Understanding Self-Harm and Suicide: Prevalence, Management, and Risk Factors

1. Self-harm & Suicide Dr Joanna Bennett

2. Self harm / Self injury/Self mutilation • Deliberate self-cutting, burning, poisoning, with or without the intention of committing suicide • No DSM or ICD diagnosis • A symptom for diagnosing other mental disorders • Borderline personality disorder ‘recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 

3. Self harm / Self injury/Self mutilation • self-harm behavior is seen in patients with many mental disorders • Occurs without any apparent disease and can persist after other symptoms of a particular psychological disorder have subsided • Call for a separate diagnosis

4. Prevalence • Prevalence is 3-5% of the population in Europe & US • Risks are higher in: • women • young adults • socially isolated or deprived • psychiatric and personality disorders

5. Around one-quarter will repeat self harm in 4 years • Younger adults repeat non-fatal self-harm • Adults (>45yrs) more likely to commit suicide

6. Prevalence - Caribbean • On the rise • Ingestion of tablets – females • Strong chemicals – men • Self- mutilation/cutting – adolescents and young adults • Trinidad – 3 people daily deliberate self harm (Hickling & Sorel)

7. Aetiology • Biological - familial, genetic • Psychosocial • Other suggested personality traits: • impulsive, aggressive, inflexible • impaired decision making and problem solving

8. Self-harm & suicide • 30-fold increase in risk of suicide, compared with the general population • Long-term suicide risk 3-7% • Suicide rates are highest within the first 6-12 months after the index self-harm episode.

9. Self-harm & suicide • Predictors of subsequent suicide include: • avoiding discovery at the time of self-harm • not living with a close relative • previous psychiatric treatment • self-mutilation • alcohol misuse • physical health problems.

10. Management: self harm • No drug treatment shown to be of benefit in reducing recurrent self harm • Flupentixol depot injections may reduce the recurrence of self-harm, but with associated adverse effects. • Paroxetine has not been shown to reduce the risks of repeated deliberate self-harm but may increase suicidal ideation

11. Psychological interventions • Problem-solving therapy may reduce depression and anxiety, but may not be effective in preventing recurrence of self-harm. • Intensive follow up plus outreach , nurse led management or hospital admission have not been shown to reduce recurrent self-harm compared with usual care.

12. Psychological interventions • Cognitive therapy plus usual care reduces the incidence of deliberate self-harm in adults with a recent history of self-harm compared with usual care problem-solving approaches, dynamic psychotherapy, short-term counselling, does not reduce rates of repetition at 1 year compared with usual treatment

13. Psychological interventions • Cognitive therapy plus usual care more effective at 6–18 months than usual care • reducing suicide attempts and severity of depression • reducing hopelessness • no more effective at reducing suicidal ideation

14. Management: self harm • Aims of interventions • reduce repetition of deliberate self-harm • reduce desire to self-harm • prevent suicide • improve social functioning and quality of life

15. Self harm: Patient’s views • Patients with a history of deliberate self harm lack of control over their lives, through: • alcohol dependence • untreated depression • uncertainty within their family relationships.

16. Accident and emergency staff's perceptions of deliberate self-harm • 89 A&E medical and nursing staff. • rate attributions for the cause of the deliberate self-harm • their emotional responses, • optimism for change, • willingness to help change the behaviour. • general attitudes towards deliberate self-harm patients • perceived needs for training in the care of these patients were also assessed

17. Accident and emergency staff's perceptions of deliberate self-harm • The greater attributions of controllability, the greater the negative affect of staff towards the person, and the less the propensity to help. • Male staff and medical staff had more negative attitudes, and medical staff saw less need for further training.

18. Suicide • WHO: • each year approximately one million people die from suicide. A global mortality rate of 16 per 100,000. One death every 40 seconds • In the last 45 years suicide rates have increased by 60% worldwide. • Suicide is now among the three leading causes of death among those aged 15-44 (both sexes). • Suicide attempts are up to 20 times more frequent than completed suicides.

19. Suicide • suicide rates among young people have been increasing - they are now the group at highest risk in a third of all countries. • Mental disorders (particularly depression and substance abuse) are associated with more than 90% of all cases of suicide.

20. Suicide • suicide results from many complex socio-cultural factors and is more likely to occur during periods of socioeconomic, family and individual crisis • In many cases, swift, decisive intervention can prevent suicide. Recognizing risk and taking action if the potential arises is critical.

21. Assessment: suicide risk Determine whether the person has any thoughts of hurting him or herself. Suicidal ideation is highly linked to completed suicide. Any plans for suicidal acts - more specific plans indicate greater danger: purchased a gun, has ammunition, has made out a will

22. Assessment: suicide risk • Determine whether they have a weapon or access to it. • Determine what the patient believes suicide would achieve - suggests how seriously the person has been considering suicide and the reason for death • Potential for homicide

23. Assessment: suicide risk • Any family members or friends who have killed themselves. • Symptoms of depression, psychosis, delirium and dementia, losses (especially recent ones), and substance abuse

24. Assessment: suicide risk The clinician's gut feeling- clinician's reaction counts and should be considered in the intervention. Use of rating scales – e.g. Beck depression Inventory

25. Management: Suicide risk • Close observation - individual must not be left alone • Remove anything that the patient may use to hurt or kill him or herself

26. Some Nursing Diagnoses • Risk for self-directed violence • Hopelessness • Ineffective individual coping