Deliberate self-harm/suicide

Essentials

1
Deliberate self-harm is a frequent presentation to emergency departments and is a symptom of diverse underlying problems, be they biological, social or psychological.
2
Patients with deliberate self-harm form a heterogeneous group, most of whom do not have ongoing suicidal behaviour.
3
Assessment of suicide risk following deliberate self-harm is to inform treatment and to identify risks amenable to intervention and protective factors. It involves assessment of background demographic, psychiatric, medical and psychosocial factors as well as the presenting crisis. The patient should feel listened to and understood following the assessment.
4
There is no ‘gold standard’ for suicide risk assessment and the level of risk can change quickly.
5
The most consistent factors predicting fatal and non-fatal repetition following deliberate self-harm are psychiatric illness, personality disorder, substance abuse, multiple previous and types of attempts, hopelessness, social disconnectedness and intoxication.
6
A planned strategy to deal with these patients should address triage, restraint and observation, medical and suicide risk assessment, treatment, disposition and follow-up.
7
Management requires coordinated care with emergency, mental health and primary care clinicians, as well as carers.
8
Treatment decisions should be collaborative wherever possible and take into account any advance statement that may have been made. The next of kin should be contacted wherever practicable for both collateral information and collaboration.
9
The legal framework for the location in which individuals practice should be known and considered.

Introduction

Suicide is a deliberate act of intentional self-inflicted death. It is the most extreme manifestation of deliberate self-harm (DSH), where the spectrum spreads from superficial lacerations through to actions intended to end life. Although suicide is uncommon, 10% of people who complete suicide are seen in an emergency department (ED) in the month prior to death, with a substantial proportion not having psychosocial assessment, thus providing an opportunity for intervention. Regardless of the presentation to ED, about 8% of patients have experienced recent suicidal ideation or behaviour, which they may not disclose unless specifically explored. However, the major ED impact is in the identification and assessment of large numbers of patients potentially at risk of suicide, with initial management of co-morbidities and modifiable risk factors.

DSH is a maladaptive response to internal distress and may not have suicidal intent; however, it may indicate a risk for suicide. DSH is a common ED presentation (approximately 0.4% of all ED visits) and the goals of management include treating the physical health sequelae, assessing the risk of non-fatal or fatal repetition and prevention, and diagnosing and commencing treatment of potentially reversible psychosocial causes.

Epidemiology

In Australia there were 3128 deaths from intentional self-harm in 2017, with age standardised rates of approximately 19.1 per 100,000 in males and 6.2 in females ( fig. 20.3.1 ). Intentional self-harm accounted for 1.9% of all deaths in 2017. However, with a median age at death of 44.5 years, intentional self-harm (11.4%) was responsible for the most Years of Potential Life Lost (YPLL) of all diseases and trauma. As a comparison Ischemic Heart Disease which contributed 7.4% of YPLL in 2017 has a median age at death of 85 yrs.

Fig. 20.3.1, Suicide rates Australia (2008–2017).

Across OECD (Organisation for Economic Cooperation and Development) countries, suicide rates were lowest in South Africa, Greece, Mexico, Israel and Brazil, at less than 7 deaths per 100,000. They were highest in Lithuania, Hungary, Japan and Latvia, at more than 17 deaths per 100,000. The World Health Organization estimates that the low- and middle-income countries account for 78% of global suicides.

Hospital presentations for DSH are at least 10 times higher than suicide rates. The 2007 Australian National Survey of Mental Health reported 1.9% of males and 2.7% of females experienced suicidal ideation within 12 months. This rate may be as high as 25% in certain populations and age groups.

Risk of suicide

An episode of DSH is one historical risk factor predictive of future suicide behaviours. Approximately 1% to 2% of patients complete suicide during the year following an attempt, and in approximately 40% of suicides there is a history of a previous self-harm. A systematic review of fatal and non-fatal repetition of self-harm reported a suicide rate of 2% at 1 year and 7% after 9 years. Hospitalization and aftercare decrease the short-term risk of suicide, but have little impact on the long-term risk of suicide. However, this may be due to undertreatment of psychiatric illness.

Repeated episodes of deliberate self-harm

DSH usually invokes help from friends, family and the medical profession so the patient’s social situation and psychological well-being tends to improve. This effect is prominent in younger patients, but may not occur in patients aged over 60 years. The risk of repetition is 12% to 16% in the following year, with 10% of these occurring in the first week. This is more likely in females who are unemployed, have cluster B (e.g. borderline, narcissistic and histrionic) personality traits or have substance-abuse problems. A younger age at first attempt, the presence of long-standing affective disorders, drug/alcohol misuse disorders and anxiety all correlate with repeated attempts. Some patients have chronic suicidal ideation and multiple repetitions of DSH. They often suffer from personality disorders, psychotic disorders, chronic medical conditions, alcohol or drug use, a history of childhood sexual abuse and violent behaviour. They use DSH as a means of fighting off anxiety, hopelessness, loneliness or boredom, as well as subjective experiences of emptiness or extreme distress. They may also be maladaptive ways of eliciting assistance from family, friends or health carers. These patients are at increased risk of eventual suicide. Reversible potentiating factors should be addressed where possible.

Patients with DSH who leave the ED prior to a psychosocial assessment may have a higher risk for repeat DSH, probably associated with lack of specialist follow-up and treatment of reversible factors.

Patient characteristics

Demographic factors

Age

Suicide and DSH are rare in children under 12 years of age. Australian data suggest a peak at 30 to 34 years in males (27.5 per 100,000) and 50 to 54 years in females (10.4 per 100,000). There is another peak in the elderly, with suicide rates increasing with age from 65 years.

The incidence of DSH increases throughout puberty, reaching a peak at 15 to 24 years of age and decreasing thereafter. The ratio of rates of DSH to suicide decreases markedly with age. DSH is uncommon in the elderly, who have a high ratio of successful to unsuccessful attempts.

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