Self harm

Self-harm includes self-injury [e.g. Self inflicted wounds] and self-poisoning with drugs. It can take various forms including -:

• Taking too many tablets
• Cutting themselves
• Burning their body
• Banging their head
• Sticking things in their body
• Swallowing inappropriate objects

Among people who deliberately self harm, the risk of later suicide is much increased. For example, in the first year afterwards, the risk of suicide is about 1 – 2% (100 times greater than the general population) and among patients who were previously admitted with deliberate self harm almost 3% took their own lives over an 8 year follow up period. Among people who deliberately self harm, the risk of eventual suicide is much greater in those with other risk factors for suicide. For example, the risk is greater among older patients who are male, depressed or alcoholic. A ‘non dangerous’ method of self harm does not necessarily indicate a low risk of subsequent suicide, partly because patients may not have much knowledge of the dangerous consequences of many methods. However, the risk is certainly high when violence or highly dangerous drug overdoses have been used.”

There are several factors associated with a significant increase in risk of suicide. These include low socio-economic and educational status, living alone, being unemployed or retired, certain occupations (vets, farmers, doctors, dentists, pharmacists) and adverse life events. Also important is the presence of co-morbid psychiatric illness such as depressive illness, personality disorders, alcohol related disorders and psychotic illness.

A health care professional assessing an individual’s suicide risk examine a number of key psychological characteristics such as -:

• Planning and preparation, e.g. buying equipment or collecting medication.
• Precautions taken to avoid discovery, e.g. doors locked, the act timed to avoid disturbance or carried out in isolation.
• No help sought after the act.
• A violent method attempted, e.g. hanging, electrocution, shooting, jumping or drowning.
• A final act was performed, e.g. making a will or leaving a suicide note.
• Regret for not having died and still wanting to die.

In depressive illness, although there is an increased risk of suicide, the majority of people with a mild or moderate condition do not constitute an active suicidal risk.

The onset of depressed mood is rarely sudden. Where a doctor considers a patient may be at significant risk of suicide or serious self harm it is likely that the patient would be admitted to hospital, possibly under a section of the Mental Health Act, to treat the depression and provide supervision to prevent self harm.

However, in the absence of inpatient treatment, it should not be assumed that there is no significant risk of suicide. If there is any doubt as to the suicide risk, a factual report should be obtained from the relevant Health Care Professional.

Patients with psychomotor retardation are at greater short-term risk of suicide once their symptoms begin to improve, when they develop the energy to carry out the act of suicide.

However, the risk of suicide diminishes with successful treatment and hence is not likely to be an ongoing problem in the majority of cases.

Those who have self harmed are not only at increased risk for suicide, but also for repeated self harming. 1 in 3 people who self-harm will do it again within a year. The factors that determine repeat self harming overlap with those associated with increased risk of suicide (e.g. depression, low socio-economic status etc).

Predicting suicide/ self-harm risk is difficult and requires assessment by a trained mental health professional. However, it is important to consider all relevant factors and if in doubt consult Medical Services when determining supervision requirements. There are several factors that may increase the likelihood of supervision requirements, these include -:

• Assessed as high risk by a trained mental health professional
• Recent self harm especially requiring hospitalisation
• Chronic history of serious self harm
• Having a care plan especially an enhanced care plan
• Presence of additional co-morbid mental health problem

Amended June 2010