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. Author manuscript; available in PMC: 2023 Jul 1.
Published in final edited form as: Arch Suicide Res. 2021 Jan 6;26(3):1186–1197. doi: 10.1080/13811118.2020.1865223

Phenotypic characterization of youth admitted to acute psychiatric inpatient unit following self-harm behavior

Maya Schwartz-Lifshitz 1, David H Ben-Dor 2, Yael Bustan 2, Gil Zalsman 2,3, Doron Gothelf 1, Abraham Weizman 2, Ran Barzilay 4
PMCID: PMC9534345  NIHMSID: NIHMS1832339  PMID: 33403931

Abstract

Objective:

Deliberate self-harm (DSH) is a major health concern among adolescents, and is often associated with the need for inpatient psychiatric hospitalization. The aim of this study was to identify clinical and demographic characteristics associated with DSH behavior among adolescents admitted to an acute psychiatric inpatient unit.

Method:

We retrospectively analyzed data from the electronic medical records of consecutive admittances to a single acute adolescent inpatient unit (N=703, mean age 15.2). We compared inpatients with DSH to inpatients without DSH, and further compared within DSH group based on the presence of suicidal intent.

Results:

Compared to Non-DSH inpatients (N=497), youths admitted following DSH (N=206) were more likely to be female (OR=2.6, 95%CI 1.7–4), currently in depressive exacerbation (OR=2.4, 95%CI 1.6–3.6), with concurrent suicidal ideation (OR=3.9, 95%CI 2.5–5.9), and history of alcohol use (OR=5.6, 95%CI 3.2–9.5). Within DSH youths, no significant clinical differences were identified between those admitted following suicide attempt (N=102) compared to non-suicidal-self-injury (N=104), who were generally younger.

Conclusions:

Findings suggest that early detection and intervention of DSH and depressive crisis is warranted, regardless of the self-harm subtype.

Keywords: Suicide, Non-suicidal self-injury, Deliberate self-harm, Adolescence psychiatry

Introduction

Suicide attempts (SA) and non-suicidal self-injury (NSSI) are major public health concerns among adolescents (Glenn et al., 2017; Jacobson & Gould, 2007). In clinical practice it is often difficult to discriminate between SA and NSSI due to the overlap between the two phenomena (Kapur et al., 2013). Suicide attempts and NSSI are differentiated by the presence or absence of a clear suicidal intent (Andover et al., 2012), lethality of means (Whitlock et al., 2011) and the frequency of self- harm (Muehlenkamp, 2005). It was suggested that various aspects of self-harm, encompassing suicide, SA and NSSI, may represent a spectrum of deliberate self-harm (DSH) behavior, although some consider self-harm with intention to die as a separate entity than NSSI (Whitlock & Knox, 2007).

NSSI is associated with elevated risk for repeated NSSI (Tuisku et al., 2014) and SA (Cooper et al., 2005), and is a significant predictor of subsequent NSSI or SA (Wilkinson et al., 2011). The number of NSSIs and self- harm methods employed correlates with the number of SAs (Whitlock et al., 2013; Yen et al., 2016). In addition, there is a relative increase in the frequency and severity of NSSI occurring in the months prior to a SA (Glenn et al., 2017; Stewart et al., 2017; Yen et al., 2016). Studies suggest that 40% to 85% of individuals who engage in NSSI also report history of SA (Nock et al., 2006). This phenomenon is similar to a previous observation demonstrating that SA is a predictor of subsequent SA and death by suicide (Spirito & Esposito-Smythers, 2006). Adolescents with a history of both NSSI and SAs engage in significantly more episodes of self-injury than their counterparts with a history of one type of self-injury (Jacobson et al., 2008). A possible reason for this association is that recurrent NSSIs might desensitize an individual to the pain and fear associated with self-harm, thus making the pathway to suicide easier (Klonsky, 2011; Selby et al., 2012). However, it is difficult to differentiate SA from NSSI in youth due to the clinical overlap between the two entities (Hamza et al., 2012; Silverman et al., 2007; Victor & Klonsky, 2014).

