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Evidence review for consent, confidentiality and safeguarding
Evidence review C
NICE Guideline, No. 225
Consent, confidentiality and safeguarding
Review question
What is the most effective approach to obtain consent, ensure confidentiality and promote safeguarding when people have self-harmed?
Introduction
Self-harm may be associated with mental health concerns and can occur in people who are vulnerable. It is therefore important that people who attempt to help someone who struggles with self-harm are aware of how to gain consent, protect confidentiality and safeguard the wellbeing of that person. The aim of this review is to identify the most effective approach to obtain consent, ensure confidentiality and promote safeguarding when people have self-harmed.
Summary of the protocol
See Table 1 for a summary of the Population, Intervention, Comparison and Outcome (PICO) characteristics of this review.
Table 1
Summary of the protocol (PICO table).
For further details see the review protocol in appendix A.
Methods and process
A modified version of the GRADE approach to rate the certainty of evidence in systematic reviews was used as part of a pilot project undertaken by NICE. Instead of using predefined clinical decision/minimal important difference (MID) thresholds to assess imprecision in GRADE tables, imprecision was assessed qualitatively during committee discussions. Other than this modification, GRADE was used to assess the quality of evidence for the selected outcomes and this evidence review developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document (supplementary document 1).
Declarations of interest were recorded according to NICE’s conflicts of interest policy.
Effectiveness evidence
Included studies
A systematic review of the literature was conducted but no studies were identified which were applicable to this review question.
See the literature search strategy in appendix B and study selection flow chart in appendix C.
Excluded studies
Studies not included in this review are listed, and reasons for their exclusion are provided in appendix J.
Summary of included studies
No studies were identified which were applicable to this review question (and so there are no evidence tables in Appendix D).
Summary of the evidence
No studies were identified which were applicable to this review question (and so there are no GRADE tables in Appendix F).
Economic evidence
Included studies
A single economic search was undertaken for all topics included in the scope of this guideline but no economic studies were identified which were applicable to this review question. See the literature search strategy in appendix B and economic study selection flow chart in appendix G.
Excluded studies
Economic studies not included in the guideline economic literature review are listed, and reasons for their exclusion are provided in appendix J.
Economic model
No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.
Evidence statements
Economic
No economic studies were identified which were applicable to this review question.
The committee’s discussion and interpretation of the evidence
The outcomes that matter most
Self-harm repetition, suicide and service user satisfaction were prioritised as critical outcomes by the committee. Self-harm repetition and suicide were prioritised as critical outcomes because they are direct measures of any differential effectiveness associated with the method of initial contact and captures both fatal and non-fatal self-harm. Service user satisfaction was chosen as a critical outcome due to the importance of delivering services which are centred around the patients’ experiences and because patient satisfaction is likely to influence whether the patient engages with the intervention.
The committee agreed that quality of life, safeguarding incidents (such as failure to ensure safeguarding), serious incidents and breaches of confidentiality should be important outcomes. Quality of life was chosen as an important outcome as it is a compound measure of well-being, which may capture health-related outcomes associated with the effectiveness of the interventions not captured by the other outcome measures. Safeguarding incidents, serious incidents and breaches of confidentiality were included as important outcomes as they are all direct measures of potential serious harms associated with the interventions and therefore important to take into account when assessing the effectiveness associated with the interventions.
The quality of the evidence
No studies were identified that met the inclusion criteria. There was no evidence on the most effective approach to obtain consent, ensure confidentiality and promote safeguarding when people have self-harmed, so the committee made recommendations by informal consensus based on their knowledge of current best practice as well as existing guidance and protocols.
Benefits and harms
Consent and confidentiality
The committee agreed, based on their knowledge and experience, healthcare professionals and social care practitioners should be aware of the Mental Capacity Act (2005) and Mental Health Act (1983; amended 1995 and 2007) to ensure staff understand and work within established legal and medical principles regarding consent when working with people who have self-harmed. The committee agreed the existing guidance was comprehensive, and although more widely applicable for staff working with people presenting for mental health reasons, the advice was also relevant for staff specifically working with people who had self-harmed. The committee also discussed what skills pertaining to consent were important for professionals to have when working with people who had self-harmed. They agreed it was necessary to highlight the importance of having the ability to assess mental capacity, so professionals could recognise circumstances when it may be necessary to give care without consent, as well as when it was inappropriate to do so. The committee agreed based on their experience that having this knowledge would allow healthcare professionals and social care practitioners to be as collaborative as possible when making decisions about care, while still ensuring the patient receives necessary treatment in the least restrictive way. The committee discussed the potential risks of healthcare professionals making decisions regarding consent without confidence and agreed this had the potential for patients to be given inappropriate care without consent, potentially leading to distress and future self-harm or suicide. Based on their discussion of the potential risks, the committee agreed that healthcare professionals and social care practitioners should feel empowered to seek guidance about consent when they were unsure of how to proceed with care for a person who had self-harmed. The committee also agreed, based on their knowledge and experience, that it was important for healthcare professionals and social care practitioners to direct people to Independent Mental Capacity Advocates (IMCAs); for example, when a patient is lacking capacity. The committee discussed the benefits of access to IMCAs and agreed this would allow people who have self-harmed to feel confident that their opinions are being respected to allow for the best decisions to be made regarding their care. The committee also agreed it would be beneficial to signpost to the NICE guidelines on Decision-making and mental capacity (NG108), Service user experience in adult mental health (CG136) and Babies, children and young people’s experience of healthcare (NG204), and the government’s consensus statement on information sharing and suicide prevention so healthcare professionals and social care practitioners could make informed decisions about consent based on existing guidance.
