Download The management of self-harm in primary care

Self-harm:
short term treatment and
management
The management of self-harm in primary care
November 2011
NICE clinical guideline 16
What this presentation covers
Background
Epidemiology
Scope
Recommendations relevant to
primary care
Discussion
NICE pathways
NHS Evidence
Find out more
Definition and background
‘Self-harm’ refers to any act of self-poisoning or
self-injury.
Methods can be divided into:
• self-poisoning
• self-injury.
People who survive a medically serious suicide
attempt may have poorer life expectancy.
Epidemiology
• Self-harm is common, especially among younger
people
• For all age groups, annual prevalence is
approximately 0.5%
• Self-harm increases the likelihood that the person will
eventually die by suicide by between 50 and 100 fold
• Psychiatric problems such as borderline personality
disorder, depression, bipolar disorder, schizophrenia
and drug and alcohol-use disorders are
associated with self-harm.
Scope
The guideline covers:
• all people aged 8 years and over who have carried out
an act of intentional self-harm, regardless of whether
the behaviour is accompanied by a mental illness
• the acute care of self-harm in people with learning
disabilities, but not repetitive self-injurious behaviour,
such as head banging
• guidance about care provided by primary, community
and secondary health and social care services.
Key priorities for
implementation
• Respect, understanding and choice
• Staff training
• Assessment of needs
• Assessment of risk
• Psychological, psychosocial and
pharmacological interventions
Managing self-harm in
primary care
Primary care has an important role in assessing and
treating 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.
Respect, understanding
and choice
People who have self-harmed should be treated with the
same care, respect and privacy as any patient.
Take full account of the likely distress associated with
self-harm.
All staff caring and providing treatment for people who
self-harm should have regular clinical supervision in
which the emotional impact upon staff members can
be discussed.
Staff training
Clinical and non-clinical staff in any setting should have
appropriate training.
Involve people who self-harm in the planning and
delivery of staff training.
Make training available in the assessment of mental
health needs and the preliminary management of mental
health problems.
Service planning
Involve people who self-harm in planning and evaluating
services.
Emergency departments, PCTs and local mental health
services should jointly plan to ensure that physical and
mental healthcare services are integrated.
Management in primary care
Urgently establish physical risk and mental state in a
respectful and understanding way.
Assess risk of further self-harm (consider depression,
hopelessness and suicidal intent).
Inform relevant staff and organisations of the outcome of
this assessment.
Self-injury
Where there is a significant risk to the service user refer
to an emergency department urgently.
If in doubt about whether to refer discuss with an
emergency consultant.
If service user lives in a remote area and can’t get to an
emergency department quickly:
• discuss with an emergency consultant
• consider initiating treatment.
Self-poisoning
Refer to an emergency department urgently unless you
are sure this is not necessary.
If in doubt about whether to refer discuss with an
emergency consultant.
If the service user lives in a remote area and can’t get to
an emergency department quickly:
• discuss with an emergency consultant
• consider initiating treatment
• collect samples to test for paracetamol and
other drugs, as indicated in TOXBASE.
Non-urgent referrals
Consider whether the person needs urgent referral to
secondary mental health services.
Base decision on risk and needs assessment, including:
• social and psychological aspects of the episode of
self-harm
• mental health and social needs
• hopelessness
• suicidal intent.
Send full details of assessments and treatment to
the secondary mental health team as soon
as possible.
Prescribing to service users
at risk of self-poisoning
When prescribing drugs to people who have previously
self-poisoned, people who are at risk of self-poisoning,
or people who live with someone at risk of
self-poisoning:
• prescribe drugs that are the least dangerous in
overdose
• consider prescribing fewer tablets at a time
• consider alternatives to co-proxamol.
Assessment of needs
Offer an assessment of needs.
This should be comprehensive and include:
• evaluation of social, psychological and motivational
factors specific to the act of self-harm
• current suicidal intent and hopelessness
• a full mental health and social needs assessment.
Assessment of risk
Assess risk for all people who have self-harmed and
include identification of:
• the main clinical and demographic features known to
be associated with risk of further self-harm and/or
suicide
• key psychological characteristics associated with
risk, in particular depression, hopelessness and
continuing suicidal intent.
Psychological, psychosocial
and pharmacological
interventions
After psychosocial assessment, decide whether referral
is needed for further treatment and help:
• based on a comprehensive psychiatric, psychological
and social assessment, including an assessment of
risk
• not solely on the basis of having self-harmed.
Discussion
• How does care provided for people who self-harm by
our primary care service compare with the guidance?
• What staff training is needed to support this guidance?
• What changes do we need to make?
• Who is leading on this review and action plan?
NICE Pathway
The NICE self-harm
pathway covers:
•
planning of services
•
general principles of
care
•
assessment, treatment
and management
•
longer-term treatment
and management.
Click here to go to
NICE Pathways
website
NHS Evidence
Visit NHS Evidence
for the best available
evidence on all
aspects of self-harm
Click here to go to
the NHS Evidence
website
Find out more
Visit www.nice.org.uk/guidance/CG16 for:
• the guideline
• ‘Understanding NICE guidance’
• slide set for emergency department staff
• slide set for ambulance staff.
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