While efforts have been made at identifying risk factors for adolescent DSH, it remains difficult to predict this behavior (Hawton & van Heeringen, 2009; Schwartz-Lifshitz, Zalsman, Giner, & Oquendo, 2013). Furthermore, although non-suicidal self-injury (NSSI) and suicide attempts (SA) frequently co-occur among youth, there is increasing evidence that the risk factors of the behaviors are distinct (Wolff et al., 2013). Therefore, there is a need to further investigate the differences between the two entities. Youth that require hospitalization due to DSH are high risk population for consequent suicide (Hawton & Harriss, 2007), making them an interesting population to study in attempt to identify early risk factors for suicidal behavior. Yet there is scarce research on the factors associated with DSH in psychiatric adolescent inpatients (Stewart et al., 2017), and there is a gap in the field pertaining studies that teases apart factors associated with NSSI and SA in this high risk population.

In the current study, we aimed (1) to compare demographic and clinical characteristics of adolescents admitted to an acute psychiatric inpatient ward due to DSH (SA and/or NSSI) to their admitted counterparts without recent history of DSH; and (2) to investigate differences within DSH youth, comparing SA and NSSI subgroups in an attempt to identify factors specific to each self- harm behavior. We hypothesized that adolescent inpatients with recent DSH will present with more severe psychopathology including major depression, substance use and cluster B personality disorders compared to those without DSH, and that within the DSH group, adolescents hospitalized due to SA will present with higher rates of past suicide attempts, higher rates of substance abuse and more depressive episodes (Piqueras et al., 2019; Zubrick et al., 2017)

Methods

Design

Data from the electronic medical records (EMR) were analyzed retrospectively. Data were retrieved from the EMR of all consecutive admittances between March 2010 and September 2015, to a single adolescent acute ward at the Geha Mental Health Center (GMHC), a regional mental health center, with a catchment area of approximately 500,000 inhabitants. The GMHC Review Board approved the study and waived the need for informed consent due to the retrospective nature of the study. Subjects were assessed in an interview conducted by a senior child and adolescent psychiatrist within 24 hours of admission. Diagnoses at discharge were established by an attending child and adolescent psychiatrist according to ICD-10 criteria following a consensus meeting of the clinical team.

In preparation of EMR data for analyses, two child and adolescent psychiatrists (YB and MLS) reviewed the patient’s files and consensus regarding the type of the nature of DSH (SA, NSSI or both) was obtained. In case of disagreement between reviewers, discussions were held and consensus was reached following discussion with a third child-adolescent psychiatrist (RB).

Subjects and clinical assessment

We included in the study all adolescent inpatients admitted to GMHC acute inpatient unit during the study period (N=703, age range 12–19). For patients with multiple hospitalizations within the study period, we included the earliest hospitalization. As standard practice at the unit, all admitted youths undergo a multidisciplinary clinical interview within a day after admission. The procedure is a conversational, phenomenologically oriented, semi structured-interview, led by an experienced and reliability-trained senior child-adolescent psychiatrist. Each interview includes direct assessment of DSH behavior and evaluation of intent to die while engaging in DSH (i.e., differentiating NSSI from SA). Following this interview, clinical findings including the presence/absence of DSH is documented in the patient’s EMR. Deliberate self- harm was considered if patients were engaging in self-harm (suicide attempt or NSSI) in the week prior to admission, and included intentional act of self-poisoning (such as overdoses), self-cutting, scratching, hitting or banging, carving, and scraping. These behaviors were identified through the psychiatric and physical examination during admission and the data was retrieved from the EMR. Excluded were accidental and indirect self-injurious behaviors (e.g., disordered eating or drug abuse), as well as socially accepted behaviors like tattooing, piercing, or religious rituals.

Diagnoses at discharge were established by an attending child and adolescent psychiatrist according to ICD-10 criteria following a consensus meeting of the clinical team.

Analysis overview

All included patients were classified as admitted with a recent history of DSH (N=206), or not (non-DSH, N=497). Among participants with DSH, we compared three types of patients admitted due to self-harm behavior as follows: SA, NSSI, and SA +NSSI.

