (e.g., gender, age, sexual orientation), illness and treatment factors (duration of illness, degree of depression), behaviors and lifestyles (Internet addiction, stressful events), and family and social environment (family functioning, social support).

Conclusion

Factors affecting NSSI behaviors in adolescent patients with depression are intricate and complex, covering multiple dimensions such as personal traits, family environment. The findings of this review emphasize that when conducting NSSI risk assessment for depressed adolescents in clinical practice, in addition to the depressive symptoms themselves, it is also necessary to systematically evaluate those individual psychological traits, behavioral patterns, and environmental factors. We should integrate relevant risk factors to create personalized prevention plans. We aim to decrease the frequency of NSSI behaviors in teenage patients suffering from depressive disorders and halt the progression of additional suicidal actions. Future research can focus on verifying the role of these risk factors in the predictive model and the effectiveness of intervention measures.

Introduction

Depressive disorder is a common mental disorder whose core symptoms reflect persistent depressed mood, loss of interest, and loss of energy, accompanied by inattention, declining self-confidence, and strong feelings of guilt and worthlessness [1]. As a person moves from childhood to adulthood, adolescence is a unique developmental stage during which their physiological and psychological control systems are being built and perfected. During this period, their physical and mental development happens at different times. They are more likely to be affected by several interconnected factors that can make them depressed, less willing to do things, and even experience more severe depressive symptoms like self-harm and injury. Researchers [2] have found that about 34% of teens around the world report having a depressive disorder, and 8% of those have severe depressive disorders. Among these adolescents with depression, non-suicidal self-injury (NSSI) is common and seriously harmful [3].

NSSI is defined as a series of repeated, intentional behaviors that cause mild to moderate damage to one's tissues, committed by an individual without suicidal intent, which, although not socially accepted or sanctioned, have become an independent risk factor for suicidal behaviors in the adolescent population [4, 5]. Studies have shown [6] that the global detection rate of NSSI in adolescents is 17.7%. Meanwhile, some studies have pointed out that NSSI has a higher incidence rate in adolescent depressive disorder groups, and an Australian study of adolescents aged 12–17 years found that the incidence rate of NSSI in adolescent depressive disorders was 46.6% [7]; in China, the incidence rate of NSSI in individuals with depressive disorders was as high as 54.6% [8].NSSI not only causes adolescents to suffer great psychological pain, which seriously affects their schooling, interpersonal relationships, and quality of life, but also results in a significantly higher risk of long-term suicide and a worse prognosis for NSSI patients, which has a far-reaching negative impact on the family and society [9].

Although NSSI is prevalent among adolescents with depressive disorders and has serious consequences, its mechanism of occurrence is relatively complex. Previous studies have demonstrated that the interplay of personal experiences, rather than a single factor alone, causes NSSI behaviors [10]. Family upbringing [11], adverse social events [12], and other factors all play a role in NSSI behaviors. However, most studies on the factors influencing NSSI in this specific population are cross-sectional, leading to fragmentation in existing research. This results in issues such as fragmented evidence, methodological heterogeneity, and insufficient cultural adaptation, particularly lacking a theoretical framework or comprehensive summary that systematically integrates multidimensional factors. This situation may lead to an incomplete understanding of NSSI behaviors among adolescents with depressive disorders, thereby hindering the development of effective prevention and intervention strategies. Therefore, this study aims to use a systematic scoping review method to focus on the population of adolescents with depressive disorders, identify and integrate the key factors influencing NSSI behaviors, and systematically integrate multi-dimensional research findings to provide a scientific basis for developing practical prevention strategies and intervention recommendations in the future.

Aim

The purpose of this review is to systematically sort out the factors influencing NSSI in adolescent patients with depressive disorders, and to provide a reference for the future construction of a prevention and intervention framework for NSSI in adolescent patients with depressive disorders based on risk classification.

Method

Design

Given that the goal of the study was the exploratory integration of multidimensional evidence rather than an assessment of intervention effects, the scope review framework proposed by Arksey and O'Malley was used, which is suitable for panoramic evidence grooming in emerging research areas [13]. The framework of a scoping review report is: ① identifying the research question; ② identifying relevant studies; ③ selecting studies; ④ data mapping; and ⑤ organizing, summarizing, and reporting results.

