Primary care has an important role in the assessment and treatment of people who self-harm. Careful attention to prescribing drugs to people at risk of self harm, and their relatives, could also help in prevention. When an individual presents in primary care following an episode of self harm, healthcare professionals should urgently establish the likely physical risk, and the person's emotional and mental state.¹

A recent survey completed by members of the Royal College of Psychiatrists found that fewer than half of the respondents felt that they or their teams had sufficient training to assess people who self-harm. The burden of care often rests with junior doctors and trainee psychiatrists because of the out-of-hours nature of many self-harm incidents. Many of those who self-harm never see a psychiatrist, and are discharged from accident and emergency departments, without a psychosocial needs assessment.²

Deliberate self harm is defined as an act with a nonfatal outcome in which an individual deliberately did one or more of the following:

• A behaviour (e.g. self cutting) intended to cause self harm.
• Ingesting a substance in excess of the prescribed or generally recognised therapeutic dose.
• Ingesting a recreational or illicit drug that was an act that the person regarded as self harm.
• Ingesting a non-ingestible substance or object.

Deliberate self harm is not an attempt at suicide in the vast majority of cases. It is usually an attempt to maintain control in very stressful situations or emotional pressures, e.g. bullying, abuse, academic pressure or work pressure. Self harm is usually done in private and hidden from anyone else.

Epidemiology³

• Self harm is common, especially among younger people. A survey of young people aged 15-16 years estimated that more than 10% of girls and more than 3% of boys had self-harmed in the previous year.
• Self harm increases the likelihood that the person will eventually die by suicide by between 50- and 100-fold above the rest of the population in a 12-month period.
• A wide range of psychiatric problems, such as borderline personality disorder, depression, bipolar disorder, schizophrenia, drug misuse and alcohol abuse are associated with self harm.
• Other risk factors include victims of domestic violence,⁴ socio-economic disadvantage,⁵ and those with eating disorders.⁶ There is an increased risk in South Asian women.⁷

Initial management

See separate article Acute Poisoning - General Measures.

• In most circumstances, people who have self-poisoned and present to primary care should be referred urgently to the nearest emergency department.
• If urgent referral to an emergency department is not considered necessary, a risk and needs assessment should be undertaken to assess the need for urgent referral to secondary mental health services.
• For information about specific poisoning, the National Poisons Information Service (NPIS) should only be contacted after accessing TOXBASE or if there is concern about the severity of poisoning. The phone number for the NPIS is (0844 892 0111).⁸

Drugs

• For the majority of drugs taken in overdose, activated charcoal should be given as early as possible, preferably within one hour of ingestion, in order to prevent or reduce absorption of the drug.
  • Activated charcoal should be used with caution for drowsy or comatose patients because of the risk of aspiration (therefore ensure the airway is protected) or reduced gastro-intestinal motility (risk of obstruction).⁹
  • Toxins not bound to charcoal include hydrocarbons and alcohols (methanol, ethanol, ethylene glycol), metals (lithium, iron, potassium, lead, silver, mercury), malathion and corrosives.
• Emetics, including ipecac (ipecacuanha), should not be used in the management of self-poisoning.
• Gastric lavage should not be used in the management of self poisoning unless specifically recommended by TOXBASE or NPIS.

Assessment and further management³

People who self-harm should be fully involved in decision-making about their treatment and care. There should be an integrated and comprehensive psychosocial assessment of needs and risks to understand and engage people who self-harm and to initiate a therapeutic relationship. Management after self harm includes forming a trusting relationship with the patient, jointly identifying problems, ensuring support is available in a crisis, and treating psychiatric illness vigorously. Family and friends may also provide support.⁵

• Self harm is a way of expressing distress. Often people don't know why they self-harm. It is a means of communicating and has been described as expressing an inner scream. It is important that all people who have self-harmed be properly assessed by local mental health services and appropriately managed and supported by all health professionals involved in their care.
• Care plans should be agreed with the person who self-harms and should include short-term and long-term goals, and a risk management plan.
• Assessment of needs: all people who have self-harmed should be offered an assessment of needs, which should include evaluation of the social, psychological and motivational factors specific to the act of self harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.¹
• Assessment of risk: all people who have self-harmed should be assessed for risk: this assessment should include identification of the main clinical and demographic features known to be associated with risk of further self harm and/or suicide, and identification of the key psychological characteristics associated with risk, especially depression, hopelessness and continuing suicidal intent.¹ Strong suicidal intent, high lethality, precautions against being discovered, and psychiatric illness are indicators of high suicide risk.⁵
• Psychological intervention that is structured for people who self-harm should be offered, with the aim of reducing self harm. The National Institute for Health and Clinical Excellence (NICE) recommends 3 to 12 sessions of a psychological intervention that is specifically structured for people who self-harm, with the aim of reducing self harm.
• Psychological, pharmacological and psychosocial interventions should be used for any associated mental health conditions.
• Drug treatment should not be offered as a specific intervention to reduce self harm.

Prognosis

• Risk of repetition of self harm and of later suicide is high. More than 5% of people who have been seen at a hospital after self harm will have committed suicide within nine years.⁵
• Some young people self-harm on a regular basis while others do it just once or a few times.
• For some people it is part of coping with a specific problem and they stop once the problem has resolved.
• Other people self-harm for years whenever certain kinds of pressures or feelings arise.
• A history of deliberate self harm increases the risk of suicide.¹⁰

Prevention

• For any person considered at risk, it is essential to assess the risk of self harm.
• The presence of a suicide note is an indication of a failed but serious attempt at suicide. A suicide note is one indication of a higher risk of future completed suicide than self-harm presenters who have not left a note.¹¹
• For patients at risk of self poisoning, medications prescribed should be the least dangerous in overdose, and should be prescribed as a small number of tablets at any one time.
• This should also apply to prescribing for relatives who live with the person at risk because medications intended for relatives are often used in self poisoning.

Document references

1. Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care, NICE Clinical Guideline (2004)
2. No authors listed; Helping those who self-harm. Lancet. 2010 Jul 17;376(9736):141.
3. Self-harm (longer term management), NICE Clinical Guideline (November 2011)
4. Boyle A, Jones P, Lloyd S; The association between domestic violence and self harm in emergency medicine patients. Emerg Med J. 2006 Aug;23(8):604-7. [abstract]
5. Skegg K; Self-harm.; Lancet. 2005 Oct 22-28;366(9495):1471-83. [abstract]
6. No authors listed; Self-harm and bulimia nervosa: a complex connection. Eat Disord. 2002 Fall;10(3):257-67. [abstract]
7. Cooper J, Husain N, Webb R, et al; Self-harm in the UK : Differences between South Asians and Whites in rates, characteristics, provision of service and repetition. Soc Psychiatry Psychiatr Epidemiol. July 2006. [abstract]
8. National Poisons Information Service
9. British National Formulary
10. Hawton K, Zahl D, Weatherall R; Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry. 2003 Jun;182:537-42. [abstract]
11. Barr W, Leitner M, Thomas J; Self-harm or attempted suicide? Do suicide notes help us decide the level of intent in those who survive? Accid Emerg Nurs. 2007 Jul;15(3):122-7. Epub 2007 Jul 2. [abstract]

Internet and further reading

• Toxbase®; (Registration is free for doctors who are employed by an NHS practice)