Deliberate self-harm (DSH)/ attempted suicide

Question 1

Define suicide and self-harm.

Answer 1

Suicide is any act that deliberately brings about one’s own death.

Self-harm is any act intentionally causing physical injury to the body, but not resulting in death.

Question 2

How common is suicide?

Answer 2

Top 10 cause of death in every country

The elderly (over 65s) and younger (15–30 years) age groups are at highest risk of suicide.

Question 3

Why is risk of death by suicide x3-4 higher in men than women?

Answer 3

Men usually choose violent methods e.g. hanging, shooting

Question 4

Which social classes are at highest risk of suicide?

Answer 4

Classes I and V (but IV and V are at highest risk of self-harm)

Question 5

What % of people who die by suicide have previously self-harmed?

Answer 5

60%

Other:

• 80% who die were depressed
• 10-15% have previously attempted suicide

Question 6

History taking tips in suicide attempt:

Answer 6

Antecedent

• What has happened that has brought you here?
• When did the precipitating factor happen exactly?
• Did you post anything on social media before attempting this? Did you speak to anyone about how you were feeling? Did you communicate this to anyone else?

Event

• Where did you get the medication?
• How lethal did you think this would be?
• Did you research how much to take?
• What did you think would be the outcome of taking this?
• Do I need to be worried about your safety? Do your parents need to be worried about your safety?
• I can see that you are very distressed. Is there anything that you still wish you live for?

After:

• What happened after you took the overdose?

Question 7

What are the different systems which must be considered as contributing to the condition? e.g. school

Answer 7

• All the factors in a person’s life which may be aggrevating or alleviating their condition.
• Individual - PMH, PPH, DH, Sx of drug use
• Family history - what is the family structure, PPH in family e.g. overdoses, DH in family, siblings, any protective factors like a supportive family member,
• Work/school - bullying, academic, support from teachers e.g. knowing, support, trust,; negative peers e.g. others engaging in self-harm (some kids may end up in groups who all self-harm), unrecognised autism/ADHD.
• Local community -

Answer 8

Question 9

What are 5 risk factors for suicide.

Answer 9

• male sex (hazard ratio approx 2.0)
• history of deliberate self-harm (HR 1.7)
• alcohol or drug misuse (HR 1.6)
• history of mental illness
  
  • depression
  • schizophrenia: NICE estimates that 10% of people with schizophrenia will complete suicide
• history of chronic disease
• advancing age
• unemployment or social isolation/living alone
• being unmarried, divorced or widowed

Question 10

What are 5 risk factors for repeated completed suicide

Answer 10

• Planning
• Final act in anticipation of death e.g. suicide note or text, sorting out finances
• Efforts to avoid discovery
• Violent method

Other:

• Regretting that method failed
• Choice of violent potentially lethal method e.g. massive overdose, hanging, jumping from height
• Belief about lethality of chosen method
• Clearn unambiguous wish to die
• Persisting suicidal intent
• Still hopeless
• Persistence of trigger(s)

= increased risk of repetition or suicide

Question 11

What are 3 protective factors for suicide?

Answer 11

• Family support
• Having children at home
• Religious belief

Question 12

Does a death due to suicide need to be reported?

Answer 12

Yes - reported to the coroner as this is a notifiable cause of death

Tell the patient’s family this as this may delay the funeral

Question 13

How do you deal with friends/relatives of someone who has died by suicide?

Answer 13

Assure them that it was not their fault

Encourage a companion to identify body

Don’t avoid topic of organ donation - this might be the only positive outcome for the bereaved

Signpost to services that may help e.g. hospital chaplains, counsellors, charities like SOBS (survivors of bereavement of suicide)

Question 14

If a patient at high risk of suicide is insiting on leaving the hospital what should be done?

Answer 14

Assess capacity

Question 15

What physical treatment may be required in attempted suicide/self-harm patients?

