26th January 2024

Self-harm and suicide

Deliberate self-harm (DSH) and suicide are manifestations of emotional distress and illness. Their incidence is rising over the years and is common in patients of all ages and social groups.

Unfortunately, there is relatively poor provision of resources and treatment available to help those who self-harm, and unhelpful attitudes from health and care staff, as well as the wider public, are commonplace.

Rates of self-harm are higher among females than males; however, completed suicide is more prevalent among males.

The majority of self-poisonings involve over-the-counter or prescribed medications, and the majority of self-injury incidents involve cutting.

Definitions

• Self-harm: an intentional act of self-injury or self-poisoning, regardless of the motivation or the degree of suicidal intent. It is a wide spectrum of behaviour with harmful physical effects.
  • A person who repeatedly self-harms is at higher risk of committing suicide. It is important to note that an act of self-harm is not always an attempt at suicide; for some patients, it can be an act of self-preservation, for example, to reduce internal tension. In most cases, the motivation for DSH is complicated, involving a number of biological, social, and psychological factors.
• Suicide: an intentional self-inflicted death
• Suicide attempt: an act that is potentially self-injurious, that is committed with an intent to die
• Suicidal intent: the intensity of the individual’s wishes to die. Suicidal thoughts can be present without suicidal intent (known as passive suicidal ideation)

Factors influencing suicide risk

Risk factors for DSH include:

• Age:
  • DSH rates peak between 16-35 years
  • Suicide rates peak between 45-49 years
• Socio-economic problems or disadvantage
• Social isolation
• Mental health problems, especially depressive, psychotic and personality disorders
• Chronic physical health problems/illness
• Stressful life events such as relationship breakdown, abuse, neglect, domestic violence
• Exposure to suicide, e.g., through bereavement
• Early adversity, e.g., childhood abuse
• Drug and/or alcohol misuse
• Involvement with the criminal justice system
• High-risk occupations (e.g., healthcare professionals, farmers, construction workers)

Protective factors that may reduce the risk of suicide include:

• Effective coping strategies
• Supportive relationships
• Dependents (e.g., children, pets, other family members)
• Religious beliefs

Symptoms and diagnosis

The assessment and management of persons presenting with DSH should utilise a bio-psycho-social approach to consider the person’s problems, needs and future risk.

It is impossible to precisely predict suicidal risk, and various assessment tools can be used, such as the Columbia Suicide Severity Rating Scale (C-SSRS Screener) and the Patient Safety Screener 3 (PSS-3).

These scales are designed to measure the severity and intensity of suicidal ideation, the suicidal behaviour and the lethality of any attempts.

All psychiatric assessments should include screening for suicidal ideation and self-harm. 

The SAD PERSONS scale was developed to help screen suicide risk in adults. Although the scale has been found to have poor predictive validity in real-world studies, it can provide a useful memory aid for some of the risk factors for suicide rather than being an official risk-calculation tool.

Source: MD App. (n.d.). SAD PERSONS Scale Calculator. Retrieved July 12, 2022, from https://www.mdapp.co/sad-persons-scale-calculator-411/

It is scored with 1 point for each factor, with the final score reflecting risk:

0 – 4: low risk

5 – 6: medium risk

7 – 10: high risk

Management

Acute management

Patients who present with self-harm should be met with a sensitive, compassionate attitude to help minimise their distress.

If possible and appropriate:

• See the individual alone for the initial psychosocial interview
• Allow family members, friends, or advocates to be present if requested
• Assess the individual’s emotional and mental state
• Ask the individual to explain their feelings and understanding of the episode in their own words
• Make treatment decisions jointly with the individual
  • If there is doubt regarding the person’s capacity to make informed decisions, the opinion of a psychiatrist with experience in this area should be sought
• Examine physical injuries

Patients who are found to be at acute risk of suicide will require immediate and intensive management; the exact nature of this depends on the presentation and mental state; for example, some patients will need treatment under the Mental Health Act.

