Nonsuicidal self-injury and healthcare providers: a qualitative study exploring people’s lived experiences

Life problems and deliberate self-harm: Associations with gender, age, suicidal intent and psychiatric and personality disorder

Previous self-harm has been identified as a risk factor for subsequent suicide by adolescents. The objective of the study was to identify further risk factors for subsequent premature death and suicide in a population of adolescents presenting with self-poisoning. A longitudinal cohort design using data-linkage of consecutive adolescent patients presenting to the Hunter Area Toxicology Service, a regional toxicology service for Newcastle, Australia, with the National Death Index of the Australian Institute of Health and Welfare was used. A total of 441 adolescents aged 10 to 19 years presented with self-poisoning over 5 years from January 1991 to December 1995, with follow-up to March 2001. There were 14 deaths total, eight of which were likely suicides. There was a 22-fold increase in suicide rate for males and a 14-fold increase for females compared with age-normalized population rates. Adjusted hazard ratios (95% CI) forpremature death were male gender 3.77 (1.11-12.78), nonaffective psychotic disorders 16.3 (3.83-69.34) and the mental illnesses of childhood 6.12 (1.68-22.23). There was a similar pattern for suicide: Male gender, nonaffective psychotic disorders, and the mental illnesses of childhood confer greater risk for subsequent suicide or premature death in this population.

Both nonsuicidal self-injury (NSSI), defined as the direct, deliberate damage of one's body tissue without suicidal intent, and internet addiction among adolescents are public health concerns. However, the possible association of NSSI with internet addiction is not well understood. To examine the occurrence of internet addiction with NSSI and any sex differences among Chinese adolescents. A multicenter, cross-sectional, survey study was conducted from February 18 to October 15, 2015, among adolescents aged 11 to 20 years from 343 classes in 45 public high schools across 5 provinces of China. Data analysis was performed from August 1, 2018, to March 1, 2019. Possible internet addiction and internet addiction. Less-frequent (1-4 times) NSSI and more-frequent (≥5 times) NSSI were surveyed using the Chinese version of the Functional Assessment of Self-Mutilation. A total of 15 623 students (8043 male [51.5%] and 7580 female [48.5%]) aged 11 to 20 years (mean [SD] age, 15.1 [1.8] years) participated. Of these, 4670 participants (29.9%) met the criteria for possible internet addiction and 509 participants (3.3%) met the criteria for internet addiction. A total of 2667 students (17.1%) engaged in less-frequent NSSI, while 1798 students (11.5%) engaged in more-frequent NSSI in the 12 months preceding the survey. Both possible internet addiction and internet addiction were associated with less-frequent or more-frequent NSSI. The adjusted odds ratios were 1.29 (95% CI, 1.17-1.42) for possible internet addiction and 1.41 (95% CI, 1.11-1.80) for internet addiction for less-frequent NSSI; for more-frequent NSSI, the adjusted odds ratios were 1.75 (95% CI, 1.56-1.96) for possible internet addiction and 2.66 (95% CI, 2.10-3.38) for internet addiction. These associations were similarly observed among age groups of 11 to 14, 15 to 17, and 18 to 20 years. No sex disparities were found in the associations of internet addiction with NSSI, except among adolescents aged 11 to 14 years, where the odds ratios for possible internet addiction with less-frequent NSSI were higher in male adolescents (1.53; 95% CI, 1.25-1.88) than female adolescents (1.13; 95% CI, 0.90-1.47). Internet addiction appears to be associated with NSSI, and the findings of this study suggest that the association was similar between male adolescents and female adolescents. These data suggest that evaluation of the risk of NSSI for adolescents in association with internet addiction may help health care professionals in developing preventive interventions for NSSI.

