The Lancet Commission Tackles Self-Harm

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The Lancet Commission report on nonfatal self-harm addresses the global prevalence, causes, cultural perspectives, and responses to self-harm.¹ It identifies key challenges, especially the lack of policy attention and support for those engaging in self-harm, contrasting it with the comparatively stronger focus on suicide prevention.

The report highlights that self-harm is widespread, affecting at least 14 million people worldwide annually, but is likely underreported, particularly in low-and middle-income countries (LMICs) due to limited clinical support and surveillance systems. While self-harm affects individuals of all ages, it is especially prevalent among young people.^2-5 Indigenous communities and marginalized groups also show high rates of self-harm, with factors such as colonization, racism, and poverty contributing significantly to these behaviors.⁶

The report describes self-harm as a behavior, not a psychiatric diagnosis, with a wide variety of underlying causes and contributing factors with varied functions, including emotional management, self-soothing, and identity validation. This behavior is complex, and influenced by individual factors and broader social determinants, though understanding of the interaction between these factors remains limited. Emerging technologies like Ecological Momentary Assessment together with machine learning and triangulation of data sources, including qualitative data, are suggested for gathering better data on self-harm.

Treatment for self-harm varies significantly by region and is often inaccessible, especially in LMICs. As per the report, racial minority groups and LGBTQIA+ communities face greater barriers to treatment and decreased possibility of receiving evidence-based treatments.^7,8 Stigma, lack of empathetic responses, and punitive attitudes exacerbate the situation, especially in places where self-harm with suicidal intent is criminalized. The Commission calls for the removal of punitive measures and advocates for culturally sensitive prevention strategies, particularly for indigenous peoples.

A key recommendation is for online media to focus on recovery stories to provide supportive narratives for at-risk users. Additionally, individuals with lived experience should be involved in designing care models. Existing programs such as The Trevor Project, an online social community for LGBTQIA+ youth,⁹ and the Peers for Valued Living (PREVAIL), a 3-month peer mentorship intervention program,¹⁰ are examples of such programs where one of the main components is support and guidance from individuals with lived experiences. Overall, the report emphasizes an inclusive, coordinated approach to addressing self-harm, advocating for changes in policy and support structures that align with the lived experiences and diverse cultural backgrounds of those affected.

The report concludes by calling for unified, long-term efforts across government and societal sectors to improve outcomes for people who self-harm, aiming for significant, positive change in their lives through better-integrated health and social services.

Key Recommendations for Addressing Self-Harm

The document discusses essential actions for reducing self-harm, divided into key recommendations for governments, service delivery improvements, and research. It highlights the need for a multidisciplinary approach that respects diverse views within the team. These teams would be expected to work across long-established perimeters such as primary and secondary care, acute care, and mental health settings. One of the challenges noted is balancing different perspectives on what constitutes self-harm, particularly in distinguishing nonfatal self-harm from other behaviors.

Divergent Views in Self-Harm Approaches

The report acknowledges that self-harm can serve as a coping mechanism in the form of emotional management, self- protection, self-expression, enaction of power or agency amongst other things for some individuals,^11,12 even as professionals may view cessation as the main objective. This divergence is evident among those with lived experience of self-harm, who may see it as a necessary, albeit harmful, strategy rather than something that should be eliminated immediately. The document also notes that health care systems may unintentionally harm those seeking help due to judgmental attitudes, excessive focus on risk assessment, and inadequate attention to underlying emotional needs.

Epidemiology and Prevalence

Self-harm is prevalent worldwide, with estimates suggesting around 14 million episodes annually, though this is likely an underestimate. Community and school surveys show a prevalence rate of approximate lifetime prevalence of self-harm of around 3% in adults and 14% in children and adolescents. Self-harm is more common in youths, particularly females, and rates have risen in recent years.¹³ Per the report, within the last decade, the prevalence of self-harm in youth seems to have increased in several countries. Cutting is the frequently chosen method in community settings, while poisoning is more common in hospital cases.

