Drugs, alcohol and violence as much a suicide risk as self-harm in adolescents

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The risk of suicide 10 years after adolescents were hospitalised for drug problems, alcohol abuse or violent injury was similar to the risk among those hospitalised for self-harm, found a University College London study.

"All of these kids should be having a psychological assessments," said lead author Annie Herbert, of University College London.

Herbert and colleagues write that substance abuse, violence and self-inflicted injuries are all forms of self-harm that likely share underlying psychological issues related to adversity, poor mental health and poor social circumstances like poverty.

For the new study, Herbert's team tracked adolescents who were hospitalised between 1997 and 2012 for accidental injuries or for "adversity-related injuries" (self-inflicted, drug-related or alcohol-related, or violent injuries). The children were 10 to 19 years old at the start of the study. Overall, the researchers had data on nearly 650,000 adolescents with accidental injuries and 333,000 with adversity-related injuries. Altogether, a small number of them – fewer than 1% – died within 10 years of being hospitalised.

Overall, the risk of death in those next 10 years was twice as high for adolescents hospitalised for adversity-related injury (7.3 deaths per 1,000 girls and 15.6 per 1,000 boys) than after accidental injuries (3.8 per 1,000 girls and 6.0 per 1,000 boys).
Among those who died, the likelihood that death was caused by suicide, drug or alcohol use, or homicide was much higher if they'd been hospitalised for an adversity-related injury.

The risk of suicide during the study period was similar for adolescents hospitalised for self-harm (2.9 per 1,000 girls and 9.8 per 1,000 boys) or for drug or alcohol-related injuries (2.5 per 1,000 girls and 7.2 per 1,000 boys). As a group, for the youngsters hospitalised for self-harm or drug or alcohol-related injuries, the risk of suicide was five to six times higher than it was for children hospitalised after accidents.

Herbert said parents should share information about their adolescents' activities with their doctors. "If the parent has additional information about self-harm and violence, that may encourage more follow up," she is quoted in the report as saying.

These youngsters need long-term, detailed care, suggest George Patton and Rohan Borschmann, of Royal Children's Hospital in Parkville, Australia. They write in an editorial accompanying the new study that temporary help for these adolescents is inadequate since the risks appear to be heightened for at least a decade.

"Health-care professionals should no longer see an adolescent presenting in distress as a nuisance, wasting valuable clinical time, but as a vulnerable person deserving the second chance that responsive and sustained health care can provide," they write.

Background: Emergency hospital admission with adversity-related injury (ie, self-inflicted, drug-related or alcohol-related, or violent injury) affects 4% of 10–19-year-olds. Their risk of death in the decade after hospital discharge is twice as high as that of adolescents admitted to hospitals for accident-related injury. We established how cause of death varied between these groups.
Methods: We did a retrospective, nationwide, cohort study comparing risks of death in five causal groups (suicide, drug-related or alcohol-related, homicide, accidental, and other causes of death) up to 10 years after hospital discharge following adversity-related (self-inflicted, drug-related or alcohol-related, or violent injury) or accident-related (for which there was no recorded adversity) injury. We included adolescents (aged 10–19 years) who were admitted as an emergency for adversity-related or accident-related injury between April 1, 1997, and March 31, 2012. We excluded adolescents who did not have their sex recorded, died during the index admission, had no valid discharge date, or were admitted with injury related to neither adversity nor accidents. We identified admissions for adversity-related or accident-related injury to the National Health Service in England with the International Classification of Diseases-10 codes in Hospital Episode Statistics data, linked to the Office for National Statistics mortality data for England, to establish cause-specific risks of death between the first day and 10 years after discharge, and to compare risks between adversity-related and accident-related index injury after adjustment for age group, socioeconomic status, and chronic conditions.
Findings: We identified 1 080 368 adolescents (388 937 [36·0%] girls, 690 546 [63·9%] boys, and 885 [0·1%] adolescents who did not have their sex recorded). Of these adolescents, we excluded 40 549 (10·4%) girls, 56 107 (8·1%) boys, and all 885 without their sex recorded. Of the 333 009 (30·8%) adolescents admitted with adversity-related injury (181 926 [54·6%] girls and 151 083 [45·4%] boys) and 649 818 (60·2%) admitted with accident-related injury (166 462 [25·6%] girls and 483 356 [74·4%] boys), 4782 (0·5%) died in the 10 years after discharge (1312 [27·4%] girls and 3470 [72·6%] boys). Adolescents discharged after adversity-related injury had higher risks of suicide (adjusted subhazard ratio 4·54 [95% CI 3·25–6·36] for girls, and 3·15 [2·73–3·63] for boys) and of drug-related or alcohol-related death (4·71 [3·28–6·76] for girls, and 3·53 [3·04–4·09] for boys) in the next decade than they did after accident-related injury. Although we included homicides in our estimates of 10-year risks of adversity-related deaths, we did not explicitly present these risks because of small numbers and risks of statistical disclosure. There was insufficient evidence that girls discharged after adversity-related injury had increased risks of accidental deaths compared with those discharged after accident-related injury (adjusted subhazard ratio 1·21 [95% CI 0·90–1·63]), but there was evidence that this risk was increased for boys (1·26 [1·09–1·47]). There was evidence of decreased risks of other causes of death in girls (0·64 [0·53–0·77]), but not in boys (0·99 [0·84–1·17]). Risks of suicide were increased following self-inflicted injury (adjusted subhazard ratio 5·11 [95% CI 3·61–7·23] for girls, and 6·20 [5·27–7·30] for boys), drug-related or alcohol-related injury (4·55 [3·23–6·39] for girls, and 4·51 [3·89–5·24] for boys), and violent injury in boys (1·43 [1·15–1·78]) versus accident-related injury. However, the increased risk of suicide in girls following violent injury versus accident-related injury was not significantly increased (adjusted subhazard ratio 1·48 [95% CI 0·73–2·98]). Following each type of index injury, risks of suicide and risks of drug-related or alcohol-related death were increased by similar magnitudes.
Interpretation: Risks of suicide were significantly increased after all types of adversity-related injury except for girls who had violent injury. Risks of drug-related or alcohol-related death increased by a similar magnitude. Current practice to reduce risks of harm after self-inflicted injury should be extended to drug-related or alcohol-related and violent injury in adolescence. Prevention should address the substantial risks of drug-related or alcohol-related death alongside risks of suicide.

Annie Herbert, Ruth Gilbert, David Cottrell, Leah Li

University College London material The Lancet article summary The Lancet editorial

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