SOCIAL BEHAVIOR AND PERSONALITY, 2005, 33(8), 777-792 © Society for Personality Research (Inc.)
PREVALENCE OF DELIBERATE SELF-HARM IN TEENAGE STUDENTS IN THE STATE OF GUANAJUATO, MEXICO: 2003
CATALINA GONZÁLEZ-FORTEZA, MARGARITA ALVAREZ-RUIZ, ANDRÉS SALDAÑA-HERNÁNDEZ, AND SILVIA CARREÑO-GARCÍA Ramón de la Fuente Muñiz, National Institute of Psychiatry, Mexico ANA-MARÍA CHÁVEZ-HERNÁNDEZ AND ROSAURA PÉREZ-HERNÁNDEZ University of Guanajuato, Mexico
The presence of deliberate self-harm (DSH) among adolescents in Guanajuato State in 2003 was identified by sex, age, educational attainment and health jurisdiction and the charac- teristics were described by sex according to number of times, age of only/first/last DSH, motive, method, purpose and death wish. The sample design was stratified, bistage and by conglomerates. A total of 2,530 students from high school affiliated to the University of Guanajuato participated. The results showed that 3.1% of males and 10.7% of females had engaged in at least one episode of DSH; age of first DSH was 13 in both males and females; age at last DSH was 13 in males and 14 in females. The characteristics of the DSH were also described.
In Mexico, nearly 20% of its 97,483,412 inhabitants are aged between 10 and 19 (INEGI, 2000). In 2003, the population in Guanajuato state was 4,663,032, of whom 501,053 (10.7%) were teenagers between 15 and 19, with a male:
Dr. Catalina González-Forteza, Margarita Alvarez-Ruiz, Andrés Saldaña-Hernández, Silvia Carreño- García, Researchers at the Head Offices of Epidemiological and Psychosocial Research of the Ramón de la Fuente Muñiz, National Institute of Psychiatry, Tlalpan, Mexico; Ana-María Chávez- Hernández, Rosaura Pérez-Hernández, Researchers at the Faculty of Psychology, University of Guanajuato, Mexico. The authors would like to thank the adolescents who participated in the study, the school authorites who provided the facilities for carrying out the survey, and the Guanajuato State Population Council. Appreciation is due to reviewers including: Enrique Baca-Garcia, PhD, Servicio de Psiquiatria, Fundacion Jimenez Diaz, Avda. Reyes Catolicos, 2, Madrid, Spain 28040, Email:
THE PROBLEM OF SUICIDE Several disciplines have sought to explore the reasons behind this type of behavior in order to attempt to understand it, by distinguishing various stages that are part of a dynamic process, rather than being an isolated, static fact (Fergusson, Woodward, & Horwood, 2000). According to Durkheim (1974), suicide is a conscious, intentional act, the ultimate goal of which is one’s own death. Two categories of this phenomenon can be distinguished: consummated suicide, when the purpose of death is achieved, and parasuicide, which involves the suicide attempt and suicidal risk in different types. In the problem of suicide, self-inflicted harm also becomes an object of study, in that it is configured as parasuicidal behavior that threatens life, according to the type of injury and intention involved. On the one hand, there are nonsevere injuries, such as superficial cuts on the arms, which do not constitute a suicide attempt in the strict sense according to Durkheim’s definition, but which entail a self-destructive risk. On the other hand, there are injuries such as deep cuts involving blood vessels, nerves and tendons, as well as shooting, drowning, throwing oneself off a building, among other acts that can cause far more serious damage, which constitute a suicide attempt if the aim is to take one’s own life Distinguishing these conceptual categories is complex, since each of them involves a certain amount of risk, given that they are self-destructive forms of behavior that may be accentuated and therefore warrant attention and prevention, whether or not they are lethal (Hawton, Harriss, Simkin, Bale, & Bond, 2001). On the basis of the above, in this paper, deliberate self-harm (DSH) is referred to in the context of parasuicidal behaviors (Renberg, 2001). SELF-HARM AMONG MEXICAN TEENAGERS 779
PROBLEM OF SUICIDE IN ADOLESCENCE Studies conducted in Western countries indicate that the increase in the suicide rates of young people is a reflection of societies’ failure to provide appropriate places or sources of social identity and attachment, since they promote inappropriate, unreal expectations of individual freedom and autonomy (Eckersley, 2002). Moreover, in a country like Mexico, economic necessity is another factor that drives young people to seek sources of work in another country like the United States, with the hope of improving their living standards through a better paid job (Contreras, 1993). It is, therefore, important to identify parasuicidal behavior in Mexican teenagers, particularly from the state of Guanajuato, in order to be able to determine the scope of the problem and to design mental health prevention and promotion strategies for a potentially migrant population. The aims in this paper were to 1) determine the prevalence of deliberate self-harm (DSH) among teenage high-school students in the state of Guanajuato, Mexico, according to the following indicators: sex, age, school year and geographical jurisdiction within the state; and 2) describe the characteristics of the only/last DSH in males and females according to: number of times (to determine single and recurrent DSH), motives, methods, age at only/first time and age at last time.
