NICE guidance for GPs to regularly review self-harming patients finalised

NICE has rubber-stamped guidance on self-harm that said GPs should ‘regularly review’ patients and offer a ‘specific CBT intervention’.

The guidance is the first to be drawn up in 11 years and 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.

The final guideline mirrors the draft guidance in advising that self-harming patients, when treated in primary care, must receive:

• regular follow-up appointments;
• regular reviews of self-harm behaviour;
• a regular medicines review.

GPs must also provide care for co-existing 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, it said.

The guidance said 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 recommended a CBT-based psychological intervention that is ‘specifically tailored 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, it said.

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, it added.

But the guidance also said ambulance staff should suggest self-harming patients see their GP to maximise the chance of engagement with services.

It said: ‘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 noted 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 guidance also said:

• 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)’.

Reiterating existing guidance, the guideline added: ‘Do not offer drug treatment as a specific intervention to reduce self-harm.’

Dr Faraz Mughal, GP, NIHR Doctoral Fellow, Keele University, and NICE self-harm guideline committee member told Pulse: ‘Primary care is an important setting for self-harm care and suicide prevention. The primary care recommendations should give GPs and primary care teams confidence that they can provide high-quality care for self-harm.

‘While the evidence remains immature, continuity of care, reviewing prescribed medications in particular in people with a history of overdose, and treating any co-existing mental illness are all important.’

He added: ‘Where GPs and primary care clinicians are concerned for the safety of a patient who has self-harmed, follow-up of the patient should be arranged within the following two days because this is when the risk of repeat self-harm is highest.’ 

In June, final NICE guidance on depression advocated a wider choice of treatments and a move away from antidepressants in people whose condition is ‘less severe’.

But a Pulse survey earlier this year found that NHS pressures mean two-thirds of GPs are having to provide specialist mental health support beyond their competence.