Variables

SA was defined as a potentially self-injurious behavior, associated with at least some intent to die, as a result of the act. Evidence that the individual intended to kill him/ herself, at least to some degree, can be explicit or inferred from the behavior or circumstance. The suicide attempt may or may not result in actual injury. (Posner et al., 2007)

Non suicidal self- injury was defined as self-injurious behavior associated with no intent to die. The behavior is intended purely for other reasons, either to relieve distress or to effect change in others or the environment (Posner et al., 2007). Suicide attempts +NSSI included patients who in the week prior to admission attempted suicide but also engaged in NSSI.

Sociodemographic and clinical data that were retrieved from the patients’ EMR included age at hospitalization, sex, number of prior admissions, duration of index hospitalization, family history of mood disorder, smoking, and history of cannabis and alcohol use, as determined following clinical interviews and intake during the hospitalization. Clinical data also included major diagnosis at discharge, psychiatric diagnosis prior to admission (e.g. depressive or psychotic episode), the presence of suicidal ideation at time of admission and need for special protective measures (restraining, isolation or observation) during hospitalization, as documented in the EMR.

Statistical analysis

For univariate analysis of patients presenting with and without DSH we used Mann-Whitney U test (for two group comparison) or Pearson’s Chi-square test, as appropriate. Descriptive statistics are expressed as mean ± standard deviation for continuous variables and rates (%) for categorical variables. Multivariable analysis was conducted using binary logistic regression. We only included independent variables (IVs) that were assessed at the clinical presentation, in line with the study aim to identify clinically measurable factors associated with DSH in acutely presenting adolescent psychiatric patients.

The first regression model included DSH as the dependent variable, with variables that were significantly different in the univariable comparison (between participants with and without DSH) as the IVs, co-varying for age. This model therefore included patients’ sex, suicidal ideation, current depressive exacerbation, and history of alcohol. This model also included cannabis and cigarette use as independent variables, as cannabis smoking has been suggested as an indicator associated with DSH (Moran et al., 2012).

We then conducted comparisons within DSH sub-groups (NSSI, SA or both), using Kruskall-Wallis test or Pearson’s Chi-square test, as appropriate, to test the hypotheses that SA presentations will be associated with more previous SAs, more depression and more substance abuse. A p-value < .05 was considered to indicate statistical significance. SPSS for Windows ver. 24 (IBM SPSS Statistics for Windows, Version 24.0. IBM Corp., Armonk, NY) was used for statistical analysis.

Results

Comparison of adolescent inpatients with DSH to patients without DSH

Demographic and clinical characteristics of adolescent inpatients with DSH (N=206) and without DSH (N=497) is described in Table 1. DSH was positively associated with female sex, suicidal ideation at admission, a diagnosis of depression at admission, a history of alcohol use, a diagnosis of depression/dysthymia at discharge and a family history of mood disorders. Patients with DSH also had higher rates of cluster B personality disorders diagnoses compared to Non-DSH. Negative association existed between DSH and non-affective psychosis leading to hospitalization. No differences were found between DSH and Non-DSH groups in terms of age distribution, smoking and cannabis use status, or restrain/isolation/observation during hospitalization. A slightly shorter duration of hospitalization was found in the DSH group (Table 1).

TABLE 1.

Demographic and clinical characteristics of the adolescent inpatients with and without deliberate self-harm behavior.