Influencing Factors and Risks for Adolescents

The onset of self-harm often occurs during adolescence, a critical developmental period marked by biological, social, and mental transitions. Adolescents face unique pressures in today’s society, including social and economic uncertainties, the lingering effects of the COVID-19 pandemic, and environmental anxieties, which increase the risk of self-harm. Many youth avoid seeking help from health care providers due to stigma and barriers such as cost, accessibility, and privacy concerns. A 2016 study from the UK reported far-reaching consequences following abusive, dismissive, or negative treatment, including avoiding help-seeking in the future.¹⁴

Risk of Repetition and Suicide

Repetition of self-harm is common, with significant risks associated with certain factors such as borderline personality disorder (BPD), mood disorders, alcohol misuse, and prior suicidal ideation. The document notes that individuals who have self-harmed are at a higher risk of suicide and reports that 16% of individuals die by suicide within a year after presentation with self-harm,¹⁵ highlighting the need for timely and supportive intervention sensitive to local and cultural nuances.

The report discusses individual, neurobiological, and social factors that influence self-harm behavior, emphasizing its multifaceted and complex nature. Self-harm occurs for various reasons, such as managing emotional distress, creating environmental change, and, for some, preventing suicidal action. Risk factors are numerous, including emotional dysregulation, past trauma, interpersonal issues, psychopathology, and exposure to self-harm content both personally and through media. The text also links self-harm to BPD, highlighting that BPD's symptoms, such as emotional instability and impulsivity, often involve self-harm. Psychological treatments like dialectical behavior therapy have shown effectiveness for those with BPD.

Neurobiologically, self-harm risk factors range from genetic and epigenetic influences to immediate stress responses and behavioral traits like impulsivity.^16-19 Adolescence is a critical period for the onset of self-harm, where developing social skills intersect with increased vulnerability to psychological stressors. While specific genes related to self-harm are yet to be conclusively identified, recent studies suggest that certain genetic loci on chromosomes 20 and dopamine receptor D2 might be involved, potentially distinct from those associated with mood disorders.¹⁶ Epigenetic processes also play a role, as early life adversity can result in biological changes, such as DNA methylation, that elevate self-harm risk through altered stress responses.

Neural studies of self-harm show that areas involved in emotional regulation, like the prefrontal cortex and amygdala, often have altered structures or connectivity in individuals who self-harm.²⁰ For example, structural, functional, and neurochemical alterations in the ventrolateral prefrontal cortex and the ventromedial prefrontal cortex have been associated with maladaptive strategies, negative self‐referential thinking, and anhedonia.²¹ The text advocates for better integration of neurobiological data with real-world monitoring to improve understanding and intervention.

On a social level, self-harm is tied to broader determinants of health, such as socioeconomic status, education, housing, and social inclusion, which disproportionately impact marginalized communities. Gender disparities also affect self-harm rates, with women facing unique risks due to gender-based violence, discrimination, and economic inequalities. Social media further exacerbates these pressures. Socioeconomic inequalities within high-income countries (HICs) reveal that self-harm incidents are higher among those in deprived areas or experiencing homelessness. For example, an Irish national registry-based study showed that homeless individuals had significantly higher odds of presenting with self-cutting and having psychiatric admissions. The text argues that addressing these social inequities is essential for reducing self-harm.

Cultural factors also shape self-harm behavior, with certain groups, such as indigenous communities or migrants, facing unique mental health stressors. Historical trauma, marginalization, and health care disparities contribute to increased self-harm risks in these populations. An Indian context example illustrates the intersection of caste, gender, and limited healthcare access as influences on self-harm. The text critiques a purely clinical view of self-harm, advocating for a broader approach that addresses social and cultural influences, as cultural messages heavily impact coping behaviors and self-harm tendencies.

