Key priorities for implementation

Guidance

The following guidance is evidence-based. The grading scheme used for the recommendations (A, B, C and good practice point (GPP)) is described in Chapter 3 (3.4.3.2); a summary of the evidence on which the guidance is based is provided in the full guideline (Chapters 5, 7, 8 & 9).

This guideline makes recommendations for the physical, psychological and social assessment and treatment of people in primary and secondary care in the first 48 hours after having self-harmed. For the purpose of this guideline, the term self-harm is defined as ‘self-poisoning or injury, irrespective of the apparent purpose of the act’. Self-harm is an expression of personal distress, not an illness, and there are many varied reasons for a person to harm him or herself.

The recommendations in section 4.1 apply across the whole health community, wherever people who self-harm present for help, including good practice points to improve the integration of the different services involved. In the following sections, the recommendations directly address the care offered to people who self-harm presenting in primary care, in the community, or in secondary care. Throughout the guideline, the need to treat people who self-harm with compassion and understanding is emphasised.

The guideline is relevant to all people aged 8 years of age and older who have self-harmed. Where it refers to children and young people, this applies to all people who are between 8 and 16 years of age inclusive. However, it should be borne in mind that local services vary the upper age limit depending upon whether a young person is in full-time education or not.

4.1. Issues for all services and healthcare professionals

4.2. The management of self-harm in primary care

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. In remote areas, access to TOXBASE (the national database of the National Poisons Information Service [NPIS]) may be necessary.

4.2.1.1.

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, in an atmosphere of respect and understanding. (GPP)

4.2.1.2.

All people who have self-harmed should be assessed for risk, which should include identification of the main clinical and demographic features and psychological characteristics known to be associated with risk, in particular depression, hopelessness and continuing suicidal intent. The outcome of the assessment should be communicated to other staff and organisations who become involved in the care of the service user. (C)

4.2.1.3.

In the assessment and management of self-injury in primary care, healthcare professionals should refer service users for urgent treatment in an emergency department, if assessment suggests there is a significant risk to the individual who has self-injured. (GPP)

4.2.1.4.

In most circumstances, people who have self-poisoned and present to primary care should be urgently referred to the nearest emergency department, because the nature and quantity of the ingested substances may not be clearly known to the person who has self-poisoned, making accurate risk assessment difficult. (GPP)

4.2.1.5.

If there is any doubt about the seriousness of an episode of self-harm, the general practitioner should discuss the case with the nearest emergency department consultant, as management in secondary care may be necessary. (GPP)

4.2.1.6.

Consideration should be given to the service user’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 or reluctance to attend other care centres, or the service user is very distressed. (GPP)

4.2.1.7.

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. (GPP)

4.3. The assessment and initial management of self-harm by ambulance services

Ambulance staff have an increasingly important role in the assessment and early treatment of self-harm, a role that needs to be well supported through effective collaboration with other professional groups.

4.3.1.1.

When ambulance staff attend a person who has self-harmed, they should urgently establish the likely physical risk, and the person’s emotional and mental state, in an atmosphere of respect and understanding. (GPP)

4.3.1.2.

Ambulance staff should be trained in the assessment and early management of self-harm. Training should particularly address the different methods of self-harm and the appropriate treatments, the likely effects if untreated, and issues of consent and mental capacity, as these apply both to adults, and to children and young people. (GPP)

4.3.1.3.

In cases where, following an act of self-injury, the service user does not require emergency treatment in the emergency department, ambulance staff should consider, having taken full account of the service user’s preferences, taking the service user to an alternative appropriate service, such as a specialist mental health service. The decision to do so should be taken jointly between the ambulance staff, the service user and the receiving service. (GPP)

4.3.1.4.

Ambulance Trusts, the emergency department and Mental Health Trusts should work in partnership to develop locally agreed protocols for ambulance staff to consider alternative care pathways to emergency departments for people who have self-harmed, where this is appropriate and does not increase the risks to the service user. (GPP)

4.3.1.5.

In cases of self-poisoning, ambulance staff should obtain all substances and/or medications found at the scene of an emergency call, whether thought to be involved in the overdose or not, and pass these to staff upon arrival at the emergency department. (GPP)

4.3.1.6.

Unless the service user’s clinical condition requires urgent treatment that should not be delayed, ambulance staff should record relevant information about the service user’s home environment, social and family support network, and history leading to self-harm, as well as the service user’s initial emotional state and level of distress. This information should be passed to emergency department staff. (GPP)

4.3.1.7.