Statistics
DSH n = 206 Non-DSH n = 497 Mann–Whitney U/Pearson χ2(df) p-Value
Demographics
 Age in years, mean (SD) 15.2 (1.8) 15.2 (1.9) 51667.5 0.846
 Females, n (%) 153 (74.3) 216 (43.5) 55.44 (1) <0.001
Pre-admission clinical parameters
 No history of prior psychiatric admissions, n (%) 160 (77.7) 392 (78.9) 0.125 (1) 0.724
 Family history of mood disorder, n (%) 33 (22) 52 (13.8) 5.42 (1) 0.02
Clinical parameters reported at admission
 Cigarette smoker, n (%) 58 (28.2) 119 (26.2) 0.290 (1) 0.59
 Alcohol use, n (%) 71 (34.5) 55 (11.1) 53.81 (1) <0.001
 Cannabis use, n (%) 19 (9.3) 31 (6.4) 1.81 (1) 0.178
 Depressive episodes leading to current admission, n (%) 120 (58.5) 129 (26.2) 65.81 (1) <0.001
 Non-affective psychosis leading to current admission, n (%) 11 (5.4) 141 (28.5) 45.73 (1) <0.001
Clinical characteristics of hospitalization
 Hospitalization duration in days, mean (SD) 53.9 (81.5) 59.6 (76.9) 51.667 0.044
 Suicidal ideation at admission, n (%) 145 (72.5) 153 (32.2) 92.652 (1) <0.001
 Patients requiring restrain or isolation, n (%) 17 (8.3) 34 (6.8) 0.431 (1) 0.511
Diagnoses at discharge
 Depression or dysthymia, n (%) 71 (34.5) 66 (13.3) 113.385 (3) 0.001
 Cluster B personality disorder, n (%) 47 (22.8) 29 (5.8)
 Psychotic disorder, n (%) 12 (5.8) 151 (21.5)
 Other diagnoses, n (%) 76. (36.9) 263 (52.9)
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DSH: deliberate self-harm within a week prior to admission; SD: standard deviation.

Multivariable logistic regression analysis revealed that female sex, suicidal ideation, depressive episode diagnosis at admission and history of alcohol consumption were independently associated with risk for self-harm behavior (Table 2).

TABLE 2.

Multivariable logistic regression analysis of the demographic and clinical parameters associated with DSH in adolescent inpatients.

Odds Ratio Lower CI 95% Upper CI 95% p-Value
Alcohol use 5.5 3.2 9.5 <0.001
Suicidal ideation at admission 3.9 2.5 5.9 <0.001
Female sex 2.6 1.7 4 <0.001
Depressive episodes leading to index admission 2.4 1.6 3.6 <0.001
Cigarette Smoking 0.6 0.4 1.1 0.087
Cannabis use 0.9 0.5 1.8 0.79
Age at admission 1 0.9 1.1 0.764
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The table represents values derived from binary logistic regression model run with DSH as the dependent variable, and all variables in the table as independent variables. DSH: deliberate self-harm; CI: confidence interval.

Comparison within DSH youths group: NSSI, SA and NSSI+SA

Out of the 207 patients that presented with self-harm at admission to the inpatient unit, 103 were admitted due to NSSI, 68 due to SA, and 35 were admitted due to SA+NSSI. Demographics and clinical characteristics of each group are detailed in Table 3.

TABLE 3.

Comparison within subtypes of self-harmers based on suicidal intent as described by the patients at admission.

Statistics
NSSI n = 103 SA n = 68 NSSI + SA n = 35 Kruskall–Wallis F/Pearson χ2(df) p-Value
Demographics
 Age in years, mean (SD) 14.9 (1.7) 15.7 (1.8) 15.5 (1.8) 91.836 0.01
 Females, n (%) 80 (77.7) 43 (63.2) 30 (85.7) 7.355 (2) 0.025
Pre-admission clinical parameters
 No history of prior psychiatric admissions, n (%) 82 (79.6) 53 (77.9) 25 (71.4) 1.013 (2) 0.603
 Family history of mood disorder, n (%) 12 (15.6) 12 (26.7) 9 (32.1) 4.097 (2) 0.129
Clinical parameters reported at admission
 Cigarette smoker, n (%) 34(34) 17 (25.4) 6(17.1) 4.038 (2) 0.133
 Alcohol use, n (%) 40(40) 20 (29.9) 10 (28.6) 2.517 (2) 0.284
 Cannabis use, n (%) 11 (11) 6 (9) 2(5.7) 1.935 (2) 0.748
 Number of prior suicide attempts, mean (SD) 0.36 (0.7) 1.73 (1.4) 1.63 (1.4) 9.257 <0.001
 Depressive episodes leading to current admission, n (%) 54 (52.4) 40 (58.8) 26 (76.5) 6.092 (2) 0.048
 Non-affective psychosis leading to current admission, n (%) 4 (3.9) 4 (5.9) 3(8.6) 1.163 (2) 0.559
Clinical characteristics of hospitalization
 Hospitalization duration in days, mean (SD) 56.2 (91) 47.6 (69) 59.2 (76) 2 0.344
 Suicidal ideation at admission, n (%) 66 (66.7) 53 (80.3) 26 (74.3) 3.761 (2) 0.152
 Patients requiring restrain or isolation, n (%) 9 (8.7) 6 (8.8) 2 (5.7) 0.359 (1) 0.836
Diagnoses at discharge
 Depression or dysthymia, n (%) 33(32%) 23(33.8%) 15(42.9%) 9.945 (6) 0.127
 Cluster B personality disorder, n (%) 27 (26.2%) 11(16.2%) 9(25.7%)
 Psychotic disorder, n (%) 3(2.9%) 5(7.4%) 4(11.4%)
 Other diagnoses, n (%) 40 (38.8%) 29 (42.6%) 7 (20%)
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NSSI: non-suicidal self-injury; SA: suicide attempt.