In summary, self-harm is influenced by an array of individual, neurobiological, and sociocultural factors, demanding comprehensive prevention and intervention strategies that address both personal behaviors and societal conditions.

The Commission’s report emphasized the importance of reconceptualizing thinking about self-harm to prioritize lived experiences. Sources of evidence traditionally relied upon by researchers in HICs, such as quantitative data, should be augmented by qualitative studies in the tradition of survivor research that incorporate experiential knowledge. Harnessing such knowledge will require both the investment of resources and the curtailing of institutional gatekeeping that, in the name of safety, often creates unnecessary barriers for those with the most lived experience from becoming research subjects. Reconceptualization also requires tempering the current overemphasis on biomedical and psychocentric approaches while acknowledging the structural and systematic forces, such as colonialism and racism, that shape self-harming behaviors in LMICs and Indigenous communities. Increasing the limited knowledge base regarding self-harm in LMICs is essential.

As the Commission noted, the significance of self-harm may vary greatly among settings. For instance, individuals with the least social capital may live in environments where verbal expressions of distress are stigmatized, so they may choose to communicate their distress nonverbally through self-harm. Patients with lived experience may also view treatment success differently from clinicians or researchers, prioritizing general wellbeing over reduced self-harm episodes.

The Commission highlighted the value of a tool known as experience sampling methodology (ESM) that captures self-reports of subjective patient experiences on several occasions each day over extended periods of time. ESM can be used to inquire about thoughts of self-harm directly, but also feelings such as rejection, numbness, loneliness and anger. The benefit of ESM is that it allows for assessment of various triggers and risk factors for self-harm on an individual basis rather than requiring a comparison between individuals. This approach permits a far more nuanced understanding of the real-time experiences of self-harming individuals, which in turn might permit both patients and clinicians to anticipate and target high-risk episodes. In addition, the Commission raised the possibility that, in the future, machine learning tools and AI will prove able to incorporate such data into predictive models. Finally, the Commission observed that while strong evidence supports a major role for social determinants in causing self-harm, the relative role of various specific determinants remains largely unclear and should be the subject of further investigation.

New responses to self-harm are also needed. At present, most individuals contemplating self-harm either do not seek care with trained professionals or do seek care but are not recognized as being at risk. In both cases, rates of prevention and treatment are likely reduced. One evidence-based mechanism for improving detection of patients at risk is to employ a diverse health care workforce that includes individuals from high-risk communities, such as Indigenous populations, and to train these workers to engage with patients in a culturally sensitive manner. Considerable evidence also supports the incorporation of peer support in the management of self-harm—both following crisis episodes and through long term support in the community. Digital tools, including smart phone apps and crisis text chats, may also be of value, although the data that supports text and app-based approaches draws largely from limited populations in HICs and may not be generalizable.

The conclusion of the report presents 12 recommendations aimed at governments, the media, researchers, and service providers. Among these are that self-harm should be decriminalized, that efforts to address self-harm should be focused on upstream factors such as poverty and targeted at LMICs and youth, and that lethal pesticides, that often turn self-harm episodes into fatalities, should be banned. In addition, the media ought not describe acts of self-harm in detail, for fear of normalizing them or generating replication, but rather should emphasize narratives of survival and help seeking. The Commission noted that governments have not only an ethical duty to address self-harm, but also that doing so holds out the promise of large-scale financial savings through lives saved and productivity preserved. Unfortunately, efforts to address self-harm in LMICs often fail because they assume universal solutions to context-driven challenges. An effective approach to targeting self-harm in LMICs might rely upon coproduction and codesign through which providers, patients, families, and communities are all involved in the creation and implementation of interventions. “Cultural wounds,” the report explains, “require cultural medicines.”

The overall message of the Commission’s report is that self-harm, and particularly nonfatal self-harm, is a major international crisis that has been neglected for far too long. Outside-the-box thinking and novel approaches to this issue are necessary to overcome a major global health challenge.

