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Management of self-harm in adults: which way now?

  • Navneet Kapur (a1)
Summary

Self-harm remains an important public health problem and two sets of clinical guidelines have been published recently. While these include elements of accepted good practice they are not evidence-based. Further research might concentrate on either very large trials of low-intensity interventions or smaller trials of longer-term psychological treatments. The current management of self-harm may be improved by shifting professionals' views, involving users in staff training, and changing service provision – perhaps moving from risk assessment to needs assessment.

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References
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The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
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Management of self-harm in adults: which way now?

  • Navneet Kapur (a1)
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eLetters

Assessment of self harm in the A&E department

James Fox, Foundation Year 2- Psychiatry of the Elderly
30 January 2008

I read this editorial with great interest while auditing the Royal College’s guidelines on the assessment of self-harm in the A&E department of Princess Alexandra Hospital in Harlow. Self harm is the single biggest risk factor for completed suicide, it is becoming more prevalent and around 150,000 people present to A&E each year (Royal College of Psychiatrists, 2004). As the author remarks, ‘The main recommendations are uncontroversial and will be regarded by many as simple components of good practice’. With this in mind the importance of raising awareness and implementing the nationally recommended guidelines cannot be overstated.

Many of the authors concerns were supported by my audit results, a few examples of which are given below. There are multiple areas where the service can fail and it is thus difficult to pick out the main issues thatneed to be addressed. On reflection my overriding impression is that lack of training and negative attitudes are fundamental principles which obstruct progress in this field. A recent study regarding this issue states ‘in those staff without previous training, a longer period working in A&E was correlated with higher levels of anger towards patients and inclination not to view patients as mentally ill’ (Friedman et al, 2006). The relationship between nurse and client is of great professional and ethical importance in any situation but it is of particular importance in cases where many of the patients are mentally unwell or emotionally disturbed. Several studies have shown educational programs to be effective in changing attitudes (Patterson et al, 2007). Unfortunately while such evidence is useful, proving a direct link with a reduction in suicide is more difficult and implementing guidelines without strong evidence is a well recognised problem.

Another issue brought to my attention is those patients who do not have there capacity assessed but leave the department without a psychosocial review. Studies have shown these patients are more likely to be male, unemployed, self-cutting, taking illegal drugs/alcohol and attending out of office hours (Bennewith et al, 2005). Patients who do notreceive a psychosocial assessment are more likely to self-harm again and similarly are more likely to need psychiatric treatment in the future whencompared to assessed patients (Hickey et al, 2001). The results of my audit uphold this concern, 99 out of 100 patients had no documentation as to whether they were likely to wait for further assessment. Furthermore 35out of 100 patients left without psychosocial assessment and of these, only 2 had their capacity documented. Once again I speculate the origins of the problem lie in poor levels of training and I believe a long term commitment to educational programs is needed if significant change is going to be seen. Achieving this goal without strong evidence is proving difficult and thus it can be concluded that more long term, multi-centeredtrials are needed if further training is to become a requirement of A&E departments rather than an option.

Royal College of Psychiatrists (2004) Assessment Following Self-Harm in Adults. London: Royal College of Psychiatrists.

Friedman, T. Mitchell, AJ. et al. (2006) Predictors of A&E staff attitudes to self-harm patients who use self-laceration: influence of previous training and experience. J Psychosom Res, 60(3):273-7.

Patterson, P. Whittington, R. & Bogg, J. (2007) Testing the effectiveness of an educational intervention aimed at changing attitudes to self-harm. J Psychiatr Ment Health Nursing 14, 100-105.

Bennewith, O. Gunnel, D. et al. (2005) Factors associated with the non-assessment of self-harm patients attending and Accident and Emergency Department: results of a national study. J Affect Disord, 89(1-3):91-7.

Hickey, L. Hawton, K. et al. (2001) Deliberate self-harm patients wholeave the accident and emergency department without a psychiatric assessment: a neglected population at risk of suicide. J Psychosom Res, 50(2):87-93.
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