The committee discussed how principles of consent applied specifically to children and young people, and again agreed that existing guidance about this topic for children and young people was comprehensive and relevant to those who had self-harmed. The committee therefore agreed any healthcare professionals and social care practitioners should be aware of this guidance, in particular the Children Act 1989, the Children and Families Act 2014, and the Mental Health Act 2007, in order to make appropriate decisions regarding the care of children and young people. Due to the variability of specific issues regarding consent depending on the age of the child, the committee also agreed it is important that health and social care staff know how to apply these principles for children and young people of different ages in order to prevent dissatisfaction with care if, for example, their capacity to consent is assessed inappropriately for their age. The committee also agreed it is important that healthcare professionals understand Gillick competence in order to assess competence adequately in children and young people of different ages. They agreed that having these skills would enable young people to make decisions with their care when appropriate, which could have the benefit of empowering the person and improving satisfaction with their care.
The committee discussed potential legal issues surrounding circumstances when decisions are made about a person’s care without their consent or when confidentiality is broken, including incidents where staff working with people who have self-harmed have faced legal repercussions even when they thought as though they are acting in the best interests of the person. The committee discussed the benefits of having access to advice from specialists such as liaison psychiatrists and agreed it would provide reassurance to clinicians and allow them to have confidence in any decisions made regarding the person’s capacity and consent. Access to this advice should always be available to health and social care staff as standard, to enable skill-sharing and good communication between staff members. The committee agreed that any staff seeking advice regarding the best course of action for a person who has self-harmed should also have access to formal legal advice as needed, to minimise the risk of staff withholding necessary care or providing inappropriate care due to lack of knowledge of specific law or fear of legal repercussions.
The recommendation regarding the limits of confidentiality was made after a committee discussion of the benefits and risks of information sharing. The committee agreed based on their experience that the risks of information sharing, such as breaching the person’s consent and confidentiality, were widely acknowledged while the benefits were not as commonly discussed, and that this led to staff often feeling unable to share information about a patient even when it would benefit them. The committee discussed the principle that information sharing improves outcomes and agreed that withholding information can be a detriment to the person, as it carries the risk of other staff members delivering inappropriate care. The committee agreed to make a recommendation on the benefits of information sharing in order to prevent situations where confidentiality may become a barrier to collaborative working with other staff.
The committee similarly discussed the benefits of information sharing with family members and carers, for example where family members and carers may need information to continue with appropriate ongoing care. The committee acknowledged the potential safeguarding risks of information sharing and concluded that consent should still be sought when sharing information with family members and carers to ensure that the confidentiality requests of the person who has self-harmed are respected.
The committee agreed that whenever confidentiality is broken, staff should still endeavour to include patients in their own care at all times, including informing them about the breach if this is practical. The committee discussed the fact that it might not always be possible to inform the person of a confidentiality breach in advance if there are immediate concerns about the person’s safety and the staff member expects that the person may not engage with services if informed of the breach. However, when possible, they agreed that doing so would prevent the person feeling disempowered and reduce the risk of service user dissatisfaction. Additionally, continuing to make decisions collaboratively with the person even after a break of confidentiality would protect the person’s autonomy, allow them to stay engaged with their care, and reassure the person that the staff are working with their best interests in mind.