To analyze the risk factors for suicide, premature death and all-cause death in a representative population of hospital-treated deliberate self-poisoning patients. A prospective cohort study using data-linkage between the Hunter Area Toxicology Service Database and the National Death Index of the Australian Institute of Health and Welfare, from January 1991 to December 2000. There were 4105 subjects, of whom 228 (5.6%) died, 122 (2.9%) by premature death and 58 (1.4%) by suicide. The probability of suicide after 10 years follow-up was 2%. The adjusted hazard ratios (95% CI) for suicide were: 'disorders usually diagnosed in infancy, childhood and adolescence', 5.28 (95% CI = 2.04-13.65): male gender, 4.25 (95% CI = 2.21-8.14); discharge to involuntary psychiatric hospital admission, 3.20 (95% CI = 1.78-5.76); and increasing age, 1.02 (95% CI = 1.01-1.04). Men and women showed different patterns of multivariate risks, although increased risk with increasing age and discharge to an involuntary psychiatric admission was true for both. The standardized all-cause mortality ratio (95% CI) was: for men, 6.42 (95% CI = 5.44-7.57), and for women 4.39 (95% CI = 3.56-5.41). The standardized suicide mortality ratio (95% CI) was: for men, 20.55 (95% CI = 15.24-27.73), and for women 22.95 (95% CI = 13.82-38.11). Men and women have different risk factors for subsequent suicide after self-poisoning. Hospital-treated self-poisoning patients have increased risk of subsequent suicide, premature and all-cause death. Psychiatric assessment, leading to discharge decisions, is worthwhile in identifying patients at long-term risk of suicide, premature and all-cause death.

Suicidal thoughts and behaviours (STB) are a common reason for presentation to emergency departments and general hospitals. A meta-analysis of the strength of clinical risk factors for subsequent suicide might aid understanding of suicidal behaviour and help suicide prevention. We conducted a meta-analysis of cohort and controlled studies on clinical risk factors and later suicide among people presenting to emergency departments and general hospitals with STB. Data were extracted from papers meeting inclusion criteria, published in Medline, PsycINFO, and Embase between 1 January 1960 and 10 October 2022 using papers located with the search terms ((suicide*).m_titl AND (emergency* OR accident and emergency OR casualty OR general hospital OR toxicology service).mp) or were indexed in PubMed and had titles located with the search terms (suicide* OR self-harm OR self-harm OR self-injury OR self-injury OR self-poisoning OR self-poisoning OR overdose OR para-suicide OR parasuicide [title/abstract]) AND (Emergency department OR emergency room OR Casualty OR general hospital OR toxicology OR accident and emergency [all fields]). Data about the association between clinical risk factors and suicide extracted from three or more studies were included in a random-effects meta-analysis of the odds of later death by suicide. The study was registered in PROSPERO and conducted according to MOOSE and PRISMA guidelines. Seventy-five studies reported on 741,624 people, of which 19,649 died by suicide (2.65%). Male sex (odds ratio (OR) = 1.99) and age (OR = 2.01) were the most consistently reported risk factors. The strongest associations with subsequent death by suicide related to violent self-harm methods at the hospital presentation, including: unspecified violent method (OR = 4.97), any violent method (OR = 4.57) and the specific violent methods of drowning (OR = 4.32), hanging (OR = 4.26), and use of firearms (OR = 10.08). Patients categorised as higher risk using suicide prediction scales or any other method that combined risk factors had moderately increased odds of suicide (OR = 2.58). Younger age, Black and Hispanic ethnicity, overdose, a diagnosis of adjustment disorder, and the absence of any psychiatric diagnosis were protective against suicide. Most risk factors for suicide among people who have presented with STB are not strongly associated with later suicide. The strongest risk factors relate to self-harm methods. In the absence of clear indicators of future suicide, all people presenting with suicidality warrant a thorough assessment of their needs, and further research is needed before we can meaningfully categorise people with STB according to suicide risk.

