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


self-harm


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The new draft guidance emphasises the importance of referring patients to specialist mental health services, but stresses that, for patients who are treated in primary care,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But the draft guidance, out for consultation until 1 March, also says ambulance staff should suggest self-harming patients see their GP to maximise the chance of engagement with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.

Draft guidance on self-harm

Assessment and care in primary care

1.6.5 When a person presents in primary care after an episode of self-harm, consider referring them to mental health or social care services for a psychosocial assessment or informing their existing mental health team, with agreement from the person and their family members or carers (as appropriate).

1.6.6 Make referral to mental health services a priority when:
• the person’s levels of distress are rising, high or sustained
• the frequency or degree of self-harm or suicidal intent is increasing
• the physical consequences of self-harm cannot be safely managed in primary care
• the person asks for further support from mental health services
• levels of distress in parents or carers of children and young people are rising, high or sustained, despite attempts to help.

1.6.7 If the person who has self-harmed is being supported and given care in primary care, their GP should ensure that the person has:
• regular follow-up appointments with their GP
• regular reviews of self-harm behaviour
• a medicines review
• information, social care, voluntary and non-NHS sector support and self-help resources

Source: NICE

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READERS' COMMENTS [17]

Turn out The Lights 18 January, 2022 10:00 am

The magic 10 minute time warp again yawn…

Kevlar Cardie 18 January, 2022 10:08 am

Papamikesierralima.

Adam Crowther 18 January, 2022 11:06 am

Superb. Does that mean they have suggested that we can have hour long appointments and retire on full benefits at 55 🤔🤦🏼‍♂️

Jonathan Heatley 18 January, 2022 11:46 am

Brilliant, the ship is sinking and they are suggesting new colour schemes for the paintwork. (the deck chairs have already fallen in the water).

Simon Gilbert 18 January, 2022 11:56 am

Commissioning by Standards Inflation again.
I can imagine all A/E mental health assessments will interpret this as ‘GP to do 48 hour assessment’ to cover themselves and drop us in it whilst they await their (same trust) community psych colleagues to follow up.
It’s usual NHS doublethink that self harm is so important lots of active intervention by the GP is needed yet not so important the guidelines mandate proper specialist mental health provisioning.

David jenkins 18 January, 2022 12:10 pm

more drivel

if it’s YOUR job to tell me how to do MY job, you should at least be capable of doing my job !

Darren Tymens 18 January, 2022 12:14 pm

It is very frustrating that other bodies – NICE, CQC, various charities – can decide and publish standards of care without consulting our representative bodies and without making reference to the prevailing context in general practice.
It just puts more pressure on us, and sets us up to look like we are failing – when in reality every single day we continue to deliver decent care is a minor miracle given the conditions we are forced to work under.
What these bodies should state is that this is their idea of what good practice looks like, but it is for commissioners to make sure that there is a decently-funded workforce in place who can deliver it, and until that is the case they understand these standards will not be deliverable.

Karen Potterton 18 January, 2022 12:15 pm

I already review all mine regularly. Once a year. Thats the difference between regular and frequent and thank Christ NICE too thick to realise 😎

Timothy Roger Moss 18 January, 2022 3:33 pm

Although reference is made to “Medication Review” and “Self harm exclusions include harm to the self arising from excessive consumption of alcohol or recreational drugs”: I found no specific advice relating to self harm arising as an adverse reaction to prescription drugs. AKATHISIA induced by SSRIs was reported prior to their mass marketing, and in combination with emotional blunting and and disinhibition, it is reported to cause self harm. This is not addressed. The same concern applies to SNRIs and atypical antidepressants. Akathisia is caused by many other classes of prescription medication. It is also a feature of Antidepressant Withdrawal Syndromes.
Surely it is a missed, key preventive opportunity to exclude this common ADR from these Self Harm draft guidelines?

Patrufini Duffy 18 January, 2022 5:44 pm

Please read point 16.61.21..3333.3b.c. and follow guidance appropriately.

Slobber Dog 18 January, 2022 9:12 pm

Not going to happen without increased support from expanded community health facilities.

James Weems 18 January, 2022 10:36 pm

One hour. 😂

David Banner 18 January, 2022 11:47 pm

Mental Health Services will either reject your referral or discharge after first consultation, the wait for CBT stretches into 2023, and they don’t want us to prescribe self-harmers any medication.
Fantastic.
Setting us up to fail yet again.

Michael Mullineux 19 January, 2022 9:46 am

Parallel NICE Universe in which GP’s have the time to spend at least an hour seeing a single patient. Nice guidance once again, characterized by or holding idiosyncratic beliefs or impressions that are contradicted by reality or rational argument, typically as a symptom of mental disorder.

Dan Sears 19 January, 2022 12:57 pm

Don’t forget all if you don’t agree with this then you must leave a comment on the the link https://www.nice.org.uk/guidance/indevelopment/gid-ng10148/consultation/html-content-2

Rogue 1 19 January, 2022 5:58 pm

No problem, Im not a specialist – so its my job to refer to someone who is (that’s a review!)
So join a year long queue to be seen and then be discharged
In the mean time, they will surely be back in AED a few times, which if they are lucky enough to be seen by a Mental Health nurse, may get a single follow-up appointment
Might be best in future to refer them to their MP, to get a better resourced service.

Dylan Summers 22 January, 2022 8:23 am

Cochrane’s verdict:

“… case management, brief emergency department-based interventions, remote contact interventions, and other mixed interventions may have little to no benefit in terms of reducing repetition of self-harm”.

(https://evidentlycochrane.net/interventions-for-self-harm/)

So it would perhaps be hard to justify making this a priority.