Introduction
Self-harm or self-injury is seen as a way for dealing with emotional problems, anger, depression, and distress [1]. Deliberate self-harm is defined as the intentional direct and indirect harm the self [2]. It is a behavior that causes minor or severe physical injury. For example, trying to burn oneself, head banging, jumping from high places, poisoning oneself without attempting suicide [1], cuting/scratching the skin, and preventing wounds from healing [2]. Self-harm behavior is a wrong way to cope with psychological distress. This behavior is a risk factor for suicide [3]. The most common type of self-harm behavior is self-cutting which usually occurs on the forearm or wrist [4]. In addition to physical consequences, self-harm behaviors have psychological outcomes [5]. Self-harm behaviors may be associated with various disorders, including substance abuse, post-traumatic stress disorder, severe depression, anxiety, schizophrenia, and personality disorders (especially borderline personality disorder) [6], most common of which are anxiety and depression [7]. In a study on 140 high school students in southern Taiwan, the correlation between self-harm behaviors and depressive symptoms was positively significant, and depressive symptoms could significantly predict self-harm behaviors [8]. In a study by Zubrick et al. on Australian adolescents aged 12-17 years with a major depressive disorder, it was found that depressive symptoms were related to non-suicidal self-harm and suicidal ideation [9]. Morgan et al. in a study on 1943 adolescents in Australia, also reported the significant relationship of depression and anxiety with self-harm behaviors [10]. Several studies have shown the effect of stress on self-harm behaviors [11, 12]. For example, Hinze et al. in 2021, showed an association between stressful life events and self-harm behaviors in youth [13].
The results of a meta-analysis showed that, in 686, 672 children and adolescents from different countries, the lifetime prevalence of non-suicidal self-injury was 22.1% and its 12-month prevalence was 19.5% [14]. The prevalence of self-harm behaviors in European adolescents was reported at 25-35% [15]. In China, the prevalence of self-harm behaviors in 4,176 adolescents from senior middle schools was 27.6%. Being female, living in a urban area, being an only child, poor school performance, stressful life events, strict parenting style, and poor mental health were the risk factors for self-harm behaviors [16]. In Irland, the prevalence of self-harm behaviors in adolescents was reported 10%. Alcohol use, drug use, physical and sexual abuse, and low self-esteem were associated with self-harm in girls, while lack of physical activity, sexual orientation concerns, anxiety, and impulsivity were risk factors in boys [17]. The findings of a study in southern Iran reported self-harm behaviors in 2166 individuals (Mean±SD age=25.7±2.6 years) from 2007 to 2011, which were more frequent in male, low-educated, and unemployed individuals [18]. Another research in Iran showed a self-harm prevalence of 40.5% in 100 male and 100 female college students, which were more prevalent in males (48%) than in females (33%) [19].
Self-harm has increased among secondary and high school students; hence, it should be considered as one of the major public health concerns in adolescents [20, 21, 22, 23]. Despite the high prevalence of self-harm in adolescents [24], few studies have assessed it in Iran. It is necessary to pay more attention to the mental health of adolescents and take decisive measures to prevent and address their mental and behavioral problems. In this regard, this study aims to determine the prevalence of self-harm behaviors in high school students in Rasht, northern Iran, and assess its relationship with anxiety, depression, and stress.
Materials and Methods
This is a cross-sectional study conducted from January to July 2018. The study population consists of all high school students (Grade 7-12) in Rasht, Iran. After obtaining permission from the Education Organization in Guilan province, eight high schools in Rasht were selected through multistage cluster random sampling method based on different educational districts of Rasht city and gender of students. From each school, different classrooms were selected by cluster random sampling method and from each class, students who were willing to participate in the study were selected. The sample size was estimated 411 according to Ross’s study [25], where the self-harm prevalence was 13%, and considering a test power of 90% at 95% Confidence Interval (CI). Since the cluster sampling method had been used, and considering the design effect, the sample size was increased by 1.5 times and reached 617.
The data collection tools included a demographic form (surveying age, gender, Grade Point Average (GPA) of the past year, family size, history of suicide or self-harm in the family and close relatives, and history of substance abuse and smoking), and the 21-item Depression, Anxiety, and Stress Scale (DASS-21) where each question is rated on a scale from zero (Did not apply to me at all) to 3 (Applied to me very much). Based on this scale, the severity of depression (Scores 0–9 indicates no depression; scores 10–13, mild depression; scores 14–20, moderate depression; scores 21–27, severe depression; and scores ≥28, extremely severe depression), anxiety (scores 0–7 indicates no anxiety; scores 8-9, mild anxiety; scores 10–14, moderate anxiety; scores 15–19, severe anxiety; and scores ≥20, extremely severe anxiety), and stress (scores 0–14 indicates no stress; scores 15–18, mild stress; scores 19–25, moderate stress; scores 26–33, severe stress; and scores ≥34, extremely severe stress) are determined [26]. Henry et al. performed a factor analysis on this instrument and confirmed its validity and reliability [27]. In our study, the Persian version of this scale was used [28]. For measuring self-harm behaviors, we used the Self-Harm Inventory (SHI) developed by Sansone et al., which consists of 22 items with dichotomous scoring (yes/no) assessing the direct and indirect self-harm behaviors. Higher scores of this scale indicate higher severity of self-harm behaviors. In this study, zero indicates no any self-harm behavior while score 1 and higher represents different degrees of self-harm behaviors. The relationship between self-harm behaviors and other variables were scored from 0 to 22 [29]. Since this scale had been previously used in Iranian studies [30, 31], we used the Persian version of this questionnaire localized by Tahbaz Hoseinzadeh et al., who confirmed its validity and reliability [32]. For determining the reliability of SHI in the present study, we tested it on 30 students as a pilot study, and its internal consistency using Cronbach’s alpha was obtained 0.87, indicating its good reliability. In this study, the second question was used to assess deliberate self-cutting (Cut yourself on purpose? If yes, number of times).
After sufficient explanations about the study objectives and procedures, the students filled out the questionnaires. Incomplete questionnaires were excluded. The collected data were analyzed in SPSS v. 21 software. We used Mean, Standard Deviation (SD), frequency, independent t-test, Kruskal-Wallis test, one-way analysis of variance, chi-square test, Fisher’s Exact test, and linear and logistic regression in data analysis. The statistically significance level was set at 0.05.
Results
Of 640 students, 617 completed the questionnaires. Therefore, the response rate was over 96%. The mean age of students was 16.11±1.35 years and their mean GPA for the past year was 18.92±1.21. Most of them had a family size of 4 people; 5% had a history of suicide in their family or relatives; 6.3% had a history of self-harm behaviors in their family or relatives, and 7.5% had a history of substance abuse in their family or relatives. The frequency of self-harm behaviors was 339 (54.9%), 69 in girls (20.3%) and 270 in boys (79.7%). The mean score of SHI was 2.37±3.42 (ranged 0-22). It was found that 68 (11%) had deliberate self-cutting.
Table 1 shows the mean scores of SHI in terms of demographic variables and levels of depression, anxiety, and stress.


