GPs should regularly review self-harm patients, says draft NICE guidance

GPs should regularly review self-harm patients and offer a specific CBT intervention, according to a consultation on the first new guidance for self-harm to be drawn up in 11 years.

The new draft guidance emphasises the importance of referring patients to specialist mental health services, but stresses that, for patients who are treated in primary care, continuity is crucial.

If someone who has self-harmed is being treated in primary care, GPs must ensure regular follow-up appointments and reviews of self-harm behaviour, as well as a medicines review, the draft guideline say.

They must also provide care for coexisting mental health issues, including referral to mental health services where appropriate, as well as information, social care, voluntary and non-NHS sector support and self-help resources.

The guidance says that referring people to mental health services would ‘ensure people are in the most appropriate setting’.

However, the committee agreed that ‘if people are being cared for in primary care following an episode of self-harm, there should be continuity of care and regular reviews of factors relating to their self-harm to ensure that the person who has self-harmed feels supported and engaged with services’.

The guidance also recommends a CBT-based psychological intervention that is ‘specifically structured for adults who self-harm’.

For children and young people who often self-harm and have emotional dysregulation difficulties, dialectical behaviour therapy adapted for adolescents (DBT-A) should be considered.

Non-specialists should arrange for self-harm patients to undergo a psychosocial assessment by a mental health professional as soon as possible after an episode, to evaluate the person’s needs and recognise factors which might explain the self-harm.

But the draft guidance, out for consultation until 1 March, also says ambulance staff should suggest self-harming patients see their GP to maximise the chance of engagement with services.

It says: ‘When attending a person who has self-harmed but who does not need urgent physical care, ambulance staff and paramedics should discuss with the person (and any relevant services) if it is possible for the person to be assessed or treated by an appropriate alternative service, such as a specialist mental health service or their GP.’

It notes that ‘ambulance staff often felt that the emergency department was not the preferred place that the person who had self-harmed wanted to be taken. They agreed that referral to alternative services could facilitate the person’s engagement with services’.

The draft guidance also says:

• After an episode of self-harm, the format and frequency of initial aftercare and which services will be involved must be discussed with the patient. 
• If the psychosocial assessment after a self-harm episode was made by a GP, initial aftercare must be provided by the GP within 48 hours of the assessment.
• GPs should use consultations and medicines reviews as ‘an opportunity to assess self-harm if appropriate, for example, asking about thoughts of self-harm or suicide, actual self-harm, and access to substances that might be taken in overdose (including prescribed, over-the-counter medicines, herbal remedies and recreational drugs)’.

Meanwhile, reiterating existing guidance, the draft guideline adds: ‘Do not offer drug treatment as a specific intervention to reduce self-harm.’

Dr Paul Chrisp, director of the centre for guidelines at NICE, said: ‘Self-harm is a growing problem and should be everyone’s business to tackle – not just those working in the mental health sector.

‘These guidelines set out a way for every person who self-harms to be able to get the support and treatment they need.’

Professor Nav Kapur, topic advisor for the self-harm guideline and professor of psychiatry and population health at the University of Manchester said: ‘Self-harm can occur at any age and present to any setting. Historically, people who have harmed themselves have had a highly variable experience of services.

‘This new guideline is an opportunity to make things better, particularly from the point of view of assessment and aftercare.’

Professor Kapur told Pulse: ‘Primary care is a really important setting for providing care after self-harm and we’ve attempted to strengthen the existing guidance in this area.’

Regarding the requirement for an urgent psychosocial assessment, he said: ‘A full psychosocial assessment might take an hour, perhaps more, and can be done by anyone with appropriate training. But in practice they are usually carried out by mental health professionals. 

‘It wouldn’t usually be the role of the GPs to carry out full assessments but they need to be aware of the general principles of assessment and care for people who have harmed themselves and to refer to other services as necessary.’

It comes as NICE recently recommended that GPs should provide regular reviews for patients on antidepressants and drugs for chronic pain that may be addictive in draft guidance on managing withdrawal.

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