عوامل مرتبط با رفتار خود آسیبی عمدی در بیماران سرپایی نوجوان افسرده

This study examined whether depressed adolescent outpatients with deliberate self-harm behaviour (DSH) differed from non-suicidal depressed adolescent outpatients in depressive and anxiety symptoms, alcohol use, perceived social support and number of negative life-events. Depressed adolescent outpatients (n = 155) aged 13–19 years were interviewed using K-SADS-PL for DSM-IV Axis I diagnoses and completed self-report questionnaires. Suicidal behaviour was assessed by K-SADS-PL suicidality items. Depressed adolescents with DSH were younger, perceived less support from the family, had more severe depressive symptoms and used more alcohol than non-suicidal depressed adolescents. Adolescents with DSH and suicidal ideation or suicide attempts had more depressive and anxiety symptoms than adolescents with DSH only. Adolescents with severe internalizing distress symptoms are at risk not only for DSH, but also additional suicidal behaviour. Family interventions may be needed in the treatment of depressed adolescents with DSH.

Deliberate self-harm (DSH) is defined as the intentionally injuring of one's own body without apparent intent to die (Brunner et al., 2007). Understanding deliberate self-harm (DSH) is, however, complicated by the multiple terminology used to describe the behaviour and the confusion as to whether or not DSH represents a suicide attempt (Muehlenkamp & Gutierrez, 2004). Actions with a low likelihood of death but covered by the term “self-harm” have been described as suicidal behaviours, deliberate self-harm, other self-harm behaviours, self-mutilation, self-wounding and self-injurious behaviour (Skegg, 2005). A suicide attempt, by definition, is an intentional action to end life (Nock, Joiner, Gordon, Lloyd-Richardson, & Prinstein, 2006). The most serious forms of DSH relate closely to suicide, while behaviours at the milder end of the spectrum merge with other reactions to emotional pain (Skegg, 2005). Previous studies have shown that it is difficult to draw the line between suicide attempts and DSH acts of adolescents because of the serious forms of DSH and complexity and mix of intentions behind the latter (Skegg, 2005). Between 5 and 9% of adolescents in Australia, USA and England report having self-harmed in the previous year, with few episodes seeming to be true suicide attempts (Skegg, 2005). The incidence of DSH among adolescent inpatients is much higher, ranging from 40% to 61% (Suymoto, 1998). DSH is linked with suicide, since 25–50% of those committing suicide have previously self-harmed (Hawton & James, 2005). Previous research has shown high prevalences of depressive disorders (Burgess et al., 1998 and Harrington et al., 2006) in adolescents presenting to hospitals or psychiatric services following DSH. Moreover, in a prospective cohort study rates of depression distinguished adolescents with DSH who self-harmed in adulthood from those who did not (Harrington et al., 2006). Besides depression, common disorders among hospitalized adolescents with DSH have been oppositional defiant disorder, conduct disorder, substance use disorders, post-traumatic stress disorder and generalized anxiety disorder (Burgess et al., 1998 and Nock et al., 2006). Further, adolescents with DSH have had higher levels of depressive (Haavisto et al., 2005, Hawton et al., 2002 and Ross and Heath, 2002) and anxiety symptoms (Haavisto et al., 2005 and Ross and Heath, 2002) in community samples. Most studies of DSH have been conducted on adolescent community samples or adolescent inpatients, so information regarding depressed adolescent outpatients with DSH is scarce. Despite the high prevalence of risks related to DSH among adolescents, little is known about the determinants of DSH. Previous studies show that family structure, parental divorce, severe illness of a parent, and living apart from parents are associated with DSH both in community studies (Haavisto et al., 2005 and Mittendorfer-Rutz et al., 2004) and among adolescent inpatients (Beautrais, 2001, Haavisto et al., 2005 and Skegg, 2005). Moreover, heavy alcohol use has been shown to increase the risk of DSH (Haavisto et al., 2005 and Skegg, 2005). Lack of family support is associated with greater severity of adolescents' depressive symptoms and suicidal ideation among inpatients (Kerr, Preuss, & King, 2006) and outpatients (Epstein, 1994 and Perkins and Hartless, 2002). Suicidal adolescents in community studies have had fewer supportive adults and more commonly unsupportive parents than non-suicidal adolescents (Evans et al., 2004 and Martin et al., 1995). Evans et al. (2004) reported an association between problems in peer relations and suicide attempts, but not between the degree of perceived support from peers and suicide attempts in a community sample of adolescents (Evans et al., 2004). Little is known about perceived social support among depressed adolescents with DSH. There is little detailed information on depressed adolescents with DSH and negative life-events. Adolescent suicide attempts have been associated with negative life-events and failure to adapt to them (Beautrais et al., 1996 and Horesh et al., 2003). Furthermore, in the community based study by Haavisto et al. (2005) negative life-events were associated with suicide attempts with or without DSH among adolescent boys (Haavisto et al., 2005). However, in the community study by Lewinsohn, Rohde, & Seeley (1996), after controlling for severity of depression, the impacts of major life events, daily hassles, and low support from friends as risk factors for suicidality were not significant (Lewinsohn et al., 1996). We have previously reported no difference in prevalence of suicidal behaviour among depressed adolescent outpatients with or without comorbid disorders (Tuisku et al., 2006). DSH was common and associated with younger age and poor psychosocial functioning (Tuisku et al., 2006). There is little research on depressive and anxiety symptoms, perceived social support, negative life-events and alcohol use among depressed adolescents with DSH and on how these determinants influence them. It is not known whether depressed adolescents only with DSH differ from those with DSH and other suicidal behaviours. The aim of the present study was to investigate the role of depressive and anxiety symptoms, perceived social support, negative life-events and alcohol use in deliberate self-harm behaviour among depressed adolescent outpatients by comparing them with non-suicidal depressed adolescent outpatients. A secondary aim was to determine whether depressed adolescents with only DSH but no suicidal intent differ in the above variables from adolescents who have suicidal ideation or suicide attempts in addition to DSH. In the present study the adolescent was defined as having DSH, if she/he had harmed him/herself occasionally or frequently without intent to die. We expected depressed adolescent outpatients with DSH to have more depressive and anxiety symptoms, to have less perceived social support, to have experienced more negative life-events and to use more alcohol compared with non-suicidal depressed adolescents. Further, as DSH is reportedly a risk factor for suicide, we expected to find no differences in depressive or anxiety symptoms, level of social support, number of negative life-events and use of alcohol among depressed adolescents with only DSH compared to those with DSH accompanied with suicidal ideation or