New guidance from NICE is a step in the right direction for GPs who feel ill-equipped to deal with these vulnerable patients, says Dr Jez Thompson
Over the course of my professional life I have met a number of patients who have harmed themselves deliberately. The self-harm has ranged from impulsive overdoses, through a number of eccentric episodes of physical harm, to suicide attempts, a significant number of which have been successful, I’m sorry to say.
In some patients the episodes have been ‘one-offs’, occurring in a period of intense distress for the person concerned; others have been part of recurrent self-harming behaviour in patients with very complex needs.
I confess that these encounters have left me feeling at various times compassion, irritation, helplessness, bewilderment and sadness. One thing I have never achieved is to feel comfortable in managing a situation in which someone has harmed him- or herself; the risks of making a mistake in assessing that person seem too great and the consequences too disturbing to contemplate.
I believe I could do a better job in the assessment and management of those who self-harm, and guidance is probably overdue.
It was with this in mind that I welcomed the publication by NICE of their 16th clinical guideline, Selfharm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care.
Developing the guideline
The guideline was developed and reviewed by a multidisciplinary group, which included mental health clinicians and specialist nurses, representatives of non-statutory mental health organisations, GPs and a paramedic. A patient representative sat on the review panel.
It focuses in the main on recommendations for assessment and care in primary care and other settings during the first 48 hours after an act of self-harm, and is applicable to patients eight years old and over. The guideline also includes specific recommendations for ambulance services, emergency departments, medical and surgical teams and mental health services.
The evidence base for each recommendation is graded A to C or identified as a good practice point (Figure 1, below).
|Figure 1: Key to evidence statements and grades of recommendations|
|Reproduced from NICE Clinical Guideline 16. Self harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care by kind permission of NICE|
Most of the guideline’s recommendations are rated as good practice points. A significant minority have been made on the basis of expert committees or recommendations, but only a small number are made on the basis of clinical evidence.
This clearly represents a lack of clinical studies on the management of self-harm and is reflected by the research recommendations contained in the guideline.
The guideline has several important themes relevant to all areas of practice.
- Self-harm is an expression of personal distress.
- There is a need to treat people who have self-harmed with respect and with full consideration of privacy.
- Providing care for people who have self-harmed is emotionally demanding and requires a high level of skill. Training, supervision and support should be available for all staff undertaking this work.
- People who have self-harmed should be involved in all management decisions. Meaningful and informed consent should be given for any procedure.
- If an individual who has self-harmed has to wait for assessment or treatment, the environment should be safe and supportive with regular monitoring.
- Triage/initial assessment should take place at first contact, whether in primary care, a community setting or emergency department. It should establish the individual’s mental capacity, ability to give informed consent to treatment, level of distress, presence of mental illness and willingness to remain for further assessment.
- Full assessment includes a comprehensive evaluation of needs, including social, psychological and motivational factors, mental health and social needs and an assessment of the risk of further self-harm or of suicide.
- Referral for further psychosocial support and treatment should be made on the basis of the psychiatric, psychological and social needs assessment and risk assessment.
- Relatives and carers of people who have self-harmed may need support in their own right.
- People who self-harm should be involved in the commissioning and planning of services, and in the training of care professionals.
Recommendations for GPs
Under the section devoted to the role of primary care, the guideline recommends that when managing a patient who has self-harmed, primary care staff should assess risk factors.These include the presence of depression, hopelessness and continuing suicidal intent. Unfortunately, the guideline lacks practical guidance on how best to achieve this.
Assessment is recommended to include identification of the main clinical and demographic features and psychological factors associated with risk. These features and factors are not given in the guideline, with the result that interested practitioners will need to go to other sources to develop personal assessment tools.
The guideline also lacks a discussion of the importance of early diagnosis and management of depression in primary care in reducing the risk of self-harm.1 .
Special issues for young people
For young people (8-16 years old), the guideline is particularly relevant to emergency and paediatric departments. Triage and assessment of young people who have self-harmed should be performed only by appropriately trained paediatricians and nurses. Admission overnight to a paediatric ward (or adolescent ward for 14 to 16 year olds) for observation and assessment is recommended.