In line with our hypothesis, patients presenting with SA had higher previous SAs (Kruskal Wallis F= 9.257, p<.001). We also found higher rates of depressive episodes leading to the acute presentation in the NSSI+SA group (Pearson X2=6.092, p=.048), but this finding loses statistical significance once correcting for multiple comparisons. There were no differences in terms of cigarette smoking, cannabis or alcohol use.

Discussion

In the present study, we identified demographic and clinical characteristics of adolescents admitted to acute psychiatric inpatient unit following DSH. As expected, we found that this specific population is characterized by higher rates of depression leading to inpatient hospitalization, with significant co-occurrence of DSH with suicidal ideation, in accordance with a previous report (Glenn et al., 2017).

In our study, female gender was positively associated with DSH. Similar findings were reported previously (Beautrais, 2002; De Leo & Heller, 2004; K. Hawton, 2002). It is well established that a substantial portion of adolescent girls engage in DSH (Evans et al., 2005), and epidemiological studies of DSH have shown that in the age range 12–15 years the female: male ratio is as high as 5–6:1 (Chesin et al., 2017; Hawton, Saunders, & O’Connor, 2012). This may be related, at least partially, to the higher rates of depressive presentation among teenage girls (Patton et al., 2007). In accordance with previous studies (De Leo & Heller, 2004; K. Hawton, 2002), multivariable analysis revealed that suicidal ideation, depressive episode, and a history of alcohol use were also associated with DSH. Within the DSH group, most of admissions were due to NSSI, followed by SA and SA+NSSI. There was a negative association between DSH and non-affective psychosis. We found a slightly shorter duration of hospitalization in the DSH group that can be ascribed to the lower rate of psychotic patients in this group, that often require longer hospitalizations. Furthermore, a higher rate of cluster B personality disorders in the DSH group, specifically borderline personality disorder, may contribute to a less prolonged hospitalization, as the prevailing opinion is that inpatient admissions of borderline personality patients to a general psychiatric ward should usually be brief, time-limited and goal oriented (Fagin, 2004).

In the current study we sought to further characterize the various types of self-harm through comparing SA to NSSI and SA+NSSI. As expected, the number of prior suicide attempts was significantly higher in the SA group. The higher rate of depressive features (major depression and dysthymia) prior to admission in the SA+NSSI is consistent with previous studies (Brausch & Gutierrez, 2010; Taliaferro et al., 2012). Adolescents with a history of NSSI+SA report more symptoms of borderline personality disorder, higher rates of depression (Dougherty et al., 2011) and anhedonia (Brausch & Gutierrez, 2010) than those with a history of NSSI only.

We found that NSSI patients were slightly younger than patients admitted due to suicide attempt. It can be explained by the fact that NSSI (Kiekens et al., 2018; Victor & Klonsky, 2014) requires less planning and means than SA, thus more available to younger adolescents. Another potential explanation is that on the trajectory of self-harm over time, NSSI presents earlier and then some of these adolescents subsequently progress to suicidal attempts. Within the SA+NSSI group the majority engaged in NSSI prior to the actual suicide attempt. This finding supports the notion that NSSI, especially with current depression and alcohol use, should be considered as a pre-suicidal act, justifying early intervention. While the cross-sectional nature of the study precludes conclusions about directionality, exploration of developmental trajectories of NSSI to SA are a promising avenue for future research.