When transporting people who have self-harmed to an emergency department, wherever possible, ambulance staff should take into account the service user’s preferences when more than one emergency department facility exists within a reasonable distance, unless doing so significantly increases the risk to the service user, or when one department has specialised in the treatment of people who have self-harmed. (GPP)

4.3.1.8.

When a person who has self-poisoned presents to the ambulance service within 1 hour of ingestion and is fully conscious and able to protect his or her own airway, ambulance staff should consider offering activated charcoal at the earliest opportunity. Activated charcoal should be offered only when the substance(s) ingested are likely to be adsorbed by activated charcoal and when the person is considered to be at risk of significant harm. (B)

4.3.1.9.

Activated charcoal may also be considered between 1 and 2 hours after ingestion as there is some evidence that activated charcoal may still be effective in reducing absorption, especially if the ingested substance delays gastric emptying, such as tricyclic antidepressants. Activated charcoal should be offered only when the substance(s) ingested are likely to be adsorbed by activated charcoal and when the person is considered to be at risk of significant harm. (C)

4.3.1.10.

In the emergency treatment of opioid overdose when using intravenous naloxone, ambulance staff should adhere to the guidelines established by the Joint Royal Colleges Ambulance Liaison Committee. Particular attention should be given to the possible need for repeated doses of naloxone and frequent monitoring of vital signs, because the effects of naloxone are short-lived in comparison with the effects of most opioids and service users frequently relapse once the effect of naloxone has worn off. All people who have overdosed with opioids should be conveyed to hospital, even if the initial response to naloxone has been good. (GPP)

4.3.1.11.

The ambulance services should ensure that there is rapid access to TOXBASE and the NPIS so that their crew can gain additional information on substances and/or drugs ingested in cases of self-poisoning in order to assist in decisions regarding urgent treatment and the transfer of patients to the most appropriate facilities. (GPP)

4.3.1.12.

When people who have self-harmed are considering refusing further treatment, ambulance staff should assess mental capacity and provide information about the potential consequences of not receiving treatment when attempting to gain valid consent. When consent is withheld, the guidance on consent and capacity in this guideline should be followed. (GPP)

4.3.1.13.

PCTs, in conjunction with acute and mental health trusts, should consider the level of support needed for the delivery of an adequate pre-hospital care system for self-harm. Specific consideration should be given to the provision of telephone advice to ambulance staff from crisis resolution teams, approved social workers and Section 12 approved doctors, regarding the assessment of mental capacity and the possible use of the Mental Health Act in the urgent assessment of people who have self-harmed. (GPP)

4.3.1.14.

Ambulance Trusts should regularly update ambulance staff about any change in local arrangements for services available for the emergency treatment of people who have self-harmed. (GPP)

4.3.1.15.

Ambulance Trusts should routinely audit incidents of overdose, both to ensure that interventions are being used consistently and effectively, and to monitor adverse incidents. (GPP)

4.4. The treatment and management of self-harm in emergency departments

The emergency department provides the main services for people who self-harm. Emergency department staff should assess risk and emotional, mental and physical state quickly, and try to encourage people to stay to organise psychosocial assessment.

4.5. Medical and surgical management of self-harm

Self-poisoning can be treated by reducing absorption, increasing elimination and/or countering the biological effects of the poison, depending upon the nature of the poison and the route of intake. Superficial uncomplicated wounds can be closed with tissue adhesive, whilst more complicated injuries will need surgical assessment and possibly exploration.

4.6. Support and advice for people who repeatedly self-harm

4.7. Psychosocial assessment

Everyone who has self-harmed should have a comprehensive assessment of needs and risk; engaging the service user is a prerequisite.

4.8. Referral, admission and discharge following self-harm

Referral, treatment and discharge following self-harm should be based on the overall assessment of needs and risk.

4.8.1.1.

The decision to refer for further assessment and/or treatment or to discharge the service user should be taken jointly by the service user and the healthcare professional whenever this is possible. When this is not possible, either as a result of diminished mental capacity or the presence of significant mental illness, this should be explained to the service user and written in their notes. (GPP)

4.8.1.2.

Referral for further assessment and treatment should be based upon the combined assessment of needs and risk. The assessment should be written in the case notes and passed onto the service user’s GP and to any relevant mental health services as soon as possible to enable follow-up. (C)

4.8.1.3.

The decision to discharge a person without follow-up following an act of self-harm should be based upon the combined assessment of needs and risk. The assessment should be written in the case notes and passed onto their GP and to any relevant mental health services. (C)

4.8.1.4.