METHOD
POPULATION AND SAMPLE Two-stage random sampling by conglomerate was carried out. The survey was conducted during the 2002-2003 school year in Guanajuato, León, Irapuato, Salamanca, Celaya, Penjamo, Salvatierra, San Luis de la Paz and Silao, the municipalities where the high schools affiliated to Guanajuato University are located. The Mexican educational system is divided into three periods, primary school starting at six years old and lasting six years, secondary school starting at 12 years old for a period of three years, and high school for another three years. Of the 9,569 students in these high schools (UG, 2003), the representative sample calculated was 2,799 students belonging to 62 groups in three school years, considering a 10% rate of nonresponse. The total of questionnaires applied was 2,531, owing to the fact that some students no longer belonged to the educational system or failed to attend on the day of the questionnaire. A total of 1,154 males (45.6%) and 1,376 females (54.4%) participated, with a mean of age of 15.7 for both sexes. A total of 43.9% were enrolled in the first year of senior high school, 29.6% were completing the second year, while 29.6% were in their third year. The majority (92.2%) were full-time students, and 11.3% had worked and studied during the previous school year. Most of the students reported having lived mainly in an urban context: 19.6% in a large city, 47.8% in a medium- 780 SELF-HARM AMONG MEXICAN TEENAGERS sized city and 21.1% in a small city, while only 11.6% reported having lived in villages or hamlets. As for the educational level of the head of the household – in other words, the person male/female who contributed the greatest amount of money towards the support of the family – 35% had completed up to primary or secondary school, 22.8% had finished senior high school, 23.9% had obtained a university degree and 13.7% had pursued postgraduate studies.
INSTRUMENT In terms of the objectives of this study, the sections analyzed were: sociode- mographic data and the Parasuicidal Indicators Record (“Cédula de Indicadores Parasuicidas: CIP”) in a self-applicable format (González-Forteza, 1996) which has been widely used to identify the prevalence of parasuicidal behavior in representative samples of teenage students in Pachuca City, the capital of the state of Hidalgo-(González-Forteza, Mariño, Rojas, Mondragón, & Medina- Mora, 1998) and three measurements in Mexico City: 1997, 2000 and 2003 (González-Forteza, Villatoro et al., 2002; Villatoro et al., 2004). In addition to using it in studies to identify protective and risk factors from the psychosocial perspective of everyday stress (González-Forteza, Ramos, Caballero & Wagner, 2003), the CIP permits the identification of the occurrence of DSH at any time in one’s life, number of times, age at last or only time, age at last time, motives, methods, death wish and purpose. Motives, methods and purposes were reported in the form of open questions, in order to obtain the range of possibilities of the teenagers’ own reports. The category of analysis to identify the prevalence of DSH at any time in one’s life were evaluated with reference to an affirmative response to the filter question: “Have you ever hurt, cut, intoxicated or harmed yourself on purpose to take your life?” and all other questions of the CIP were also congruously answered.
