Self Harm and Suicide, Risk Assessment, Safegaurding Flashcards
Suicide risk assessment: Key questions to ask about current episode of self harm - before
Was there a precipitant?
(e.g. argument with a spouse or a recent bereavement. May help establish psychological, physical or social problems)
Was the self-harm planned, or impulsive?
Did the patient carry out any final acts?
(e.g. write a suicide note/leaving a will/terminating contracts)
Were any precautions taken against discovery?
(e.g. closing curtains/locking doors/waiting until home alone/going somewhere remote)
Was alcohol used?
(amount/type, previous alcohol use)
Suicide risk assessment: Key questions to ask about current episode of self harm - during
What method of self-harm was involved?
Was the patient alone?
Where were they when they self-harmed?
What was going through their mind at the time?
Did they think their self-harm would end their life?
What did they do straight after the self-harm?
Suicide risk assessment: Key questions to ask about current episode of self harm - after?
Did the patient call anyone? How did they get to A&E? Who were they found by?
How did they feel when help arrived?
How does the patient feel about the attempt now? Do they regret it?
What is the patient’s current mood?
Does the patient still feel suicidal?
If the patient were to go home today, what would they do? (make sure you cover the next few days)
If the patient were to feel like this again, what might they do differently?
What does the patient think might prevent them from doing this again in the future?
Does the patient feel there is anything to live for? (i.e. protective factors)
Will the patient accept treatment?
When a patient takes an overdose, what specific questions must you asked them?
What medication or medications did the patient take?
Where did the patient get the medication from?
How much of the medication did the patient take?
What did the patient take the medication with?
What did the patient think that amount of medication would do?
What made the patient decide to take the medication/how long had they been thinking about taking an overdose for?
What did the patient do after taking the medication?
How did the patient get to the hospital?
Specific questions to ask about cutting when a patient presents with self harm/suicide attempt?
Where are the cuts?
How many cuts are there?
How deep are the cuts?
How did the patient feel whilst they were cutting?
How did the patient feel when they saw blood?
What was the patient hoping the cutting would do?
Suicide risk assesment: Screen for other mental health disorders which increase the risk of suicide
Depression
Ask about anhedonia/low mood/fatigue
Psychosis
Ask about thought insertion/auditory hallucinations
Anorexia
Ask about eating habits/intake/appetitie/recent weight loss/feelingd about current weight
What should be asked when inquiring about previous episodes of self harm?
Has the patient ever carried out self-harm in the past?
What methods of self-harm were involved?
Did they get any help from their support network or other agencies as a result of their self-harm?
What should be established in regard to the psychiatric past medical history when assessing for suicide equipment?
Does the patient have any psychiatric diagnoses?
Has the patient had any previous admissions to a psychiatric hospital?
Why might past medical history and drug history be relevant in cases of self harm/suicidal ideation or attempt
It is important to ask about a patient’s past medical history as this may be relevant to their current episode of self-harm (e.g. bleeding disorder/liver dysfunction).
Chronic pain and chronic illness are also risk factors for suicide.
It’s important to take a thorough drug history as this may be relevant to the current episode of self-harm (e.g. anticoagulants/overdose/interactions).
Suicide risk assesment - family history
Have any of the patient’s family members ever attempted or completed suicide?
Are there any psychiatric conditions present in close family members?
Taking a thorough social history allows identification of social risk factors for suicide. What should be asked about?
Living situation (with who/where, support network, able to do activities of daily living, any children - safegaurding)
Occupation (what is it, feelings towards job, coping, needing to take time off, debt/financial situation)
Alcohol (particularly important to ask about if used during the episode of self-harm, do they drink - if so how much, pattern of drinking (binge/daily))
Recreational drugs (are they used, what/when, how much/how frequent)
Things to include when assessing for risk of suicide?
Current episode of self harm
Specific questions about overdose or cutting if applicable
Screen for mental health disorders
Previous episodes of self harm/suicide attempts
Past psychiatric history
PMH + DHx
Family history
Social History
Plans
Precipitating factors
Protective factors
Suicide risk assessment: If the patient is not suicidal and you intend to send them home with no follow-up
Safety plan:
Seek the support of their family and friends (clarify who they have already told ).
Recognise stressors and address them where possible.
Avoid harmful alcohol use when stressed.
Ask the patient who they could tell if they felt like this again.
Suggest that if the patient feels like this again, they can seek help from a number of places (A&E, samaritans, GP, personal support nerwork)
Signpost to appropriate agencies which may be able to address stressors/risk factors:
GP
Housing services
Citizen’s Advice Bureau
Alcohol and drugs services
Domestic violence services
Counselling services
Suicide risk assessment: If the patient requires support from a mental health team
Some patients may require support from the local mental health team. Have a discussion about whether the patient could manage safely at home with the support of an intensive home treatment team or will accept voluntary admission to a psychiatric hospital.