The mean SHI scores were significantly different in terms of gender, grade, age, GPA of the past year, and levels of depression, anxiety, and stress. There was also a significant difference between SHI scores in terms of substance use and family history of self-harm or suicide (P=0.001). The mean of SHI was higher in students with a history of substance use and family history of self-harm or suicide. Most of the students had no depression, anxiety, or stress (86.9%, 88.2%, and 96.1%, respectively).
Table 2 presents the frequency of deliberate self-cutting in terms of demographic variables and levels of depression, anxiety, and stress.


According to the results, deliberate self-cutting was significantly more in students with a history of substance use and with family history of self-harm or suicide (P=0.001). The frequency of deliberate self-cutting was significantly different among students with different levels of depression, anxiety, and stress (P=0.001). Students with moderate depression and stress, and severe anxiety showed more deliberate self-cutting behaviors.
Based on the results of linear regression (Table 3) by backward selection method, the variables of gender, grade, family size, age, and GPA of the past year had relationship with self-harm behaviors.


In boys, the score of SHI was significantly higher than in girls (B=0.704, 95% CI; 0.149-1.258, P=0.013). Moreover, the score of SHI was higher in students with more family members (B=0.620, 95%CI; 0.344-0.895, P=0.001) and older age (B=0.624, 95%CI; 0.286-0.962, P=0.001), while it decreased by the increase of grade (B=-1.011, 95%CI; -1.517- -0.504, P=0.001). Table 4 presents the simultaneous relationship between independent variables and deliberate self-cutting using logistic regression model.