Clarifying the research questions

The analyses in this study aimed to provide comprehensive coverage of the factors influencing the NSSI in adolescents with depressive disorders to avoid selective bias and to ensure the completeness of the evidence.

Search strategy

We easily changed the search formula and wildcard characters to fit the needs of each database, using a mix of subject terms and free words. The system then conducted a search across relevant guideline networks and databases, spanning from the database's creation to November 12, 2024. Three researchers conducted a total of three independent searches, and two researchers cross-validated the results to ensure the search was comprehensive. Relevant websites searched included the Guidelines International Collaboration (GIN), the National Institute for Healthcare Optimization (NICE) in the United Kingdom, the Scottish Intercollegiate Guidelines Network (SIGN), the National Guidelines Consortium (NGC) in the United States, the Registered Nurses Association of Ontario (RNAO) in Canada, the New Zealand Guideline Writing Network (NZGG), the Canadian Medical Association's Clinical Practice Guidelines Repository (CMA Infobase), BMJ Best Practice, and Medical Pulse. Search databases included China Knowledge, Wanfang, PubMed, Web of Science, CINAHL, Cochrane Library, and China Biomedical Literature Database (CBM). The Chinese search formula was (adolescents OR middle school students) AND (depression OR depressive disorder OR depressive disorder) AND (non-suicidal self-injury OR self-injury) AND (risk factors OR protective factors OR influencing factors). Figure 1 displays the English search formula.

Fig. 1.

English search formular

Inclusion and exclusion criteria

Inclusion criteria

① Study population: adolescents diagnosed with depressive disorders; ② Study content: relevant factors affecting NSSI; ③ No limitation on the type of study; ④ For revised or updated guidelines, the latest version was included; ⑤ Literature language: Chinese or English.

Exclusion criteria

① Literature whose full text could not be detected; ② Literature other than Chinese or English; ③ Literature whose valid data could not be extracted after reading; ④ Literature with the same content published repeatedly.

Data extraction and analysis

The retrieved literature was imported into EndNote X9 for the screening process, and after removing duplicates, two researchers screened the literature according to the specified criteria and noted any discrepancies. We introduced a third researcher for discussion in cases of disagreement. On this basis, two researchers independently extracted relevant literature information from the table, including authors, research types, sample sizes, and influencing factors. They used Microsoft Excel software to assist in organizing and conducting a preliminary analysis of the information. To ensure the reliability of data extraction and decision-making, this study employed cross-validation, with the second researcher independently verifying the first researcher's decisions. We reached consensus through discussion or consulted a third researcher for arbitration if discrepancies arose.

To integrate fragmented evidence into a coherent system, this study employed thematic mapping methods to classify and visualize the extracted influencing factors in a multidimensional manner. The specific steps included: ① preliminary reading of the extracted content to identify recurring themes; ② categorization of influencing factors into predefined dimensions based on an ecological model framework of individual-family-sociocultural factors; ③ clustering of factors within the same dimension into sub-themes; and ④ optimization of the classification framework through team discussions to ensure logical consistency and comprehensive content coverage.

Furthermore, to ensure rigorous and reliable research methods, all studies included in the research underwent strict quality evaluation. The guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation Ⅱ (AGREE Ⅱ) [14]. The criteria consisted of six domains and 23 entries, with each entry scored on a scale a scale of 1 to 7, where 1 indicated complete non-compliance and 7 indicated complete compliance. A standardized percentage was used as the final score for each domain, with the scoring formula: (actual score - lowest possible score)/(highest possible score - lowest possible score) × 100%, with higher scores resulting in higher guideline quality; systematic evaluations and literature reviews were conducted using the JBI Center for Evidence-Based Health Care's Evaluation Criteria (2016) [15], this tool contains 11 items, each of which is evaluated as “yes,” “no,” “unclear,” or “not applicable”; and cross-sectional studies were conducted using the JBI Center for Evidence-Based Health Care's Cross-sectional Research study's authenticity assessment [16], this tool contains 8 items, each of which is evaluated as “yes,” “no,” “unclear,” or “not applicable”. Included evidence was categorized into levels 1 to 5 according to the JBI evidence grading and recommendation level criteria [17].