PROCEDURE The operative design of the survey included a central coordinator, two supervisors and 30 interviewees. The training course, lasting 18 hours, included conceptual aspects related to the aims of the study, the management of the questionnaire and instructions for its application and the selection of groups. The ethical aspect involved was anonymity. According to the guidelines of the sampling procedure, the coordinator and the interviewees carried out a selection of groups in the schools and administered the self-applicable questionnaires. A computer program was designed to verify the congruence of the information. Answers to the open questions were recorded verbatim, and for the analysis of content four judges used the deductive method to define the categories regarding motives, methods and purposes of the only and last DSH registered. SELF-HARM AMONG MEXICAN TEENAGERS 781 RESULTS
PREVALENCE OF DELIBERATE SELF-HARM IN THE STATE OF GUANAJUATO Guanajuato State is located in the central part of Mexico, 365 km from the capital, Mexico City. Overall prevalence of DSH was 7.2%, with a male/female ratio of 1:3, since the rate for males was 3.1% and for females was just over three times this: 10.7%. Table 1 provides an analysis of the prevalence in each Health Jurisdiction in the Health Secretariat (Figure 1) showing that 63% of the Health Jurisdictions reported a prevalence over the state mean of 7.2%; No. 1 (including the city of Guanajuato, the state capital) with 22.4%, No. 7 (comprising the city with the highest degree of urban and industrial development in the state, León), with 17.5%, No. 6 (with major cities such as Moroleón, Salamanca and Valle de Santiago, cities with an enormous migratory flow to the US) with a prevalence of 16.9%, No. 3 (whose main city is Celaya) with 15.8% and No. 8 (whose main city is Silao) with 11.5%.
Guanajuato: 365 km from Mexico City
Figure 1: Location of Health Jurisdictions in Guanajuato
As for the frequency of DSH, Table 2 shows that just over half of both males and females reported having harmed themselves with the aim of taking their lives just once in their lifetime; 58.3% and 59.9% respectively (single incidence of parasuicidal behavior), and therefore a significant proportion of both males and females reported having done so twice or more in their lives: 41.7% and 40.1% respectively (recurrent parasuicidal behavior). The mean number of times in males was 3.13 ± 1.4 with a range of 2 to 5 times – whereas in females it was 3.7 ± 3.0 with a range of 2 to 20 times in their lives. 782 SELF-HARM AMONG MEXICAN TEENAGERS TABLE 1 PREVALENCE OF DELIBERATE SELF-HARM IN THE STATE OF GUANAJUATO
Prevalence Overall 7.2 By Sex* Male 3.1 Female 10.7 By Age 14 or less 5.6 15 to 17 7.3 18 or more 9.8 By Schooling 10th grade 7.5 11th grade 7.7 12th grade 6.4 By Health Jurisdiction** Prevalence 1 Ocampo, San Felipe, San DiegoDolores Hidalgo, Gto 22.4 2 San Miguel Allende, San José Iturbide, Tierra Blanca, Dr. Mora, Sta. Catarina, Atarjeo, Xichú, Victoria, San Luis De La Paz 3.3 3 Cortazar, Celaya, Apaseo El Alto, Apaseo El Grande, Comonfort, Sta Cruz, Villagrán 15.8 4 Salvatierra , Maravatio, Acámbaro, Tarandacuao, Coroneo, Jerécuaro, Tarimoro 4.4 5 Irapuato, Pueblo Nuevo, Abasolo, Huanimaro, Cuerámaro, Penjamo 4.9 6 Salamanca, Valle De Santiago, Yuriria, Moroleón, UriangatoJaral Del Progreso, 16.9 7 León 17.5 8 Silao, San Fco Del Rincón, Romita, Purísima Del Rincón, Manuel Doblado 11.5
*x2= 51.230, gl=1, p=.000** Municipalities grouped together by Health Jurisdiction, according to Health Secretariat
TABLE 2 DELIBERATE SELF-HARM: SINGLE OR RECURRENT, BY SEX: 2003
DSH – Males (n=36) Females (n=146) (number of times) F % F % Single (once) 21 58.3 88 59.9 Recurrent (twice or more) 15 41.7 59 40.1 t=-.518, gl=180, p=.605 t-test the age at only/ first time and age at last time x s x s Only/First 13.0 2.6 13.3 1.8 t=-.519, gl=43.979, p=.606 Last 13.7 2.2 14.0 1.7 SELF-HARM AMONG MEXICAN TEENAGERS 783 The analysis of the age at which DSH was carried out was based upon single/ recurrent parasuicidal behavior. For starting age or single behavior, the results showed a similar profile in males and females, since the only or first DSH occurred at the age of 13.0 ± 2.6 and at the age of 13.3 ± 1.8 years, respectively; whereas among those with recurrent behavior, the age at the last DSH was similar by sex: at 13.7 ± 2.2 and 14.0 ± 1.7, respectively, without significantly statistical differences. The time between the first and last DSH was less than a year in both sexes, at ages when students are generally in the last two years of primary education (5th, 6th grades) or secondary education (7th, 8th and 9th grades). Given that the mean age of students at the time of the survey was 15.7 ± 1.0, the last DSH may have occurred approximately two years previously, in both males and females, indicating that most students engaged in this conduct while they were at secondary school.