Suicide risk assessment: If the patient is unsafe to send home
For some patients, it may be clear that they are at high risk of completing suicide or further self-harm and lack insight. In these cases, a Mental Health Act assessment will need to be carried out.
Factors that increase the risk of suicide: demographics
Male
Older
Widowed/separated/single
Living alone/social isolation
Low income/unemployed
Certain occupation (e.g. doctor, farmer)
Family history of suicide
Factors that increase the risk of suicide: diagnosis
A previous suicide attempt (risk x 40)
Severe depression (risk x 20)
Anorexia (risk x 25)
Haemodialysis (risk x 14)
Recreational opiate use/dependence (risk x 14)
Alcohol dependence (risk x 6)
Schizophrenia
Factors that increase the risk of suicide: the act itself
The patient carried out final acts (e.g. writing a will)
The patient has researched methods and prepared for the act (e.g. stockpiling tablets)
The patient perceived the act to have a high lethality
The patient took precautions against being found
The patient used a violent method of suicide (e.g. firearms, jumping from a height)
The patient’s attempt is discovered by chance
The patient resists/tries to evade medical intervention
The patient downplays the seriousness of the attempt
Common protective factors against suicide
family support
having children at home
religious belief
Clinical features of paracetomol overdose?
No symptoms
Nausea and vomiting
Loin pain
Haematuria and proteinuria
Jaundice
Abdominal pain
Coma
Severe metabolic acidosis
Pathophysiology of paracetamol overdose?
When taken as an overdose, the metabolism of paracetamol results in a buildup of a toxic substance called NAPQI (N-acetyl-p-benzoquinone-imine).
NAPQI is inactivated by glutathione.
In an overdose, glutathione stores are rapidly depleted, and NAPQI is left un-metabolised.
It can cause liver and kidney damage.
Paracetamol overdose: If ingestion less than 1 hour ago + dose >150mg/kg
If ingestion less than 1 hour ago + dose >150mg/kg: Activated charcoal
When can activated charcoal be used in paracetamol overdose?
If ingestion in the last hour
If dose >150mg/kg (aprox 10 paracetomol in a 70kg pt)
Paracetamol overdose: If staggered overdose or ingestion >15 hours ago
Start N-acetylcysteine immediately
When should N-acetylcysteine be started immediately in paracetamol overdose?
If staggered overdose or ingestion >15 hours ago
NAC can also be administered immediately if there is an increased risk of toxicity. This occurs in the following:
Patient on long-term enzyme inducers
Regular alcohol excess
Pre-existing liver disease
Glutathione-deplete states: eating disorders, malnutrition and HIV.
When should paracetamol level be taken following ingestion?
If ingestion <4 hours ago: Wait until 4 hours to take a level and treat with N-acetylcysteine based on level
If ingestion 4-15 hours ago Take immediate level and treat based on level
If over 15 Start N-acetylcysteine immediately
What bloods should be taken in addition to paracetamol level in ?overdose
FBC
Urea and Electrolytes
INR
Venous gas
Management of paracetamol overdose
If ingestion less than 1 hour ago + dose >150mg/kg: Activated charcoal
If staggered overdose or ingestion >15 hours ago: Start N-acetylcysteine immediately
If ingestion <4 hours ago: Wait until 4 hours to take a level and treat with N-acetylcysteine based on level
If ingestion 4-15 hours ago: Take immediate level and treat based on level
FBC
Urea and Electrolytes
INR
Venous gas
Consider need for transfer to liver unit if blood tests are worsening
Deciding whether to treat is based on a nomogram. If paracetamol levels are above the treatment line then start NAC.
If a patient presents after 16 hours, there is uncertainty about timing or has a staggered overdose then NAC should be started regardless of the nomogram.
NAC can also be administered immediately if there is an increased risk of toxicity. This occurs in what conditions?
Patient on long-term enzyme inducers
Regular alcohol excess
Pre-existing liver disease
Glutathione-deplete states: eating disorders, malnutrition and HIV.
Internal potential reasons for self harm
Suicide
Self hatred
Hate the body
Overcome numbness
Psychical pain rather than psychic
Self soothing
Cope with a strong emotion
External reaons someone may deliberately self harm
A communication
To make others feel something
To make others do something
The greatest risk factors for suicide
The greatest risk factors for suicide include a history of self-harm or a previous suicide attempt
What is suicide
The act of killing oneself intentionally
What is DSH?
An act of self harm where the action was not with the intention of death, but to cause harm
What is meant by para-suicide
An act of self harm where the action was not with the intention of death, but to cause harm
What is the most common method of suicide
Hanging
What is the most common method of suicide in the elderly?