In particular, the decision to discharge a person without follow-up following an act of self-harm should not be based solely upon the presence of low risk of repetition of self-harm or attempted suicide and the absence of a mental illness, because many such people may have a range of other social and personal problems that may later increase risk. These problems may be amenable to therapeutic and/or social interventions. (GPP)

4.8.1.5.

Temporary admission, which may need to be overnight, should be considered following an act of self-harm, especially for people who are very distressed, for people in whom psychosocial assessment proves too difficult as a result of drug and/or alcohol intoxication, and for people who may be returning to an unsafe or potentially harmful environment. Reassessment should be undertaken the following day or at the earliest opportunity thereafter. (GPP)

4.9. Special issues for children and young people (under 16 years)

Children and young people who self-harm have a number of special needs, given their vulnerability. Physical treatments will follow similar principles as for adults.

4.9.1.1.

Children and young people under 16 years of age who have self-harmed should be triaged, assessed and treated by appropriately trained children’s nurses and doctors in a separate children’s area of the emergency department. (GPP)

4.9.1.2.

Children’s and young people’s triage nurses should be trained in the assessment and early management of mental health problems and, in particular, in the assessment and early management of children and young people who have self-harmed. (GPP)

4.9.1.3.

All children or young people who have self-harmed should normally be admitted overnight to a paediatric ward and assessed fully the following day before discharge or further treatment and care is initiated. Alternative placements may be required, depending upon the age of the child, circumstances of the child and their family, the time of presentation to services, child protection issues and the physical and mental health of the child; this might include a child or adolescent psychiatric inpatient unit where necessary. (C)

4.9.1.4.

For young people of 14 years and older who have self-harmed, admission to a ward for adolescents may be considered if this is available and preferred by the young person. (C)

4.9.1.5.

A paediatrician should normally have overall responsibility for the treatment and care of children and young people who have been admitted following an act of self-harm. (C)

4.9.1.6.

Following admission of a child or young person who has self-harmed, the admitting team should obtain parental (or other legally responsible adult) consent for mental health assessment of the child or young person. (C)

4.9.1.7.

Staff who have emergency contact with children and young people who have self-harmed should be adequately trained to assess mental capacity in children of different ages and to understand how issues of mental capacity and consent apply to this group. They should also have access at all times to specialist advice about these issues. (GPP)

4.9.1.8.

In the assessment and treatment of self-harm in children and young people, special attention should be paid to the issues of confidentiality, the young person’s consent (including Gillick competence), parental consent, child protection, the use of the Mental Health Act in young people and the Children Act. (GPP)

4.9.1.9.

During admission to a paediatric ward following self-harm, the Child and Adolescent Mental Health Team should undertake assessment and provide consultation for the young person, his or her family, the paediatric team and social services and education staff as appropriate. (C)

4.9.1.10.

All children and young people who have self-harmed should be assessed by healthcare practitioners experienced in the assessment of children and adolescents who self-harm. Assessment should follow the same principles as for adults who self-harm, but should also include a full assessment of the family, their social situation, and child protection issues. (GPP)

4.9.1.11.

Child and adolescent mental health service practitioners involved in the assessment and treatment of children and young people who have self-harmed should:

• be trained specifically to work with children and young people, and their families, after self-harm
• be skilled in the assessment of risk
• have regular supervision
• have access to consultation with senior colleagues. (C)

4.9.1.12.

Initial management should include advising carers of the need to remove all medications or other means of self-harm available to the child or young person who has self-harmed. (GPP)

4.9.1.13.

For young people who have self-harmed several times, consideration may be given to offering developmental group psychotherapy with other young people who have repeatedly self-harmed. This should include at least six sessions. Extension of the group therapy may also be offered; the precise length of this should be decided jointly by the clinician and the service user. (B)

4.10. Special issues for older people (older than 65 years)

When older people self-harm, treatments will be much the same as for younger adults, but the risk of further self-harm and suicide are substantially higher and must be taken into account.

4.10.1.1.

All people older than 65 years of age who have self-harmed should be assessed by mental healthcare practitioners experienced in the assessment of older people who self-harm. Assessment should follow the same principles as for younger adults who self-harm, but should also pay particular attention to the potential presence of depression, cognitive impairment and physical ill health, and should include a full assessment of their social and home situation. (GPP)

4.10.1.2.

All acts of self-harm in people older than 65 years of age should be regarded as evidence of suicidal intent until proven otherwise because the number of people in this age range who go on to complete suicide is much higher than in younger adults. (GPP)

4.10.1.3.

Given the high risks amongst older adults who have self-harmed, consideration should be given to admission for mental health risk and needs assessment, and time given to monitor changes in mental state and levels of risk. (GPP)

4.10.1.4.

