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'I've overdosed again' - managing recurrent self-harm

Consultant community psychiatrist Dr Madhvi Belgamwar and GP trainee Dr Rolla Ibrahim discuss this emergency self-harm presentation

Case

A 38 year old female comes to see her GP in clinic as an emergency appointment. She has a known history of emotionally unstable personality disorder and has recently been self-harming more. She is very tearful when she walks in the room. She immediately breaks down and admits to taking 25 paracetamol tablets.

She has taken multiple overdoses in the past and known to self-harm using a razor blade to the forearm when stressed. On examination, her GCS is 15. ECG shows normal sinus rhythm.

The GP calls 999 and informs the A&E team of the incoming patient.

The problem

Population estimates of the prevalence of self-harm in the community vary considerably.

Much of the detailed epidemiological study of self-harm has been based in hospital settings and suggests self-harm might account for over 200,000 hospital attendances in England every year.1

The demographic with the highest suicide rate (of 23.9 per 100,000 population) was reported to be for men aged 45–59 in 2014.2

Self-harm (intentional self-poisoning or self-injury) is often repeated and strongly associated with suicide.3 Self-harm (unlike suicide) occurs more commonly in females and predominantly in those under 35.4 It is often associated with substantial morbidity and healthcare costs.5

Between 15 and 25% of individuals who present to hospital with self-harm repeat this within a year, and 1 to 3% die by suicide in the same period.6 A history of self-harm is the strongest risk factor for suicide across a range of psychiatric disorders and repetition of self-harm further increases this risk.7

Features

Self-harm refers to an intentional act of self-poisoning or self-injury, irrespective of the motivation or apparent purpose of the act.8 It includes acts intended to result in death (attempted suicide), those without suicidal intent (e.g. to communicate distress, to reduce unpleasant feelings) and those with mixed motivation.

Self-harm methods can be divided into two categories: self-injury and self-poisoning. There are many ways of self-harming, some of which are accepted in some cultures, for example, smoking, excessive alcohol, or over-eating. Other methods may include pinching, head banging, tattoo removal, scratching, punching, sticking things in to the body and swallowing things. Complications of self-harm can also be a presenting feature. For example, deep scars can damage tendons and blood vessels. In addition, patients may also present with scars and infected open wounds.

Reasons for self-harm: 9,10

  • Mental health disorders, including personality disorders, anxiety and depression.
  • Social and family difficulties such as difficulties at home, arguments or problems with friends, school pressures, bullying, transitions and changes, such as changing schools, relationship problems with partners and family, being unemployed, or having difficulties at work.
  • Psychological difficulties such as low self-esteem, physical or sexual abuse, feeling bad about themselves, feeling that people don’t listen to them, feeling hopeless, isolated, alone, out of control and powerless.
  • Alcohol and drug use.

Assessment

Raising the importance of an assessment in general practice is vital because studies show that 45% of suicide victims had contact with primary care providers within one month of suicide.11

NICE recommended that none of the simple risk measurement tools or checklists should be used in isolation to determine treatment decisions (because of their poor predictive ability), and a comprehensive clinical interview should be the main basis of assessment.12

Questions to include in a risk assessment may include, but are not limited to:

  • Exploring the person’s feelings of hopelessness: how do they see the future?
  • Exploring any wishes to be dead, and whether such thoughts are fleeting or persistent.
  • Have they been feeling that life is not worth living?
  • Have they had any thoughts about ending their life? Have they made any plans to end their life? Can they tell you more?
  • Would they carry out these plans? What would make this more likely?
  • Asking about any other self-harming behaviour such as cutting, burning, etc. Escalation in the frequency or intensity of such behaviour may indicate imminent risk of suicide.
  • What helps them stay safe? What makes them feel unsafe?
  • What previous attempts of self-harm have been made?
  • How does the patient feel about the current self-harm episode? Do they regret it?
  • Asking about details of current self-harm such as events leading to the episode, the degree of planning, the seriousness of the attempt, the patient’s expectations of the outcome of the self-harm, precautions against discovery, or seeking help, the person’s mental state at the time of self-harm and afterwards.
  • Are they able to keep themselves safe at home?
  • Considering the following social factors:
    • Age
    • Sex
    • Occupation
    • Any triggers identified and stability of their life situation
    • The support that the patient has in the community and reliability of such support
  • Considering other risk factors to take into account:
    • Recent discharge from mental health hospital
    • Under 25 and prescribed antidepressants
    • Access to lethal means
    • Suicide notes
    • Changes to will
    • Use of the internet: a study by Cardiff University13 has found that some young people use social media to share images of self-harm and that some go further and use the images as part of their own self-harming behaviour.
  • Considering protective factors:
    • Dependent children
    • Family members who would be upset
    • Religious beliefs

Management in primary care14

Referral to A&E:

GPs should refer patients for urgent treatment in an emergency department if assessment suggests there is a significant risk to the individual who has self-injured. Should there be a need, attempt to have a further discussion with the emergency consultant.

Consideration should be given to the patient’s welfare during transportation to any referral organisation and, if necessary, this should be supervised by an appropriate person where there is a risk of further self-harm, reluctance to attend other care centers, or if the patient is very distressed.

In remote areas at considerable distance from an emergency department or where access is likely to be delayed, consideration should be given to initiating assessment and treatment of self-harm in the primary care setting, following discussion with the nearest emergency department consultant. This should include taking samples to test for paracetamol and other drugs, as indicated in TOXBASE. The most common substances reported to the National Poisons Information service (NPIS) London center in 2002 were related to paracetamol, other analgesics and antidepressants.