CHARACTERISTICS OF DELIBERATE SELF-HARM, BY SEX Motives Table 3 shows the motives by categories: 1) Emotional sphere (males = 52.8%, females = 45.9%); 2) Interpersonal (males = 30.6%, females = 43.8%); and 3) Trigger events (males = 8.3%; females = 8.2%), without statistical differences by sex. In the emotional sphere, the most frequent motives in both sexes were “Personal problems” and “Loneliness.” In males, a common reason was “Lack of affection-love”. It is worth noting that the range of motives was almost three times broader in females (21 vs. 8). In the interpersonal sphere, “Family problems” was the most common motive in both sexes (males = 11.1%, females = 20.5%) with a slightly higher density in females. In most cases, the interpersonal sphere was related to the family sphere, specifically parents, followed by peer relations (friends/boyfriend). As for the trigger events, the proportion was similar for both sexes. The range of responses was just over twice as broad in females. The potential severity of the effect of each event obviously varies widely, some of the main trigger events in females being, “Loss of a loved one”, “Death of my mother”, “Rape, abuse, sexual harassment”, and “My abortion”.
TABLE 3 MOTIVES FOR DELIBERATE SELF-HARM, BY SEX: 2003
Male Female Motives (n = 36) (n = 146) F % F % EMOTIONAL SPHERE1 19 52.8 67 45.9 Personal Problems 5 13.9 20 13.7 Loneliness 4 11.1 10 6.8 Lack of affection-love 4 11.1 3 2.1 Low self-esteem 2 5.6 7 4.8 784 SELF-HARM AMONG MEXICAN TEENAGERS Table 3 continued
Male Female Motives (n = 36) (n = 146) F % F % Anger 1 2.8 1 0.7 Curiosity 1 2.8 1 0.7 Inability to get on with life 1 2.8 ------I didn’t care about my existence 1 0.7 ------Depression ------7 4.8 Felt misunderstood ------4 2.7 Experimentation ------2 1.4 Psychological problems ------1 0.7 Insecurity ------1 0.7 Felt bad ------1 0.7 Did not want to cause the family problems ------1 0.7 Felt s/he was a nuisance ------1 0.7 Feeling of emptiness ------1 0.7 Frustration ------1 0.7 Was fat ------1 0.7 Nothing encouraged me to go on ------1 0.7 My life was meaningless ------1 0.7 Confusion ------1 0.7 Entertainment/ passion ------1 0.7 INTERPERSONAL SPHERE1 11 30.6 64 43.8 Family problems 4 11.1 30 20.5 Problems with mother 1 2.8 8 5.5 End of relationship 1 2.8 7 4.8 Problems with friends 1 2.8 5 3.4 Problems at school 1 2.8 3 2.1 Problems with parents 1 2.8 2 1.4 Parental indifference 1 2.8 2 1.4 Rejection 1 2.8 1 0.7 Betrayal of friends/boyfriend ------3 2.1 Problems with father ------2 1.4 Distancing from parents ------1 0.7 TRIGGER EVENTS1 3 8.3 12 8.2 Sickness 1 2.8 1 0.7 Pressure 1 2.8 1 0.7 To avoid work 1 2.8 ------Loss of a loved one ------4 2.7 Rape-abuse-harassment ------3 2.1 Death of mother ------1 0.7 Physical blows ------1 0.7 My abortion ------1 0.7 OTHER ANSWERS1 3 8.3 3 2.1 1 x2= 2.549, gl=2, p=.280 SELF-HARM AMONG MEXICAN TEENAGERS 785 Methods Table 4 shows that the majority of males and females used sharp objects to harm themselves (55.6% and 45.6%) followed by pills and/or medication, although this was more common in females (males = 22.2%, females = 44.2%), and a variety of other methods were more frequent in males = 22.2% (females=10.3%) with significantly statistical differences (x2=7.50, p=.024). Males reported more methods such as intoxication by poison or gas (8.3%) which females did not report, or throwing themselves off heights or under cars (5.6% vs. 2.7%). Likewise, only males reported using firearms (2.8%), females did not report this method. At the same time, only females reported trying to drown (2.0%) or hit themselves (0.7%).
