Practical aspects of risk assessment in self harm

Practical Aspects of Risk Assessment in Self Harm

The Evidence Base and Real Life Clinical Scenarios

Yasir Hameed (MRCPsych)

Psychiatrist and Honorary Lecturer

UEA

22.5.2015

OutlineDiscuss the basics of risk assessment

Explore risk of self harm in more details

Special focus on young people

What interventions work

MCQs

Clinical scenarios and videos

Learning Objectives

Describe a structure for assessing the level of risk the patient poses to themselves or others.

Describe the demographic and other relevant features which underpin an assessment of risk (e.g. age, sex, substance use etc).

Debate key concepts associated with risk such as “right to die”, deliberate self harm and when and why people do this, confidentiality and when one can break this, safe prescribing in deliberate self harm, and public health measures aimed at reducing suicide and DSH.

Ever wondered whether their deaths could have been prevented?

Risk Assessment

The process of assessing whether or not , and in what circumstances, a person may harm themselves or others (or be harmed).

It is about assessing the likely occurrence of a future event , the likely impact of that event, upon whom or what and with what consequences.

Risk assessment is a dynamic process. Inner London Probation Service,1997

Risk FactorsIs any personal quality or circumstance that is associated with a negative event through causation or facilitation.

Knowing the risk factors of the individual person can help to predict the risk.

Risk factors are static and dynamic.

‘Self-harm is not an illness, but is more or less dangerous behaviour that should alert us to an underlying problem, difficulty or disorder.’

National Collaborating Centre for Mental Health, 2004: p. 16

‘Suicide risk among self-harm patients is hundreds of times higher than the general population’. Owens D, Horrocks J, House A. Fatal and non-fatal repetition of self-harm: systematic review. Br J Psychiatry 2002;181:193–9.

Self harm is often repeated

For any young person with self harm:

Around half will have a history of prior harm

18% will repeat the behaviour within a year (and present to hospital) again.

40–60% of those who die by suicide having self-harmed in the past

In one study, 80% of young people who died by suicide had self-harmed in the preceding year

1 in 25 patients presenting tohospital emergency departments for self-harm will die by suicide in the following 5 years Carroll R, Metcalfe C, Gunnell D. Hospital presenting self-harm and risk of fatal and non-fatal repetition: systematic review and meta-analysis. PLoS ONE 2014:e89944.

Risk of completed suicide

Higher in:

Young people who self harm by cutting

Male

Received treatment for psychiatric disorder

Substance misuse

Negative psycho-social factors

Why do people self-harm? Many theories, but limited evidence

The coping and emotion regulation functions

“Escape function” of the behaviour and the complex bio-psycho-social factors

Psychological mechanisms (self-esteem, impulsivity, hopelessness)

Negative life events

Knowing someone who has self harmed

Patients’ perspective

‘I don’t see it as a prelude to suicide; I see it as a survival thing.’

‘In some ways it gave me control over the pain I felt, rather than having it inflicted on me by someone else, somehow inflicting harm on myself as I say, got me through the other afflictions […] it was just helping me through life in general.’

‘After a while it just feels like routine and a way to keep your mind in check.’

Adolescent self-harm and mental health status in young adulthood

Main findings1 in 10 young people report self-harm

Self harm is the strongest clinical predictor of death by suicide

Compared with those who had never self-harmed, adolescents who engaged in ‘non-suicidal self-injury’ (NSSI) had a greater than twofold increase in the odds of depression and anxiety at age 18 years.

Suicidal self-harm was associated with a fivefold increase in the odds of both depression and anxiety at age 18 years.

NSSI experienced a greater than twofold increase in the odds of problematic cannabis use at age 18 years.

Suicidal self-harm was associated with a greater than sixfold increase in problematic cannabis use at age 18 years.

The odds of harmful alcohol use at age 18 years was more than doubled for both non-suicidal and suicidal self-harm.

Self-harm with suicidal intent was associated with a doubling in the odds of not being in education, employment or training at age 19 years.

Other longitudinal research indicates that the majority will cease self-harming yet the behaviour may still signal an underlying vulnerability to serious difficulties in later adult life.

Adolescents who report self-harming behaviour (regardless of whether or not they report suicidal intent) should be carefully followed-up to assess their need for support and treatment.

It is a COMMON problem

Main findingsSelf-harm is strongly associated with completed suicide and

therefore needs to be treated effectively.

Very limited evidence base on what intervention works.

Hospital based statistics are “tip of the iceberg”

Suicide is the second commonest cause of death in young people globally.

Standards of assessment (NICE)

Comprehensive assessment both for risk of further episodes and clinical, social, psychosocial and physical needs.

Assessment of depression, hopelessness and current/past self-harm and suicidal intent

Assess the method of self-harm (cutting is a significant risk factor for completed suicide in children and adolescents)

Use of risk assessment tools alone is not recommended

How you can help?

Make them feel “listened to”

Avoid being judgmental

Attitudes among clinicians towards self-harm are negative

“Therapeutic assessment”

Offer psychosocial assessment

Limited evidence for interventions

Group-based psychotherapy versus treatment as usual (equivocal)

Individual psychotherapy (CBT, Mentalisation-based therapy)

Home-based family therapy

Prescribing in DSH

Careful prescribing.

Limited evidence for antipsychotic medications, mood stabilisers and other psychotropic medications.

Medication has to be part of a holistic approach.

MCQs: Courtesy of Birmingham MRCPsych Course ®

The epidemiology of suicide reveals that in males in the UK, the commonest method of completing suicide is

a. CO poisoning

b. Burns

c. Hanging

d. Analgesic overdose

e. Opioid overdose

The epidemiology of suicide reveals that in males in the UK, the commonest method of completing suicide is

a. CO poisoning

b. Burns

c. Hanging

d. Analgesic overdose

e. Opioid overdose

The suicide rate in patients with epilepsy as compared to general population is

a. Four fold more

b. Same

c. 25 times more

d. Five fold less

e. Difficult to compare

The suicide rate in patients with epilepsy as compared to general population is

a. Four fold more

b. Same

c. 25 times more

d. Five fold less

e. Difficult to compare

The epidemiology of suicide reveals that in women in the UK, the commonest method of completing suicide is

a. Hanging

b. Drug overdose

c. Gun shot

d. CO poisoning

e. Burns

The epidemiology of suicide reveals that in women in the UK, the commonest method of completing suicide is

a. Hanging

b. Drug overdose

c. Gun shot

d. CO poisoning

e. Burns

Select the commonest psychiatric diagnosis in people who have committed suicide in the UK

a. substance misuse

b. personality disorder

c. schizophrenia

d. anxiety disorder

e. mood disorder

Select the commonest psychiatric diagnosis in people who have committed suicide in the UK

a. substance misuse

b. personality disorder

c. schizophrenia

d. anxiety disorder

e. mood disorder

The epidemiology of suicide reveals that in UK the commonest method of attempting suicide is

a. Analgesic overdose

b. Insulin overdose

c. antipsychotic overdose

d. Opioid overdose

e. Hypnotic overdose

The epidemiology of suicide reveals that in UK the commonest method of attempting suicide is

a. Analgesic overdose

b. Insulin overdose

c. antipsychotic overdose

d. Opioid overdose

e. Hypnotic overdose

The rate of self harm in teenagers who identify with Goth culture is around

a. 0.1

b. 0.25

c. 0.75

d. 0.5

e. 0.15

The rate of self harm in teenagers who identify with Goth culture is around

a. 0.1

b. 0.25

c. 0.75

d. 0.5

e. 0.15