Assessment should follow the same principles as for adults, but include awareness of child protection issues and family circumstances. Consent for a mental health assessment should be obtained from a legally responsible adult. The guideline also recommends that special attention should be paid to issues of confidentiality, parental and young person’s consent (including Gillick competence), and use of the Mental Health Act and the Children Act.
However, there was no advice on managing the young person who has self-harmed but who refuses to go to the emergency department; and I was surprised that neither drug nor alcohol use were recommended for inclusion in the assessment of a young person who self-harms.
As the guideline does not cover primary prevention, the opportunity is missed to discuss exploration of the risk of self-harm in young people who express feelings of hopelessness, use drugs, have a history of sexual abuse or concerns about sexuality, 2 or who are frequent attenders with mental health concerns or physical symptoms without clinical signs.3
Special issues for older people
Management of an older person (over 65 years) who has self-harmed follows similar lines to that of younger adults. However, the risk of further self-harm or suicide is significantly higher in this age group.
All older people who have self-harmed should be assessed by a mental healthcare practitioner with relevant experience. In addition to the features of adult assessment, particular attention should be paid to the possible presence of depression, cognitive impairment and physical ill health and to the social and home situation. Again, alcohol use is not discussed as a risk factor to identify during assessment.
Because of the high risk among older people, all self-harm should be regarded as evidence of suicidal intent, and admission for assessment of risk and need should be considered.
Some other recommendations are already accepted practice. For example, referring patients to an emergency department: those who have self-harmed through poisoning should be referred because of uncertainty over which substances and what amounts have been ingested, and those who have self-injured should be referred when they are at risk.
A subsection of the guideline discusses management in primary care when urgent referral to an emergency department after an episode of self-harm is not necessary. Unfortunately, no guidance is given on how to make this assessment safely. Those considered to be at risk should be referred to secondary mental health services for further care.
Owing to the length of time needed to reach the nearest emergency care department, GPs in remote areas are encouraged to initiate emergency treatment themselves, for example taking blood samples for paracetamol level.
The immediate use of activated charcoal to reduce absorption of an overdosed drug is discussed under the recommendations for ambulance services; however, there is no mention of this for GPs in remote areas. Similarly, there is no recommendation that primary care practitioners, rural or otherwise, should carry naloxone for the emergency treatment of opioid overdose or glucagon for insulin overdose.
Primary care staff are encouraged to exercise care when prescribing to patients at risk of self-poisoning by choosing, whenever possible, drugs that are the least dangerous in overdose, prescribing smaller amounts and avoiding dangerous preparations such as co-proxamol.
The guideline encourages GPs to adopt similar measures when prescribing for the relatives of those at danger of self-harm, while at the same time preserving confidentiality. However, no advice is given on how to achieve this, or on how to mitigate the cost to the patient in prescription charges.
A more useful approach might be to involve community pharmacists in interval dispensing and monitoring prescribed medication or, having first gained consent, to allow a patient’s relative to supervise prescribed medication.
Challenges to primary care staff
Issues relevant to primary care staff include identifying development needs and the requirement for support and supervision. Training should address beliefs and attitudes relating to self-harm in addition to developing assessment skills. I shall, in particular, review our policy for monitoring these patients during their wait for an ambulance.
By limiting itself to addressing secondary prevention, the guideline misses the opportunity to advise on primary prevention of self-harm, while more practical advice on how to apply the recommendations would have been welcome.
Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. Clinical Guideline No 16 can be downloaded from the NICE website: www.nice.org.uk
- Houston K, Haw C, Townsend E, Hawton K. General practitioner contacts with patients before and after deliberate self harm. Br J Gen Pract 2003; 53: 365-70.
- Beckinsale P, Martin G, Clark S. Youth suicide issues in general practice. Aust Fam Physician 2001; 30: 391-4.
- McNeill YL, Gillies ML,Wood SF. Fifteen year olds at risk of parasuicide or suicide: how can we identify them in general practice? Fam Pract 2002; 19: 461-5.