Answer 15

Examine any physical injuries

Overdoses:

• Naloxone (for opioid overdoses)
• Activated charcoal (decreases intestinal absorption of some substances e.g. antidepressants). Must be used <1 hour of ingestion
• Antidotes (e.g. N-acetylcysteine for paracetamol overdose)

Lacerations

• Superficial cuts: sutures or Steristrips
• Plastic surgery for deep cuts
• Adequate analgesia should be given

Question 16

How do you risk assess someone who has attempted suicide/self-harmed?

Answer 16

Ask about:

1. Thoughts about hurting themselves again
2. Thoughts of hurting others
3. Concerns about being hurt by others
4. Specific features of increased risk (see prevous slide on risks for completed repeated suicide)

Question 17

Do suicidal patients have capacity?

Answer 17

Depends

Study found that 40% of patients presenting to hospital with self-harm had the capacity to make a decision about their medical treatment and 30% of those intended to refuse life-saving treatment.

Question 18

Define capacity. What 5 MCA principles are used in decision making?

Answer 18

MCA states that you lack capacity to make a decision if you cannot do one or more of the following:

• understand the information relevant to the decision (incl. reasonably foreseeable consequences)
• retain that information in making the decision
• use or weigh the information available, and
• communicate the decision by any means, including speech, sign language, or simple muscle movement.

MCA principles when assessing capacity:

1. Presume capacity
2. Support the individual
3. Right to make unwise decision
4. Act in person’s best interest if lacking capacity
5. Choose the least restrictive option

Question 19

How do you decide where a patient should be managed after a suicide attempt?

Answer 19

If at high risk of suicide + lacking capacity –> need to be admitted to a psychiatric ward for their own safety

If at lower risk –> may be managed at home (depending on home circumstance e.g. if they have a supportive family)

Question 20

What does a crisis plan include?

Answer 20

A crisis plan is made to deal with future suicidal ideation or thoughts of self-harm and includes:

1. Who they will tell
2. How they will get help (e.g. coming straight to hospital)

Question 21

What follow up may be necessary in a patient after attempted suicide? What long-term management is considered?

Answer 21

Follow-up within 1 week of the self-harm or discharge from the inpatient ward e.g.

• CMHT or OPD
• GP
• Counsellor

Underlying disorders (e.g. depression) should be treated

• SSRIs are safest for depression
• Prescriptions should be short and reviewed regularly to prevent stockpiling for overdose

Psychological therapies

• CBT-based therapies (e.g. CBT, dialectical behaviour therapy)
• Mentalisation-based treatment
• Transference-focused psychotherapy

Harm minimisation techniques (agreed with MDT) may be used if stopping self-harm is unrealistic in the short-term, e.g. using ice cubes, rubber bands

Coping strategies e.g. distraction techniques or mood-raising activities (e.g. exercise, writing)

Question 22

List 3 examples of harm minimisation techniques.

Answer 22

Strategies to decrease or avoid self-harming

• Put tablets and sharp objects away
• Avoid triggers (e.g. photos online)
• Stay in public places or with supportive people when tempted to self-harm
• Call a friend or support line
• Avoid drugs and alcohol
• Squeeze ice cubes
• Snap a rubber band around their wrist
• Bite into something strongly flavoured (e.g. lemon)

Question 23

What is the prognosis with suicide attempts after discharge?

Answer 23

30% of suicides occur within 3 months of discharge from psychiatric wards

Question 24

How does suicide rate change during war?

Answer 24

The suicide rate decreases during wars (Stengel 1964), presumably because the suicidal impulse is subsumed by a sense of being connected to other people in resisting a common enemy.

Question 25

How has the UK goverment lowered suicide rates?

Answer 25

• limiting pack sizes of paracetamol
• installing barriers at suicide ‘hotspots’ and providing a free telephone for calling the Samaritans
• catalytic converters (these have decreased the suicide rate from inhaling car exhaust fumes).