Result

Literature screening results

The search obtained the pieces of Literature from 1953, tracing five highly cited references; 569 duplicates were deleted by the software, 1298 non-compliant pieces of Literature were eliminated by reading the title and abstract, and 15 pieces of Literature were finally included after reading the full text. Including 1 guideline [18], 3 systematic evaluations [19–21], 1 literature review [22], and 10 cross-sectional studies [23–32], the Literature Search Flowchart is shown in Fig. 2.

Fig. 2.

Literature search flowchart

Characteristics of the included studies

Among the 15 kinds of Literature included, 12 were in Chinese and 3 were in English, and the specific characteristics are shown in Tables 1 and 2.

Table 1.

Basic information about the included literature (n = 15)

Inclusion of studies	Year	Type of literature	sample size	Relevant factor numbera
NICE[18]	2022	guideline	None	11
Xiong LL et.al [19]	2024	meta-analysis	A total of 25 studies were included, with a total sample size of 4310 cases	1;7;10;21;22
Li Yalan et al. [20]	2020	system review	A total of 46 studies were included	5;11;12;17;22;23
Hui-Ming Niu et.al [21]	2021	meta-analysis	A total of 19 studies were included, with a total sample size of 707 cases	2;21
Zhang Yuan et.al [22]	2023	Literature review	None	1;3;5;6;7;12;13;19;21;24
Sun Ting et.al [23]	2024	Cross-sectional studies	323 cases	6;7
Liza Mansour [24]	2024	Cross-sectional studies	35 cases in the NSSI group; 49 cases in the non-NSSI group	1;2;11;13;15;22;23
Li Chuan-Liang et.al [25]	2024	Cross-sectional studies	59 cases in NSSI group; 68 cases in non-NSSI group	14;17;22
Ji Yanhui et.al [26]	2024	Cross-sectional studies	43 cases in the NSSI group; 62 cases in the non-NSSI group	8;16;17;18;22
Zhao F et.al [27]	2024	Cross-sectional studies	110 cases in NSSI group; 189 cases in non-NSSI group	4;7
Li Chang[28]	2023	Cross-sectional studies	209 cases in the NSSI group; 60 cases in the non-NSSI group	1;2;9;10;11
Hou YB et.al [29]	2023	Cross-sectional studies	39 cases in the NSSI group; 78 cases in the non-NSSI group	6
Ge Yiran et.al [30]	2023	Cross-sectional studies	150 cases in the NSSI group; 164 cases in the non-NSSI group	17
ZHENG Xiu-xiu et.al [31]	2022	Cross-sectional studies	62 cases in the NSSI group; 78 cases in the non-NSSI group	6;20
Cai et.al[32]	2022	Cross-sectional studies	44 cases in the NSSI group; 91 cases in the non-NSSI group	1;4;11;20

^aSee Table 2 for numbered elements

Table 2.

Correlates and their evidence and strength of recommendation

Factor category	concrete content	Strength of evidence	Recommended Strength
Individual characteristics and psychological factors
1. Demographic characteristics	a. The detection rate of NSSI behaviors is higher in women than in men [19, 22, 24, 28, 32]	1b	A
	b. Younger adolescents are more likely to [21, 24, 28]	1b	A
	c. Sexual minorities, including homosexuals and bisexuals, are more likely to engage in NSSI behaviors [20, 22]	1b	A
2. Personality and self-awareness	d. Adolescents with introverted personalities and low self-esteem are less emotionally stable and more prone to NSSI [22]	1b	A
	e. Low mental health and self-esteem status are important risk factors for NSSI in adolescents [27, 32]	4b	B
3. Emotion regulation and impulse control	f. Emotional management and cognitive deficits are important psychological risk factors for NSSI in adolescents [22, 23, 29, 31]	1b	A
	g. Adolescents'difficulty in controlling impulses in the face of stress or negative emotions is a risk factor for the development of NSSI [19, 22, 23, 27]	1b	A
	h. Coping strategies adopted by individuals in the face of stress are strongly associated with the occurrence of NSSI behaviors in adolescents [25]	4b	B
	i. NSSI becomes a means of emotion regulation in adolescents with depression when faced with negative life events [24]	4b	B
Disease and treatment factors
4. Characteristics of depressive disorders	k. Duration of depression ≥ 3 years[26]	4b	B
	k. Adolescents with depressive disorders with poor prior outcomes are more likely to [28]	4b	B
	l. Risk of NSSI increases with increasing levels of depression [18, 20, 24, 28, 32]	1b	A
5. History of suicide attempts	m. Patients with a history of suicide attempts [19, 28]	1b	A
Behavioral and lifestyle factors
6. Substance use and addictive behavior	n. Adolescents with irrational behaviors such as alcohol and drug use have a higher probability of NSSI behaviors [20, 22]	1b	A
	o. Depressed patients with internet addiction are more likely to have increased rates of NSSI [22, 24]	1b	A
Family and social environment factors
7. Family Function and Structure	p. Effective family functioning may have a reducing effect on the risk of NSSI in adolescents [20, 25, 26, 30]	1b	A
	q. The absence or change of family structure due to parental divorce or remarriage may foster a high level of negative emotions, affecting the control of the disease and making them more prone to self-injurious behaviors [26]	4b	B
	r. There is a correlation between NSSI behaviors and parenting behaviors [22]	1b	A
	s. Family closeness and family adjustment are protective factors for NSSI behaviors in adolescents with depressive disorders [31, 32]	4b	B
8. Trauma and negative life events	t. Re-exposure of adolescents to a stressful event with significant impact can further stimulate the condition and the development of NSSI [26]	4b	B
	u. Experiences of abuse are often an important trigger and risk factor for NSSI in adolescents [19, 20, 24–26]	1b	A
9. Peer relationships and social support	v. There is a correlation between peer isolation, bullying and NSSI behavior [19, 21, 22]	1b	A
	w. Patients with low social support have poor interpersonal relationships, and NSSI may become one of the ways to release emotions [20, 24]	1b	A
	x. Poor upbringing can lead to the development of NSSI behavior in individuals [22]	1b	A

