How GPs can intervene to prevent repetition of self-harm and suicide

Professor Carolyn Chew-Graham, Professor of General Practice Research, Keele University; Honorary Professor of Primary Care Research, University of Manchester; RCGP Curriculum Advisor, Mental Health

Around 220,000 people annually in England attend hospital immediately after harming themselves. However, little is known about their subsequent healthcare trajectories. Our study has filled this gap.

The original National Institute for Health and Clinical Excellence (NICE) guideline on the management and secondary prevention of self-harm (CG16, 2004) stated unequivocally that: "Primary care has an important role in the assessment and treatment of people who self-harm" (Section 1.2). The latest NICE self-harm guidelines, on longer term management (CG133, 2011), again had a specific section on primary care, but contains just 3 guidelines, amounting to just 5% of all 57 guidelines disseminated in CG133.

The data source for the study, the Clinical Practice Research Datalink, is a continually updated electronic repository of patient records inputted by GPs and other primary healthcare workers during routine consultations. These records are routinely downloaded into the database. The study thus provides evidence at a nationally representative level.

Following NICE guidelines (CG16, CG133), we defined self-harm (SH) as "any act of self-poisoning or self-injury, irrespective of the apparent purpose".

Results of our analysis showed that:

Rates of SH:

  • Northern Ireland had the highest rates of SH, followed by Scotland, Wales, and then England)
  • Risk of SH is higher in poorer localities
  • There are higher rates SH for females aged 15-24 years

Impact of deprivation:

  • Patients at practices in more deprived areas are less likely to be referred to mental health (MH) services

Repetition:

  • Repetition of SH occurred for 1 in 5 of the cohort within the year

Primary care management:

  • 10% patients had one or more psychotropic medication prescribed with no psychiatric diagnosis or MH referral
  • 9.6% received tricyclic antidepressant within a year of SH
  • 10% patients had one or more psychotropic medication prescribed with no psychiatric diagnosis or MH referral

Risks of SH:

  • Premature all-cause mortality is elevated following SH
  • Risk of death is particularly raised during first year of follow-up
  • Raised risks of dying from suicide through self-poisoning/other methods; accident (including by poisoning); alcohol or drug-related; or respiratory disease and lung cancer
  • Alcohol misuse or dependence was the strongest predictor of mortality
  • Premature all-cause mortality is elevated following SH

Main take home messages

  • People who attend primary care following self-harm have an increased mortality rate from all causes of death which is most pronounced within the first year – GPs can intervene and make a difference.
  • Clinically significant alcohol misuse or dependence is the strongest predictor of all-cause mortality – always assess risk of SH in patients with alcohol problems.
  • People who attend primary care following SH repeat this action, and 1 in 5 do so within the following year.
  • Take people who present with self-harm seriously - it could be an opportunity to intervene and potentially save their life.
  • Find out how to contact your ‘crisis’ team when risk is high, and what third sector services are available to work with people who self-harm.

The following resources may be useful to help you support people who self-harm:

Connecting with people

RCPysch health advice on self harm

Samaritans: Telephone and email support for anyone who is worried, upset, or suicidal; 08457 90 90 90; ROI 116 123; email: jo@samaritans.org.

PAPYRUS HOPELine UK: A professionally staffed helpline providing support, practical advice and information to young people worried about themselves, and to anyone concerned that a young person may harm themselves. Tel: 0800 068 41 41.

Get Connected: Offers help by telephone and email for people under 25 who self-harm. Tel: 0808 808 4994.

Selfharm.co.uk: a project dedicated to supporting young people who are affected by self-harm. Email: info@selfharm.co.uk.

Self-harm in primary care patients: a nationally representative cohort study examining patterns of attendance, treatment and referral, and risk of self-harm repetition, suicide and other causes of premature death- 023/0166

  • The study was conducted by researchers at University of Manchester and Keele University, with involvement of an active patient and public involvement and engagement group.

  • This report is independent research commissioned and funded by the Department of Health Policy Research Programme.

  • The views expressed in this publication are those of the author(s) and not necessarily those of the Department of Health.

A blog reporting on the Keele PPIE input can be found here.

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