Research paperThe continuity and duration of depression and its relationship to non-suicidal self-harm and suicidal ideation and behavior in adolescents 12–17
Introduction
Adolescence and early adulthood – the period from age 10–24 years – is celebrated as a time of relatively good health with an accompanying lower demand and need for public and tertiary health services by young people this age. However, in terms of the global burden of disease, depression (both unipolar depression and bipolar disorder) in young people in this age is a major contributor to years lived with disability (Gore et al., 2011). And depression during these years brings additional burden through the mortality and morbidity associated with both suicidal and self-harming behaviors (Thapar et al., 2012). For example, in Australia, among 12–17 year-olds with Major Depressive Disorder (MDD), 47% report non-suicidal self-harm behavior and 19.7% report a suicide attempt over a 12 month period. In contrast, among 12–17 year-olds with no mental disorder, only 4.2% report non-suicidal self-harm behavior and 0.4% report a suicide attempt (Lawrence et al., 2015).
While the descriptive epidemiology of non-suicidal self-harm is at an earlier stage relative to that of study of suicidal ideation and behavior, what is known is that non-suicidal self-injury is characterised by substantial diagnostic heterogeneity in the mental disorders associated with it (Nock, 2012); with mixed evidence of a higher prevalence overall in females relative to males (Muehlenkamp et al., 2012); and, a strong positive association with suicidal behavior (Hawton et al., 2003, Martin et al., 2010, Nock et al., 2006). Importantly, longitudinal study indicates a substantial reduction in non-suicidal self-harming behavior with increasing age with onward persistence (ie. duration) of self-harm into young adulthood only associated with adolescent symptoms of depression and anxiety (Moran et al., 2012).
Suicidal ideation and behavior and non-suicidal self-harm are not independent. Guan et al. (2012) observed non-suicidal self-injury to be prospectively associated with onward suicidal ideation and suicide attempts in a community adolescent sample (Guan et al., 2012). In their meta-analysis of the correlates of suicide attempts among self-injurers, Victor and Klonsky (2014) concluded that after suicidal ideation, the strongest predictors of suicide attempt were the frequency of non-suicidal self-injury, the number of self-injury methods and hopelessness (Victor and Klonsky, 2014). In our own work, we found that for young people aged 12–17 years with self-reported DISC-IV Major Depressive Disorder, 40.7% of those that had ever engaged in non-suicidal self-harm between 1 and 3 times also reported that they had suicidal ideation in the past 12 months; 35.6% reported making a suicide plan in the last 12 months, and 14.2% had ever attempted suicide. When non-suicidal self-harm was reported to have occurred 4 or more times among young people aged 12–17 years with self-reported DISC-IV Major Depressive Disorder, these proportions rose to 78.3%, 67.8% and 49.0% respectively (Zubrick et al., 2016).
Given the high co-dependence of suicidal ideation and behavior and non-suicidal self-harm – particularly in the presence and persistence of depression –it may be that better documentation of the timing and duration of symptoms of depression in young people would offer more precision in targeting public health prevention to reduce health burden (Santelli and Galea, 2011). Using data from the National Comorbidity Study Replication (NCS-R), Thompson reported younger age of onset of depression to be associated with higher levels of suicidal intent irrespective of the age of the respondent at the time of their interview (Thompson, 2008). These data were based upon the reports of adults aged 18 years and older. So too in Australia, Zubrick et al., (2015, 2016) found that 17.4% of the young people who had MDD at interview reported the first onset of any symptoms of depression to have occurred 5 or more years ago. With respect to their current episode, 38.1% reported the onset of symptoms to have occurred with the past 2–5 years (Zubrick et al., 2015, 2016). This suggests a considerable period of potential suffering among young people with depression and is congruent with Kovacs et al. (1994) findings that the first episode of MDD may be experienced two to three years after the onset of Depressive Disorder (i.e. dysthymia, chronic disturbance in mood) (Kovacs et al., 1994).
