Self-Harm and Attempted Suicide

Clinical Description

• An act of self-harm without suicidal intent is deliberately harming oneself, e.g., cutting oneself. A suicide attempt is an act of self- harm with suicidal intent but not resulting in death
• Both are to be taken very seriously because they are high risk factors for completed suicide in the future
• Risk of future attempt is raised if:
• Underlying psychiatric disorder (depression, bipolar affective disorder, schizophrenia/ drug or alcohol misuse or personality disorder)
• Ongoing suicidal thoughts or plans
• Regret at having survived the attempt
• Access to dangerous means e.g., firearms/ agro-chemicals/ medicines
• Evidence of hopelessness, marked emotional distress
• Previous self-harm/ suicide attempts
• Family history of completed suicide
• Male gender, older age, lack of social support

Signs and Symptoms

• Evidence of injuries from or history of actual suicide attempt method e.g., hanging, poisoning, drowning, etc.

Treatment

• Asking about suicidal thoughts in a routine assessment
• First establish therapeutic rapport
• Ask how they feel about their life at the moment, how they see the future and if they think life is not worth living?
• Do they have thoughts about trying to harm them-self or end their life? If yes, have they made any plans. Do they have access to lethal means at home?
• What has prevented them from acting on these thoughts? What protective factors are in their life? (family/ religious faith/ hope that things will get better)
• Have they made an attempt to harm them-self end their life in the past? If yes, what happened?
• If assessing someone presenting with a serious attempt at self-harm, first treat the physical effects of the attempt whilst ensuring that they are in a safe environment e.g.

suture any wounds and manage bleeding, monitor appropriately if ingested poisons such as rat poison/fertiliser/ overdose of prescribed or over-the-counter medication

• All people with a self-harm/ suicide attempt should be referred for assessment by the social worker or mental health team before leaving the health facility
• If there is current active suicidal ideation with a plan and access to dangerous methods, the person should be referred for assessment for admission by the psychiatry team urgently. If patient is unwilling or uncooperative, involuntary admission and subsequent referral for psychiatric assessment may be done under the Mental Health Act (Temporary Treatment Order).
• If suicidal thoughts are present but there is no plan and protective factors are in place, treat any underlying psychiatric disorder, give supportive counselling, with patient’s consent alert guardians or relatives, eliminate potentially lethal means in home environment and provide pathway to care e.g., contacts for subsequent suicidal ideation. Monitor the suicidal thoughts at follow up visits. If the suicidal ideation does not improve, refer for assessment by the psychiatry team