TABLE 4 METHODS OF DELIBERATE SELF-HARM, BY SEX: 2003
Male Female Methods (n = 36) (n = 146) F % F % SHARP OBJECTS* 20 55.6 67 45.6 PILLS / MEDICATION* 8 22.2 65 44.2 OTHER METHODS* 8 22.2 15 10.3 Intoxication by poison or gas 3 8.3 -- --- Throwing oneself off a high building or under a car 2 5.6 4 2.7 Strangling /asphyxiation 1 2.8 4 2.7 Stopping eating / Taking medication 1 2.8 3 2.0 Firearm 1 2.8 -- --- Drowning -- --- 3 2.0 Hitting oneself -- --- 1 0.7 * x2= 7.497, gl=2, p=.024
Purposes Table 5 shows that males and females reported that they “Wanted to die or stop living” (33.3% and 31.5%) more than any other reason for their behavior. In view of the open answer format, it is interesting to observe the range of answers attributed to the purposes of DSH, in which both sexes displayed a similar profile, since after the goal of wishing to die, both sexes (³ 10%) reported that they had engaged in DSH as an “Attempt at a solution” (19.4% and 22.6%), followed by “Other purposes” (nonspecific answers) (19.4% and 15.1%), without significantly statistical differences by sex. 786 SELF-HARM AMONG MEXICAN TEENAGERS TABLE 5 PURPOSES OF DELIBERATE SELF-HARM, BY SEX: 2003
Male Female Purposes (n = 36) (n = 146) F % F %
Die or stop living1 12 33.3 46 31.5 Attempt at solution1 7 19.4 33 22.6 Different purposes1 17 47.2 37 45.9 Other answers 7 19.4 22 15.1 Escape or flight 4 11.1 10 6.8 Because of other people 3 8.3 15 10.3 Self-destructive or taunting behavior 2 5.6 12 8.2 Confused response 1 2.8 4 2.7 To gain acceptance ------4 2.7 1 x2= .172, gl=2, p=.917
Death wish According to Guertin, Lloyd-Richardson, Spirito, Donaldson, and Boergers (2001) the death wish is an indicator of lethality in suicidal behavior. “The only or last time you harmed yourself to take your life…” The options were: “I didn’t want to die, I wanted to go on living,” which refers to the lowest level of death wish, “I did not care whether I lived or died,” which indicates a higher death wish, and “I wanted to stop living, I wanted to die” denoting the highest level of death wish. Table 6 shows that the profile of death wish level was similar in both sexes, without significantly statistical differences. The majority replied that they did not care whether they lived or died (males=63.9%, females=47.9%), followed by the answer denoting that they wanted to stop living or die (males=25.0%, females=31.5%), and to a lesser extent, that they had engaged in DSH without wanting to die, they wanted to go on living (males=11.1%, females=20.5%). It is worth noting that the proportion of males and females who engaged in DSH with the aim of wanting to stop living or to die also corresponded to the proportions of the aim: to die/stop living, which accounted for 33.3% males and 31.5% females (see Table 5). If one considers the presence of the death wish implicit in DSH in a strict sense, either because it was explicit (“I wanted to stop living, I wanted to die,” or because it was expressed as a possibility, “I didn’t care if I lived or died,” then 32 out of the 36 males with DSH (88.9%) and 116 of the 146 females who reported DSH (79.4%) were seriously at risk of committing suicide, since the death wish was both purposeful and conscious. Seen from another point of view, since DSH includes suicide attempts and on the basis of the conceptual proposal of Guertin et al. (2001) where a suicide attempt is defined as deliberate self-harm with the conscious, purposeful desire to die, then the prevalence of suicide attempts in this SELF-HARM AMONG MEXICAN TEENAGERS 787 representative sample of senior high school students in the state of Guanajuato was 7.2%, with 2.8% males and 8.4% females.
