Influences on and prevention of self-harm behavior among the most at-risk adolescents: study protocol for the SH-MARA...

Both suicidal and non-suicidal self-injuring behaviors (NSSI) are common during adolescence In Slovenia, adolescent suicide rates are high, making suicide the leading cause of death in the year 2022 in this age group. These behaviors are influenced by a complex interplay of environmental, psychological, and genetic factors. Previous research has identified risk and protective factors mainly for suicidal behavior in adults, a notable gap in understanding these factors in adolescents remains, especially for NSSI. Notably there is an important lack of effective clinical tools or psychometric assessment methods to reliably assess the risk for either suicidal or NSSI behaviors in acutely hospitalized adolescents.

The proposed study uses a mixed-method observational design consisting of a prospective longitudinal cohort component involving adolescents hospitalized for high risk of DSH, and a cross-sectional comparison with a control group of healthy adolescents recruited from primary care settings. It is aimed at identifying genetic, psychosocial, and clinical factors associated with suicidal behaviors and NSSI in adolescents. The study group is recruited from adolescents aged 12-19, admitted to the Intensive Child and Adolescent Psychiatry Unit in Ljubljana due to severe self-harm risk. Exclusion criteria include involuntary treatment, acute psychotic disorders, intellectual disability, severe physical or central nervous system illnesses and acute intoxication. The control group comprises adolescents of comparable age, recruited through regular scheduled health check-ups in Slovenia. Exclusion criteria include suicidality, severe mental disorder, a history of self-harm behavior in a first-degree relative, intellectual disability, severe physical or central nervous system illnesses and acute intoxication. Enrollment runs from February 1, 2023, to December 31, 2025. Participation is voluntary, requiring parental or guardian consent for those 14 or younger. Data collection involves psycho-diagnostic tools assessing demographic, psychopathology, personality traits, trauma and traumatic events, and attachment patterns. Genetic analysis of blood samples will be performed using long-read sequencing to detect DNA methylation and bioinformatic tools for further analyses. Various statistical methods will be used to identify factors potentially linked to suicidality and NSSI. Additionally, the utility of a newly developed tool for the assessment of inpatient self-harm risk (Adolescent Self-Harm Risk Scale; ASHRS) will be tested. The efficacy of the proposed scale will be assessed using data on inpatient self-harm episodes, as well as subsequent suicidal and NSSI behavior collected during follow-ups at 6 and 18 months after the initial inpatient assessment. The study has been approved by the National Medical Ethics Committee of the Republic of Slovenia (No: 0120-507/2022/3) and financed by Slovenian Research Agency grants J3-4534, J5-50176 and P3-0343.

This study represents the first longitudinal examination of psychosocial and genetic factors associated with severest suicidal and NSSI behavior in the Slovenian adolescent population. The development of the ASHRS will add to the gap in the quick assessment of inpatient self-harm risk and better inpatient safety for adolescents.