In contrast to our observation, a previous study found in adolescent outpatients that suicidal ideation levels were lower among adolescents engaging in NSSI than among suicide attempters (Jacobson et al., 2008). This discrepancy may be related to a difference in the population composition of the two samples, as our study was conducted on acutely self -harming inpatients, where suicidal ideation tends to be high. It is of note that a study by Perez et al. (Pérez et al., 2017) found that recent suicide attempters show higher levels of borderline personality disorder symptoms and higher rates of NSSI. Thus, it is possible that among our adolescent population, there was a high similarity with regard to the presence of suicidal ideation. Furthermore, there is a high correlation between the presence of NSSI and suicidal ideation. In a study by Ammerman and colleagues (Ammerman et al., 2018), most of the NSSI engagers reported suicidal ideation during their lifetime, and similar observation was reported in a community-based sample (Klonsky, 2011). Finally, the degree of intent to die can vary during the performance of the self- harm act (Kapur et al., 2013), and as much as 40% of self-harmers reported ambivalence regarding the wish to die while engaging in self- harm. In the present study, any self-injurious act performed with a certain degree of suicidal intent (as determined in clinical evaluations during hospitalization) was categorized as a suicide attempt.

The main strength of the present study is the relative large sample of hospitalized adolescents admitted due to DSH, primarily hospitalized for the first time. Study population consisted of suicide attempters, NSSI engagers and a combination of both, allowing a comparison among three different clinical phenotypes. Moreover, the collected data allowed controlling for confounders such as sex, substance use, suicidal ideation and the presence of depressive episode.

Several limitations of our study should be noted. First, the composition of the study population, inpatients in an acute adolescent’s inpatient unit ward, represents the extreme end of the spectrum of patients and consequently limits the ability to generalize these findings to milder clinical groups and non-hospitalized adolescents. The criteria for admission of NSSI patients in our study was not necessarily set by the medical severity of the injury, rather by the presence of suicidal ideation. Therefore, it is possible that our NSSI patients are more similar to those with SA than milder presentations of NSSI which does not require hospitalization. Second, due to the retrospective nature of this study we did not have valid rating tools to dimensionally phenotype for suicidal ideation and depression. However, we propose that the fact that the EMR were thoroughly analyzed by two child and adolescent psychiatrists and the use of a consensus on a generic clinical category as the primary outcome (DSH: suicide attempt, NSSI or both, or Non-DSH), make the data of this study reliable and of clinical relevance. Moreover, the coding of DSH behaviors was assigned by the “non- zero rule” (i.e., if a subject reported engaging in a DSH even with ambivalence in the intent to die, the subject was coded as having engaged in a suicide attempt). It is possible that ambivalent participants differ from participants who reported engaging in a suicide attempt with a persistent intent to die. Finally, it should be highlighted that the cross-sectional nature of the current analysis does not allow causal inferences. Nonetheless, as various factors were suggested to influence DSH in adolescents, studies in young hospitalized self- harm patients allow an evaluation of the associated characteristics that might contribute to NSSI and SA in severe clinical population of inpatient youth. Future longitudinal studies are required to identify causal pathways.

Conclusions

This study highlights female sex, suicidal ideation, current depressive episode and a history of alcohol use as factors associated with DSH in psychiatric youth inpatients. Within self-harmers, we report similar demographic and clinical features in NSSI compared to SA youths, supporting the notion of a spectral nature of self- harm behaviors rather than distinct categorical division. Findings suggest that very early detection and intervention is warranted in all youth with DSH, regardless of the deliberate self-harm subtype.

Highlights.

  • Deliberate self-harm is common among adolescent psychiatric inpatients.

  • Adolescent inpatients with deliberate self-harm are predominantly females with concurrent depression and suicidal ideation.

  • We did not detect significant clinical and demographic differences between self-harmers with or without suicidal intent.

Funding details:

Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under Award number K23MH120437.

Footnotes

Disclosure statement: Dr. Barzilay serves on the scientific board and reports stock ownership in ‘Taliaz Health’, with no conflict of interest relevant to this work. All other authors declare no potential conflict of interest.

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