Self-harm among adolescents : correlates, treatment, and healthcare consumption

Abstract

Background: Self-harm is common in adolescence and young adulthood, and it is associated with adverse outcomes, such as general psychopathology and suicide. We need a better understanding of self-harm and its correlates such as perceived invalidation/validation, emotional awareness, and sexual- and gender minority (SGM)-status to inform interventions. Dialectical Behavioral Therapy for adolescents (DBT-A) is currently regarded as a well-established treatment. However, DBT-A is not widely available to all self-harming adolescents, and in some cases, integrated and intensive outreach treatments are needed. Intensive Contextual Therapy (ICT) includes principles and interventions from DBT-A and Functional Family Therapy (FFT) and was initiated in Sweden to prevent long periods of hospitalization and residential treatment for adolescents with self-harm and complex psychosocial symptomatology. Self-harm and suicide generate large expenses for society. Economic evaluations of interventions for self-harm are warranted as it can inform social policy and political decision makers.

Aims: The aims of the present thesis were to examine the relationship between self-harming behavior and emotional awareness, emotion dysregulation, SGM-status, and the experience of invalidation/validation, and to evaluate the novel ICT treatment in terms of feasibility, and preliminary outcome, as well as its cost and related changes in healthcare consumption.

Methods: Study I and II are based on the same cross-sectional sample (aged 15-20) from the general population, responding to an anonymous Web-based survey. In Study I (N = 1910), we investigated the associations between perceived invalidation/validation measured through a novel instrument: Responses to my Emotions, Thoughts, and Action (REMTA) and self-harm as well as emotion dysregulation, and potential mediational pathways. In Study II (N = 6345) we investigated the associations between emotional awareness, assessed by a performance-based measure, and self-harm, as well as the mediational role of emotion dysregulation. In Study III (N = 49) we used a within-group design with repeated measures to evaluate the feasibility and preliminary outcome of ICT. The participants were adolescents with self-harm and/or suicidal behaviors. Study IV was an economic evaluation of ICT and included clinical outcomes and costs from the same participants as in Study III. Data on healthcare consumption (outpatient and inpatient care, pharmacological treatment) were retrospectively collected from medical records for the time points one-year pre-treatment and one-year post-treatment.

Results: Validation/invalidation were associated with self-harm and to a larger extent with emotion dysregulation (Study I). The association between invalidation/validation and self-harm was significantly mediated by emotion dysregulation. Invalidation/validation from family members showed stronger correlations with both self-harm and emotion dysregulation than from non-family members. In Study II, mediation analysis suggested a significant indirect association between emotional awareness and self-harm through the effects of some of the subscales of Difficulties in Emotion Regulation Scale (DERS). SGM youth reported higher frequency of self-harm and emotion dysregulation.The results from Study III suggest that ICT is feasible, with a low attrition rate (0.09%) and generally high satisfaction ratings. The adolescents reported a reduction of self-harm, suicide attempts and general symptomatology. We also found a sigificant reduction of inpatient care from pre- to post-teatment. Parents reported reduced levels of stress and lower levels of criticism after completing the treatment. The results were maintained at six-month follow-up and improved further at the one-year follow-up. The results from Study IV showed that the estimated average cost of ICT per family was €5293, which corresponds to the cost of other treatments of simlar length and intensity. The average cost for residential care is five times the cost of ICT. There were no statistically significant differences pertaining to cost of health care consumtion between one year before ICT and one year after. However there was a non-significant increase in the utilisation of outpatient and primary care and a non-significant reduction of inpatient care.

Conclusions: The association between invalidation/validation and self-harm was mediated by emotion dysregulation. In addition to emotion dysregulation, it could be valuable to examine levels of emotional awareness as it has an indirect association with self-harm via emotion dysregulation and as such can give a more nuanced picture about the pathway. SGM youth reported a higher symptom load. Their health disparities and the potential role of SGM status merits further investigations. ICT seems to be a feasible intervention for adolescents with self-harm and high symptom burden. The preliminary evaluation also suggests that ICT is beneficial at individual, contextual, and family level. ICT might also have the potential to prevent fulltime institutional and inpatient care, although replications are needed. The treatment cost of ICT is comparable to other similar treatment options, but economically favorable compared to full-time residential care. After completion of the ICT the adolescents consumed more outpatient and primary care, and less specialized and inpatient care.