Literature quality evaluation results

Guidelines

One guideline was included in this study, which had standardized scores of 91.7%, 97.2%, 69.81%, 83.3%, 81.25%, and 97.5% for scope and purpose, participants, rigor of guideline development, clarity of presentation, guideline application, and editorial independence, respectively. We evaluated the guideline as a grade A recommendation.

Systematic review

A total of 2 meta-analyses, 1 systematic evaluation, and 1 literature review were included in this study: the meta-analyses from CNKI and PubMed, respectively; the systematic evaluation from the Wanfang database; and the literature review from CNKI. We permitted the inclusion of all the systematic reviews by evaluating the overall study design as more complete. See Table 3 for details.

Table 3.

Results of the quality assessment of systematic evaluations

Inclusion of studies	Evaluation entries
	①	②	③	④	⑤	⑥	⑦	⑧	⑨	⑩	⑪	Inclusion or exclusion
Xiong LL et.al [19]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	No	Yes
Li Yalan et al. [20]	Yes	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes	No	Yes	Yes
Hui-Ming Niu et.al [21]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Zhang Yuan et.al [22]	No	Yes	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	No	Yes

① Was a pre-design program provided? ② Was the selection of included studies and data extraction reproducible? ③ Was an extensive and comprehensive literature search implemented? ④ Was publication status considered in the inclusion criteria, e.g., gray literature? ⑤ Was a list of literature on included and excluded studies provided? (vi) Are the characteristics of the included studies described? (vii) Is the scientific quality of the included studies evaluated and reported? (viii) Is the science of the included studies appropriately applied to the derivation of conclusions? ⑨ Are the methods used to synthesize the results of the included studies appropriate? ⑩Is the potential for publication bias assessed? ⑪ Are relevant conflicts of interest described?

Cross-sectional studies

This study included ten cross-sectional studies, eight from China Knowledge, one from the Wanfang database, and one from PubMed. After evaluation, the overall study design was more complete, and the overall quality of the literature was high. Inclusion was granted, as shown in Table 4.

Table 4.

Results of the cross-sectional study quality assessment

Inclusion of studies	Evaluation entries
	①	②	③	④	⑤	⑥	⑦	⑧	Inclusion or exclusion
Sun Ting et.al [23]	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	Yes	Yes
Liza Mansour [24]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Li Chuan-Liang et.al [25]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Ji Yanhui et.al [26]	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	Yes	Yes
Zhao F et.al [27]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Li Chang[28]	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	Yes	Yes
Hou YB et.al [29]	Yes	Yes	Yes	Yes	Unclear	Yes	Yes	Yes	Yes
Ge Yiran et.al [30]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
ZHENG Xiu-xiu et.al [31]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Cai et.al [32]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes

① Are the inclusion criteria for the study subjects clearly defined? ② Are the study subjects and study sites described in detail? ③ Are valid and credible methods used to measure exposure factors? ④ Are objective and standardized methods used to measure health problems? ⑤ Were confounders identified? ⑥ Are measures taken to control confounders? ⑦ Are valid and credible methods used to measure outcome indicators? ⑧ Is the method of data analysis appropriate?

