Reducing self-harm: a key role for GPs

Self-harm is the intentional, direct injuring of body tissue, done without suicidal intentions. General practitioners and practice nurses are to the fore in assisting with people who self-harm, frequently over  a period of years. It is a very common behaviour. From January 1, 2015 to December 31, 2015 the National Self-Harm Registry Ireland recorded 11,189 self-harm presentations to hospital that were made by 8,791 individuals. One in five young people in Ireland have self-harmed by the time they reach the age of 18.

The most common form of self-harm outside of a hospital setting is self-cutting. The most common form of self-harm seen in hospitals is drug overdose and the most common drugs used are paracetamol and minor tranquillisers. Most of these injuries occur without another adult being aware and self-harm is usually a repeated behaviour. Patients who present with self-cutting are more likely to repeat the behaviour. Alcohol has been shown to be involved in almost half of all self-harm presentations. 

Risk factors for non-fatal self-harm include female gender, younger age, poor social supports, poverty, major life events, mental illness and previous episodes of self-harm. Self-harm is a behaviour but it is not simply a ‘cry for help’; 50% of those who die by suicide have previously self-harmed. The majority of self-harm presentations occur outside of normal working hours. This highlights the need for service provision to be designed to ensure health services are available to provide a timely response when needed. There is evidence that having a psychosocial assessment following self-harm is associated with lower rates of non-fatal repetition. Open discussion and identifying risk factors can help to guide management. Effective treatment of mental illness and addiction can help to reduce the chance of further episodes of self-harm. Patients who have evidence-based problem-solving therapies such as cognitive behavioural therapy or interpersonal therapy also have reduced rates of repetitive self-harm. 

There are two recent studies in Ireland, funded by the HRB,  to identify risk and protective factors associated with suicide and high-risk self-harm. SSIS-ACE is a retrospective case control study which originated from the Suicide Support and Information System (SSIS) and it aims to improve the knowledge base on specific psychosocial, psychiatric and work-related risk factors associated with suicidal behaviour in Ireland and to gain insight into protective factors that may prevent suicide and high-risk self-harm.

Improving Prediction and Risk Assessment of Suicide and Self-Harm (IMPRESS) is a research programme that commenced in 2015. As well as identifying psychosocial, psychiatric and work-related stressors it will also examine the sensitivity and specificity of risk factors associated with repeated self-harm and aims to develop a risk assessment procedure for repeated self-harm and suicide in a hospital setting. Recruitment is ongoing until September 2018.

Some of its key findings include:

• Psychiatric, psychosocial and work-related factors were significantly more prevalent among suicide cases
• The presence of negative coping skills was more significantly associated with suicide than the absence of positive coping skills
• The findings show more similarities than differences between people with high-risk self-harm and those who died by suicide.

The outcomes underline the need to improve assessment and management of self-harm in order to prevent repeated self-harm/method escalation and suicide. The ICGP through its engagement with the National Office for Suicide Prevention (NOSP) and the Connecting for Life Steering Group (Ireland’s National Strategy to Reduce Suicide 2015-2020) is working towards reducing self-harm and suicide. Increasing access to psychologists in primary care, having trained mental health professionals on primary care teams as well as on-site sessional counselling and crisis intervention training are part of a potential suite of measures that could reduce morbidity and mortality in this patient population. 

It is the view of the ICGP that were more resources invested directly into general practice, GPs would be better placed to engage in earlier intervention, and provide greater volumes of holistic care. In addition, given the gradual increase in size of general practice teams, there is a case to be made for basing sessional psychotherapists (psychologists/counsellors) in general practices, closest to where people live and more convenient in terms of access.

Further information on the above studies is available on the National Suicide Research Foundation’s website www.nsrf.ie