Transcript Assessment following deliberate self harm and referral to

Assessment following deliberate
self harm and referral to Mental
Health Services
Dr J van Niekerk
Crisis Resolution Home Treatment Team
Trafford General Hospital
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
DSH is a behaviour and not an illness
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
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
Services
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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
Trends
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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
Figure 1 Epidemiology of self harm attendances at the ED in 32 hospitals in England.
Mitchell, A J et al. Emerg Med J 2006;23:251-255
Copyright ©2006 BMJ Publishing Group Ltd.
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
Social
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Social circumstances are important:
Isolation
Socioeconomic deprivation
Excess of life events (month before SH)
Younger people : relationship difficulties
Older people: health or bereavement
Vulnerability factors
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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
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
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
Psychosocial assessment
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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:
Are there current mental health difficulties?
What is the risk of further self harm/suicide
Are there any current medical or social
problems?
Assessment
Short term risk assessment
1. Careful history of events surrounding self harm
serious medical attempt/perception of seriousness ie in
children/learning disability
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Precautions against being found
Previous mental health problems (DSH)
Harmful use of alcohol or drugs
Social circumstances and problems – loneliness
and lack of network
6. Forensic history – impulsive or aggressive traits
7. MSE – symptoms of depression, suicidal
thoughts , plans or intent to self harm
Circumstances and comorbid
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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
Risk assessment tool
• Will help when referring to Mental Health
Services : short screening tool
• SAD PERSONS: NOT good at predicting risk
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Sex
Age
Depression
Previous attempt
Ethanol abuse
Rational thought loss
Social supports lacking
Organized plan
No spouse
Access to lethal means
Sickness
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
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
If someone refuses treatment
• 1. Simple persuasion
• 2. If lacks capacity to consent (medical or mental
health reasons) – treat in best interest of patient
Capacity: 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.
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
When to refer to Psychiatry
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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
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
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
Other measures
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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
References
• 1. Regular review: Management of patients who deliberately harm themselves
BMJ 2001;322;213-215
Göran Isacsson and Charles L Rich
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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