In all other respects, the assessment and treatment of older adults who have self-harmed should follow the recommendations given for adults. (GPP)

4.11. Psychological, psychosocial and pharmacological interventions

Referral for further assessment and/or treatment should be based upon a comprehensive psychosocial assessment, and should be aimed at treating a person’s underlying problems or particular diagnosis rather than simply treating self-harming behaviour, although intensive therapeutic help with outreach may reduce the risk of repetition. Whatever the treatment plan, primary care and mental health services should be informed.

4.11.1.1.

Following psychosocial assessment for people who have self-harmed, the decision about referral for further treatment and help should be based upon a comprehensive psychiatric, psychological and social assessment, including an assessment of risk, and should not be determined solely on the basis of having self-harmed. (C)

4.11.1.2.

Clinicians should ensure that service users who have self-harmed are fully informed about all the service and treatment options available, including the likely benefits and disadvantages, in a spirit of collaboration, before treatments are offered. The provision of relevant written material with time to talk over preferences should also be provided for all service users. (GPP)

4.11.1.3.

The mental health professional making the assessment should inform both mental health services (if they are involved already) and the service user’s GP, in writing, of the treatment plan. (GPP)

4.11.1.4.

For people who have self-harmed and are deemed to be at risk of repetition, consideration may be given to offering an intensive therapeutic intervention combined with outreach. The intensive intervention should allow frequent access to a therapist, when needed, home treatment when necessary, and telephone contact; and outreach should include following up the service user actively when an appointment has been missed to ensure that the service user is not lost from the service. The therapeutic intervention plus outreach should continue for at least 3 months. (C)

4.11.1.5.

For people who self-harm and have a diagnosis of borderline personality disorder, consideration may be given to the use of dialectical behaviour therapy. However, this should not preclude other psychological treatments with evidence of effectiveness for people with this diagnosis, but not reviewed for this guideline. (C)

4.12. Research recommendations

4.12.1.1.

Research, using appropriate survey and rigorous qualitative methods, should be conducted about the meaning of self-harm to people from different ethnic and cultural groups. This should include the exploration of issues of intentionality.

4.12.1.2.

Epidemiological research should be conducted to determine the prevalence of self-harm in refugees and asylum seekers.

4.12.1.3.

Appropriate multi-methodology research on self-harm as a response to child sexual and other abuse should be carried out, to include a review of the substantial service user literature, and to examine the range of interventions that service users believe to be supportive and helpful, including survivor organisations and networks and other voluntary organisations for women who self-harm.

4.12.1.4.

An adequately powered epidemiological study, reporting all relevant outcomes, including quality of life, occupational status and potential, income, physical well-being and quality of relationship status, should be undertaken to establish the morbidity and mortality rates for specific drug ingestions used in self-harm.

4.12.1.5.

A study using an appropriate and rigorously applied qualitative methodology should be undertaken to explore user experiences of services.

4.12.1.6.

Qualitative research methods, such as Q sort and Interpretive Phenomenological Analysis, should be used to better understand staff attitudes to self-harm and their psychological and social origins.

4.12.1.7.

Comparative pilot studies should be undertaken to evaluate different approaches to introducing and using advance directives for people who self-harm repeatedly. Studies should address ethical, legal and practical implications and consequences, as well as acceptability to service users and healthcare practitioners. Service users should be included in the design and evaluation of each pilot.

4.12.1.8.

A large-scale audit, reporting all relevant outcomes, of the use of activated charcoal in cases of poisoning in pre-hospital settings should be undertaken.

4.12.1.9.

An adequately powered epidemiological study reporting all relevant outcomes should be undertaken to establish morbidity and mortality rates for specific drug ingestions.

4.12.1.10.

A national programme should be developed to coordinate the surveillance by NPIS and other agencies of health risks in self-poisoning so that the combined data can be used to inform and guide recommendations on treatment and prevention.

4.12.1.11.

A study of appropriate design reporting all relevant patient outcomes (mortality, morbidity, numbers lost to the service, patient satisfaction) should be undertaken to assess the impact of the introduction of the Mental Health Triage Scale.

4.12.1.12.

A well-designed, prospective multicentre study of screening for plasma paracetamol concentrations, including health economic analyses, is required in order to develop detailed guidelines on the selection criteria, clinical value and cost-effectiveness of screening for paracetamol.

4.12.1.13.

An RCT, recording all relevant biochemical and clinical outcomes, is needed to determine the relative efficacy of activated charcoal given to patients presenting between 1 and 2 hours following ingestion of poison, as compared with giving no activated charcoal, in the treatment of overdose, particularly when used in paracetamol overdose. Particular attention should be paid to the differences with different ingested poisons and to the incidence of side effects.

