1. The role of the General Practitioner in the management of patients with self-harm behaviour in primary care: a systematic review
SAPC North Conference, Kendal
29 November 2018
Dr Faraz Mughal
General Practitioner and NIHR In-Practice Fellow
Research Institute for Primary Care and Health Sciences, Keele University
@farazhmughal

2. Declarations of interest:
4 session NHS salaried GP at Coventry Road Surgery, Birmingham, B26 3JS
Royal College of General Practitioners (RCGP) Clinical Fellow in Mental Health and have received payment from RCGP for my time and travel
I am in receipt of a National Institute for Health Research (NIHR) In-Practice Fellowship, Research Institute for Primary Care and Health Sciences, Keele University
Honorary research fellow at the Unit of Academic Primary Care, Warwick University

3. Social media as protective factor for SH but also as inspiration for SH – active research in this area

4. Background
Self-harm (SH) is ‘self-injury or self-poisoning irrespective of suicidal intent’ (NICE CG133)
Major Global Public health concern & strongest risk factor for suicide
Annual NHS cost £162 million - one hospital SH episode £809
General Practitioners (GPs) are seeing more SH
Two-thirds of patients present to their GP in month prior to SH
Two-thirds of patients present to their GP in month after a SH episode
The GP may be well placed to intervene early to prevent SH and suicide
SH increases your risk of suicide by up to 50 times.

5. Review Question
To explore the role of the GP in the management of patients with self-harm behaviour in primary care

6. Methodology
Systematic literature search of: MEDLINE, PsychINFO, EMBASE, CINAHL, AMED, and Web of Science from inception to February 2018 (Registered on PROSPERO (CRD ))
SH in all ages and international primary care setting
Studies included: Observational, cross-sectional, qualitative, and mixed methods. RCTs were excluded
Titles, abstracts, and full-texts independently screened by two reviewers – discrepancies resolved by a third reviewer
Quality assessed by the Mixed Methods Appraisal Tool
Outcomes: knowledge, attitudes, behaviours of GPs in SH management, barriers and facilitators of GP management, and outcomes of GP consultation (referral, f/u, length of consult)
A narrative synthesis of study findings (Popay et al 2006)

7. PRISMA Flow Diagram
7,111 citations identified through MEDLINE, PsychINFO, EMBASE, AMED, CINAHL, and WoS
6976 citations after de-duplication
Titles & abstracts of 6976 screened
6930 citations excluded
46 full-text articles being assessed for eligibility
35 full-text articles excluded:
Commentary (n = 6)
Grey literature (n = 2)
Not GPs/family medicine or primary care doctors (n = 7)
Not SH relevant (n = 16)
Inappropriate outcome measure (n = 4)
2 full texts were obtained through author contact. Study 10 and 31.
11 full-text articles included in synthesis
1 full-text article identified in hand searching of references
12 full-text articles included in synthesis

8. Quality Assessment (MMAT)
Study (Author and ID)
MMAT % score
Chandler A et al 2016 (8)
75%
Crawford M 2000 (10)
Le Pont F et al 2004 (13)
100%
Keeley et al 1997 (15)
25%
Fox F et al 2015 (16)
Grimholt TK et al 2014 (17)
Michail M 2016 (31)
Prasad L et al 1999 (36)
Saini P et al 2016 (37)
Slaven J et al 2002 (39)
Taliaferro L et al 2013 (41)
Saini et al 2010 (X)
Can observe the papers on whole were good in quality

9. Initial pre-synthesis theoretical framework
Frontline identification/ assessment/ management
Providing support for patients
Access to specialist care
This cycle illustrates the role a GP plays at any point in the patient journey
This diagram highlights the interconnectedness of the GP role
When synthesis complete – look to go back to this model and modify
Theory cycle showing the role of the GP in management of patients with self-harm behaviour in primary care (Mughal, 2018)

10. Preliminary Synthesis
GP knowledge:
GPs describe difficulty in establishing suicidal intent in patients who SH
GPs find risk assessment difficult due to relationship between SH and suicide
GP attitudes and behaviours:
GPs feel SH is a way of ‘releasing’ emotions and ‘cry for help’
GPs see SH as a coping strategy
GPs see themselves as ‘being part of the service’ and frontline support for young people (YP) who SH
Barriers for GP management:
GPs report lack of time, concern about ‘opening a can of worms’, and fear of parents of YP thinking assessing SH is inappropriate
Facilitators for GP management:
GPs express a need for better communication and liaison with mental health services
Resources:
GPs express a preference for referring patients who SH to specialist care
Mention NSSI – North American’s – non suicidal self injury – Europe has moved away from this due to difficulty in assessing suicidal intent on both patient and Dr perspective.
Relationship between SH and suicide oft debated and often intertwined in each presentation

11. Preliminary Conclusions
The ‘role of the GP’ is key and multidimensional, including sub-roles in:
Assessing
Managing
Referring
Supporting
Advocating
Further GP training in identification and management of people who self-harm
Need for accessible specialist services
Importance of developing and sustaining self-harm community services
This review will help to inform the development of general practice SH interventions and services to support people in the community

12. Acknowledgments Dr Opeyemi Babatunde, Ms Isabela Troya,
Professor Carolyn Chew-Graham, Dr Lisa Dikomitis

13. Thank you Email: f.mughal@keele.ac.uk Twitter: @farazhmughal
Research Institute for Primary Care and Health Sciences David Weatherall Building Keele University Newcastle-under-Lyme ST5 5BG
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