In this paper, we seek to more closely examine the co-occurrence of non-suicidal self-harm with suicidal ideation and behavior in the presence of a diagnosis of Major Depressive Disorder as measured in the self-reports of young people themselves. Both practical and substantive reasons guided this focus. First, time and cost considerations prevented the collection of youth self-reports on other DSM-IV disorders – we only administered the Major Depressive Disorder criteria directly to the young people. Second, while other DSM-IV disorders in these young people were measured via the parent-reports, the concordance between the parent report of MDD and youth report of MDD was very low. The total prevalence of MDD using both the parent and youth reports was 10.5%. Of this total prevalence, 5.8% was attributable to the youth report, 2.8% was attributable solely to the parent report, and 1.9% of this prevalence was shared by youth and parent reports (see Lawrence et al., 2015, p.9).
Our focus on Major Depressive Disorder as measured from the reports of young people themselves, reduces diagnostic heterogeneity and focusses on a key mental disorder associated with high rates of both non-suicidal self-harm and suicidal behaviors and their onward persistence. A key feature of this is a focus on the severity of the depression as measured by its duration and continuity as a potential predictor of both self-harm and suicide. We employ a large representative national population sample of Australian 12–17 year olds (Lawrence et al., 2015) with measures collected from the young people themselves as well as their parents. These data contain standard diagnostic measures for DSM related disorders, measures of symptom duration and continuity, measures of mental health distress, as well as self-reported measures of non-suicidal self-harm, suicidal ideation and suicidal behaviors. Our aims are to estimate: 1) the relationship of age and gender to self-harm and suicidal behaviors; 2) the independent effect that duration of symptoms of depression has on reports of non-suicidal self-harm and suicidal behaviors, and; 3) the independent effects that continuity of depression has on the association between reports of non-suicidal self-harm and suicidal behaviors.
Section snippets
Methods
The design, sampling and survey interview methods are described extensively elsewhere (Hafekost et al., 2015). Briefly, the survey employed area-based random sampling with voluntary recruitment and consent of households in scope where there was at least one child aged 4–17 years. One child was randomly selected for inclusion where there was more than one eligible child in the household. The overall response rate to the survey was 55% with 6310 parents and carers of eligible households
Sample selection
The focus of this report is upon the results from those young people who met the DSM-IV diagnostic criteria for MDD based upon their self-reported DISC-IV interview information. A total of 265 young people met the DSM-IV criteria for Major Depressive Disorder with impairment as defined by the DISC-IV.
Statistical analysis
The principal focus of our research questions was on the outcome variables of non-suicidal self-harm and suicidal ideation and behavior. In line with our aims, we hypothesize that: 1) Significantly higher proportions of females and older adolescents (16–17 year-olds) will report self-harming and suicidal ideation and behavior relative to males and younger adolescents (12–15 year-olds); 2) The odds of self-harming and suicidal ideation and behaviors will be significantly higher where MDD is of
Results
The majority (70.6%) of the 265 young people who met the diagnostic criteria for Major Depressive Disorder was female (Table 1). Of the 265 young people who met the criteria for MDD at the time of the survey, 70.6% were 16 years or over in age. For 75 (28.3%) of the young people symptom duration had been less than 2 years while about half of them (48.3%) reported the duration of their current symptoms to be between 2 and 5 years, with the remaining 23.4% reporting the duration of their current
Discussion
There are several important features of our findings that should be noted.
First, in a well-comprised sample of young people with Major Depressive Disorder, the findings here show that their self-reports about the duration of their depressive symptoms as well as the continuity of these symptoms, each independently contributes to elevating the risks of non-suicidal self-harming and suicidal ideation and behavior. This finding adds to our understanding of the nature of mental health severity by
Role of the funding source
The second Australian Child and Adolescent Survey of Mental Health and Wellbeing was funded through a competitive research tender by the Australian Government Department of Health. The Australian Government Department of Health was responsible for the funding and accountable for the delivery of the survey findings.
Acknowledgements
The second Australian Child and Adolescent Survey of Mental Health and Wellbeing was funded by the Australian Government Department of Health. SRZ, DL and SEJ are supported by a Centre of Excellence grant from the Australian Research Council (CE140100027). GP is supported by a Senior Principal Research Fellowship from the National Health and Medical Research Council of Australia (1117873).
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