TABLE 6 DEATH WISH OF DELIBERATE SELF-HARM, BY SEX: 2003
Male Female Death wish (n = 36) (n = 146) F % F %
Did not care if s/he lived or died 23 63.9 70 47.9 Wanted to stop living 9 25.0 46 31.5 Did not want to die, wanted to go on living 4 11.1 30 20.5 x2= 3.218, gl=2, p=.200
DISCUSSION
Studies conducted in Mexico with representative samples of students, using the same (self-applicable) “Cédula de Indicadores Parasuicidas” (CIP) as in this study have revealed the presence of parasuicidal behavior: DSH among teenage student populations, with a higher proportion among females. In the city of Pachuca, the capital of the state of Hidalgo, the ratio was 2:1, 13.3% in female and 6.3% in male secondary and senior high school students (González-Forteza, Mariño, et al, 1998). In Mexico City, three measurements of teenage students have been carried out, showing an increase in DSH. Senior high school students showed rates of 8.8% in 1997, with a 3:1 ratio, 15.1% females and 3.9% males (González-Forteza, & Villatoro et al., 2002) and a ratio of 2:1 in 2003, with 10.7% females and 3.1% males. These prevalence rates are significant, meaning that epidemiological monitoring is a significant resource for supporting decision making in the field of public health. It is also worth noting that the highest prevalence of DSH was located in the health jurisdictions in which the main cities in the state are located, in other words, with a higher index of urbanization (INEGI, 2000). In comparison, in Great Britain in the year 2000, the Survey of Psychiatric Morbidity in Adults revealed that 2.9% of men and 7.8% of females, between 16 and 24 years old, had shown nonfatal suicidal behavior (Meltzer et al., 2002). In a study by the University of Oxford it was found that in the year 2002 in the city of Oxford, the number of hospitalized 15- to 24-year-olds, both genders, had decreased by 3.8% (Hawton, Casey, Simkin, Bale, & Shepherd, 2002). Available data for hospital admissions for deliberate self-injury in Australia in 1992-1993 showed a higher overall incidence of females receiving hospital- based care for self-inflicted injury. They also showed clearly that the rates of 788 SELF-HARM AMONG MEXICAN TEENAGERS self-harm for both males and females peak in the 15 to 24 age group (AIHW, 1997). From both these figures and those from the present study, it can be seen that the population of adolescents and young adults are at risk – particularly the females – and in countries with urbanized populations, these facts accentuate the importance of more research and more reliable measures of DSH. Since parasuicidal behavior involves a range of behaviors, in this study we refer to DSH as a broad, conceptual construct that includes suicide attempts. According to Guertin et al. (2001), an element that can help distinguish suicide attempts is the intentionality underlying DSH, such as the strength of the death wish involved. With this in mind, in a strict sense the prevalence of suicide attempts in high school students in Guanajuato was 7.2% overall: 2.8% in males and 8.4% in females. In order to determine the percentage of DSH that implies suicide attempts, according to Guertin et al.’s proposal, the filter indicator: “Have you ever hurt, cut, poisoned or harmed yourself to take your life?” was correlated with the indicator referring to the conscious death wish involved, showing that 88.9% of males and 79.4% of females that reported DSH specifically corresponded to the conceptual category of suicide attempts. At the same time, the open answer to the question referring to the aim of DSH, “Why did you do it?” – in other words, the underlying purpose – showed that the proportions identified with the aim of “Dying, stopping living” are similar to those identified in the indicator of intentionality, “I wanted to stop living, I wanted to die” in just over 30% of males and females. Thus, this filter indicator can be said to record DSH with a broad margin of certainty regarding suicide attempts in particular. Obviously, in order to obtain a self-applicable instrument for surveys, certain issues must be resolved to delimit more accurately parasuicidal behavior in all its complexity. For example, lethality indicators – such as the use of emergency services, medical care, mental health care – must be incorporated as well as the clinical validation (concurrent validity) of DSH: Cédula de Indicadores Parasuicidas (González-Forteza, 1996) on which a project is currently being undertaken1. Another element which, according to Beautrais (2003), should be distinguished in DSH as well as in suicide attempts is the lethality of the method used, which can be divided into two categories: highly lethal, such as hanging, firearms, jumping, vehicle exhaust gas, and less lethal, such as self-poisoning, cutting and all other methods. Within this line of thought, it is worth noting that in this study, most males (77.8%) and females (89.8%) used sharp objects or medication, both methods with a low level of lethality. Conversely, of the highly lethal
