Digging deeper to stem self-harm, suicide rates
A&Es are not pleasant and are frequently overcrowded. There is little privacy in which to discuss a self-harm episode
Last week, significant media coverage was given to a report that large numbers of patients presenting to Emergency Departments (EDs) after self-harm episodes were leaving before they were assessed psychiatrically. One headline ran 'Hundreds of suicide-risk patients quit A&E unseen'. This was based on a report from a colleague Dr Anne Jeffers based in Galway. She is charged with developing and implementing a consistent national policy directed towards ensuring that everybody who presents to EDs across the country after such an episode is fully evaluated regarding their suicidality, their social circumstances and whether they have a psychiatric illness. Her report found that the proportion of those leaving varied from 5.2pc to 27pc.
There is a lot of information available regarding self-harm in Ireland due to the publication annually of the National Self-Harm Registry. We know that over 11,000 presentations in our EDs nationally are due to self-harm and additionally many more have suicidal thoughts that are not included in these numbers. This has been the figure for over a decade now and it shows the magnitude of the burden. The most common methods used are overdosing, cutting/scratching, attempted hanging and less commonly, attempted drowning, carbon monoxide poisoning, among others. Worryingly, the report for 2016 shows that there has been an increase in the more lethal methods used, for men and women alike, ultimately increasing the risk of death.
In the public mind, self-harm is often equated with a failed attempt at suicide. In some instances the desire may be death, but most attempts at self-harm are not driven by such motivation. Rather they are impulsive. The national registry points out there are effectively two groups involved in self-harm - a small number using lethal methods rendering them at high risk of suicide - while the second, and largest group, are those who use less lethal methods but are at risk of repeating such methods. The motivations in these groups is variable and includes anger, often directed to a person who has let them down or abandoned them in some way, others simply feel overwhelmed by a myriad of seemingly unsolvable problems, others believe the feeling of pain, especially with cutting, will relieve the numbness they feel.
This is often the description given by those who have been victims of sexual abuse. Some are trying to change an outcome that is unwelcome such as avoiding a court appearance, while others simply overdose as a consequence of short-term mood changes secondary to substances.
What these groups have in common are their poor problem-solving skills, many are socially isolated and unsupported and women are over-represented. Up to one third repeatedly engage in such acts.
Finally, a smaller proportion have a mental illness and wish to terminate their extreme emotional pain - this is the group most at risk of death
It is clear from our knowledge of the diverse motivations behind most of these acts that assuming they are "suicide attempts" is manifestly inaccurate.
The objectives of the national strategy are two-fold: firstly to identify those who are suicidal and/or have mental illness and offer appropriate treatments promptly. The second is to reduce the risk of repeating such acts by directing them to evidence-based interventions. The service is delivered to ensure that the evaluation takes place in every ED by highly trained psychiatric nurses between 8am and 8pm. Out of these hours junior doctors carry out all these assessments. So promptness of response to a suicidal crisis for those of high lethality, and directing those using low lethality methods to evidence-based treatments in community settings, could potentially have a significant impact on suicide and suicidal behaviour in this country.
Therein lies a major problem with those who leave the EDs unassessed. Do they belong to the high lethality group who are at serious risk of death? Or the low-risk category that engages in repeated self-harming? There is little to assist the clinician regarding this group since there is no mechanism for gathering data about their suicide intent. The most that can be achieved at present is to ensure a prompt assessment is carried out.
EDs are not pleasant and are frequently overcrowded, frenetic and there is little privacy in which to discuss personal matters that may have prompted a self-harm episode. Many do not have dedicated rooms for such assessments and they are carried out in curtained cubicles more suited to examining abdomens. The availability of such basic assessment facilities is recommended in the report, a facility that would almost certainly reduce the numbers leaving without assessment.
Only time will tell if this new national policy impacts on our suicide rate and our rate of repeated self-harm. It is one of the most sensible healthy strategies that we have seen in psychiatry for some time in this country, but efforts must now be put in place to reduce the attrition rate of up to 27pc and it must be underpinned by well-designed outcome research.
Health & Living