Self harm and suicide

Question 1

Suicide and self harm exist as a spectrum

Answer 1

Risky behaviours –> ‘life weariness’ –> Death wishes –> suicidal thoughts/plans –> suicidal behaviours –> completed suicide

Question 2

Epidemiology of suicide

Answer 2

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

Question 3

Epidemiology of Deliberate self harm

Answer 3

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

Question 4

Psychiatric assessment after DSH

Answer 4

Patient must be awake –> should be somewhere private

Be patient and assess the risk factors to distinguish acute and chronic risk

Question 5

Risk factors specific to suicide attempt

Answer 5

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

Question 6

Demographic Risk factors

Answer 6

Male gender –> living alone and recently widowed, divorced/separated
Older, unempolyed
Certain professions –> Farmers or doctors

Question 7

Clinical/medical risk factors

Answer 7

Psychiatric disorder –> depression/psychosis, personality disorder
Previous or recent attempts, substance misuse
Medical illness –> particularly chronic, painful conditions

Question 8

Management of DSH in the emergency setting

Answer 8

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

Question 9

Consent in treating DSH/Suicide

Answer 9

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

Question 10

Reasons patients lose capacity

Answer 10

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)

Question 11

Suicide prevention

Answer 11

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

Question 12

Antidepressants and suicidal thoughts

Answer 12

Hammad 2006 meta-analysis found that antidepressants moderately increase the risk of suicide

Question 13

Suicide and days of the week

Answer 13

Greatest on mondays, particularly in women

Question 14

Adolescent self harm

Answer 14

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

Question 15

Hospital presentations of DSH

Answer 15

Only represent about 22.9% of cases
90% of cases which get to hospital are poisoning
Numbers are increasing from 2000

Question 16

Self harm by cutting

Answer 16

Less life threatening and under-reported

Only 6.3% said they had gone to hospital

Question 17

Causitive Factors associated with adolescent self harm

Answer 17

Difficulties with siblings and parents
School or work problems
Physical illness or depression
Romantic, sexual or peer Relationship problems (bullying)

Question 18

Risk factors associated with adolescent self harm

Answer 18

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

Question 19

Group psychotherapy for self harming adolescents

Answer 19

Better than standard aftercare at reducing repetition of self harm - this also worked in repeat self harmers

Question 20

Huey 2004

Answer 20

Compared intensive family and social system-based intervention for 4 months vs hospitalization –> 9% repeated suicide attempts compared to 17% for hospitalized

Question 21

Self harm and suicide risk

Answer 21

10% of self harmers repeat and this increases suicide risk ten times

Question 22

Gun and knife injuries

Answer 22

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

Question 23

First medical assessment in cases of DSH/parasuicide

Answer 23

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

Question 24

History in the case of DSH/parasuicide

Answer 24

What was taken and when Or Injury method and weapon
PMH including previous DSH
Assess immediate risk of self discharge or further harm

Question 25

Causes of acute confusional state in DSH/parasuicide

Answer 25

Hypoxia/hypovolaemia, hypoglycemia if alcohol involved
Infections? (UTI, chest, CNS), 
MI or CVA 
Metabolic distrubance or organ failure 
Post-ictal states

Question 26

Alcohol intoxication in DSH/parasuicide

Answer 26

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

Question 27

Most common drugs to overdose on

Answer 27

Intentional –> Paracetamol, aspirin, antidepressants
Accidental–> analgesia or digoxin
Recreational –> MDMA, Crack, LSD, GHB
Criminal –> ‘date rape’ - GHB, Rohypnol

Question 28

Possible Complications of Drug overdose

Answer 28

Resp - dyspnoea, bronchospasm, pulmonary oedema,
CVS - tachycardia, hypotension, arrhythmias, broad QRS
CNS - low GCS, agitation, hallucinations,
Other - pupil size changes, core temperature changes

Question 29

Emergency management of DSH

Answer 29

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