To investigate suicide ideation and behavior as risk factors for suicide in schizophrenia during varying time periods. Cases were 84 patients who died by suicide within 5years from diagnosis in a source population of patients discharged for the first time from psychiatric hospitals in Stockholm County, Sweden, with a schizophrenia spectrum diagnosis. One control was individually matched with each suicide case. Data were retrieved from clinical records in a blind fashion. Thoughts of death, thoughts of suicide, suicide plan, and suicide attempt during varying time periods were investigated as risk factors for subsequent completed suicide. In adjusted analyses, thoughts of suicide, suicide plan, and suicide attempt were significantly associated with subsequent completed suicide in the following year. The highest suicide risk was found within a year following suicide attempt (adjusted OR 9.9, 95% confidence interval 2.5-39.0). The association between suicide ideation and behavior and subsequent suicide declined over time. Several types of suicide ideation and behavior were associated with suicide, and the association was stronger for suicidal behavior. The clinical significance of suicidal communication appears highest during the following month or/and year. Many suicides occurred without recorded short-term suicidal communication.

A Global Call for Action to Prioritize Healthcare Worker Suicide Prevention During the COVID-19 Pandemic and Beyond.

Social context during non-suicidal self-injury indicates suicide risk

Ed Shneidman reports on his 1971 analysis of the suicides that had occurred in the Terman Gifted Children Study. Begun in the 1920s at Stanford University, Professor Lewis Terman identified 1,528 high-IQ California students and, over the years, they have been continuously followed. Today, the remaining subjects (about 100) have a mean age of 93. In his uniquely Shneiderian manner, Ed relates how, in 1971, he utilized a psychological autopsy approach to accurately predict the suicides of a small subsample of the 20 suicides that had occurred to date among the 857 male participants. Almost 35 years later, he shares with us his slightly revised view of those factors that he believes play significant predictable roles in the eventuality of suicide. Jeremy Kisch et al. report on analyses from the Spring 2000 National College Health Assessment Survey (NCHA), sponsored by the American College Health Association. This is the largest and most comprehensive survey to date (15,977 college students) that provides a replication of the CDC's 1995 National College Health Risk Behavior Survey (NCHRBS). This study investigates the relationship between suicidal behavior and depressed mood, as well as other risk factors which increase vulnerability to suicidal behavior. Of particular note is that less than 20% of college students reporting suicidal ideation or attempts were receiving treatment (psychotherapy and/or medications). Adolescent suicide continues to be a major focus of much research as evidenced by the number and range of studies published in SLTB over the years. Researchers have appropriately focused on identifying critical risk factors associated with suicidal behaviors. Thompson et al. explored the roles of anxiety, depression, and hopelessness as mediators between known risk factors and suicidal behaviors among 1,287 potential high school dropouts. As a step toward theory development, a model was tested that posited the relationships among these variables and their effects on suicidal behaviors. The results showed direct effects of depression and hopelessness on suicidal behaviors for males, and direct effects of hopelessness, but not depression, for females. For both males and females, anxiety was directly linked to depression and hopelessness; drug involvement had both direct and indirect effects on suicidal behavior. Lack of family support showed indirect influences on suicidal behaviors through anxiety for both males and females as hypothesized. As the authors point out, for mental health professionals, school personnel, and prevention scientists working with at-risk or suicidal youth, the findings make evident the need to address multiple co-occurring problem behaviors such as drug involvement, emotional distress, and suicidal behaviors. Over the years, SLTB has published data emanating from the CDC's Youth Risk Behavior Survey (YRBS), which is conducted biannually. (see SLTB 30: 304–312; 32: 321–323). The four questions that measure suicidal ideation and attempts are ordered along an implicit continuum of development and severity from seriously considering suicide, to planning, to actually attempting suicide, and, finally, to requiring medical attention for a suicide attempt. As presented by Victor Perez, this process assumes a straightforward sequence of suicidal thought and action and is the underpinning of the content and order of the YRBS questions. However, the assumed ordinal properties of the four questions had never been empirically tested. Brener, Krug, and Simon (SLTB 30: 304–312) found discrepancies in the trends of responses to the questions measuring suicidal activity in their analysis of the YRBS from 1991–1997. Specifically, they showed that although the percentage of students who reported having seriously considered or attempted suicide in the past 12 months had declined steadily since 1991, the percentage of students requiring medical attention for an injurious suicide attempt had increased. They concluded that injurious suicide attempts might not be linked to seriously considering or planning a suicide attempt. Perez examines the assumed ordinal relationship in the 1999 Youth Risk Behavior Survey by constructing a trajectory that identifies all possible response patterns among the four questions measuring suicidal activity. Significant differences between means of dependent variables at each level of the normative trajectory supported the hypothesis that frequency of risk behaviors increases monotonically with successive suicidal thought and behavior. Research on the relationship between schizophrenia and suicidal behaviors has languished until recently (see SLTB 30: 34–49; 34: 66–76; 34: 76–86; 34: 311–319). Camilla Haw et al. identify the risk factors for deliberate self-harm (DSH) in schizophrenia. They provide an explanation and reference to their use of the broader (European) term DSH, rather than attempted suicide. Although there are several published review articles on risk factors for suicide and suicidal behavior in schizophrenia, there are few reviews which make any mention of risk factors for DSH, and there is an assumption that the risk factors for DSH and suicide are the same. Haw et al. examined cohort and case-control studies of patients with schizophrenia or related diagnoses that reported DSH as an outcome. Five variables (past or recent suicidal ideation, previous DSH, past depressive episode, drug abuse or dependence, and higher mean number of psychiatric admissions) were associated with an increased risk of DSH, while one (unemployment) was associated with a reduced risk. In a continuing series of studies (see SLTB 27: 153–163), Eric Blaauw et al. focus on the prevention of suicide in jails and prisons. This current study aims to identify combinations of characteristics (demographic, psychiatric, and criminal) that are capable of identifying potential suicide victims. Characteristics of 95 suicide victims in the Dutch prison system were compared with those of a random sample of 247 inmates in ten jails. Combinations of indicators for suicide