Safeguarding
The committee discussed whether additional consideration was necessary for children regarding safeguarding, but agreed that adults could be equally vulnerable when the person has self-harmed. They therefore agreed that safeguarding principles were similarly applicable to both children and vulnerable adults. For this reason, the committee made the safeguarding recommendations to encompass all people who have self-harmed. The committee referred to existing best practice when discussing issues regarding safeguarding and agreed that the guidance in the Care Act (2014), the Children Act 1989, and Children and Families Act 2014 was appropriate to signpost to, in order to ensure professionals and practitioners adhere to current safeguarding principles. The committee agreed it was important to highlight the potential for safeguarding concerns especially when working with people who have self-harmed, as presentation for self-harm can provide an opportunity for healthcare staff to intervene in situations where safeguarding is a concern. The committee discussed the risk of asking about abuse in front of a person who could potentially be their abuser and agreed that asking someone about safeguarding concerns when they are alone would remove this risk. However, they agreed that someone might have brought a person for support in order to disclose abuse and might need them there to have the courage to do so. Additionally, the committee discussed their experience that a family member, friend, or carer might be the one to bring up safeguarding issues instead of the person who has self-harmed. Due to the fact that friends, family members and carers may either support or inhibit disclosure, the committee agreed that consideration should be given to enquiring about safeguarding concerns in the most appropriate circumstances The committee therefore agreed staff should always consider whether such concerns exist for children and adults who have self-harmed and be prepared to enact safeguarding procedures when necessary, to reduce the risk of further harm to the person. The committee also agreed it would be beneficial to signpost to NICE guidelines on Domestic violence and abuse: multi-agency working (PH50), Looked-after children and young people (NG205), Child abuse and neglect (NG76), and Child maltreatment: when to suspect maltreatment in under 18s (CG89) so healthcare professionals could make informed decisions about safeguarding people who have self-harmed based on existing guidance.
The recommendation about a multi-agency approach to safeguarding was made after the committee agreed based on their knowledge and experience that a multi-agency approach would allow for collaborative working between different sectors, allowing for information-sharing which would ensure a holistic vision of a person’s life informs their care and therefore improve the service provided to the person.
Cost effectiveness and resource use
The committee noted that no relevant published economic evaluations had been identified in the literature review. In addition, a bespoke economic model in this area of the guideline was not prioritised, as potential changes in current practice caused by the drafted recommendations were not expected to result in significant resource impact. When drafting the recommendations, the committee noted that, overall, these recommendations are in line with existing recommended practice, and should result in easier access to legal advice, better awareness of the benefits of information sharing as well as better communication and transitions across services through multi-agency approaches. The committee expressed the view that in some services there may be some increase in staff time to obtain consent from people who have self-harmed and their carers; they noted that there might also be extra costs incurred if specific extra training is required. However, such additional costs are likely to be minimal and may be offset by better health outcomes by improving the care and quality of life of people who have self-harmed.
Recommendations supported by this evidence review
This evidence review supports recommendations 1.2.1–1.2.6 and 1.3.1–2.
References – included studies
Effectiveness
No studies were identified that met the inclusion criteria.
Economic
No studies were identified that met the inclusion criteria.
Appendices
Appendix A. Review protocols
Appendix B. Literature search strategies
Appendix C. Effectiveness evidence study selection
Appendix D. Evidence tables
Evidence tables for review question: What is the most effective approach to obtain consent, ensure confidentiality and promote safeguarding when people have self-harmed?
No evidence was identified which was applicable to this review question.
Appendix E. Forest plots
Forest plots for review question: What is the most effective approach to obtain consent, ensure confidentiality and promote safeguarding when people have self-harmed?
No meta-analysis was conducted for this review question and so there are no forest plots.
Appendix F. Modified GRADE tables
Modified GRADE tables for review question: What is the most effective approach to obtain consent, ensure confidentiality and promote safeguarding when people have self-harmed?
No evidence was identified which was applicable to this review question.
Appendix G. Economic evidence study selection
Appendix H. Economic evidence tables
Economic evidence tables for review question: What is the most effective approach to obtain consent, ensure confidentiality and promote safeguarding when people have self-harmed?
No evidence was identified which was applicable to this review question.
Appendix I. Economic model
Economic model for review question: What is the most effective approach to obtain consent, ensure confidentiality and promote safeguarding when people have self-harmed?
No economic analysis was conducted for this review question.
Appendix J. Excluded studies
Excluded studies for review question: What is the most effective approach to obtain consent, ensure confidentiality and promote safeguarding when people have self-harmed?
