Self-Harm & Suicide Summary

Definition

  • Intentional self-poisoning/injury
  • Expression of emotional distress
  • Includes suicide & non-suicidal acts

Common Methods

  • Poisoning: Medications most common
  • Injury: Cutting most common
  • Burning, hanging, stabbing

Risk Factors

  • Age peaks: 16-34yo self-harm
  • Mental health disorders
  • Substance misuse
  • Social isolation
  • Previous attempts

Assessment

  • Ask about suicidal thoughts/plans
  • Identify protective factors
  • Use SAD PERSONS scale
  • High-risk: young/middle-aged men

Management

  • Help appropriate to risk level
  • Urgent referral if immediate risk
  • Safety planning for lower risk
  • Assess consent/capacity carefully

SAD PERSONS Scale

  • 0-5: May discharge
  • 6-8: Psychiatry consult
  • >8: Hospital admission

Self-Harm and Suicide

Assessment and management in emergency settings

Introduction

Self-harm refers to an intentional act of self-poisoning or self-injury, irrespective of the motivation or apparent purpose of the act, and is an expression of serious emotional distress.

Self-harm includes suicide attempts as well as acts where little or no suicidal intent is involved (for example, where people harm themselves to reduce internal tension, communicate distress, or obtain relief from an otherwise overwhelming situation).

Self-Poisoning

  • Majority involve prescribed or over-the-counter medication
  • Minority involve illicit drugs, household substances, or plant material

Self-Injury

  • Majority involve cutting
  • Less common methods: burning, hanging, stabbing, drowning
  • Other methods: swallowing objects, insertion, shooting, jumping

Risk Factors

Demographic Factors

  • Age: self-harm peaks in 16-24yo women and 25-34yo men
  • Suicide rates highest in both genders aged 45-49 years
  • Socio-economic disadvantage
  • Social isolation
  • Male gender (for completed suicide)

Psychosocial Factors

  • Stressful life events (relationship difficulties, etc.)
  • Previous experience in armed forces
  • Child maltreatment or domestic violence
  • Bereavement by suicide
  • Involvement with criminal justice system

Health Factors

  • Mental health problems (depression, psychosis, bipolar, PTSD, personality disorders)
  • Chronic physical health problems
  • Alcohol and/or drug misuse

Gender Difference Note

The overall higher rate of suicide in men despite higher self-harm rates in women may be due to choice of more lethal methods (firearms and hanging vs cutting or poisoning).

Risk Assessment

Initial Screening Questions

If Positive Responses

Ask about suicide plans:

  • Have you considered a method?
  • Do you have access to the materials?
  • Have you made any preparations (e.g., written a note)?

Protective Factors

Additional Risk Factors

Historical Factors

  • Previous suicide attempts or self-harm
  • History and frequency of past self-harm
  • Medical seriousness of previous attempts
  • Use of violent methods
  • Evidence of planning (suicide note, will changes)
  • Precautions taken to prevent rescue

Current Factors

  • Active mental illness
  • Family history of mental disorder/suicide
  • Low socioeconomic status
  • Unemployment
  • Physical health problems
  • Living alone, being unmarried
  • Abusive or violent relationships
  • Drug/alcohol dependence
  • Feelings of hopelessness
  • Exposure to suicidal behavior

High Risk Groups

Management Recommendations

  • Assess social support and awareness of help sources
  • Identify treatable dynamic risk factors (mental illness, substance use)
  • Arrange help appropriate to risk level
  • Advise to seek further help if situation deteriorates
  • Assess safeguarding concerns for dependents
  • Urgent referral to specialist services if considerable immediate risk
  • Create safety plan for low-risk individuals

Modified SAD PERSONS Scale

Scoring System

  • Sex (male) – 1 point
  • Age (< 19 or > 45 years) – 1 point
  • Depression or hopelessness – 2 points
  • Previous suicidal attempts or psychiatric care – 1 point
  • Excessive alcohol or drug use – 1 point
  • Rational thinking loss (psychotic or organic illness) – 2 points
  • Single, widowed or divorced – 1 point
  • Organised plan – 2 points
  • No social support – 1 point
  • Stated future attempt – 2 points

Risk Assessment Scale

0–5 Points

May be safe to discharge (depending upon circumstances)

6-8 Points

Probably requires psychiatric consultation

>8 Points

Probably requires hospital admission

Consent and Capacity Issues

Consent Principles

  • Ensure informed consent for management wherever possible
  • If person declines treatment, assess mental capacity
  • Assume capacity in persons aged 16+ unless evidence otherwise
  • Gather information from family/carers if person allows

Management of Refusal

Capacity and Refusal

If person has capacity and no mental disorder signs, they have the right to refuse treatment. Steps to take:

  • Take all steps to persuade them
  • Involve family and carers if allowed
  • Seek advice from senior staff
  • Clearly document wishes against medical advice