Self-Harm and Suicide

Self-harm involves intentional self-injury without suicidal intent. Cutting is the most common method of self-harm. It is more common in females and those aged under 25. It is often a response to emotional distress and acts as a way for the person to cope with their emotions. Self-harm is not always associated with depression, anxiety or suicide, although it does increase the risk of these conditions.

Suicide involves a person causing their own death. Death by suicide is around three times more common in men and most common around the age of 50 years. It also increases in older age.

Cycle of Self-Harm

The cycle of self-harm involves the following six repeating steps:

1. Emotional suffering
2. Emotional overload
3. Panic
4. Self-harming
5. Temporary relief
6. Shame and guilt

Suicide Risk Assessment

Suicidal thoughts range from a passing idea that is quickly dismissed and involves no intention to robust and persistent thoughts with intentions and a plan. They need to be explored in detail to determine the risk and suitable management strategy. They can change over time, so a safety plan and reassessment when required are necessary.

Presenting features that increase the risk of suicide include:

• Previous suicidal attempts
• Escalating self-harm
• Impulsiveness
• Hopelessness
• Feelings of being a burden
• Making plans
• Writing a suicide note

Background factors that increase the risk of suicide include:

• Mental health conditions
• Physical health conditions
• History of abuse or trauma
• Family history of suicide
• Financial difficulties or unemployment
• Criminal problems (prisoners have a high rate of suicide)
• Lack of social support (e.g., living alone)
• Alcohol and drug use
• Access to means (e.g., firearms)

Protective factors that may help reduce the risk of suicide include:

• Social support and community
• Sense of responsibility to others (e.g., children or family)
• Resilience, coping and problem-solving skills
• Access to mental health support

Management

The management of patients with self-harm, suicidal thoughts or suicidal attempts is subjective and based on many individual factors, clinical judgment and experience. There are no easy-to-follow rules and it involves risk and uncertainty. This is only a very brief summary of some key points. Seek input from experienced clinicians when seeing patients.

Safety-netting, a safety plan and follow-up are important aspects of management. Potential safeguarding issues need to be considered. With the person’s consent, involving others (e.g., relatives or friends) may be helpful.

Patients may require immediate referral to A&E after a suicide attempt or for physical injuries, overdoses or safety concerns. Once their physical health problems have been managed, they will be seen by the mental health team to decide on further management. This may result in an informal admission to hospital (meaning the patient agrees to the the admission). The Mental Health Act (1983) provides a legal framework for admitting patients to hospital against their wishes for a mental health disorder when required for treatment or safety.

Management considerations for self-harm include:

• Empathy, supportive communication and building rapport
• Identifying triggers for episodes
• Separating the means of self-harm (e.g., removing blades or medications from the environment)
• Discussing strategies for avoiding further episodes (e.g., distractions, alternative coping strategies and getting help)
• Providing details for support services in a crisis (e.g., mental health services, Samaritans and Shout)
• Treating underlying mental health conditions (e.g., depression and anxiety)
• Cognitive behavioural therapy

Treatment of Overdose

Generally, the first step when a patient presents with an overdose is to check TOXBASE for recommendations about treating an overdose of almost any substance. They also have a contact number for advice.

Activated charcoal may be given within one hour of overdose of various substances to reduce the absorption (e.g., aspirin, SSRIs, tricyclic antidepressants, antipsychotic drugs, benzodiazepines and quinine).

Below is a table of specific treatments that are commonly tested in exams.

Last updated June 2024

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