risk were also tested for their capability of identifying 209 suicides in U.S. jails and 279 prison suicides in England and Wales. A combination of two demographic characteristics (age over 40, homelessness), two criminal characteristics (one prior incarceration, violent offense), and two indicators of psychiatric problems (history of psychiatric care, history of hard drug abuse) proved capable of identifying 82 percent of the suicide victims in the Netherlands at a specificity of .82 in the general inmate population. Less powerful combinations correctly classified 53% of the U.S. suicides and 47% of the U.K. suicides. Blaauw and colleagues conclude that a small set of demographic and criminal characteristics and indicators of psychiatric problems is useful for the identification of suicide risk in jails and prisons. They point out that the characteristics can easily be incorporated in a screening device that can be administered during the intake process for new inmates. Some risk factors for suicidal behavior are similar to those often studied in the field of criminology. The link between suicide and crime is most apparent when there is a homicide followed by suicide. People who kill others rarely kill themselves afterward. When they do, they are more likely to have killed someone with whom they are intimately involved—an intimate partner or a child. A review of the literature on this phenomenon in Australia, Canada, and the United States showed that, in all three countries, the majority of those who commit suicide after a homicide are male partners or ex-partners of female victims. Using data on over 700 intimate femicides, Myrna Dawson examined the role of premeditation in cases of intimate femicide-suicide compared to killings that do not culminate in a suicide. Her results show that premeditation is more likely to occur in cases involving the offenders' suicide, but that evidence of premeditation varies depending on the type of suicidal killer. Michel Préville et al. present the results of a psychological autopsy investigation of 101 adults aged 60 years and older who died by suicide in Quebec in 1998–1999. The study looks at a number of variables from proxy survivor interview data, including health- and mental health-related behaviors, mental health diagnoses, and social and demographic variables. In this study, 42.6% of the suicide cases presented with mental disorders at the time of their death (mainly depression), and nearly 44% of the suicide cases had no current or pre-existing psychiatric condition. Only 27.7% of the cases did not express any idea of death during the 6-month period preceding their suicidal death. Interestingly, 53.5% of the suicide cases consulted a general practitioner or specialist during the 2-week period preceding their death. The authors suggest that family members and friends could play an important role in preventing elderly suicide attempts by encouraging their parents to discuss their suicidal thoughts with their general practitioner. The results show some similar and some disparate results compared to other studies of elderly suicides, indicating the need for research that examines the complex causal nature of the relationship between mental disorders and suicide among the elderly. Adding to his studies of homeless veterans who abuse substances (SLTB 33:430–432), Brent Benda studied 315 male and 310 female homeless military veterans in a V.A. inpatient program designed to treat substance abusers, many of whom also suffer psychiatric disorders. The study examined gender differences in factors associated with the odds of having suicidal thoughts, and of attempting suicide, in comparison to being nonsuicidal. Childhood and current sexual and physical abuses, depression, fearfulness, relationship problems, limited social support, and low self-esteem were more strongly associated with suicidal thoughts and attempts for women than for men veterans. Extent of alcohol and other drug abuse, aggression, resilience, self-efficacy, combat exposure, combat-related PTSD, and work problems were more strongly associated with suicidal thoughts and attempts for men than for women. While anticipating the release of the CDC's final 2002 national suicide death numbers and rates, there have been different explanations offered for the apparent slow, but steady decline in national suicide rates over the last years. In 1996 the rate was 11.52/100,000; 11.23 in 1997; 11.13 in 1998; 10.47 in 1999; 10.43 in 2000, and 10.69 in 2001. By the time you receive this issue, we will know whether the trend is heading downward or beginning to climb back up. Recently, my attention was drawn to an Editorial originally published on July 30, 1904, in the Journal of the American Medical Association, entitled, “The Increase in Suicide.” I have excerpted portions as follows: The increase of suicide has come to be such a marked feature of social statistics in this country that physicians must be made to realize the possibilities there may be of bringing about a decrease in this unfortunate matter by more care and prevision. Suicides are somewhat more than twice as frequent now as they were ten years ago. … Carefully collected statistics show that there was a constant increase from 3,531 suicides in 1891 to 6,600 in 1897, then a drop in 1898 to 5,920, and in 1899 to 5,340. In 1900 there were 6,755 suicides, an increase of over 150 above the figures for 1897, the highest previous number, and there has been a constant increase since, in 1903 the number of suicides being very close to 8,600. During the last thirteen years—that is, since 1891, there have been altogether 77,617 cases of suicide reported in the newspapers of this country. The decrease in the number of suicides during 1898 and 1899 is not surprising, if we remember the conditions that prevailed in the commercial world at that time. After a period of hard times there was the wave of prosperity and a decided reaction in men's feelings that made the future look bright enough for everyone. Curiously enough, the statistics, however, do not show that city life is so much harder on the people than country life. During the last ten years, the suicide rate in fifty cities of this country has about doubled. That is, however, only in proportion to the suicide rate throughout all the rest of the country and does not especially condemn the high pressure of large city life as a disturbing factor of mentality. The most serious thing about the statistics is the fact that, though suicides are more common among men than women in all countries, the difference is gradually growing less, and in recent years, this has been quite marked. (43: 333–334) The 1890 census data from some states was partially destroyed by a fire in 1921; however, the federal records indicate an 1890 U.S. census of 62,116,811. Using this number, the rates are as follows: 5.68/100,000 in 1891, 10.63 in 1897, 9.53 in 1898, and 8.60 in 1899. The official U.S. census in 1900 was 74,607,225. In 1900, there were 6,755 suicides, yielding a rate of 9.05/100,000. In 1903, there was a significant increase in the number of suicides to approximately 8,600. Using the 1900 census, the suicide rate rose to 11.53/100,000. During the 13-year period between 1891–1903 there were 77,617 suicides, or approximately 5,971/year. This yields a roughly estimated rate of 9.61/100,000 for this 13-year period. Taken as a whole for the years surrounding the turn of the 20th century, the rate hovered around 9–10/100,000. One hundred years later, we continue to grapple with similar rates and similar risk factors.

