Dr Clare Taylor (left), Professor Navneet Kapur, and Professor Tim Kendall discuss the importance of communication in the NICE guideline on long-term management of self-harm
|NICE Clinical Guideline 133 on long-term management of self-harm has been awarded the NHS Evidence Accreditation Mark.
This Mark identifies the most robustly produced guidance available. See evidence.nhs.uk/accreditation for further details.
People who attend an emergency department after an episode of self-harm will have visited their GP in the previous month.1 Given that one in five people who attend an emergency department following self-harm will self-harm again during the next 12 months,2 the contact that GPs have with these individuals presents an opportunity to increase rates of identification and to initiate treatment before the person self-harms again.
Self-harm is any act of self-poisoning or self-injury (commonly self-poisoning with medication or self-injury by cutting), irrespective of motivation.3 The motivation for self-harming behaviour is complex and is not always about ending life.4 It may be a way of obtaining relief from an emotional state or an overwhelming situation, or a means of communicating distress to others.
Self-harm is common especially among young people. In the UK, more than 10% of girls aged 15–16 years and 3% of boys of the same age had self-harmed in the previous year.5 Approximately 2.7% of adults also report self-harm.6
Although the act of self-harm does not necessarily coincide with a wish to die, suicide is common among people who self-harm. Once a person has self-harmed, the probability that they will die by suicide increases to between 50 and 100 times the rate seen in the general population, with 1 in 15 dying by suicide within 9 years of the index episode.7 The UK suicide rate per 100,000 population is 17.5 for males and 5.2 for females, which is nearly 10 times the homicide rate.8,9
NICE guideline on self-harm
This article summarises the key recommendations for GPs from the recent NICE guideline on Self-harm: longer-term management, which was developed by the National Collaborating Centre for Mental Health (NCCMH). 10 It is the first NICE guideline on longer-term management of self-harm and complements the earlier guideline, Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care,11 which covered treatment within the first 48 hours of an episode of self-harm.
Although the NICE guideline on longer-term management of self-harm recommends that mental health teams (including community mental health teams, liaison psychiatry teams, and child and adolescent mental health services [CAMHS]) should be generally responsible for the routine assessment and longer-term treatment and management of self-harm,10 GPs have an important role to play in these processes.
General principles for care
The NICE guideline recommends acknowledging that stigma and discrimination are sometimes associated with self-harm,10,12 and encourages healthcare professionals to be non-judgmental and to build a trusting, supportive, and engaging relationship with the person, thereby fostering their autonomy and independence and maintaining the continuity of therapeutic relationships wherever possible.10
Written information about self-harm should be provided so the person can be fully informed and involved in decision-making about their treatment and care.10 This information should cover the dangers and long-term outcomes associated with self-harm, and the available interventions and possible strategies to help reduce self-harm, and/or its consequences.10 The guideline recommends between three and 12 sessions of a psychological intervention that is structured specifically for people who self-harm.10 Any personal details relating to self-harm should be communicated sensitively to other team members.10
Referral to community mental health services
When a person presents in primary care with a history of self-harm and a risk that they will repeat the behaviour, NICE recommends that GPs and other primary care healthcare professionals should consider referring them to community mental health services (or CAMHS if they are below the age of 18 years) for an integrated and comprehensive psychosocial assessment of needs and risks. Referral should be a priority when:10
- the person’s level of risk is rising, high, or sustained
- the person’s level of risk is increasing or unresponsive to pharmacological or psychosocial treatments to date
- parents or carers are very distressed or their distress is increasing because of the child or young person’s self-harm.
Referral should also be prioritised if the person asks for further help from specialist services.10
Working across services
The NICE guideline recognises that a person who self-harms may be treated within both primary and secondary care and, therefore, advises professionals from both services to work cooperatively and share up-to-date care routinely along with risk-management plans.10 It is, therefore, advised that primary care healthcare professionals should attend care programme approach (CPA) meetings.10
Care and risk-management plans
The care plan should be multidisciplinary. It should be developed with the person, and, if they agree, with their family, carers, or significant others. The aims of longer-term treatment should be discussed and agreed with the person who self-harms and then documented in their care plan. These aims may include:
- prevention of escalation of self-harm
- reduction or stopping of self-harm or other risk-related behaviour
- reduction in harm arising from self-harm
- improving social or occupational functioning, quality of life, or any associated mental-health conditions.
The care plan should also identify realistic and optimistic long-term goals (which may encompass education, employment, and other occupations) and set out the steps required to achieve them.10 In the plan, the roles and responsibilities of any team members (and the person who self-harms) should be defined. The person’s care plan and the aims of the treatment should be reviewed with them and revised at agreed intervals of not more than 1 year.10
A risk-management plan should be incorporated into the care plan and should be based on a risk assessment carried out by community mental health services.10 It should address both the long-term and more immediate risks identified in the risk assessment and the specific factors (psychological, pharmacological, social, and relational) identified as associated with increased risk. The aim is to reduce the risk of repetition of self-harm and/or the risk of suicide.10
A crisis plan should also be included that outlines self-management strategies and how to access services during a crisis when self-management strategies fail.10 The crisis plan may include recognition of warning signs that could trigger an episode of self-harm, or using other coping strategies rather than self-harm.10 The person should be informed about the limits of confidentiality and that information in the plan may be shared with other healthcare professionals.