Factors influencing NSSI in adolescents with depressive disorders

The things that affect the behavior of NSSI in teens with depressive disorders were put into 4 main themes and 24 sub-themes based on the analysis of qualitative data from a systematic scoping review of selected studies. The major themes of factors influencing NSSI behavior in adolescent patients with depressive disorders include individual characteristics and psychological factors, disease and treatment factors, behavioral and lifestyle factors, and family and social environment factors.

Discussion

Understanding the factors that affect non-self-harming behaviors in depressed teens can help quickly spot teens with depressive disorders who are planning to hurt themselves, lower the number of times they hurt themselves, and stop any more suicides from happening. Therefore, this paper provides a comprehensive and in-depth review of the multiple factors that influence NSSI behaviors in adolescents with depressive disorders. Through comprehensive analysis, we found that the NSSI behaviors of adolescent patients with depressive disorders are closely related to multiple aspects of their characteristics and psychological factors, disease and treatment status, daily behaviors and lifestyles, as well as family and social environments. In summary, an in-depth exploration of these influencing factors can not only improve our understanding of the complexity of NSSI behaviors in adolescents with depressive disorders, but also provide a scientific basis for clinical practice and public health policy, to more effectively reduce the occurrence of this high-risk behavior.

Focusing on the differences in individual characteristics and psychological factors of adolescent depressed patients to avoid potential risks

Relevant studies [33, 34] have shown that NSSI behaviors are particularly prevalent in early and middle adolescence, especially among adolescents aged 14–15 years. Adolescents in this period have not yet fully developed their emotion regulation abilities, and when faced with stress or negative life events, they may lack effective emotional management and cognitive abilities, encounter difficulty controlling their impulses, or resort to negative coping mechanisms, often viewing NSSI as a means of regulating their emotions [35, 36]. Among them, gender differences are also an important factor influencing the behavior of NSSI. Jacobson [37] found in their study of American adolescents that the detection rate of female NSSI behavior was twice that of males. The incidence of NSSI among girls was significantly higher than that among boys, which may be related to the sensitive personality and relatively weak emotional self-control of adolescent females [32]. The research of Peters [38] indicates that sexual minority groups, such as homosexuals and bisexuals, are also more prone to engaging in NSSI behavior. Their behavior may be closely related to the discrimination, exclusion, and pressure they face in society. Sexual minorities may frequently encounter prejudice and misunderstanding during their upbringing, leading them to feel lonely, helpless, and marginalized. To cope with these negative emotions, some sexual minority adolescents may choose NSSI as a form of self-expression or a way to seek attention. In addition, studies have shown [22] that individual personality traits also play an important role in the occurrence of NSSI behaviors. Introverted adolescent tend to be more inclined to suffer alone, are unwilling to seek help, or have difficulty sharing their inner feelings with others. This closedness may lead to the accumulation of negative emotions inside, increasing the risk of NSSI behaviors. Meanwhile, personality traits such as low self-esteem, low self-esteem, and emotional instability are also common triggers of NSSI behavior [22, 27, 32]. These adolescents may be more likely to feel helpless and hopeless in the face of frustration or stress, and thus choose to release stress by hurting themselves. In summary, adolescents may be more likely to adopt NSSI behaviors as a coping mechanism if they lack effective cognitive emotion regulation strategies during the critical period of development of their emotion regulation abilities and are also affected by multiple factors, such as individual personality traits, gender differences, and social pressures. To prevent this phenomenon, clinical assessments and mental health screenings should prioritize adolescents with depression in middle school, particularly girls with depressive disorders. To address the issue of weak emotional regulation skills, relevant personnel need to strengthen mental health education for this group, enhance adolescents'emotional management and cognitive abilities, and help them develop positive coping strategies. Given that some adolescents are introverted and reluctant to seek help, intervention programs should design low-threshold, accessible support channels, such as anonymous online counseling and peer support groups, and proactively identify and engage with these silent, high-risk individuals. Closely monitor adolescents'mental health and self-esteem, promptly identifying and addressing the emotional issues they face. Additionally, for sexual minority groups, we should provide an equal and respectful growth environment to reduce the social pressures they face, thereby effectively lowering the incidence of NSSI behavior.

