Knowing the extent of self-harm and suicidal ideation in our communities, particularly in our young people, requires immediate investigation and action.
The “iceberg effect” is an expression used by researchers and policy makers to describe the incidence of self-harm and suicide attempts in samples of people from Western countries.
At the top, emerging from the sea, there are people who die by suicide; in the middle there are those who are in contact with the health services and thus identified “at risk”; and at the bottom and under the water are the majority who have thoughts or attempts to harm themselves but remain submerged in the light of day.
Establishing the scope of any problem is the critical first stage in addressing it.
The latest Australian Bureau of Statistics (ABS) National Survey of Mental Health and Wellbeing (released July 2022) is to be commended for its first work to estimate the prevalence of self-harm in our community. The ABS defines self-harm as referring to “a person who intentionally causes pain or harm to their own body”. Self-harm may, but not necessarily, involve suicidal intent and may be used as a way of coping or expressing emotional distress.
The ABS methodology used surveys of Australia’s population aged 16 to 85 to give us a better view of the underground that had not been captured in previous population-level data. Before the survey, we knew that emergency hospitalizations for self-harm were increasing for young people. But now, by asking the public about their experiences, we know how many people have self-harmed without going to hospital. This new data can be combined with even more recent data from the Australian Institute of Health and Welfare (AIHW) on suicide deaths (top) and hospital admissions for self-harm (middle).
What does the iceberg look like?
Let’s start with the tip.
Each year, about 3100 people die by suicide, many of them young men or adults, reflecting a slight upward trend since 2011. The latest national data indicates 3139 deaths in 2020. Just over half of these deaths occurred in midlife, in people aged 30 to 59.
However, despite the coronavirus disease 2019 (COVID-19) pandemic, there has been no increase (yet) in the number of deaths during the period 2019-2022. The latest data from New South Wales (one of the most comprehensive registration states) reveals non-significant differences. From 1 January 2022 to 31 July 2022, 586 suspected suicide deaths were reported in NSW, compared with 537 suspected suicide deaths recorded during the same period in 2021, 506 recorded in 2020 and 504 in 2019. In summary, the advice remains. practically the same.
What about the middle?
Hospitalization data in recent years have shown an increase in the rate of self-injury hospitalizations in some states, but not in others. In 2020-2021 there were approximately 29,900 self-harm hospitalizations in Australia.
While state-by-state data is mixed, what is clear is that hospitalization rates have risen rapidly for young people over the past decade across Australia. From 2008-2009 to 2020-21, AIHW data shows that there has been a considerable increase in self-harm hospitalization rates for young people aged up to 24. This increase has been observed in the adolescent population, but has been particularly pronounced for young women.
For example, the rate of self-injury hospitalizations for females aged 14 and under has tripled over this 13-year period, to approximately 71 hospitalizations per 100,000 (from 19). Similarly, the hospitalization rate for females in the 15-19 age group has almost doubled, now standing at 698 per 100,000 (from 374).
What about the bottom layer data?
Estimates from new data from the National Survey of Mental Health and Wellbeing suggest that a total of 393,700 people self-harmed over a year. Comparing this new data with hospitalizations described above, we see that the number of people who reported self-harming in the past 12 months was more than ten times higher than the number of people admitted to hospital. Of those who reported self-harm, 271,000 were women, reflecting a gender difference consistent with hospitalization data. Young men and women are again disproportionately represented in these figures, with one in 14 women (7.0%) aged 16-34 reporting self-harm in the last 12 months.
figure The iceberg of self-harm. In a 12-month period, a total of approximately 393,700 Australians reported self-harm, approximately 29,900 were admitted to hospital for intentional self-harm and approximately 3,100 died by suicide. The data is approximate, as it has been collected at different times, using different methods, although each represents a recent 12-month period. Self-report data does not include under-18s, but hospitalization data does. Self-report data does not exclude individuals who contribute to hospitalization data. However, this double reporting is unlikely to change the shape of the iceberg.
What drives these trends?
These data make us ask at least two questions:
- What are the causes of the proportionally large representation of young people in the hidden parts of the iceberg?
- What can we do to prevent or improve what could make the situation worse?
Years of research suggest that the causes of self-harm are complex, cumulative and unique. Abuse, drug and alcohol abuse (for men) and domestic violence (for women) have been identified as triggers. But in this area, it is difficult to distinguish the triggers that lead to an incident of self-harm from the underlying “root” causes. Often the best understanding we have from research is identifying some factors associated with self-harm, such as mental illness, which are unlikely to be the main cause.
In recent years, our view has changed fundamentally, now recognizing that suicide and self-harm cannot be entirely due to psychological or biologically “defective” factors within the person, and that they are better understood, perhaps in their mostly as a result of biological factors. factors associated with social and economic conditions, such as unemployment, financial stress, poor housing and poverty, which make individuals and communities vulnerable.
Suicide and self-harm among First Nations peoples are also linked to experiences of racism, discrimination and colonization.
If we consider young people, there are at least two possibilities that may contribute to the increase in rates.
Factors specific to young people, such as increased competition for tertiary education places, more difficult entry-level job requirements and increased job insecurity, have made life difficult over the last decade Alternatively, the universal factors, which affect us all, may have been experienced more intensely by the current cohort of young people because of their stage of development, or their past life experiences to date (ie the current cohort may include more refugees, a greater proportion of people from marginalized communities or who have experienced multiple traumas). Given the effects of COVID-19 over the last few years, which was associated with an exacerbation of this upward trend, the data suggest (and here) that universal factors such as uncertainty and lockdowns may have more effects on young people than young people. specific factors. COVID-19 disrupted many normal developmental milestones in adolescence, such as forming peer and romantic friendships, expanding independence, establishing careers, and forming future identities, and exacerbate inequalities in the demands of girls and women in domestic and school responsibilities.
This is not the place to discuss the sweepstakes of possible factors that led to the decade-long increase (factors like social media, financial stress, or helicopter parenting), but the point certainly points to the need for data more complete
What are the trends in social and economic factors that mimic self-harm and hospitalization rates over the past decade and during COVID-19? Can we use publicly collected datasets to help test some causal hypotheses, or at least falsify some? What contributes to variation in rates in different regional locations, using geospatial mapping to identify protective and adverse factors?
We should also ask young people, especially women and girls, why they hurt. A recent review we carried out on paracetamol poisoning revealed that we have no results from current Australian research into public views on the motivations for self-poisoning and self-harm.
What do we need to do now to intervene?
It is clear that we should provide treatment and assistance to those who arrive at the hospital. But more importantly, the new findings force us to “see” and address most of the “unseen” problem. Because self-harm may be less serious at the tip of the iceberg, we have the option of prevention, at community, school and policy levels.
At school and community level, we already have easily implementable solutions. The Youth Aware of Mental Health (YAM) program in schools both in Australia and overseas has been shown to reduce suicidal ideation. It is not “rocket science” to suggest that this could be implemented in every school in Australia.
A recent smartphone app also developed by the Black Dog Institute showed a reduction in suicidal ideation, with young people working on it without the help of professional experts. Making it free and easily accessible seems like a good step.
We need to go beyond advances aimed at individual children, teenagers and young adults and think about solutions at a policy level. In recent years, we have been impressed by the reductions in suicide in adolescent males that can be achieved by…