Incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England (the iceberg model of self-harm): a retrospective study

Background Little is known about the relative incidence of fatal and non-fatal self-harm in young people. We estimated the incidence of suicide, hospital-presenting non-fatal self-harm, and community-occurring non-fatal self-harm in adolescents in England. Methods We used national mortality statistics (Jan 1, 2011, to Dec 31, 2013), hospital monitoring data for five hospitals derived from the Multicentre Study of Self-Harm in England (Jan 1, 2011, to Dec 31, 2013), and data from a schools survey (2015) to estimate the incidence of fatal and non-fatal self-harm per 100 000 person-years in adolescents aged 12–17 years in England. We described these incidences in terms of an iceberg model of self-harm. Findings During 2011–13, 171 adolescents aged 12–17 years died by suicide in England (119 [70%] male and 133 [78%] aged 15–17 years) and 1320 adolescents presented to the study hospitals following non-fatal self-harm (1028 [78%] female and 977 [74%] aged 15–17 years). In 2015, 322 (6%) of 5506 adolescents surveyed reported self-harm in the past year in the community (250 [78%] female and 164 [51%] aged 15–17 years). In 12–14 year olds, for every boy who died by suicide, 109 attended hospital following self-harm and 3067 reported self-harm in the community, whereas for every girl who died by suicide, 1255 attended hospital for self-harm and 21 995 reported self-harm in the community. In 15–17 year olds, for every male suicide, 120 males presented to hospital with selfharm and 838 self-harmed in the community; whereas for every female suicide, 919 females presented to hospital for self-harm and 6406 self-harmed in the community. Hanging or asphyxiation was the most common method of suicide (125 [73%] of 171), self-poisoning was the main reason for presenting to hospital after self-harm (849 [71%] of 1195), and self-cutting was the main method of self-harm used in the community (286 [89%] of 322). Interpretation Ratios of fatal to non-fatal rates of self-harm differed between males and females and between adolescents aged 12–14 years and 15–17 years, with a particularly large number of females reporting self-harm in the community. Our findings emphasise the need for well resourced community and hospital-based mental health services for adolescents, with greater investment in school-based prevention.