Young people's contact with healthcare before and after suicidal behaviour

Sammanfattning: BackgroundSelf-harm is a major and growing public health issue among young people worldwide. Self-harm is an important risk factor for suicide, which is one of the leading causes of death for young people. Although suicide rates are declining overall, this trend is not seen in young people. Young people with mental distress and/or suicidal thoughts are reluctant to seek help, and often drop out of treatment initiated after a self-harm episode. Many young people who self-harm have had contact with healthcare before their first self-harm episode, but often for reasons other than suicidal thoughts or psychiatric problems. In this context, physical illness is associated with increased risk for self-harm and suicide among young people. The present thesis investigated how young people perceived the help and support they received before and after an episode of self-harm. A further aim was to map the inpatient somatic healthcare contacts young patients had before an episode of self-harm, and determine any relationship to risk for self-harm and suicide.MethodFour studies were conducted using qualitative and quantitative methods. Participants were people aged 16-24 years. The definition of self-harm was based on the intentional self-harm criteria in the International Classification of Diseases, tenth revision, which includes all forms of self-harm without ascribing suicidal intent. In the first two studies, 10 respective 9 participants with a first healthcare contact for self-harm were interviewed during 2009-2011. The interviews covered participants’ knowledge and experience of professional care before their healthcare contact for self-harm. Participants were interviewed a second time 6 months later about their experiences with professional care during the period since their initial interview. Qualitative content analysis was used for all interviews. For the next two studies, we selected 16,235 participants with a first hospitalisation for self-harm during 1999-2009 from the Swedish National Inpatient Register. These cases were compared with matched controls to determine the odds of having been admitted with a non-psychiatric diagnosis during the year preceding the self-harm admission. To assess risk for suicide, data were retrieved from the Swedish Cause of Death Register for all deceased participants until 2013, and group differences were determined using survival analysis.ResultsIn the first interview, participants described how they wanted more information on where they could turn for professional help. They also wanted different help-seeking pathways and emphasised the importance of the quality of professional contact. After 6 months, participants stressed the importance of being able to rely on professionals and treatment. Their life circumstances significantly affected their treatment, and practical help was appreciated. The register studies showed that young people admitted for self-harm were more likely to have been hospitalised with symptomatic diagnoses such as abdominal pain and syncope/collapse, and somatic illnesses such as epilepsy and diabetes mellitus type 1. A higher proportion of cases (4.5%; women 2.6%, men 8.8%) died during the study period than controls (0.3%; women 0.2%, men 0.6%) (p<0.001). For both cases and controls, a higher proportion of those with a previous somatic admission died from suicide during the study period than those without a somatic admission (cases: 4.2% vs. 2.8%, p<0.05). For cases with a somatic admission, the hazard ratio was 1.43 (95% confidence interval 1.04-1.98) compared with those without somatic admissions (controlled for age, sex and psychiatric admission). Survival of cases with a previous somatic admission compared with those without was 98.4% versus 99.2% after the first year, 97.8% versus 98.9% after the second year, and 95.5% versus 96.9% after the tenth year.ConclusionThese findings suggest that healthcare providers need to find new ways to reach young people at risk for suicidal behaviour. Access to professional help should be easy and direct. Treatment for young people after self-harm should be flexible, and be receptive to input from the patient. The importance of and need for basic practical help should not be overlooked. Somatic healthcare contact provides an opportunity for intervention, particularly as psychiatric problems can manifest as physical symptoms, and physical illness is a risk factor for self-harm and suicide.