Letter to the Editor

We read with interest the recent article on adolescent self-harm by Joel King and co-authors.1 It is important that clinicians, patients and families are aware of the lack of evidence for prescription medicines in this area, and the potential benefits of psychological therapies.

The need for new strategies to address adolescent self-harm is increasingly urgent. Child and adolescent self-harm is rapidly increasing in Australia.2-4 We found a 98% increase in self-poisonings in people aged 5–19 years in 2006–2016, with a cohort effect showing that those born after 1997 are particularly at risk. The peak age of self-poisoning is getting younger. There is also a large increase in dispensing of psychotropic drugs to this cohort, particularly antidepressants,2 despite the lack of evidence for benefits.

The article mentioned harm minimisation by prescribing limited quantities of drugs. However, the problems presented by over-the-counter medicines were not addressed. Paracetamol and ibuprofen are the top two drugs taken in overdose by young Australians2 and are widely available. Many countries do not allow non-pharmacy sales of these medicines,5 and in Denmark paracetamol can only be purchased by people aged over 18 years.6 The UK has restricted pack sizes of paracetamol to decrease harms from self-poisoning.7 Australia has room to move in this legislative space. The recent decisions by the Therapeutic Goods Administration to up-schedule modified-release paracetamol to Schedule 3 (Pharmacist Only) and paracetamol–codeine to Schedule 4 (Prescription Only) indicate the considerable scope for harm minimisation using strategic rescheduling.

Rose Cairns
Lecturer, School of Pharmacy, University of Sydney
Director of Research, NSW Poisons Information Centre, Children’s Hospital at Westmead, Sydney 

Jared A Brown
Co-head, NSW Poisons Information Centre, Children’s Hospital at Westmead, Sydney

Nicholas A Buckley
Professor of Clinical Pharmacology, University of Sydney
Clinical toxicologist, NSW Poisons Information Centre, Children’s Hospital at Westmead, Sydney

Nicholas Buckley has received National Health and Medical Research Council grant funding to support clinical toxicology
(including suicide) research.


Author's response

Sonja Cabarkapa, Joel King and Fiona Leow, the authors of the article, comment:

The letter makes some valuable comments, especially regarding the urgency of this issue which is indeed cause for concern. The focus of our article was to address the commonly raised questions around treatment of self-harm in a GP setting. The letter offers pertinent considerations in prevention by addressing the restrictions on the sale of over-the-counter medicines and the legislative changes made by other countries. Similar strategies should be considered by the Australian Government.

Recent evidence suggests that self-harm displayed on social media poses a risk to vulnerable users through exposure leading to contagion.8 This combined with unlimited multimedia access and cyber-bullying are additional social factors that need addressing. While not all self-harm behaviour is followed by suicide, patients who self-harm remain at significant and persistent risk of suicide.9 

Self-harm remains a multifaceted issue requiring prompt attention from a societal viewpoint and prospective studies in this area remain limited. Further research can identify strategies to help reduce rates of self-harm which should be a major priority for national suicide prevention programs.

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  1. King J, Cabarkapa S, Leow F. Adolescent self-harm: think before prescribing. Aust Prescr 2019;42:90-2.
  2. Cairns R, Karanges EA, Wong A, Brown JA, Robinson J, Pearson SA, et al. Trends in self-poisoning and psychotropic drug use in people aged 5-19 years: a population-based retrospective cohort study in Australia. BMJ Open 2019;9:e026001.
  3. Perera J, Wand T, Bein KJ, Chalkley D, Ivers R, Steinbeck KS, et al. Presentations to NSW emergency departments with self-harm, suicidal ideation, or intentional poisoning, 2010-2014. Med J Aust 2018;208:348-53.
  4. Hiscock H, Neely RJ, Lei S, Freed G. Paediatric mental and physical health presentations to emergency departments, Victoria, 2008-15. Med J Aust 2018;208:343-8.
  5. Morthorst BR, Erlangsen A, Nordentoft M, Hawton K, Hoegberg LC, Dalhoff KP. Availability of paracetamol sold over the counter in Europe: a descriptive cross-sectional international survey of pack size restriction. Basic Clin Pharmacol Toxicol 2018;122:643-9.
  6. Wastesson JW, Martikainen JE, Zoëga H, Schmidt M, Karlstad Ø, Pottegård A. Trends in use of paracetamol in the Nordic countries. Basic Clin Pharmacol Toxicol 2018;123:301-7.
  7. Hawton K, Bergen H, Simkin S, Dodd S, Pocock P, Bernal W, et al. Long term effect of reduced pack sizes of paracetamol on poisoning deaths and liver transplant activity in England and Wales: interrupted time series analyses. BMJ 2013;346:f403.
  8. Arendt F, Scherr S, Romer D. Effects of exposure to self-harm on social media: evidence from a two-wave panel study among young adults. New Media Soc 2019 May 27 [Epub ahead of print].
  9. Hawton K, Zahl D, Weatherall R. Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry 2003;182:537-42.

The Editorial Executive Committee welcomes letters, which should be less than 250 words. Before a decision to publish is made, letters which refer to a published article may be sent to the author for a response. Any letter may be sent to an expert for comment. When letters are published, they are usually accompanied in the same issue by any responses or comments. The Committee screens out discourteous, inaccurate or libellous statements. The letters are sub-edited before publication. Authors are required to declare any conflicts of interest. The Committee's decision on publication is final.

Rose Cairns

Lecturer, School of Pharmacy, University of Sydney

Director of Research, NSW Poisons Information Centre, Children’s Hospital at Westmead, Sydney

Jared A Brown

Co-head, NSW Poisons Information Centre, Children’s Hospital at Westmead, Sydney

Nicholas A Buckley

Professor of Clinical Pharmacology, University of Sydney

Clinical toxicologist, NSW Poisons Information Centre, Children’s Hospital at Westmead, Sydney

Sonja Cabarkapa

Psychiatry registrar, St Vincent’s Hospital, Melbourne

Joel King

Consultant child and adolescent psychiatrist and Psychiatry training coordinator, Professorial Unit, The Melbourne Clinic

Senior lecturer, Department of Psychiatry, University of Melbourne

Fiona Leow

Consultant psychiatrist, Eating Disorders Unit, Royal Melbourne Hospital