Excluded effectiveness studies
Table 3Excluded studies and reasons for their exclusion
| Study | Code [Reason] |
|---|---|
| Bowers, L., Alexander, J., Bilgin, H. et al. (2014) Safewards: The empirical basis of the model and a critical appraisal. Journal of Psychiatric and Mental Health Nursing 21: 354–364 [PMC free article: PMC4237197] [PubMed: 24460906] | - Narrative review |
| De Hert, M., Dirix, N., Demunter, H. et al. (2011) Prevalence and correlates of seclusion and restraint use in children and adolescents: A systematic review. European Child and Adolescent Psychiatry 20: 221–230 [PubMed: 21298305] | - Systematic review, included studies checked for relevance |
| Hochstrasser, L., Frohlich, D., Schneeberger, A. R. et al. (2018) Long-term reduction of seclusion and forced medication on a hospital-wide level: Implementation of an open-door policy over 6 years. European psychiatry : the journal of the Association of European Psychiatrists 48: 51–57 [PubMed: 29331599] |
- Population not in PICO Mixed population, unclear how many of the population had self-harmed |
| Kapur, Nav, Ibrahim, Saied, While, David et al. (2016) Mental health service changes, organisational factors, and patient suicide in England in 1997–2012: a before-and-after study. The lancet. Psychiatry 3: 526–34 [PubMed: 27107805] |
- Intervention not in PICO Service level changes to mental health services, for example, implementation of the NICE self-harm guidelines vs not |
| Kelly, B. D. (2017) Confidentiality and privacy in the setting of involuntary mental health care: What standards should apply?. Ethics, Medicine and Public Health | - Narrative review |
| Lefevre-Utile, J., Guinchat, V., Wachtel, L. E. et al. (2018) Personal protective equipment and restraints alternatives in the management of challenging behaviors in inpatients with autism and intellectual disability (Part 1: Patients’ perspectives). Neuropsychiatrie de l’Enfance et de l’Adolescence 66: 443–459 | - Not published in English |
| Lefevre-Utile, J., Guinchat, V., Wachtel, L. E. et al. (2018) Personal protective equipment and restraints alternatives in the management of challenging behaviors in inpatients with autism and intellectual disability (Part 2: Caregivers’ perspectives). Neuropsychiatrie de l’Enfance et de l’Adolescence 66: 460–467 | - Not published in English |
| Lowe, Susan (2009) Safeguarding patients. Emergency nurse : the journal of the RCN Accident and Emergency Nursing Association 16: 8–9 [PubMed: 19266659] | - Narrative review |
| Maguire, Tessa, Ryan, Jo, Fullam, Rachael et al. (2018) Evaluating the introduction of the Safewards model to a medium- to long-term forensic mental health ward. Journal of Forensic Nursing 14: 214–222 [PubMed: 30433910] |
- Insufficient number of participants Not RCT and only 28 patients during study period; forensic mental health population with schizophrenia or schizoaffective disorder, and it seems only a total of 6 self-harm events |
| McCue, Robert E., Urcuyo, Leonel, Lilu, Yehezkel et al. (2004) Reducing Restraint Use in a Public Psychiatric Inpatient Service. The Journal of Behavioral Health Services & Research 31: 217–224 [PubMed: 15255229] |
- Population not in PICO Unclear whether any of the population had self-harmed; outside study dates (April 1996-March 1999 n = 6517; April 1999-March 2001: n=4236) |
| Pollard, Richard, Yanasak, Elisia V., Rogers, Steven A. et al. (2007) Organizational and unit factors contributing to reduction in the use of seclusion and restraint procedures on an acute psychiatric inpatient unit. The Psychiatric quarterly 78: 73–81 [PubMed: 17102932] |
- Population not in PICO Unclear population, including whether any of the population had self-harmed |
| Powers, K. V.; Roane, H. S.; Kelley, M. E. (2007) Treatment of self-restraint associated with the application of protective equipment. Journal of Applied Behavior Analysis 40: 577–581 [PMC free article: PMC1986685] [PubMed: 17970273] |
- Non-comparative study Case-study examining one participant |
| Rooker, Griffin W. and Roscoe, Eileen M. (2005) Functional analysis of self-injurious behavior and its relation to self-restraint. Journal of Applied Behavior Analysis 38: 537–542 [PMC free article: PMC1309716] [PubMed: 16463534] |
- Non-comparative study Case-study examining one participant |
| Samples, T. C., Woods, A., Davis, T. A. et al. (2014) Race of Interviewer Effect on Disclosures of Suicidal Low-Income African American Women. Journal of Black Psychology 40: 27–46 |
- Comparison/outcome not in PICO Study compared disclosure of suicide risk factors by African-American women who were either interviewed by African-American or European-American interviewer |
