Assessment following deliberate self harm and referral to Mental Health Services Dr J van Niekerk Crisis Resolution Home Treatment Team Trafford General Hospital

Deliberate Self Harm people with DSH pass through ED in England and Wales per year 10 – 30 per commit suicide annually Maladaptive response to acute and chronic stress DSH is a behaviour and not an illness

Definition Definition: Act of non-fatal, self destructive, behaviour that occurs when an individual’s sense of desperation outweighs their inherent self preservation instinct Also : parasuicide, attempted suicide, deliberate self poisoning, deliberate self injury, and more recently simply Self harm (PC) Suicide is a subcategory

Prognosis Subsequent risk of suicide – at least 3% and up to 10 % after 10 or more years DSH is an ominous sign for repeated acts 40 % will repeat self harm 13 % will do this within the first year

Services Services at present vary between hospitals Local resources for DSH Attitudes and experience of local ED staff 2004 NICE : National Guidelines Royal College of Psychiatrists

Trends Contrast to trends in suicide Rise in incidence of self harm over last 20 years ? More admit to self harming Two thirds of patients < 35 Two thirds of this group: Female Older people – rare event but higher degree of intent Rate in young men aged 15 – 24 is rising more quickly than in any other group Mainly due to starting to take OD more

Copyright ©2006 BMJ Publishing Group Ltd. Mitchell, A J et al. Emerg Med J 2006;23: Figure 1 Epidemiology of self harm attendances at the ED in 32 hospitals in England.

Why do patients harm themselves? Motivations vary Failed suicide attempt Escape from intolerable situation or intolerable state of mind “losing control” Only 13 % wanted to punish someone or make someone feel guilty Risk factors for repetition: Intention at the time and current wish to die

Social Social circumstances are important: Isolation Socioeconomic deprivation Excess of life events (month before SH) Younger people : relationship difficulties Older people: health or bereavement

Vulnerability factors Early loss/separation from one or both parents Childhood abuse Unemployment Absence of living in family unit Patient perceive problems as “unsolvable” Mental health difficulties: depression, alcohol, substance misuse and personality disorder

Prevention – patchy evidence Little evidence on how to prevent National and Local guidelines based on few controlled studies, unsystematic clinical experiences and “wisdom” Three controlled studies have shown significant differences in outcome but all are open to some criticism

Who should see them? Often seen by several members of staff for short periods in a busy chaotic environment ? Sensitive assessment of mental health difficulties NICE: an immediate risk assessment – Triage NICE suggests all people who self harm should be offered a full mental health and social needs assessment by a mental health professional This is the IDEAL – real world any trained health professional may perform this role Best option: dedicated multi-professional team who have expertise in self harm

Psychosocial assessment Principals : privacy, conduct interview safely and with adequate time, let patient tell their story Question relatives and friends about what patient has recently said Three main issues: 1. Are there current mental health difficulties? 2. What is the risk of further self harm/suicide 3.Are there any current medical or social problems?

Assessment Short term risk assessment 1.Careful history of events surrounding self harm serious medical attempt/perception of seriousness ie in children/learning disability 2. Precautions against being found 3. Previous mental health problems (DSH) 4. Harmful use of alcohol or drugs 5. Social circumstances and problems – loneliness and lack of network 6. Forensic history – impulsive or aggressive traits 7. MSE – symptoms of depression, suicidal thoughts, plans or intent to self harm

Circumstances and comorbid Interpersonal conflicts in 50 % who self harm Unemployment and physical illness Most common diagnosis – depression (50 – 90%) Substance use (25 – 50 %) Personality disorders common, particularly young people BUT 56 % will have 2 or more psych diagnosis Thus, what looks like another “borderline” might also have an underlying bipolar disorder etc

Risk assessment tool Will help when referring to Mental Health Services : short screening tool SAD PERSONS: NOT good at predicting risk Sex Age Depression Previous attempt Ethanol abuse Rational thought loss Social supports lacking Organized plan No spouse Access to lethal means Sickness

Treatments Antidepressants (helpful when mood or anxiety present) Problem solving therapy(again, only helpful if depression, anxiety) Priority future treatment (postcard to “drop us a note” – helps in women) Medical admission: 4 hour waiting times (no difference) When risk is high and/or serious mental health problems – psychiatric admission remains a valuable option

Treatments Offers of follow up: Adequate initial assessment -> long term benefit Staff trained in psychotherapy: Dialectical behaviour therapy (one RCT “favourable”) Psychodynamic interpersonal therapy delivered at home over 4 weeks reduce self harm from 28 % to 9 % over 6 months Patient based self help – little evidence ? Modest GP’s : 50 % will see GP in week after DSH GP intervention makes no difference in 12 month period

If someone refuses treatment 1. Simple persuasion 2. If lacks capacity to consent (medical or mental health reasons) – treat in best interest of patient Capacity: Patient need to be able to comprehend and retain information, believe it, and finally weigh in the balance to arrive at a choice. If patient has full capacity and refuses treatment – The patient’s wishes for no treatment of physical complications must be respected even though this may appear discordant with the views of the clinician.

Capacity If there is any doubt concerning capacity (if not treating will lead to serious complications) -> get a further opinion from more senior member of medical team(SPR or Consultant) and if necessary from a psychiatrist. When mental illness is suspected – MHA Cannot treat medical condition under MHA Must use Common Law for physical complications

When to refer to Psychiatry ? Always Five factors a) chronic alcohol misuse b) multiple repeat attempts c) depression d) physical illness e) social isolation Mandatory in cases of suicidal plans or intent, older people and children/adolescents

Antidepressants in those at risk of suicide Media concern SSRIs may cause emergence of suicidal thoughts or increase suicidal ideation Manifest in short term trials – not in long term No research supports a link between SSRIs and completed suicide Efficacious in moderate to severe depression Patients who commit suicide are under treated. Only 20 % treated with antidepressant. May temporarily increase risk due to activation Therefore requires close monitoring at start of therapy

What to do to reduce DSH risk Study of 219 consecutive suicides found 39 % visited ED in previous year ! Need a courteous and sensitive assessment of risk Psychological and social needs assessment ED staff needs appropriate training in self harm and management of risk Offer practical help with immediate precipitating factors

Other measures Telephone help lines Easily accessible mental health crisis teams Social support measures Communication with primary care following discharge Offer rapid follow up – ideally with the person that made the initial assessment When leaving ED – should know where, when and with whom follow up appointment will be

References 1. Regular review: Management of patients who deliberately harm themselves BMJ 2001;322; Göran Isacsson and Charles L Rich 2. Self harm and attempted suicide in adults: 10 practical questions and answers for emergency department staff AJ Mitchell, M Dennis Emerg Med J 2006;23:251 – 255