Communication with mental health team:

Outcome of the risk and needs assessment and treatment, should be forwarded to the appropriate secondary mental health team at the earliest opportunity. Consideration should be given to referring to secondary crisis team services and it may also be helpful to provide out of hours helpful numbers in addition, such as Focusline and Samaritans.

Partnership:

If a person who self-harms is receiving treatment or care in primary care as well as secondary care, primary and secondary health and social care professionals should ensure they work cooperatively.

Preventing self-poisoning:

Healthcare professionals should prescribe, whenever possible, those drugs which are least dangerous in overdose while still effective for their intended use, and should consider prescribing fewer tablets at any one time. The same consideration also needs to be given to the prescription of the relatives who live with a person. Care must be taken, however, to preserve confidentiality.

 

Dr Madhvi Belgamwar is a consultant community psychiatrist at Royal Derby Hospital.

Dr Rolla Ibrahim is a GP trainee based at Royal Derby Hospital.

 

References:

  1. Hawton, K., Bergen, H., Cassey, D., et al. (2007) Self-harm in England: a tale of three cities: multicenter study of self-harm. Social Psychiatry and Psychiatric Epidemiology, 42, 513–521.
  2. Mental Health Foundation. (2016). Fundamental Facts About Mental Health. 2016. Mental Health Foundation: London.
  3. Hawton et al, BJPsych advances Sep2016, 22 (5) 286.
  4. Townsend E (2014) Self-harm in young people. Evidence-Based Mental Health, 17: 979.
  5. Sinclair J M et al. (2011) Healthcare and social services resource use and costs of self-harm patients. Social Psychiatry and Psychiatric epidemiology, 46: 263–71
  6. Carroll R et al (2014) Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis. PLoS One, 9: e89944.
  7. Zahl DL et al, (2004) Repetition of deliberate self-harm and subsequent suicide risk: long-term follow-up study of 11583 patients. British Journal of Psychiatry, 185: 70–5.
  8. National Collaborating Centre for Mental Health (2004) Self-Harm: The Short-Term Physical and Psychological Management and Secondary Prevention of Self-Harm in Primary and Secondary Care (Clinical Guideline 16). NICE.
  9. http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/self-harm.aspx
  10. https://www.mentalhealth.org.uk/publications/truth-about-self-harm
  11. Luoma, JB, Matin, CE, Pearson, JL. ‘Contact with mental health and primary care providers before suicide: a review of the evidence.’ Am J Psychiatry 2002 Jun; 159(6):909-16.
  12. National Institute for Health and Clinical Excellence. Self-harm: longer-term management. (Clinical guideline CG133). 2012
  13. ‘Direct link’ between self-harming and the internet. BBC News. 2015. http://www.bbc.com/news/uk-wales-31878391
  14. https://www.nice.org.uk/guidance/conditions-and-diseases/mental-health-and-behavioural-conditions/self-harm

 

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Readers' comments (6)

  • Why 999? what a waste of ambulance resources.

    Yes they need to be seen bloods done etc etc but not 999 urgent. Most likely bloods normal, paracetamol levels normal, seen by mental health team, assessed as low risk and discharged.

    What is needed is aggressive psych input with DBT and ongoing support for her life issues and lack of coping mechanisms.



    Ian
    GP with a passing interest in EM

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  • Healthy Cynic

    Why do an ECG? Why a GCS score? Why 999? Presumably the intent is to give the patient all the attention she so craves.
    Attendance at A/E is of course appropriate, but what's the rush?
    If as clinicians we can't use NHS resources appropriately, then what hope is there?

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  • Just some observations
    There a few points to make here one in response to the article and the other is to the comments so far.

    Thank you for an excellent article.
    It truly does highlight many of the key issues associated with Suicide and Self-Harm and the powerful association between both. The UK has one of the highest attendances to AandE departments in EUROPE and we also have 3 times as many suicides as there are deaths on the road due to MVTAs. There is a 50-100 times multiplier of risk I believe of suicide if someone is self harming in that year...
    So where some of us, may feel that these behaviours are attention seeking, they are indeed not.
    They are connection seeking AND a warning of a highly significant risk of suicide and a marker of the enormous emotional distress and pain experienced by that person.

    We know also I believe that about 70% of younger people who are self-harming have thought about suicide and that more that 60% of people under the age of 20 who take their lives by suicide were self harming

    So I would only add/highlight 3 things in this great article
    1. is that all people who present with self harming should also be assessed for suicide and at least asked the question each time - this actually is highlighted within the piece which is so important
    2. Co-produced safety plans plays a huge part in mitigating risk both for suicide and self-harm
    3. We need to understand that demographic evidence risk factors are based on the lifetime of a population - important but that needs to be considered and we must always look for individual personalised risks and triggers - an absence of evidence -based risk factors is not an absence of risk.

    In relation to calling 999. This is a matter of the level of response required at any point in time. It is vital that GPs have the tools in place to make those response decisions commensurate with the needs of the individual. One also needs to mitigate against deterioration/elevation of risk when a patient is no longer in the room... this varies markedly over time and can shift quite rapidly and unpredictably.

    Final comment is that of course it would be better still if the provision of DBT and MBT were more widely accessible for those with Emotionally Unstable personality disorder...

    Thank you again to the authors and I only wish more of us picked up on this article with commentary...

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  • Addition

    When I mentioned highest attendances to AandE I meant WITH Self-Harm as the presenting contact...

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  • I am inclined to agree with the 999 call, because at least you know she got to A+E.

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  • 25 paracetamol = potentially fatal = 999 and goodbye from me. Time is liver (no one said, ever..except me just now).

    Pick up by Mental health team from A+E I would have thought.

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