This extensive summary highlights the broad commercial, social, and clinical factors influencing self-harm and its prevention. Here is a concise breakdown of the main points:

1. Commercial Determinants:

• Agrochemicals: The pesticide industry has had a complex relationship with self-harm prevention, especially in LMICs. While there is strong evidence that banning toxic pesticides effectively reduces self-harm deaths, the industry often promotes less effective methods, like secure storage.
• Alcohol: Alcohol is a known risk factor for self-harm. As markets shrink in HICs due to regulation, alcohol companies have increased their focus on LMICs, sometimes influencing national policies in ways that may counteract self-harm prevention efforts. The alcohol-attributable fraction of fatal self-harm is estimated at 18%.

2. Influence of Media on Self-Harm:

• Media and social platforms are powerful influencers on self-harm behavior. Social learning, both from peers and from portrayals in media, may contribute to increases in self-harm behaviors, particularly among youth.
• Some portrayals in entertainment media (eg, 13 Reasons Why) have been criticized for potentially promoting self-harm as a coping strategy, while social media platforms may inadvertently promote harmful imagery. However, social media can also offer a supportive community, which may be beneficial for individuals who self-harm but feel isolated.

3. Psychosocial and Pharmacological Treatments:

• Psychosocial Interventions: There is limited high-quality evidence for effective psychosocial treatments. Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) show promise, particularly for reducing the frequency of self-harm, but evidence quality remains low.
• Pharmacological Interventions: There is minimal strong evidence for pharmacological treatments specifically targeting self-harm. While studies on lithium, clozapine, and ketamine show some promise, the focus has primarily been on suicide risk rather than self-harm behavior.

4. Health Care Responses:

• Many cases of self-harm, especially among adolescents and in LMICs, do not reach health care services. When individuals do seek help, a supportive and empathetic response from health care providers is crucial.
• Comprehensive psychosocial assessments can be therapeutic, though current risk assessment tools are often criticized for being unreliable and may even have unintended consequences. Evidence-based aftercare is essential, as the risk of repeat self-harm is high shortly after an incident.

5. LMIC-Specific Issues:

• Self-harm prevention in LMICs may require different approaches, focusing on addressing broader social issues, such as poverty and domestic violence, which drive self-harm risks. These interventions might benefit from community health workers who understand local needs and can help coordinate services.

This overview reveals the need for further research into the intersection of corporate, social, and health care factors in self-harm, as well as for the development of effective, context-specific interventions and policies.

Concluding Thoughts

The Lancet Commission has provided a valuable and rather comprehensive framework for examining what has historically been an under-addressed topic in behavioral health. Among its most distinctive contributions are its emphasis on the aspects of self-harm that transcend the individual and the biological with a particular emphasis on the sociological and structural factors that have driven the phenomenon—and the response of clinicians and policymakers—in LMICs, among LGBTIA+ populations and in indigenous communities. Yet the report is far more than a survey of the particular tools and treatments most effective in addressing this neglected scourge. Although never polemical in tone, the Commission’s report is a welcome call to action that has the potential to spur innovative thinking and a recalibration of priorities. These efforts are highly promising and long overdue.

Dr Husain-Krautter is a board-certified general and geriatric psychiatrist, as well as an assistant professor and attending psychiatrist at Icahn School of Medicine. She is a also a member of the Group for the Advancement of Psychiatry.

Dr Appel is professor of psychiatry and medical education at the Icahn School of Medicine at Mount Sinai in New York City, where he is director of ethics education in psychiatry, associate director of the Academy for Medicine and the Humanities, and medical director of the Mental Health Clinic at the East Harlem Health Outreach Program. He is the author of 19 books. He is also the vice president and treasurer of the National Book Critics Circle, cochair of the Group for the Advancement of Psychiatry’s Committee on Psychiatry & Law, and a councilor of the New York County Psychiatric Society and of the American Academy of Psychiatry & Law.

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