1 Project financed by CONACYT (44915) and INP (4133): Towards the Prevention of Depression and Suicide Risk: use of services, detection and psychoeducational strategy in secondary school students. SELF-HARM AMONG MEXICAN TEENAGERS 789 methods, both sexes recorded throwing themselves off high buildings (5.6% males and 2.7% females), strangling or suffocating themselves (2.8% and 2.7% respectively) whereas only the males reported intoxication by poison or gas (8.3%), and use of firearms (2.8%). These data coincide with the international literature, in the sense that males tend to use more lethal methods, meaning that their suicide attempts are more successful (Beautrais, 2003). However, it has also been acknowledged that taking medication and using sharp objects, although less lethal, can also constitute lethal methods that may lead to suicide (such as fatal poisoning, deep cuts in the veins or arteries). The risk of suicide among the teenagers in this study is therefore considerable and should be taken into account. At the same time, it is essential to incorporate more indicators on the lethality of suicide in order to obtain a more accurate picture of the wide spectrum of the problem of suicide. Another key aspect of this study is that 40% of teenagers (males and females) have engaged in two or more DSH (recurrent parasuicidal behavior) which is considerably higher than the rate found among Mexico City students, which was 21% in 1997 and 27% in 2000 (González- Forteza et al., 2002). As for the DSH indicator, Guertin et al. (2001) note that self-mutilating behavior, unlike suicide attempts, is often described as a highly repetitive act, exemplifying a study where the number of episodes ranged from 2 to over 100, with an average of 21 per person. The results of this study show that this behavior is closer to suicide, since in males, the average was 3, with a range of 2 to 5 times, whereas in females it was 4, with a range of 2 to 20 times. Since this study explored the DSH that had occurred “at some time in one’s life” it determined the age at the only/last time when it had happened in teenagers and the results showed that the lapse between the first and last DSH (recurrent parasuicidal behavior) was less than a year in both sexes. The fact that several students reported over two episodes of DSH highlights the urgent need to deal with this problem in teenagers. The study also showed that most DSH occurred when students were enrolled in the secondary educational level. These data show that it is important to implement preventive strategies in both primary and secondary schools, and that, at the elementary level, it would be useful to orient efforts towards the promotion of mental health (before the first DSH) These data coincide with those identified in the 1997 and 2000 measurements in Mexico City (González-Forteza et al, 2002). Among the motives for DSH reported by students, those involving the emotional sphere were the most common in both sexes (53% in males and 46% in females) followed by motives associated with the interpersonal sphere (31% and 44% respectively). It is worth considering that motives in the emotional sphere may be derived from interpersonal relations, with the motives for DSH being widely attributed to emotions drawn from these relations, which usually 790 SELF-HARM AMONG MEXICAN TEENAGERS involve depression, anger and low self-esteem. It should be noted that a higher proportion of males reported having feelings of loneliness and lack of affection in comparison with females. These results are also consistent with the data found in Mexico City surveys, meaning that it is crucial to orient prevention efforts towards handling feelings related to loneliness and vulnerability in both sexes, particularly among males, who – because of gender impositions – do not tend to be aware of these feelings, much less express them, since they are not considered appropriate within the sphere of masculinity. An analysis of the motives in the interpersonal sphere showed that the two main areas of conflict were the family (parents) and their relationship with their peers (friends, partners). These two areas of life are crucial in adolescents’ development and can therefore be configured as either risk factors or protective factors that promote resilience. It is, therefore, essential to incorporate them into mental health prevention and promotion strategies for adolescents. Registering the trigger events leading to DSH, the results showed that dealing with mourning is an important component to be considered in prevention strategies and that situations involving sexuality and violence (such as rape and abortion) must be dealt with to prevent suicidal risk. Another striking aspect that emerged from the open question format is that the repertoire of answers and motives attributed to DSH as regards trigger events is broader in females than in males, in both the emotional and interpersonal sphere. This is interesting and opens up the possibility of considering thought processes and cognitive structures as an object of study, in order to understand these differences on the one hand and to fine-tune the written communication produced in surveys through self-applicable instruments. The results of this study show that parasuicidal behavior in senior high school students in Guanajuato is a major public health problem that must be dealt with promptly using suicide risk prevention strategies and mental health promotion. Moreover, given that this also constitutes a serious problem in Mexico City (González-Forteza et al., 2002) which has been shown to be on the increase, it is important to monitor the problem of suicide in the various Mexican states periodically
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