Introduction Non-suicidal Self-Injury (NSSI) refers to causing damage on body tissue without attending to death. It is mostly presented among the youths and not approved by the society. Studies nowadays have explored the perspectives, feelings or experience of the youths or healthcare professionals. However, negative feelings and misunderstandings toward each other remain from both sides.ObjectivesThe aim was to explore the encountering experience of the youths with NSSI and the healthcare professionals during the same hospitalization in a psychiatric acute ward.MethodsQualitative study was employed by using narrative approach. In-depth interview was conducted for the youths with NSSI and their primary nurse and resident from a medical center in southern Taiwan.Results Narratives from the patients and healthcare professionals showed that the youths seemed to be comfortable as encountering with the healthcare professionals’ caring. In contrast, the healthcare professionals’ struggles had been hidden inside and remained uneasy and unsolved. Two extreme experiences have been reported by the youths with NSSI: felt satisfied and understood about being cared vs. felt numbness and not been understood. Four kinds of experience were identified as: struggling on caring them, feeling confused and helpless, keeping a safe distance, and having contradicted values.Conclusions This study found that the healthcare professionals suffer from varied aspects when encountering the youths with NSSI, which they often hid inside without expressing. Future improvement such as care guideline or staff’s support system should be built to decrease the negative effects inside the healthcare professionals’ mind.DisclosureNo significant relationships.