Only the variables of gender, GPA of the past year, substance use, depression, stress, and father’s education remained in the model. According to the results, deliberate self-cutting was 4.87 times more common in girls than in boys (OR=4.874, 95%CI; 2.297-10.344, P=0.001), and 7.97 times more common in those with a history of substance use than in non-abusers (OR=7.972, 95%CI; 3.424-18.564, P=0.001). Moreover, deliberate self-cutting was more common in students whose fathers had a high school diploma than in those with fathers having other educational levels (OR=7.897, 95%CI; 1.138-54.807, P=0.037). 
Discussion 
This study investigated the prevalence of self-harm behaviors and deliberate self-cutting among high school students and its relationship with depression, anxiety, and stress. According to the results, more than half of the students had self-harm behaviors. We reported higher frequency of self-harm behaviors compared to other studies. There are several factors to explain this result, such as substance use, internalized anger, and despair associated with socio demographic status. This result is consistent with the results of Lim et al., who reported that in non-western countries, the youth had suicide thoughts but did not attempt suicide [14]. 
In our study, in five students with self-harm behaviors, one was female and four were male, but girls had more deliberate self-cutting. Some studies have shown higher risk of self-harm behaviors in girls than boys [16, 20, 22]. However, studies in Iran have reported similar results [18, 19]. This result may be due to cultural issues; boys in developing countries have easier access to a variety of materials such as alcohol and other substances, but the most accessible way for self-harm in girls is the razor blades; of course, this is an advantage that should be easily hidden [18, 19]. In this study, self-harm behaviors and deliberate self-cutting significantly increased with the increase of depression, anxiety, and stress. Similar to our results, other studies demonstrated a significant relationship between depression and self-harm behaviors, such that the likelihood of self-harm behaviors increases as the depression level increases [8, 9]. According to a narrative review in Iran, mental disorders such as depression are associated with self-harm behaviors, and depression is the most important risk factor for these behaviors [33]. Moreover, the results of the present study showed a high correlation between anxiety and self-harm behaviors. Other study has also reported the increase in possibility of self-harm behaviors as the level of anxiety increases [9]. Similar to depression and anxiety, our results showed the high correlation between stress and self-harm behaviors. This is also supported by other studies suggesting stressful life events as a risk factor for self-harm in adolescents [16, 34]. This behavior occurs in youth for several reasons [35]. The most common reasons for self-harm behaviors by adolescents are their consideration as a coping strategy, a method for relief and regulation of feelings, self-punishment, attention-seeking, and sensation seeking [36]. It seems that in adolescents who experience high level of anxiety and depression and do not use appropriate coping strategies for psychological distress, self-harm behaviors may temporarily reduce stress. These results showed the importance of negative emotions, like self-punishment, self-directed anger, and sense of worthlessness in self-harm behaviors. Early attention to negative emotions and using proper psychological interventions for building positive emotion can reduce the prevalence of self-harm behaviors in adolescents.
The strength of this study was the separation of deliberate self-cutting from self-harm behaviors. However, it had some limitations. The samples in our study were high school students. Therefore, the results cannot be generalized to all adolescents. Some adolescents may not be unable to study at high school due to financial constraints. It is difficult to study general population of adolescents. Another limitation was that some adolescents might be reluctant to disclose their problems, for a variety of reasons. To this end, researchers tried to assure participants that their information would be kept confidential. Based on the results of this study, it is recommended that health policies should be made in Iran to identify adolescents at risk for self-harming behaviors and to screen and treat risk factors such as depression and anxiety. It is also recommended that future studies be conducted to evaluate the effectiveness of therapeutic and family interventions in reducing these behaviors.

Ethical Considerations
Compliance with ethical guidelines
The study was approved by the ethical committee of Guilan University of Medical Sciences (Code: IR.GUMS.REC.1397.164). Informed consent was obtained from all students and their parents, and they were assured of the confidentiality of their information.

Funding
This research was funded by Guilan University of Medical Sciences (Grant No.: 97031603).

Authors' contributions
Conceptualization, writing original draft, review & editing: all authors; Methodology: Elahe Abdollahi, Maryam Kousha; Data collection: Arvin Bozorgchenani, Mohammadreza Bahmani; Data analysis: Elahe Rafiei, Fatemeh Eslamdoust-Siahestalkhi, Elahe Abdollahi, Maryam Kousha; Funding acquisition: Elahe Abdollahi; Supervision: Elahe Abdollahi, Maryam Kousha.

Conflict of interest
The authors declared no conflicts of interest.

Acknowledgments
The authors would like to thank the Guilan University of Medical Sciences and the students who participated in this research for their support and cooperation.


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