Overdose
Suicide in schizophrenia main correlates
Early onset schizophrenia (i.e adolescents)
Depressive symptoms
Positive psychotic symptoms
Male gender
High premorbid IQ
Feelings of guilt or anxiety
Substance abuse
Treatment delay
First decade of illness
Recent discharge from hospital
Previous suicide attempts
Suicide & substance misuse correlates
Male gender
Older age group
Alcohol use
Previous suicide attempts
Longer duration of problems
Single/divorced/widowed
Multiple substance abuse
Comorbid depression
Personality disorder and suicide
Nearly always associate with a depressive syndrom or substance abuse
EUPD - chronic suicide risk
Narcissistic PD is second highest
Risk of suicide in those with mental disorders is at least how many times higher than for general population
10 times
Suicide and depression - main correlates
Greater severity of illness
Elderly population (experience psychotic symptoms)
Self neglect
Hopelessness
Alcohol abuse
Previous suicide attempts
Suicide and bipolar main correlates
Occur with first depressive episode (around 25 years of age)
Illicit drug use
Male gender
First degree family history of suicide
Two main types of self harm
self injury
self poisoning
Physical illnesses with increased risk of suicide?
Increased risk in patients with chronic disorders including neurological, gastro-intestinal, cardiovascular disorders
HIV infection
Cancer diagnosis
Physical disability (i.e traumatic brain/spinal cord injury, post-stroke conditions)
Chronic pain leads to increased risk- depression.
Chronic physical illness can lead to limitations including loss of job, role, family, money for example
Associations with repeated self harm
Previous self-harm/ psychiatric contact
Alcohol / Drug misuse
Unemployment/ Social class V
H/o trauma, sexual or physical abuse
Criminal record/ history of violence
Single / divorced / separated
Family history- 4 fold increase risk, twin and adoption studies
(Do NOT solely rely on identifying risk factors)
Psychological characteristics
Impulsive
Cognitive rigdity
Difficulties in problem solving hopelessness
Substance abuse and DSH
increased use at time of DSH or just before DSH
Use of illicit substance can add to the potential dangers of an OD
Alcohol increases the toxicity of psychotropic drugs
Wish to die, cry for help, communication with others, unbearable symptoms
Societal causes of DSH and suicide
Access to means
Inappropriate media reporting
Stigma associated with help seeking behaviour
Community causes of DSH and suicide
War/conflict
Stresses of acculturation and dislocation
Discrimination
Trauma and abuse
Relationship causes of DSH and suicide
Relationship loss, discord or conflict
Lack of relationships
Individual factors leading to DSH and suicide
Chronic pain
Mental disorders
Harmful use of alcohol
Hopelessness
Loss of job or financial loss
Family history of suicide
Suicide attempts
Genetic and biological factors
Universal prevention of DSH and suicide
Policies to reduce harmful use of alcohol
Acess to healthcare
Reduce access to means
Responsible media reporting
Raising awearness of mental health, substance use disorders, suicide
Selective prevention of DSH and suicide
Intervention for vulnerable groups
Gatekeepr training
Crisis helpline
Indicated prevention of DSH and suicide
Follow up and community support
Assessment and management of suicidal behaviours
Assessment and management of mental and substance use disorders
Risk assement - to others
What is the psychiatric disorder (and its relationship to violence)
Has the risk been modified by treatment?
Relevance of premorbid personality, substance misuse, alcohol?
MDT views similar to your own
Circumstances of previous violent behaviour
Potential victims
Aftercare – ongoing treatment and support
Types of abuse
Sexual
Emotional
Neglect
Physical
Psychiatric illness and risk of homicide
DSPD, alcohol/drug misuse, Schizophrenia: cause a small increase risk to others but not affective disorders
In Psychotic disorders risk is increased by
Specific persecutory delusions or hallucinations
Command auditory hallucinations
What can be used to make judge objectiviley the risk of a patient experiencing abuse?
DASH - domestic abuse, stalk and harassment (DASH)
Urgent safegaurding concerns with regard to a child/young person
Immediate telephone call to social services
Written referral within 48hrs
MAPPA
Multi agency public protection arrangements
Police take lead
Multiple agencies involved
Community management of violent offenders
PREVENT
Safegaurding people and communities from the threat of terrorism
Prevent is one of the four elements of CONTEST, the governments counterterrorism stratergy
It aims to stop people being radicalised
Responsibility of all health and social care workers to raise concerns
Risk assessment considerations
Dependent on level of risk present
Reduce access to means
Are they safe to go home? Do they require further support? If so, what are the options?
Are they willing to engage with the management
Treat the psychiatric disorder
As an inpatient? Level of observations, adherence to treatment, staffing numbers, better staffing training, safer environment e.g. ligature points
What is the most appropriate rating scale to use when assessing the risk of violence?
The HCR-20 is a widely used and well-researched 20-item assessment tool for assessing the risk of violence. It includes Historical and Clinical factors, as well as Risk management considerations. (HCR = Historical, Clinical, Risk).