For decades, knowledge about nonsuicidal self-injury (NSSI) was limited to only a small handful of empirical studies. However, the last 10 to 15 years have witnessed an explosion of research and significant advances in knowledge about NSSI. We now understand much about the classification, prevalence, correlates, forms, and functions of NSSI, and have dispelled many misconceptions. It is time for NSSI researchers to apply tills basic knowledge to develop empirically grounded theoretical models and effective treatments. Tills In Review on NSSI was developed to help the field of mental health move forward in these 2 areas. First, tills editorial briefly reviews what we now know about NSSI. Next, Margaret S Andover and Blair W Morris1 describe an emotion regulation model for understanding and potentially treating NSSI and for explaining the emotion regulation function of NSSI in terms of basic emotion models. Finally, Brianna J Turner, Sara B Austin, and Alexander L Chapman2 provide a systematic review of NSSI treatment outcome research, and note the need for new treatment approaches specifically tailored to targetNSSI. We hope that tills In Review not only provides state-of-the-art knowledge but also motivates and facilitates future efforts to better understand and treat NSSI.NSSI refers to the intentional destmction of one's own body tissue without suicidal intent and for purposes not socially sanctioned.3 4 Coimnon examples include cutting, burning, scratching, and banging or hitting, and most people who self-injure have used multiple methods.3 Because NSSI is typically associated with emotional and psychiatric distress,5,6 and because NSSI increases risk for suicide,7,8 it is cmcial to establish accurate conceptual and clinical models of tills behaviour. In tills introduction to the In Review on NSSI, we summarize what is now known about NSSI (much of which lias been learned in just the past 10 to 15 years), dispel common myths, and describe the 2 review articles featured in tills special section.What We Now KnowDespite some notable exceptions,9-11 few researchers focused attention on NSSI until recently. One might identify the early 2000s as a turning point. Kim L Gratz12 published an influential measure that facilitated research on NSSI, E David Klonsky and colleagues5 found that NSSI is present and associated with psychiatric morbidity even in nonclinical populations, Matthew K Nock and Mitch J Prinstein13 drew attention to the reasons why people engage in NSSI, and Jennifer J Muehlenkamp (see Muehlenkamp14 and Muehlenkamp and Gutierrez15) argued that NSSI should be distinguished from other SIBs, such as attempted suicide, and regarded as an independent clinical syndrome. Each of these publications has been cited in hundreds of subsequent articles, and together they arguably provided a foundation for subsequent work that has answered many key questions about the nature of NSSI, including who self-injures, why people self-injure, and the complex relation between NSSI and suicidal behaviour.Who Self-injures?NSSI is most common among adolescents and young adults. Lifetime rates in these populations are about 15% to 20%,16,17 and onset typically occurs around age 13 or 14.6,18 In contrast, about 6% of adults report a history of NSSI.19,20 It is unclear whether the lower lifetime rate in adults reflects an increase in NSSI among recent cohorts of adolescents or an artifact of memory by which most adults who self- injured as adolescents do not recall their NSSI. Generally speaking, rates of NSSI appear to be similar across different countries.21In both adolescents and adults, rates of NSSI are highest among psychiatric populations, particularly people who report characteristics associated with emotional distress, such as negative emotionality, depression, anxiety, and emotion dysregulation.5,18,22,23 NSSI is especially common in people prone to self-directed negative emotions and self-criticism. …