| Silvana, S., Laura, F., Di Fabio, U. et al. (2012) Ergonomics in the psychiatric ward towards workers or patients?. Work (Reading, Mass.) 41suppl1: 1832–1835 [PubMed: 22316981] |
- Population not in PICO Study population is nurses. |
| Simone, A. C. and Hamza, C. A. (2020) Examining the disclosure of nonsuicidal self-injury to informal and formal sources: A review of the literature. Clinical Psychology Review 82: 101907 [PubMed: 32891855] |
- Semi-systematic review Study focus was disclosure of non-suicidal self-harm, not approaches to consent, confidentiality and safe-guarding |
| Sivak, Kim (2012) Implementation of comfort rooms to reduce seclusion, restraint use, and acting-out behaviors. Journal of Psychosocial Nursing and Mental Health Services 50: 24–34 [PubMed: 22439145] |
- Population not in PICO Mixed population, unclear how many of the population had self-harmed |
| Strand, M. and Von Hausswolff-Juhlin, Y. (2015) Patient-controlled hospital admission in psychiatry: A systematic review. Nordic Journal of Psychiatry 69: 574–586 [PubMed: 25832757] | - Systematic review, included studies checked for relevance |
| Sullivan, Ann M., Bezmen, Janet, Barron, Charles T. et al. (2005) Reducing Restraints: Alternatives to Restraints on an Inpatient Psychiatric Service--Utilizing Safe and Effective Methods to Evaluate and Treat the Violent Patient. Psychiatric Quarterly 76: 51–65 [PubMed: 15757236] |
- Population not in PICO Mixed population, unclear how many of the population had self-harmed |
| Thomsen, C. T., Benros, M. E., Maltesen, T. et al. (2018) Patient-controlled hospital admission for patients with severe mental disorders: a nationwide prospective multicentre study. Acta psychiatrica Scandinavica 137: 355–363 [PubMed: 29504127] |
- Population not in PICO Mixed population; <13% in each treatment group were patients who had self-harmed |
| Timlin, Ulla, Hakko, Helina, Riala, Kaisa et al. (2015) Adherence of 13–17 Year Old Adolescents to Medicinal and Non-pharmacological Treatment in Psychiatric Inpatient Care: Special Focus on Relative Clinical and Family Factors. Child psychiatry and human development 46: 725–35 [PubMed: 25307994] |
- Population not in PICO Mixed population: 25 of 72 patients had self-harmed and 38 of 72 patients had attempted suicide; comparison not in PICO/non-comparative study suicide (multivariate analyses about predictors of adherence to treatment) |
| Tolland, H., McKee, T., Cosgrove, S. et al. (2019) A systematic review of effective therapeutic interventions and management strategies for challenging behaviour in women in forensic mental health settings. Journal of Forensic Psychiatry and Psychology 30: 570–593 | - Systematic review, included studies checked for relevance |
| Weeden, Marc; Mahoney, Amanda; Poling, Alan (2010) Self-injurious behavior and functional analysis: where are the descriptions of participant protections?. Research in developmental disabilities 31: 299–303 [PubMed: 19879108] |
- Semi-systematic review Intervention not in PICO (functional analysis) |
| While, David, Bickley, Harriet, Roscoe, Alison et al. (2012) Implementation of mental health service recommendations in England and Wales and suicide rates, 1997–2006: a cross-sectional and before-and-after observational study. Lancet (London, England) 379: 1005–12 [PubMed: 22305767] |
- Intervention not in PICO Service level changes to mental health services, for example, a 24-hour crisis team vs not; intervention not related to consent, confidentiality or safeguarding |
Excluded economic studies
Table 4Excluded studies from the guideline economic review
| Study | Reason for Exclusion |
|---|---|
| Adrian, M., Lyon, A. R., Nicodimos, S., Pullmann, M. D., McCauley, E., Enhanced “Train and Hope” for Scalable, Cost-Effective Professional Development in Youth Suicide Prevention, Crisis, 39, 235–246, 2018 [PubMed: 29183240] | Not relevant to any of the review questions in the guideline - this study examined the impact of an educational training ongoing intervention, and the effect of the post-training reminder system, on mental health practitioners’ knowledge, attitudes, and behaviour surrounding suicide assessment and intervention. As well, this study was not a full health economic evaluation |
| Borschmann R, Barrett B, Hellier JM, et al. Joint crisis plans for people with borderline personality disorder: feasibility and outcomes in a randomised controlled trial. Br J Psychiatry. 2013;202(5):357–364. [PubMed: 23637110] | Not relevant to any of the review questions in the guideline - this study examined the feasibility of recruiting and retaining adults with borderline personality disorder to a pilot randomised controlled trial investigating the potential efficacy and cost-effectiveness of using a joint crisis plan |
