Self harm and suicide Flashcards
Suicide and self harm exist as a spectrum
Risky behaviours –> ‘life weariness’ –> Death wishes –> suicidal thoughts/plans –> suicidal behaviours –> completed suicide
Epidemiology of suicide
1% lifetime risk –> 8/100,000/yr in the UK
5th cause of life years lost but big international variance
High proportion have contact with health care professionals in month before death
More common in high and low IQ people
Epidemiology of Deliberate self harm
310/100,000/yr –> 170,000 medical presentations
1-2% of patient with DSH completed suicide in the next year –> but risk prediction v. difficult
Evidence that brief psychotheraputic interventions can be useful in patients without psychiatric disorder
Psychiatric assessment after DSH
Patient must be awake –> should be somewhere private
Be patient and assess the risk factors to distinguish acute and chronic risk
Risk factors specific to suicide attempt
Violent method or major overdose
Evidence of planning - Regret over failure
Attempts to conceal planning or aftermath
Honest belief and hope to die - continued active intent
Demographic Risk factors
Male gender –> living alone and recently widowed, divorced/separated
Older, unempolyed
Certain professions –> Farmers or doctors
Clinical/medical risk factors
Psychiatric disorder –> depression/psychosis, personality disorder
Previous or recent attempts, substance misuse
Medical illness –> particularly chronic, painful conditions
Management of DSH in the emergency setting
Admission with or without section
Refer –> community mental health/home treatment team
Drug and alcohol services
Brief psychotherapy by DSH team – ‘Crisis cards’
Good emergency care can reduce chance of repetition
Consent in treating DSH/Suicide
Mental health act allows for mental disorders to be treated but not physical –> a patient has the right to refuse treatment if they retain capacity –> if capacity impaired can treat for their best interests
Reasons patients lose capacity
Unconsciousness
Any mental disturbance or disability which prevents them: retaining/understanding information, believing it, weighing choices –> NO one else can consent for a patient (except a parent under the age of 16)
Suicide prevention
Proper management post self harm is one of few areas where suicide rates may be effected –> but suicide rates are mainly effected by socioeconomic circumstance and availability of methods
School based programs helped a bit (down by 1.5%)
Media guidlines and hot lines
Antidepressants and suicidal thoughts
Hammad 2006 meta-analysis found that antidepressants moderately increase the risk of suicide
Suicide and days of the week
Greatest on mondays, particularly in women
Adolescent self harm
25,000 presentations/yr –> 10% to hospials
7-14% of adolescents will DSH at some point, and 20-45% report having had suicidal thoughts
Prevalence much higher in females –> highest at 15-24 and 35-45
Hospital presentations of DSH
Only represent about 22.9% of cases
90% of cases which get to hospital are poisoning
Numbers are increasing from 2000
Self harm by cutting
Less life threatening and under-reported
Only 6.3% said they had gone to hospital
Causitive Factors associated with adolescent self harm
Difficulties with siblings and parents
School or work problems
Physical illness or depression
Romantic, sexual or peer Relationship problems (bullying)
Risk factors associated with adolescent self harm
Rape and sexual abuse
Having friends or family who harmed
Increasing drug, drink or cigarette abuse
Depression, anxiety and impulsivity is associated with female self harm
Group psychotherapy for self harming adolescents
Better than standard aftercare at reducing repetition of self harm - this also worked in repeat self harmers
Huey 2004
Compared intensive family and social system-based intervention for 4 months vs hospitalization –> 9% repeated suicide attempts compared to 17% for hospitalized
Self harm and suicide risk
10% of self harmers repeat and this increases suicide risk ten times
Gun and knife injuries
Must inform the police if there is a gun wound or intentional stab wound but do not give out personal information unless the patient gives you permission
Primarily consider patient’s interest & then public interest
First medical assessment in cases of DSH/parasuicide
Are you safe to approach? Danger from pt/surroundings
A - Airway - consider risks from low GCS or vomiting
B - Breathing - risk of respiratory depression from drugs
C - Circulation - treat any lacerations, replace Fe longterm
C - CNS - temperature control or fitting risk
History in the case of DSH/parasuicide
What was taken and when Or Injury method and weapon
PMH including previous DSH
Assess immediate risk of self discharge or further harm
Causes of acute confusional state in DSH/parasuicide
Hypoxia/hypovolaemia, hypoglycemia if alcohol involved Infections? (UTI, chest, CNS), MI or CVA Metabolic distrubance or organ failure Post-ictal states
Alcohol intoxication in DSH/parasuicide
Often a co-factor - wash down pills/give courage
Do not assume it is the only intoxicant/cause of low GCS
Exclude head injury or other serious injury which could account - consider chronic malnutrition/vitamin deficiency
Most common drugs to overdose on
Intentional –> Paracetamol, aspirin, antidepressants
Accidental–> analgesia or digoxin
Recreational –> MDMA, Crack, LSD, GHB
Criminal –> ‘date rape’ - GHB, Rohypnol
Possible Complications of Drug overdose
Resp - dyspnoea, bronchospasm, pulmonary oedema,
CVS - tachycardia, hypotension, arrhythmias, broad QRS
CNS - low GCS, agitation, hallucinations,
Other - pupil size changes, core temperature changes
Emergency management of DSH
Treat medically first – assess ongoing risk
Sedate if necessary - consider overnight observation
Admit children/young people for psych assessment
Offer alcohol/drug advice on discharge