Early identification and treatment of depressed adolescent patients to reduce the risk of self-injury

The prevalence of depression and NSSI among adolescents has reached or even exceeded 20% [39]. A cross-sectional study also indicated that there is a high correlation and comorbidity between depression and NSSI [40]. Poor previous treatment of depression or a long duration of the disease and recurrent episodes of the disease will cause patients to lose confidence in treating the disease, leading to the growth of a large number of negative emotions and the emergence of NSSI behaviors. The results of Ji Yanhui's study showed[26] that adolescent patients with a duration of depression of more than three years had a significantly increased risk of NSSI. Meanwhile, the risk of NSSI increased with the deepening of depression [18, 20, 24, 28, 32]. Also, people with depressive disorders are more likely to hurt themselves and have suicidal thoughts and attempts. Individuals who have previously attempted suicide are at a higher risk of self-harm, necessitating close monitoring [19, 28]. To prevent NSSI behaviors in adolescents due to disease and treatment history factors, it is recommended to strengthen the early identification and treatment of depressive disorders to avoid prolonged disease. We should promptly adjust the treatment program for patients with poor treatment outcomes to alleviate their suffering from the disease. At the same time, patients with a history of suicide attempts require long-term follow-up and targeted psychological interventions, in addition to necessary treatment for depressive disorders, to reduce the risk of self-harm.

Strengthening mental health education and guiding a healthy lifestyle

The presence of irrational behaviors such as drinking alcohol and taking poison, as well as excessive dependence on the Internet, are risk factors for NSSI in adolescents with depressive disorders [20, 21]. Some studies have found [41, 42] that adolescents who drink alcohol and use drugs are more likely to engage in NSSI behavior, and many adolescent patients who use substances exhibit recurrent NSSI behavior. Internet addiction, alcohol consumption, and drug use are all forms of addictive behavior that significantly influence the onset and progression of NSSI. Recently, adolescents have become increasingly connected to the internet, with addiction becoming more prevalent. Research has shown [43] that while online social media provides adolescents with a platform for communication, excessive reliance on the internet may lead to disconnection from the real world. The poorer an adolescent's mental health, the more likely they are to engage in NSSI. To prevent adolescents'NSSI behaviors due to behavioral and lifestyle factors, it is recommended that mental health education be strengthened and adolescents be guided to establish a positive and healthy lifestyle.

Building a harmonious family and social environment and enhancing family and social support

Good family functioning is considered a key factor in reducing the risk of NSSI in adolescents [20, 25, 26, 30]. A stable family structure, such as avoiding changes brought about by parental divorce or remarriage, can reduce negative emotions, help manage emotional distress, and decrease the likelihood of self-injurious behaviors. In addition, parenting styles directly affect adolescents'mental health [22], and positive parenting behaviors can help reduce NSSI behaviors. Family closeness and adaptability are protective factors for NSSI behaviors in adolescents with depressive disorders [31, 32], and close ties among family members and flexibility in coping with life changes help adolescents better cope with psychological distress. Trauma and negative life experiences are also important risk factors for NSSI in adolescents. Once adolescents are affected by recent major stressful events, such as family changes or academic pressure, their condition may further deteriorate, thereby stimulating NSSI behavior [26]. At the same time, both physical and emotional abuse can cause long-term damage to adolescents'mental health. Meanwhile, maltreatment experience is also an important risk factor for NSSI in adolescents, and both physical and emotional maltreatment may cause long-term damage to adolescents'mental health. In addition, adolescents with depression are more likely to fall into the grip of maladaptive emotions during academic stress, poor peer relationships, exposure to bullying, or other adverse life events, and when lacking sufficient psychological capital to cope with environmental stressors, they may turn to NSSI as a way of releasing stress or seeking help from the outside world [44]. Studies have shown [20, 24] that social support is related to the incidence of NSSI behavior. Individuals with low social support are significantly more likely to experience NSSI [45]. In conclusion, families need to provide a stable, supportive, and loving environment for schools and society to increase attention and protection for adolescents, for peer bullying and abuse to be reduced, and for social support to be enhanced to reduce NSSI behaviors in adolescent depressed patients. In the family context, efforts should be focused on enhancing family functionality, promoting positive, warm, non-violent, and supportive parenting styles, and providing professional support such as family therapy and parent–child communication training for families experiencing changes in family structure, to maintain environmental stability and strengthen family intimacy and adaptability. In schools, effective and feasible anti-bullying policies should be established to create a safe and inclusive campus environment, with particular attention and protection given to minority and marginalized student groups. We should also review and implement measures to reasonably alleviate academic stressors. Additionally, establish an effective mechanism for collaboration between schools, communities, and medical institutions to enable early identification, reporting, and intervention in cases of child abuse of any kind. Furthermore, actively promote and assist adolescents with depression in building and utilizing diverse social support networks, and provide relevant support and resources for individuals with low levels of social support.