| Bustamante Madsen, L., Eddleston, M., Schultz Hansen, K., Konradsen, F., Quality Assessment of Economic Evaluations of Suicide and Self-Harm Interventions, Crisis, 39, 82–95, 2018 [PubMed: 28914094] | Study design - this review of health economics studies has been excluded for this guideline, but its references have been hand-searched for any relevant health economic study |
| Byford, S., Barrett, B., Aglan, A., Harrington, V., Burroughs, H., Kerfoot, M., Harrington, R. C., Lifetime and current costs of supporting young adults who deliberately poisoned themselves in childhood and adolescence, Journal of Mental Health, 18, 297–306, 2009 | Study design – no comparative cost analysis |
| Byford, S., Leese, M., Knapp, M., Seivewright, H., Cameron, S., Jones, V., Davidson, K., Tyrer, P., Comparison of alternative methods of collection of service use data for the economic evaluation health care interventions, Health Economics, 16, 531–536, 2007 [PubMed: 17001749] | Study design – no comparative cost analysis |
| Byford, Sarah, Barber, Julie A., Harrington, Richard, Barber, Baruch Beautrais Blough Brent Brodie Byford Carlson Chernoff Collett Fergusson Garland Goldberg Harman Harrington Hawton Huber Kazdin Kerfoot Knapp Lindsey McCullagh Miller Netten Reynolds Sadowski Shaffer Simms Wu, Factors that influence the cost of deliberate self-poisoning in children and adolescents, Journal of Mental Health Policy and Economics, 4, 113–121, 2001 [PubMed: 11967471] | Study design – no comparative cost analysis |
| Denchev, P., Pearson, J. L., Allen, M. H., Claassen, C. A., Currier, G. W., Zatzick, D. F., Schoenbaum, M., Modeling the cost-effectiveness of interventions to reduce suicide risk among hospital emergency department patients, Psychiatric Services, 69, 23–31, 2018 [PMC free article: PMC5750130] [PubMed: 28945181] | Not relevant to any of the review questions in the guideline - this study estimated the cost-effectiveness of outpatient interventions (Postcards, Telephone outreach, Cognitive Behaviour Therapy) to reduce suicide risk among patients presenting to general hospital emergency departments |
| Dunlap, L. J., Orme, S., Zarkin, G. A., Arias, S. A., Miller, I. W., Camargo, C. A., Sullivan, A. F., Allen, M. H., Goldstein, A. B., Manton, A. P., Clark, R., Boudreaux, E. D., Screening and Intervention for Suicide Prevention: A Cost-Effectiveness Analysis of the ED-SAFE Interventions, Psychiatric services (Washington, D.C.), appips201800445, 2019 [PubMed: 31451063] | Not relevant to any of the review questions in the guideline - this study estimated the cost-effectiveness of suicide screening followed by an intervention to identify suicidal individuals and prevent recurring self-harm |
| Fernando, S. M., Reardon, P. M., Ball, I. M., van Katwyk, S., Thavorn, K., Tanuseputro, P., Rosenberg, E., Kyeremanteng, K., Outcomes and Costs of Patients Admitted to the Intensive Care Unit Due to Accidental or Intentional Poisoning, Journal of Intensive Care Medicine, 35, 386–393, 2020 [PubMed: 29357777] | Study design – no comparative cost analysis |
| Flood, C., Bowers, L., Parkin, D., Estimating the costs of conflict and containment on adult acute inpatient psychiatric wards, Nursing economic$, 26, 325–330, 324, 2008 [PubMed: 18979699] | Study design – no comparative cost analysis |
| Fortune, Z., Barrett, B., Armstrong, D., Coid, J., Crawford, M., Mudd, D., Rose, D., Slade, M., Spence, R., Tyrer, P., Moran, P., Clinical and economic outcomes from the UK pilot psychiatric services for personality-disordered offenders, International Review of Psychiatry, 23, 61–9, 2011 [PubMed: 21338300] | Not relevant to any of the review questions in the guideline |
| George, S., Javed, M., Hemington-Gorse, S., Wilson-Jones, N., Epidemiology and financial implications of self-inflicted burns, Burns, 42, 196–201, 2016 [PubMed: 26670160] | Study design – no comparative cost analysis |
| Gunnell, D., Shepherd, M., Evans, M., Are recent increases in deliberate self-harm associated with changes in socio-economic conditions? An ecological analysis of patterns of deliberate self-harm in Bristol 1972–3 and 1995–6, Psychological medicine, 30, 1197–1203, 2000 [PubMed: 12027054] | Study design - cost-of-illness study |
| Kapur, N., House, A., Dodgson, K., Chris, M., Marshall, S., Tomenson, B., Creed, F., Management and costs of deliberate self-poisoning in the general hospital: A multi-centre study, Journal of Mental Health, 11, 223–230, 2002 | Study design – no comparative cost analysis |