Nonsuicidal self-injury (NSSI) is a risk factor for suicide, yet how changes in NSSI engagement relate to suicide ideation, planning, and attempts remains largely unknown. The current study aims to fill this gap by examining how changes in NSSI frequency over time related to concurrent changes in suicide thoughts and behaviors. Data came from a sample of 403 self-injuring young adults who completed assessments of NSSI and suicide thoughts and behaviors at baseline, 6, and 12 months. Bivariate latent growth modeling, adjusting for covariates of lifetime NSSI frequency and treatment status, was used to examine the extent to which changes in NSSI frequency related to suicide ideation and suicide planning. The frequency of NSSI declined across the study period. The slopes of NSSI and suicide ideation were significantly correlated, suggesting individuals with sharper declines in NSSI across time also showed sharper declines in suicide ideation. The intercepts between NSSI and suicide planning were significantly correlated, suggesting those with high NSSI frequency at baseline tended to report higher suicide planning across time. After covariate adjustment, the intercept of suicide planning marginally (p = 0.08) correlated with the slope of NSSI, tentatively suggesting that those who had less reductions in NSSI tended to have higher frequencies of suicide planning. These results provide new evidence that changes in NSSI are related to subsequent changes in suicide thoughts and behaviors. Monitoring suicide risk among those with NSSI is important and treatment aiming to reduce NSSI may also reduce suicide risk.

IntroductionIranians comprise an immigrant group that has a very different cultural background from that of the mainstream Canadian population and speaks a language other than English or French; in this case mainly Farsi (Persian). Although Iranian immigrants in Toronto receive a high proportion of care from Farsi-speaking family physicians and health care providers than physicians who cannot speak Farsi, they are still not satisfied with the provided services. The purpose of this study was to identify the obstacles and issues Iranian immigrants faced in accessing health care services as seen through the eyes of Iranian health care professionals/providers and social workers working in Greater Toronto Area, Canada.MethodsNarrative inquiry was used to capture and understand the obstacles this immigrant population faces when accessing health care services, through the lens of fifty Iranian health care professionals/providers and social workers. Thirty three health care professionals and five social workers were interviewed. To capture the essence of issues, individual interviews were followed by three focus groups consisting of three health care professionals and one social worker in each group.ResultsThree major themes emerged from the study: language barrier and the lack of knowledge of Canadian health care services/systems; lack of trust in Canadian health care services due to financial limitations and fear of disclosure; and somatization and needs for psychological supports.ConclusionIranians may not be satisfied with the Canadian health care services due to a lack of knowledge of the system, as well as cultural differences when seeking care, such as fear of disclosure, discrimination, and mistrust of primary care. To attain equitable, adequate, and effective access to health care services, immigrants need to be educated and informed about the Canadian health care system and services it provides. It would be of great benefit to this population to hold workshops on health topics, and mental health issues, build strong ties with the community by increasing their involvement, use plain language, design informative and health related websites in both Farsi and English, and provide a Farsi speaking telephone help line to answer their health related issues.