Adapted from (BMJ Best Practice, 2020). BMJ Best Practice. (2020). Suicide risk mitigation. Retrieved July 11, 2022, from https://bestpractice.bmj.com/topics/en-gb/3000095/treatment-algorithm#patientGroup-0-0

In episodes of self-poisoning, it may be useful to access the TOXBASE® website (http://www.toxbase.org/) or telephone the UK National Poisons Information Service (NPIS) on 0344 8920111 for a patient-specific risk assessment.

Any person who presents with DSH who does not necessitate referral to an emergency department or mental health crisis team should still be fully assessed and risk evaluated.

Particular points to take note of include:

• Features of depressive illness
• Presence of mental health disorders
• Feelings of hopelessness, impulsivity, or futility
• Features suggesting suicidal intent
  • Perceived lethality of the method
  • Use of violent methods
  • History and frequency of DSH
    • Risk is increased by more frequent, recent, or lethal attempts
  • Evidence of planning (e.g., a written suicide note, changes to will, closure of bank accounts, plans for care of dependents/pets)
• Misuse of drugs and/or alcohol
• Safeguarding concerns of young persons or vulnerable adults
• Seriousness of physical injuries
• Access to methods of further self-harm and future intent

Immediate interventions that may be used to reduce harm include:

• Psychiatric admission
• Providing reassurance and reducing tension
• Acute sedation
• Making family, carers, and friends aware of the risk
• Removing access to means of harm (e.g., disposing of stockpiled medication)

Complications from DSH depend on the method employed, for example, acute liver failure after paracetamol overdose, permanent scarring or damage to nerves following cutting.

Longer term care

Upon discharge, persons who have self-harmed should be followed up in primary care within 48 hours. They should be offered risk management and psychosocial support where appropriate.

In most cases, patients are discharged to the care of their GP with no further specialist intervention; thus, prompt and clear communication with the GP is vital.

Identified mental health problems should be suitably managed. 

Patients should be offered written and verbal information about sources of support (see table, right)

Management looks different in every patient; for example, if stopping DSH completely is unrealistic, patients may be given harm-minimisation advice (e.g., advice on less dangerous methods, carer advice), producing a crisis plan with contact numbers or treatment for substance misuse.

Examples of long-term interventions include:

• Effective treatment of psychiatric disorders
• Alleviating psychosocial stress
• Enhancing positive coping strategies
• Developing crisis management plans

References

• BMJ Best Practice. (2020). Suicide risk mitigation. Retrieved July 11, 2022, from https://bestpractice.bmj.com/topics/en-gb/3000095/treatment-algorithm#patientGroup-0-0
• Cutler, J. (2014). Psychiatry (3rd ed.). Retrieved from https://ebookcentral.proquest.com/lib/ed/reader.action?docID=1665577
• Gulati, G., Lynall, M.-E., & Saunders, K. E. A. (2014). Psychiatry. John Wiley & Sons. Retrieved from https://ebookcentral.proquest.com/lib/ed/reader.action?docID=1481184
• MD App. (n.d.). SAD PERSONS Scale Calculator. Retrieved July 12, 2022, from https://www.mdapp.co/sad-persons-scale-calculator-411/
• NICE. (2020, August). Self-harm. Retrieved July 8, 2022, from https://cks.nice.org.uk/topics/self-harm/background-information/definition/
• Nodentoft, M., Madsen, T., Erlangsen, A., Kapur, N., Steeg, S., Moreton, A., … Pitman, A. (2020). Suicide. In J. R. Geddes, N. C. Andreasen, & G. M. Goodwin (Eds.), New Oxford Textbook of Psychiatry (2nd ed.). https://doi.org/10.1093/med/9780198713005.001.0001
• Royal College of Psychiatrists. (2010). Self-harm, suicide, and risk: Position statement. Retrieved from www.rcpsych.ac.uk.