| Kapur, N., House, A., May, C., Creed, F., Service provision and outcome for deliberate self-poisoning in adults - Results from a six centre descriptive study, Social Psychiatry and Psychiatric Epidemiology, 38, 390–395, 2003 [PubMed: 12861446] | Study design – no comparative cost analysis |
| Kinchin, I., Russell, A. M. T., Byrnes, J., McCalman, J., Doran, C. M., Hunter, E., The cost of hospitalisation for youth self-harm: differences across age groups, sex, Indigenous and non-Indigenous populations, Social Psychiatry and Psychiatric Epidemiology, 55, 425–434, 2020 [PubMed: 31732765] | Study design – no comparative cost analysis |
| O’Leary, F. M., Lo, M. C. I., Schreuder, F. B., “Cuts are costly”: A review of deliberate self-harm admissions to a district general hospital plastic surgery department over a 12-month period, Journal of Plastic, Reconstructive and Aesthetic Surgery, 67, e109–e110, 2014 [PubMed: 24183058] | Study design – no comparative cost analysis |
| Olfson, M., Gameroff, M. J., Marcus, S. C., Greenberg, T., Shaffer, D., National trends in hospitalization of youth with intentional self-inflicted injuries, American Journal of Psychiatry, 162, 1328–1335, 2005 [PubMed: 15994716] | Study design – no comparative cost analysis |
| Ostertag, L., Golay, P., Dorogi, Y., Brovelli, S., Cromec, I., Edan, A., Barbe, R., Saillant, S., Michaud, L., Self-harm in French-speaking Switzerland: A socio-economic analysis (7316), Swiss Archives of Neurology, Psychiatry and Psychotherapy, 70 (Supplement 8), 48S, 2019 | Conference abstract |
| Ougrin, D., Corrigall, R., Poole, J., Zundel, T., Sarhane, M., Slater, V., Stahl, D., Reavey, P., Byford, S., Heslin, M., Ivens, J., Crommelin, M., Abdulla, Z., Hayes, D., Middleton, K., Nnadi, B., Taylor, E., Comparison of effectiveness and cost-effectiveness of an intensive community supported discharge service versus treatment as usual for adolescents with psychiatric emergencies: a randomised controlled trial, The Lancet Psychiatry, 5, 477–485, 2018 [PMC free article: PMC5994473] [PubMed: 29731412] | Not self-harm. In addition, the interventions evaluated in this economic analysis (a supported discharge service provided by an intensive community treatment team compared to usual care) were not relevant to any review questions |
| Palmer, S., Davidson, K., Tyrer, P., Gumley, A., Tata, P., Norrie, J., Murray, H., Seivewright, H., The cost-effectiveness of cognitive behavior therapy for borderline personality disorder: results from the BOSCOT trial, Journal of Personality Disorders, 20, 466–481, 2006 [PMC free article: PMC1852260] [PubMed: 17032159] | Not self-harm |
| Quinlivan L, Steeg S, Elvidge J, et al. Risk assessment scales to predict risk of hospital treated repeat self-harm: A cost-effectiveness modelling analysis. J Affect Disord. 2019;249:208–215. [PubMed: 30772749] | Not relevant to any of the review questions in the guideline - this study estimated the cost-effectiveness of risk assessment scales versus clinical assessment for adults attending an emergency department following self-harm |
| Richardson JS, Mark TL, McKeon R. The return on investment of postdischarge follow-up calls for suicidal ideation or deliberate self-harm. Psychiatr Serv. 2014;65(8):1012–1019. [PubMed: 24788454] | Not enough data reporting on cost-effectiveness findings |
| Smits, M. L., Feenstra, D. J., Eeren, H. V., Bales, D. L., Laurenssen, E. M. P., Blankers, M., Soons, M. B. J., Dekker, J. J. M., Lucas, Z., Verheul, R., Luyten, P., Day hospital versus intensive out-patient mentalisation-based treatment for borderline personality disorder: Multicentre randomised clinical trial, British Journal of Psychiatry, 216, 79–84, 2020 [PubMed: 30791963] | Not self-harm |
| Tsiachristas, A., Geulayov, G., Casey, D., Ness, J., Waters, K., Clements, C., Kapur, N., McDaid, D., Brand, F., Hawton, K., Incidence and general hospital costs of self-harm across England: estimates based on the multicentre study of self-harm, Epidemiology & Psychiatric Science, 29, e108, 2020 [PMC free article: PMC7214546] [PubMed: 32160934] | Study design – no comparative cost analysis |
| Tsiachristas, A., McDaid, D., Casey, D., Brand, F., Leal, J., Park, A. L., Geulayov, G., Hawton, K., General hospital costs in England of medical and psychiatric care for patients who self-harm: a retrospective analysis, The Lancet Psychiatry, 4, 759–767, 2017 [PMC free article: PMC5614771] [PubMed: 28890321] | Study design – no comparative cost analysis |