Background: Non-suicidal self-injury (NSSI) is highly prevalent in adolescence and represents a maladaptive coping strategy. Insufficient attention has been paid to NSSI as a critical factor for suicide, the second leading cause of death in adolescents and young adults. Hopelessness frequently factors into suicide and suicide attempts. Aims: We consider NSSI from the clinician’s perspective in assessment, case formulation and treatment considerations with the added perspective for the role of hopefulness in NSSI and suicide. Method: Google and PubMed databases were searched to consider the role hopefulness plays in both NSSI and suicide of youth and young adults in assessment, clinical course, interventions, and outcome. Key words included adolescents, adults, children, NSSI, hope, assessment, treatment, clinical course, and outcome. Reverse citations were also conducted to assure timeliness. Results: Increasing attention has been paid to stratification of commonly considered risk factors for suicide and suicide attempts in the target population. Rationale for considering NSSI as a critical suicide risk factor and for hope’s role in the continuum of suicidal behavior is documented and emphasized. Relevant models for suicide are described to support and provide clinicians guidance to consider NSSI and hopefulness in case formulation, determining safety, and developing useful interventions for youth engaging in or contemplating NSSI and/or suicide. Conclusions: NSSI is a major risk factor for suicide in youth. Hope plays major roles in NSSI and suicide and should be considered in assessment, case formulation, and interventions in youth manifesting NSSI and suicidal, ideation, and behavior.

Non-suicidal self-injury (NSSI), the deliberate destruction of body tissue without suicidal intent, among adolescents is a growing concern, especially for school staff. Although NSSI is a significant risk factor for further self-injury and suicide, many adolescents who self-injure do not seek professional help, and hide their behaviour from adults. Teachers and other school staff are in a prime position to identify and intervene with these youth. However, while teachers and other school staff are likely to encounter youth who self-injure, school staff are uncertain and lack training when responding to these students. Understanding the knowledge and training needs of school staff regarding NSSI, and exploring adolescents’ views about strategies to help young people who self-injure, will inform the development of prevention and early intervention initiatives to address NSSI in the school environment. Therefore, the primary aims of this thesis were to: 1) evaluate adolescents’ perspectives on how to help youth who self-injure; 2) establish the level of knowledge, confidence, and training needs of school staff and pre-service teachers; and 3) understand how school staff currently respond, and perceived barriers to effectively responding, to NSSI in schools. To achieve these aims, self-report data were collected from 2637 students, and thematic analysis used to explore what adolescents believe teachers, parents, peers, and online friends could do to help young people who self-injure. Quantitative and qualitative data were also collected from 267 pre-service teachers and 501 school staff (including school leaders, teachers, psychologists, and counsellors), and multivariate statistics used to explore the relationships between attitudes, knowledge, and confidence towards NSSI, exposure to student self-injury, prior training, and actual responses to students who self-injure. Finally, 48 teachers and other school staff reviewed a new school policy for addressing NSSI in schools and provided written feedback on the strengths and suitability of the policy for responding to students who self-injure in the school setting. Adolescents suggested that youth who self-injure could be helped by talking to them about the behaviour and referring them to mental health professionals. However, adolescents with a history of NSSI, or with friends who had engaged in NSSI, were unsure how teachers could help young people who self-injure. Although pre-service teachers and school staff were concerned about and willing to help students who self-injure, they were unsure how to respond and acknowledged their lack of training regarding NSSI. School staff with training regarding NSSI had greater knowledge and confidence to address self-injury in schools, while those with greater perceived knowledge and confidence were more likely to communicate with students who self-injure. Collectively, although students would like access to non-judgmental teachers to talk to about NSSI, teachers feel ill-equipped to discuss self-injury with students. These results have implications for education programs to encourage adolescents to access help for peers or themselves. Additionally, the results can inform the development of training programs and school policies for school staff to enhance their knowledge and confidence, and prepare them to identify, safely communicate with, and refer students who self-injure.