28th January 2024

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