White Coat, Black Art·DR. BRIAN'S BLOG

Teens who visit ERs with self-harm injuries likely to repeat, new study suggests

New research has found that teens who visited the ER after self-harm were five times more likely to return than their peers who came to the hospital for other reasons, suggesting better interventions are needed to identify teens at risk of harming themselves again.

Researchers call for better tools to predict and prevent repeat self-harm injuries

New findings that teens who visited the ER after self-harm were five times more likely to return than their peers who came to the hospital for other reasons show more interventions are needed to identify and help adolescents at high risk of repeating self-harm, researchers say. (Photofusion/Shutterstock)

Emergency department visits for self-harm in adolescents have more than doubled in Ontario in the past 10 years. A study published Monday in the Canadian Medical Association Journal (CMAJ) concludes many of those teens are destined to become repeat visitors.   

Psychologist William Gardner, senior research chair in Child and Adolescent Psychiatry at the Children's Hospital of Eastern Ontario and the University of Ottawa, and co-authors examined data from 403,805 youth aged 13 to 17 years who visited emergency departments in Ontario between 2011 and 2013. Of the total, 5,832 were there because of self-harm.

In an effort to account for other variables that might lead to repeat visits to the ER, the researchers matched  5,661 of those teens with a control group of teens who had visited the emergency department and had similar characteristics such as sex, age, and psychiatric or medical diagnosis — but were not there because of self-harm.   

Teens who visited the ER with self-harm injuries were five times more likely to return to emergency departments repeatedly for subsequent episodes of self-harm, the study authors found. Their findings also suggested teens who had engaged in self-harm were three times more likely to die in general (from any cause) and eight times more likely to die from suicide than youth who had not harmed themselves. 

Not all of the close to 6,000 teens who came to the ER because of self-harm were destined to return repeatedly. But those who did were more likely to be younger and female. They were more likely to live in a rural part of the province. They were more likely to have had a concussion or a traumatic brain injury or epilepsy. They were also more likely to have a history of high-risk alcohol consumption.

This study dovetails with what I've seen as an ER physician — and it makes me wonder about how the ER experience itself might set up teens for repeat visits.

I think most ER personnel have a cognitive bias that makes them believe every patient with a mental health issue is a returning patient.

If one talks to teens and their parents, they would almost certainly identify their experience in the ER as unsatisfying for several reasons. They wait a long time to be seen and are not given adequate follow-up advice and appointments.

As is the case with adults, teens who come to the ER with self-harm and other mental health challenges find the experience stigmatizing and even demeaning. Many might say they wish there was another place for them to receive care.

There are several reasons that this study is important.

Repeat visits aren't good for teens.  They suggest that the underlying problems that led to self-harm are not being addressed during and following the ER visit. These include serious and complex mental health problems such as anxiety, mood disorders and substance use. The overall rate of suicide in this study was very low. Still, any completed suicide following a visit to the emergency room for self-harm is (tragically) a missed opportunity to change the risky course of a teen's life.

In addition, repeat visits increase the likelihood of stigmatization.

In economic terms, repeat visits are expensive for the system to manage. Compared to teens who do not have mental health challenges, the researchers estimated that teens who self-harm incurred $11,000 more in health-care costs over a five-year period. The authors say that cost estimate is conservative.

The authors say it should be possible to develop a tool that could be used to accurately predict the risk of readmission. Once identified, health care professionals should make certain those teens receive the care they need to reduce the need for repeat visits. In particular, the authors say teens who come to the ER after self-harm would benefit from assessment for mental health or substance misuse disorders and being connected to community services for treatment.

To make the ER experience better, it would be helpful to staff the ER with youth peer support workers. They are young individuals with shared lived experience with mental health challenges who have themselves navigated the ER and the mental health system. Some hospitals in Canada employ peer support workers for adults.

Given the trends, there is growing demand for peer support workers who focus on teens at risk.

Those of us who work in the ER should do everything in our power to help teens with mental health issues feel welcome, supported and respected.


Dr. Brian Goldman is a veteran ER physician and an award-winning medical reporter. As host of CBC Radio’s White Coat, Black Art, he uses his proven knack for making sense of medical bafflegab to show listeners what really goes on at hospitals and clinics. He is the author of The Night Shift and The Power of Kindness: Why Empathy is Essential in Everyday Life.