Self-Harm & Suicide Summary

Definitions

  • Self-harm: Intentional self-poisoning or injury
  • Expression of serious emotional distress
  • Includes suicide attempts and non-suicidal acts

Common Methods

  • Self-poisoning: Prescribed/OTC medication most common
  • Self-injury: Cutting most common method
  • Other methods: Burning, hanging, stabbing, etc.

Risk Factors

  • Age: Peaks in young women and middle-aged men
  • Socio-economic disadvantage
  • Mental health problems
  • Substance misuse
  • Stressful life events

Risk Assessment

  • Ask directly about suicidal thoughts
  • Inquire about plans and means
  • Identify protective factors
  • Use Modified SAD PERSONS scale

Management

  • Assess mental capacity for consent
  • Refer to mental health services if high risk
  • Create safety plans for low-risk cases
  • Document thoroughly

Self-Harm and Suicide

Clinical guidelines for assessment, risk management, and intervention

Understanding Self-Harm and Suicide

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.

Self-Poisoning

The majority of self-poisoning episodes involve prescribed or over-the-counter medication. A minority involve illicit drugs, other household substances, or plant material.

Self-Injury

The majority of self-injury episodes involve cutting. Less common methods include burning, hanging, stabbing, drowning, swallowing objects, insertion, shooting, and jumping from heights or in front of vehicles.

Motivations

People may harm themselves to reduce internal tension, communicate distress, or obtain relief from an otherwise overwhelming situation, not necessarily with suicidal intent.

Risk Factors for Self-Harm and Suicide

Demographic Factors

Self-harm rates peak in 16 to 24-year-old women and 25 to 34-year-old men. Suicide rates are highest in both men and women aged 45–49 years.

Social Factors

  • Socio-economic disadvantage
  • Social isolation
  • Stressful life events
  • Bereavement by suicide
  • Involvement with criminal justice system

Health Factors

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

Gender Differences

Men have higher suicide rates despite lower self-harm rates, potentially due to choice of more lethal methods (firearms and hanging vs cutting or poisoning).

Risk Assessment for Suicide

Direct Questions

When assessing suicide risk, ask directly: "Do you have thoughts about death or suicide? Do you feel that life is not worth living? Have you made a previous suicide attempt? Is there a family history of suicide?"

Suicide Planning Questions

If the answer to any initial questions is yes, ask about plans for suicide:

Protective Factors

Ask about protective factors including coping strategies, supportive relationships, dependent children, and religious beliefs:

Additional Risk Factors

Identify factors that increase suicide risk:

Historical Factors

  • Previous suicide attempts or self-harm
  • Family history of mental disorder, suicide or self-harm

Personal Circumstances

  • Low socioeconomic status
  • Unemployment
  • Living alone
  • Being unmarried
  • Abusive or violent relationships

Clinical Factors

  • Active mental illness
  • Drug/alcohol dependence
  • Physical health problems
  • Feelings of hopelessness

High Risk Groups

Modified SAD PERSONS Scale

The Modified SAD PERSONS Scale is a clinical tool to assess suicide risk. Points are assigned based on risk factors, with higher scores indicating greater risk.

Factor Points
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 Interpretation

Score 0–5

May be safe to discharge (depending upon circumstances)

Score 6-8

Probably requires psychiatric consultation

Score >8

Probably requires hospital admission

Management and Intervention

Risk Assessment - If there is a risk of self-harm or suicide, assess whether the person has adequate social support and is aware of sources of help.
Treatable Factors - Assess whether there are any dynamic risk factors that can be treated (for example, mental illness, use of alcohol or illicit drugs).
Appropriate Referral - Arrange help appropriate to the level of risk. If a person with depression presents considerable immediate risk, refer them urgently to specialist mental health services.
Safety Planning - If the person is considered at low risk, discuss and/or create a safety plan with them, detailing steps they should take if their situation deteriorates.
Safeguarding - Assess for any safeguarding concerns in children, young people, or vulnerable adults dependent for their care on the person presenting with an episode of self-harm.
Follow-up Advice - Advise the person to seek further help if the situation deteriorates.

Consent and Capacity Issues

Ensure any person who has self-harmed gives informed consent for management, wherever possible. If a person declines or refuses management, assess their mental capacity.

Capacity Assessment - Mental capacity should be assumed in a person aged 16 years or over, unless there is evidence to the contrary. If possible, gather additional information from family, carers, and significant others.
Understanding Refusal - If a person refuses treatment, determine the reason(s) why. Provide information about the potential consequences of not receiving hospital treatment and assessment.
Diminished Capacity - If a person is judged to have diminished capacity and/or the presence of a significant mental health disorder, refer for an urgent mental health assessment or hospital admission.
Best Interests - Healthcare professionals have a duty to act in the person's best interests. This may include taking the person to hospital for further assessment and treatment against their wishes.
Seeking Advice - If there is uncertainty about whether a person has capacity to make informed decisions, seek advice from a psychiatrist who has experience in assessing capacity.
Respecting Capacity - If the person is judged to have capacity, and does not have signs of a mental disorder, by law they have the right to refuse hospital admission and/or to refuse lifesaving treatment. Take all steps to persuade them to attend hospital or have treatment.
Documentation - Clearly document their wishes and that these are against medical advice. Involve family and carers if the person allows, and seek advice from senior staff.