| Tubeuf, S., Saloniki, E. C., Cottrell, D., Parental Health Spillover in Cost-Effectiveness Analysis: Evidence from Self-Harming Adolescents in England, PharmacoEconomics, 37, 513–530, 2019 [PubMed: 30294758] | This study is not a separate study from one already included in the guideline for topic 5.2 (Cottrel 2018). This secondary analysis presents alternative parental health spillover quantification methods in the context of a randomised controlled trial comparing family therapy with treatment as usual as an intervention for self-harming adolescents of (Cottrel 2018), and discusses the practical limitations of those methods |
| Tyrer, P., Thompson, S., Schmidt, U., Jones, V., Knapp, M., Davidson, K., Catalan, J., Airlie, J., Baxter, S., Byford, S., Byrne, G., Cameron, S., Caplan, R., Cooper, S., Ferguson, B., Freeman, C., Frost, S., Godley, J., Greenshields, J., Henderson, J., Holden, N., Keech, P., Kim, L., Logan, K., Manley, C., MacLeod, A., Murphy, R., Patience, L., Ramsay, L., De Munroz, S., Scott, J., Seivewright, H., Sivakumar, K., Tata, P., Thornton, S., Ukoumunne, O. C., Wessely, S., Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: The POPMACT study, Psychological medicine, 33, 969–976, 2003 [PubMed: 12946081] | Study design - no economic evaluation |
| Van Roijen, L. H., Sinnaeve, R., Bouwmans, C., Van Den Bosch, L., Cost-effectiveness and Cost-utility of Shortterm Inpatient Dialectical Behavior Therapy for Chronically Parasuicidal BPD (Young) Adults, Journal of Mental Health Policy and Economics, 18, S19–S20, 2015 | Conference abstract |
| van Spijker, B. A., Majo, M. C., Smit, F., van Straten, A., Kerkhof, A. J., Reducing suicidal ideation: cost-effectiveness analysis of a randomized controlled trial of unguided web-based self-help, Journal of medical Internet research, 14, e141, 2012 [PMC free article: PMC3517339] [PubMed: 23103835] | Not self-harm |
Appendix K. Research recommendations – full details
Research recommendations for review question: What is the most effective approach to obtain consent, ensure confidentiality and promote safeguarding when people have self-harmed?
No research recommendations were made for this review question.
Final version
Evidence reviews underpinning recommendations 1.2.1 to 1.2.6 and 1.3.1 to 1.3.2 in the NICE guideline
Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.
- Review Evidence review for involving family and carers in the management of people who have self-harmed: Self-harm: assessment, management and preventing recurrence: Evidence review D[ 2022]Review Evidence review for involving family and carers in the management of people who have self-harmed: Self-harm: assessment, management and preventing recurrence: Evidence review D. 2022 Sep
- Review Evidence review for harm minimisation strategies: Self-harm: assessment, management and preventing recurrence: Evidence review L[ 2022]Review Evidence review for harm minimisation strategies: Self-harm: assessment, management and preventing recurrence: Evidence review L. 2022 Sep
- A pragmatic randomised controlled trial and economic evaluation of family therapy versus treatment as usual for young people seen after second or subsequent episodes of self-harm: the Self-Harm Intervention - Family Therapy (SHIFT) trial.[Health Technol Assess. 2018]A pragmatic randomised controlled trial and economic evaluation of family therapy versus treatment as usual for young people seen after second or subsequent episodes of self-harm: the Self-Harm Intervention - Family Therapy (SHIFT) trial.Cottrell DJ, Wright-Hughes A, Collinson M, Boston P, Eisler I, Fortune S, Graham EH, Green J, House AO, Kerfoot M, et al. Health Technol Assess. 2018 Mar; 22(12):1-222.
- Review Evidence review for skills required by staff in specialist settings: Self-harm: assessment, management and preventing recurrence: Evidence review P[ 2022]Review Evidence review for skills required by staff in specialist settings: Self-harm: assessment, management and preventing recurrence: Evidence review P. 2022 Sep
- Review Evidence review for safer prescribing: Self-harm: assessment, management and preventing recurrence: Evidence review O[ 2022]Review Evidence review for safer prescribing: Self-harm: assessment, management and preventing recurrence: Evidence review O. 2022 Sep
- Evidence review for consent, confidentiality and safeguardingEvidence review for consent, confidentiality and safeguarding
- uncharacterized protein LOC111480657 isoform X1 [Cucurbita maxima]uncharacterized protein LOC111480657 isoform X1 [Cucurbita maxima]gi|1280995799|ref|XP_022981581.1|Protein
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