1. Self-harm & Suicide Dr Joanna Bennett

2. Self harm / Self injury/Self mutilation Deliberate self-cutting, burning, poisoning, with or without the intention of committing suicide No DSM or ICD diagnosis A symptom for diagnosing other mental disorders Borderline personality disorder ‘recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior

3. Self harm / Self injury/Self mutilation self-harm behavior is seen in patients with many mental disorders Occurs without any apparent disease and can persist after other symptoms of a particular psychological disorder have subsided Call for a separate diagnosis

4. Prevalence Prevalence is 3-5% of the population in Europe & US Risks are higher in: – women – young adults – socially isolated or deprived – psychiatric and personality disorders

5. Around one-quarter will repeat self harm in 4 years – Younger adults repeat non-fatal self-harm – Adults (>45yrs) more likely to commit suicide

6. Prevalence - Caribbean On the rise Ingestion of tablets – females Strong chemicals – men Self- mutilation/cutting – adolescents and young adults Trinidad – 3 people daily deliberate self harm (Hickling & Sorel)

7. Aetiology Biological - familial, genetic Psychosocial Other suggested personality traits: – impulsive, aggressive, inflexible – impaired decision making and problem solving

8. Self-harm & suicide 30-fold increase in risk of suicide, compared with the general population Long-term suicide risk 3-7% Suicide rates are highest within the first 6-12 months after the index self-harm episode.

9. Self-harm & suicide Predictors of subsequent suicide include: – avoiding discovery at the time of self-harm – not living with a close relative – previous psychiatric treatment – self-mutilation – alcohol misuse – physical health problems.

10. Management: self harm No drug treatment shown to be of benefit in reducing recurrent self harm – Flupentixol depot injections may reduce the recurrence of self-harm, but with associated adverse effects. – Paroxetine has not been shown to reduce the risks of repeated deliberate self-harm but may increase suicidal ideation

11. Psychological interventions Problem-solving therapy may reduce depression and anxiety, but may not be effective in preventing recurrence of self- harm. Intensive follow up plus outreach, nurse led management or hospital admission have not been shown to reduce recurrent self-harm compared with usual care.

12. Psychological interventions Cognitive therapy plus usual care reduces the incidence of deliberate self-harm in adults with a recent history of self-harm compared with usual care problem-solving approaches, dynamic psychotherapy, short-term counselling, does not reduce rates of repetition at 1 year compared with usual treatment

13. Psychological interventions Cognitive therapy plus usual care more effective at 6–18 months than usual care – reducing suicide attempts and severity of depression – reducing hopelessness – no more effective at reducing suicidal ideation

14. Management: self harm Aims of interventions – reduce repetition of deliberate self-harm – reduce desire to self-harm – prevent suicide – improve social functioning and quality of life

15. Self harm: Patient’s views Patients with a history of deliberate self harm lack of control over their lives, through: – alcohol dependence – untreated depression – uncertainty within their family relationships.

16. Accident and emergency staff's perceptions of deliberate self-harm 89 A&E medical and nursing staff. rate attributions for the cause of the deliberate self- harm their emotional responses, optimism for change, willingness to help change the behaviour. general attitudes towards deliberate self-harm patients perceived needs for training in the care of these patients were also assessed

17. Accident and emergency staff's perceptions of deliberate self-harm The greater attributions of controllability, the greater the negative affect of staff towards the person, and the less the propensity to help. Male staff and medical staff had more negative attitudes, and medical staff saw less need for further training.

18. Suicide WHO: each year approximately one million people die from suicide. A global mortality rate of 16 per 100,000. One death every 40 seconds In the last 45 years suicide rates have increased by 60% worldwide. Suicide is now among the three leading causes of death among those aged 15-44 (both sexes). Suicide attempts are up to 20 times more frequent than completed suicides.

19. Suicide  suicide rates among young people have been increasing - they are now the group at highest risk in a third of all countries.  Mental disorders (particularly depression and substance abuse) are associated with more than 90% of all cases of suicide.

20. Suicide suicide results from many complex socio- cultural factors and is more likely to occur during periods of socioeconomic, family and individual crisis In many cases, swift, decisive intervention can prevent suicide. Recognizing risk and taking action if the potential arises is critical.

21. Assessment: suicide risk Determine whether the person has any thoughts of hurting him or herself. Suicidal ideation is highly linked to completed suicide. Any plans for suicidal acts - more specific plans indicate greater danger: purchased a gun, has ammunition, has made out a will

22. Assessment: suicide risk – Determine whether they have a weapon or access to it. – Determine what the patient believes suicide would achieve - suggests how seriously the person has been considering suicide and the reason for death – Potential for homicide

23. Assessment: suicide risk – Any family members or friends who have killed themselves. – Symptoms of depression, psychosis, delirium and dementia, losses (especially recent ones), and substance abuse

24. Assessment: suicide risk The clinician's gut feeling- clinician's reaction counts and should be considered in the intervention. Use of rating scales – e.g. Beck depression Inventory

25. Management: Suicide risk Close observation - individual must not be left alone Remove anything that the patient may use to hurt or kill him or herself

26. Some Nursing Diagnoses Risk for self-directed violence Hopelessness Ineffective individual coping