COVID-19 and Nonsuicidal Self-Injury: The Pandemic’s Influence on an Adolescent Epidemic

As many countries continue to struggle with controlling the COVID-19 pandemic, another public health frontier has come into view. The mental health sequelae of quarantine- and pandemic-associated psychosocial hardship, brought about by global recession, unemployment, and an increase in domestic violence, are clearer with every recent study being published. Given an increase in several risk factors, concerns have been raised about a possible increase in many mental health conditions,¹ particularly suicide. Although these are valid concerns, it remains unclear how the COVID-19 situation has affected one of the most extensive mental health epidemics among adolescents.

Nonsuicidal self-injury (NSSI), the deliberate destruction of one’s own body tissue without suicidal intent,² has received increasing notice in the general public as well as in the scientific literature; for example, a 12-month prevalence rate of 17.6% was reported for a representative US adolescent sample.³ So far, no evidence is available on the effect of COVID-19 on NSSI; however, some recent studies raise the level of concern. A recent US online study reported an association between COVID-19–related general distress and suicidal thoughts, with higher scores of suicidal ideation in those exposing themselves intentionally to SARS-CoV-2.⁴ A recent study in an Irish emergency department reported a sharp increase in self-harm patients from April to May 2020.⁵ Ougrin et al. compared data of March through April 2019 with data of March through April 2020 from 23 child and adolescent psychiatric emergency service locations in 10 countries. The authors observed an increase in the number of children seeking emergency services owing to self-harm (odds ratio = 1.33; 95% confidence interval = 1.07, 1.64).⁶ This might be understood as an early indication that NSSI should not be overlooked in times of quarantine.

Because of a lack of data on the impact of the COVID-19 pandemic on NSSI in adolescents, we must rely on former works about risk factors for NSSI. As NSSI is often used as an emotion-regulation strategy to decrease or end negative emotions for a short time, among the strongest risk factors for NSSI are a previous history of NSSI, hopelessness, and a cluster B personality disorder (characterized by dramatic, overly emotional, or unpredictable thinking or behavior and interactions with others [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Washington, DC: American Psychiatric Association; 2013]). Parental psychopathology and family functioning also play significant roles in predicting NSSI.²

The situation imposed on adolescents worldwide during the COVID-19 crisis leads to questions about how quarantine measures might affect those with a history of NSSI. The lockdown procedures have led to a situation in which daily structure (e.g., day–night rhythm, including attending school at set times) has changed and social relationships have been restricted to social media. The lockdown conditions imposed in many countries bear the potential to aggravate existing conflicts in families, leading to an increased need to regulate emotions. Social support, found to be a protective factor against NSSI, has been available only online and access to professional support has been limited.

In a situation with reduced support structures and an accumulation of potential risk factors, it seems likely that there has been a steep increase in NSSI. Nevertheless, one should not forget that the frequency of other strong risk factors, such as bullying, school stressors, and the influence of self-injuring peers, might be reduced because of school closings and quarantine restrictions. However, because of online contacts, bullying and contact with self-injury communities may have continued even in these circumstances.

If the increase in NSSI suggested by emergency department data holds true, the question remains: how can this mental health crisis be met? Different psychotherapeutic approaches are effective in reducing NSSI, with most evidence available for dialectical behavioral therapy for adolescents.² The COVID-19 pandemic has, however, underlined the need for alternative treatment approaches that are available online. Although there is a growing literature on apps and online diaries, so far no randomized controlled trial is available on an online treatment program, although a clinical trial is under way.⁷ Strengthening research on online interventions holds the potential to provide a knowledge base for future stepped care procedures as well as a valuable therapeutic option during lockdown conditions with restricted availability of face-to-face psychotherapy. Given that the COVID-19 pandemic is far from ending, attention needs to be shifted to psychosocial outcomes, especially in youths, because the possible consequences of worsened mental health may aggravate the long-term impact of the pandemic.