Providing physical healthcare
Individuals who self-harm have worse general physical health and may access services less effectively than the general population.13 Therefore, the NICE guideline outlines a specific role for primary care healthcare professionals—monitoring the physical health of people who self-harm.10 This includes the physical consequences of self-harm as well as other general physical healthcare needs.
Associated mental health conditions
The guideline recommends that drugs should not be prescribed as a specific treatment for self-harm, but many people who self-harm take psychotropic medication to treat associated conditions such as depression,14 which is commonly managed by primary care. There are issues surrounding safe prescribing in a population at risk of overdose, and the guideline advises that when prescribing psychotropic medication for an associated condition, prescribers should consider the toxicity of the drug in overdose.10 When prescribing antidepressants, GPs should choose selective serotonin reuptake inhibitors (SSRIs) because they are potentially less lethal than other antidepressants; tricyclic antidepressants such as dosulepin should be avoided in people who self-harm.10
Implementing the guideline
Self-harm is often seen as a ‘problem behaviour’ and individuals may be regarded as hard to help.15 Stigma within the health service can be a barrier for people who self-harm and who are trying to access services. By increasing awareness of self-harm among primary and secondary care healthcare professionals and summarising the evidence for effective management, the NICE guideline should help to ensure better access and treatment for people who self-harm.
Primary care has a very important role for those who, as a result of previous stigma or negative experiences in secondary care, prefer to talk about their condition to their GP and other healthcare professionals in primary care.
People who self-harm often access a range of medical services, including primary care, secondary care mental health services, and the emergency room. It is crucial to set up effective communication between services in different settings, especially when sharing care and risk-management plans and coordinating the response of different healthcare and social care professionals.
The NICE guideline on the longer-term management of self-harm should help clarify the important role that GPs and other primary care professionals can have in helping an often shunned and excluded group of people. As the primary care team increases its knowledge and understanding about self-harm and its management in primary care, the people who self-harm will feel less stigmatised and more able to gain access to the help they need.
|NICE Implementation tools|
|NICE has developed the following tools to support implementation of Clinical Guideline 133 on Self-harm: longer term management. The tools are now available to download from the NICE website: www.nice.org.uk/CG133
Baseline assessment tool
The baseline assessment tool is an Excel spreadsheet that can be used by organisations to identify if they are in line with practice recommended in NICE guidance and to help them plan activity that will help them meet the recommendations.
Clinical audit tools
Audit tools aim to assist organisations with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. They consist of audit criteria and data collection tool(s) and can be edited or adapted for local use.
Clinical case scenarios
Clinical case scenarios are an educational and learning resource designed to improve and assess users' knowledge of the long-term management of self-harm, and its application in primary and secondary care.
Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.
Costing templates are spreadsheets that allow individual NHS organisations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates, and they quickly assess the impact the guideline may have on local budgets.
Electronic audit tool
Electronic audit tools are developed to assist organisations with clinical audit and to ensure that practice is in line with the NICE recommendations.
The slides provide a framework for discussing the NICE guideline with a variety of audiences and can assist in local dissemination. This information does not supersede or replace the guidance itself.
Two podcasts are available in relation to this guideline.
View the Guidelines summary of the NICE guideline on Self-harm: longer-term management at: egln.co.uk/go/34999
- 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 (490): 365–370.
- Bergen H, Hawton K, Waters K et al. Epidemiology and trends in non-fatal self-harm in three centres in England: 2000–2007. Br J Psychiatry 2010; 197: 493–498.
- Hawton K, Harriss L, Hall S et al. Deliberate self-harm in Oxford, 1990–2000: a time of change in patient characteristics. Psychological Medicine 2003; 33: 987–995.
- National Collaborating Centre for Mental Health. Self-harm: longer-term management. Leicester, London: British Psychological Society, Royal College of Psychiatrists, 2012.
- Hawton K, Rodham K, Evans E et al. Deliberate self-harm in adolescents: self report survey in schools in England. BMJ 2002; 325: 1207–1211.
- Nock M, Borges G, Bromet E et al. Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. Br J Psychiatry 2008; 192 (2): 98–105.
- Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm: systematic review. Br J Psychiatry 2002; 181: 193–199.
- Office for National Statistics. Suicide rates in the United Kingdom, 2000–2009. London: ONS, 2011. Available at: www.ons.gov.uk/ons/taxonomy/index.html?nscl=Suicide+Rates
- Morris P, Graycar A. Homicide through a different lens. British J Criminology 2011; 51: 823–838.
- National Institute for Health and Care Excellence. Self-harm: longer-term management. Clinical Guideline 133. London: NICE, 2011. Available at: www.nice.org.uk/guidance/CG133
- National Institute for Health and Care Excellence. Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. Clinical Guideline 16. London: NICE, 2004. Available at: www.nice.org.uk/guidance/CG16
- Baker D, Fortune S. Understanding self-harm and suicide websites: a qualitative interview study of young adult website users. Crisis 2008; 29 (3): 118–122.
- Skegg K. Self-harm. The Lancet 2005; 366 (9495): 1471–1483.
- Dickson S, Donaldson I, Matthews V et al. Self-harm in Manchester: January 2008 to December 2009. The Manchester self harm project. The University of Manchester, 2011.
- Wheatley M, Austin-Payne H. Nursing staff knowledge and attitudes towards deliberate self-harm in adults and adolescents in an inpatient setting. Behav Cogn Psychother 2009; 37 (3): 293–309. G