Conclusion

The purpose of this paper is to systematically sort out the influencing factors of NSSI behaviors in adolescent patients with depression. Through a systematic search of relevant literature, we found that the factors affecting NSSI behaviors in teenage patients with depressive disorders can be divided into four major categories: individual characteristics and psychological factors, disease and treatment factors, behavioral and lifestyle factors, and family and social environment factors. These results inform future programs for the risk prevention of NSSI behaviors in adolescents with depressive disorders. At the clinical practice level, individualized NSSI risk assessment should be integrated into the routine diagnostic and treatment process for adolescents with depressive disorders, with a priority on screening high-risk groups. At the family support level, efforts should be made to enhance family functioning, promote warm, supportive, non-violent parenting models, strengthen family psychological resilience, and develop modular treatment plans that integrate cognitive behavioral therapy with family intervention. At the societal level, the core value of early professional intervention can be emphasized through the promotion of mental health science popularization projects, emphasizing the core value of early professional intervention, and assisting adolescents in establishing diverse social support networks while improving community support systems for high-risk families. Together, these form a three-tiered ecological prevention model encompassing the individual, family, and community. This model provides a clear pathway for policymakers to establish cross-departmental collaboration mechanisms, aiming to reduce the incidence of NSSI behaviors among adolescents with depressive disorders.

However, due to differences in local environments and conditions, as well as language restrictions, most of the studies included in this research were from China, which is insufficient to offer an in-depth assessment of the factors influencing NSSI behavior in adolescents with depression. Meanwhile, the interrelationship between depressive disorders and NSSI behaviors is still in the exploratory stage, and most of the current cross-sectional studies are unable to determine whether the relationship between NSSI and related factors changes over time. Teenagers with depressive disorders still don't have access to effective interventions that change their NSSI behaviors. To find out more about what causes these behaviors, future studies should use a larger sample size, a more rigorous research design, and pay attention to differences in different cultural and geographical settings. In the meantime, future research should prioritize adopting a longitudinal research design to explore the dynamic relationship between NSSI behaviors and related factors, as well as to develop effective interventions. Through these efforts, we can provide more comprehensive and effective support for the mental health of adolescents with depressive disorders.

Abbreviations

NSSI

Non-Suicidal Self-Injury

GIN

The Guidelines International Collaboration

NICE

The National Institute for Healthcare Optimization

SIGN

The Scottish Intercollegiate Guidelines Network

NGC

The National Guidelines Consortium

RNAO

The Registered Nurses Association of Ontario

NZGG

The New Zealand Guideline Writing Network

CMA

Infobase the Canadian Medical Association's Clinical Practice Guidelines Repository

CBM

China Biomedical Literature Database

AGREE Ⅱ

The Appraisal of Guidelines for Research and Evaluation Ⅱ

Authors’ contributions

Yijing Ling and Yujia Gu contributed equally to this work Yijing Ling and Yujia Gu: conceptualization(lead); methodology(lead); date curation(lead); writing-original draft(lead); writing-review and editing(equal) O.Mensah Solomon: writing-review and editing(equal) Lihong LI: writing-review and editing(equal) Xufeng Chen: writing-review and editing(equal) Ying Wang: conceptualization(supporting); methodology(supporting);writing-review and editing(supporting) Yehong Wei: conceptualization(supporting); methodology(supporting); writing-review and editing(supporting).

Funding

“Pioneer” and “Leading Goose” R&D Program of Zhejiang (2024C03208).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

All of participants were given written informed consent.

Competing interests

The authors declare no competing interests.