4.12.1.14.

An appropriately designed and adequately powered study should be undertaken to clarify the optimum dose level at which acetylcysteine should be used (for both oral and intravenous administration) in the treatment of paracetamol poisoning, reporting all relevant biochemical and clinical outcomes, including liver function, liver failure and adverse reactions. Consideration should be given to patient characteristics such as co-ingested substances, including alcohol.

4.12.1.15.

An adequately powered national multi-centre RCT, reporting all relevant clinical outcomes, is required to evaluate the therapeutic use of flumazenil in unconscious patients in whom self-poisoning with benzodiazepines is suspected. Particular attention should be paid to the incidence of serious physical adverse events, dose, the rate of administration of flumazenil, the ingestion of other substances, and patient characteristics that may predict good and poor outcomes is required.

4.12.1.16.

An adequately powered diagnostic trial to evaluate different methods of detecting the presence of tricyclic antidepressants in the emergency setting should be undertaken.

4.12.1.17.

Adequately powered RCTs, reporting all relevant short-, medium- and long-term outcomes, including the experience of care and the acceptability of treatments, are needed to evaluate methods of wound closure for people who have self-harmed through cutting. For superficial wounds this should include trials comparing skin closure strips and tissue adhesives, and head-to-head trials of the cost and clinical effectiveness of different types of tissue adhesive.

4.12.1.18.

Appropriately designed studies to evaluate the place of self-management of wound closure for people who recurrently self-harm by cutting, identifying people for whom this approach would be most suited, should be undertaken.

4.12.1.19.

Multi-centre monitoring of the number of people who self-harm, including whether each act is a repetition of previous self-harm, taking into account cross-flow in and out of each catchment area, should be undertaken to assess local differences in self-harm presentations and to enable observational studies to be carried out to evaluate the impact of different styles of mental health service provision.

4.12.1.20.

An appropriately designed study reporting all relevant outcomes should be undertaken to assess the impact of changes in local health policy upon the management of self-harm in difference services (for example, in emergency departments), including outcomes for service users.

4.12.1.21.

An appropriately designed study should be undertaken to discover more about self-injury, particularly the similarities and differences compared with self-poisoning, such as whether repetition rates and fatal suicide attempts are different.

4.12.1.22.

An appropriately designed study should be undertaken to assess the impact on services of involving service users in service planning and delivery, especially in emergency departments, focusing particularly on outcomes, including satisfaction and loss from the service, for people with repeated presentations.

4.12.1.23.

An appropriately designed study, reporting all relevant outcomes including user satisfaction with services and the numbers lost from services, repetition rates and suicide, should be undertaken to pilot and evaluate integrated needs and risk assessment, compared with both ‘standard assessment practice’ and a separate assessment of needs and risk.

4.12.1.24.

Further research into treatments specific to people who self-harm should evaluate the differential responses of different patient subgroups, using a broad range of outcomes, especially those relevant to service users such as quality of life.

4.12.1.25.

User-led, qualitative research into the experience and views of people who self-harm is required firstly examining the benefits and adverse consequences of the services they receive and the treatments they have undertaken, and secondly investigating the benefits and adverse consequences of self-help groups and service user support groups.

4.12.1.26.

A multi-centre RCT is required reporting all relevant outcomes including quality of life, occupational status, satisfaction with services and self-harm repetition rates, addressing the clinical and cost effectiveness of emergency card services for people who have self-harmed and presented to services for the first time.

4.12.1.27.

An adequately powered RCT reporting all relevant outcomes should be undertaken to determine the relative effectiveness of group therapy for young people who self-harm. The study should address patient characteristics (such as gender, diagnosis, frequency and method of self-harm, past history of abuse) and family characteristics (such as parental disharmony and divorce, family size, socio-economic status, mental health problems in the parents and siblings). Outcomes should include loss from services, admission rates, satisfaction, repetition of self-harm, quality of life, educational attainment and employment status. Consideration should also be given to investigating the effectiveness of this type of therapy for adults.

4.12.1.28.

An adequately powered RCT reporting all relevant outcomes should be undertaken to determine the clinical and cost effectiveness of intensive interventions combined with assertive outreach for people who self-harm. The study should address patient characteristics (such as age, gender, diagnosis, frequency and method of self-harm, past history of abuse) and therapists’ characteristics (such as age, gender, training, professional discipline, parental status). Outcomes should include loss from services, admission rates, satisfaction, repetition of self-harm, quality of life and employment status.