Study suggests that adolescents admitted for drug, alcohol, or violence related injury should be seen by a mental health professional, in a similar way to adolescents who self-harm.
Adolescents who are admitted to hospital for alcohol, drug, or violence related injuries are at a similar risk of suicide 10 years later than those who have self-harmed, according to a study using data from 1 million adolescents in the UK, published in The Lancet.
While the overall risk is relatively low - for example, 2-3 girls out of 1000 and 7 boys out of 1000 who are admitted as an emergency to hospital with alcohol or drug related injuries die from suicide within 10 years - the rates are 5-6 times higher than among adolescents admitted to hospital following an accident. The risks were highest for boys, adolescents aged 18-19 years, and those with a chronic health condition.
The authors suggest that adolescents admitted to hospital with injuries related to alcohol, drugs, or violence should be treated with a similar response from mental health professionals to those who are admitted after self-harm.
"Our study shows that adolescents who are admitted to hospital following alcohol, drug or violence related injuries are at an increased risk of suicide up to 10 years later, and should be treated with a similar level of concern as adolescents who self-harm. While relatively few adolescents will die from suicide within ten years, the risk among people who self-harm or present to hospital with injuries related to alcohol or drugs is considerably higher than that of their peers. Specialist psychosocial assessment by a child and adolescent mental health professional is recommended as standard practice for adolescents who have self-harmed. Our findings suggest that this approach should also be considered for adolescents presenting to emergency departments with drug or alcohol-related injuries," says lead author Dr Annie Herbert, UCL, London, UK.
Evidence suggests that different types of injury during adolescence, whether poisonings, drug or alcohol related injury, or violent injury, are associated with similar underlying psychosocial problems, such as maltreatment, poor mental health, or poor social circumstances. But despite this overlap, the response from health professionals differs. For example, in the UK, adolescents admitted to hospital following self-harm will undergo an assessment of psychosocial circumstances and suicide risk. Within guidelines relating to alcohol or drug related injuries, it is not specifically recommended that admitted adolescents are given a psychosocial assessment, and no guidelines exist for responding to violent injury.
In the study, researchers used data from approximately 1 million adolescents aged 10-19 years who had been admitted to a hospital emergency department with adversity-related injuries (self-harm, drug, alcohol, or violence) or accident-related injuries in the UK. They then analysed the risk of suicide, drug or alcohol related death, homicide, accidental death (eg. road injury with no evidence of drug or alcohol misuse) and death from other causes (eg. physical illness) during the 10 years following discharge from hospital.
A small number of adolescents (0.5%) died within 10 years of being admitted. Overall, the risk of death during the 10 years after admission for self-harm, alcohol or drug related injuries, or violence was double that of adolescents admitted following an accident (7.3 deaths per 1000 girls and 15.6 per 1000 boys, compared with 3.8 per 1000 girls and 6.0 per 1000 boys, respectively).
Among adolescents admitted following adversity-related injury, 63.9% (1543/2415) of deaths were caused by suicide, drug or alcohol use, or homicide. By comparison, 33.6% (796/2367) of deaths among adolescents admitted following an accident were caused by suicide, drug or alcohol use, or homicide.
The risk of suicide over 10 years was similar for adolescents admitted for self-harm (2.9 per 1000 girls and 9.8 per 1000 boys) compared with adolescents admitted for drug or alcohol-related injuries (2.5 per 1000 girls and 7.2 per 1000 boys). For adolescents admitted for self-harm or drug or alcohol-related injuries, the risk of suicide was 5-6 times higher than for adolescents admitted for accident-related injuries (0.4 per 1000 girls and 1.2 per 1000 boys).
The authors estimate that 10-25% of suicides among young adults could be associated with self-harm, alcohol, drug, or violence related injury among 16-19 year olds.
Professor David Cottrell, co-author, University of Leeds, UK, says: "As clinicians we have not fully appreciated the risks facing children and young people who arrive in hospital emergency departments having suffered an adversity-related injury. It is well established that children who self-harm are at an increased risk of suicide. But the research points to the fact that the risk extends to a much broader group. Children and young people who suffered injuries through drink or drugs or violence also faced an increased risk of suicide or premature death through alcohol and drug behaviours. These young people are coming into contact with the health services and that means there's an opportunity for them to get help and support. There needs to be a look at the guidance that is given to staff in emergency departments - so these young people are also seen as being at risk."1
The authors note that there is the possibility that some causes of injury or death could be misclassified as accidental, meaning that the estimates for the risk of suicide and drug or alcohol related deaths following adversity-related injury could be underestimated.
Writing in a linked Comment, Professor George Patton, University of Melbourne, Australia, and Chair of The Lancet Commission on Adolescent Health and Wellbeing2, says that "an important message is that the emotional difficulties underlying crisis presentations are much more than a passing phase for many adolescents." He notes: "Adolescence is often considered the healthiest time of life. On strength, speed, and cognitive function, adolescents stand out for their exceptional abilities... Such attitudes to adolescent health more broadly, and the accompanying emotional distress and behavioural problems in particular, have led to a neglect of this age group in research and health service responses. However, this is now shifting as we learn more about the significance of these adolescent-onset problems. They include self-harm and suicidal behaviour, common mental disorders, alcohol and substance use, violence and aggression, and reckless behaviour leading to injury."
Article: Causes of death up to 10 years after admissions to hospitals for self-inflicted, drug-related or alcohol-related, or violent injury during adolescence: a retrospective, nationwide, cohort study, Annie Herbert, Ruth Gilbert, David Cottrell, Leah Li, The Lancet, doi: 10.1016/S0140-6736(17)31045-0, published online 25 May 2017.
Comment: Responding to the adolescent in distress, Professor George Patton, The Lancet, doi: 10.1016/S0140-6736(17)31331-4, published online 25 May 2017.