assessment following deliberate self harm and referral to mental health services dr j van niekerk...
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Assessment following deliberate self harm and referral to Mental
Health Services
Dr J van Niekerk
Crisis Resolution Home Treatment Team
Trafford General Hospital
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Deliberate Self Harm
• 140 000 people with DSH pass through ED in England and Wales per year
• 10 – 30 per 100 000 commit suicide annually
• Maladaptive response to acute and chronic stress
• DSH is a behaviour and not an illness
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DSH is a behaviour and not an illness
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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
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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
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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
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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
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Copyright ©2006 BMJ Publishing Group Ltd.
Mitchell, A J et al. Emerg Med J 2006;23:251-255
Figure 1 Epidemiology of self harm attendances at the ED in 32 hospitals in England.
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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
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Social
• Social circumstances are important:
• Isolation
• Socioeconomic deprivation
• Excess of life events (month before SH)
• Younger people : relationship difficulties
• Older people: health or bereavement
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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
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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
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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
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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/suicide3. Are there any current medical or social
problems?
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AssessmentShort 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 found3. Previous mental health problems (DSH)4. Harmful use of alcohol or drugs5. Social circumstances and problems – loneliness and
lack of network6. Forensic history – impulsive or aggressive traits7. MSE – symptoms of depression, suicidal thoughts ,
plans or intent to self harm
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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
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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
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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
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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
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If someone refuses treatment
• 1. Simple persuasion• 2. If lacks capacity to consent (medical or mental
health reasons) – treat in best interest of patientCapacity: 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.
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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
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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
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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
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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
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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
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References
• 1. Regular review: Management of patients who deliberately harm themselves
BMJ 2001;322;213-215
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