Management Of Self-harm Research Articles

Impact of a collaborative model on community clinician confidence in child and adolescent mental health care, wellbeing, and access to child psychiatry expertise.

The COVID-19 pandemic was associated with an increase in child and adolescent mental health disorders, with subsequent worsening of patient access to specialist mental health care. Clinicians working in the community were faced with increased demands to diagnose and manage pediatric mental health disorders, without always having the confidence and knowledge to do so. We therefore developed COnnecting Mental-health PAediatric Specialists and community Services (COMPASS)-a collaborative model designed to upskill community clinicians in child and adolescent mental health care and provide them with better access to child and adolescent psychiatry expertise. COMPASS comprises (1) an online Community of Practice (CoP) with fortnightly one-hour sessions covering: anxiety; aggression and challenging behaviours; depression; self-harm and suicidality; eating disorders; and autism spectrum disorder/complex cases and (2) primary and secondary consultations for general practitioners and paediatricians with an experienced child psychiatrist. We aimed to assess the impact of COMPASS on community clinician self-reported confidence in: managing common child and adolescent mental health disorders (Objective 1, primary outcome); navigating the mental health care system (i.e. knowing how services are organised, accessed, and how to refer patients, Objective 2); diagnosing conditions (Objective 3); prescribing psychotropic medications (Objective 4) as well as the impact on, clinician practice and wellbeing (Objective 5) and outcomes of patients referred by COMPASS clinicians to the child psychiatrist (Objective 6). We evaluated COMPASS in its first year, with COMPASS running from March to July 2021. Participating clinicians completed pre-post surveys evaluating change in Objectives 1 to 4 above, using study-designed measures. A purposive sample of clinicians was then invited to a semi-structured interview to understand their experience of COMPASS and its impacts on practice and wellbeing (Objective 5). We adopted an inductive approach to the qualitative analysis using the Framework Method. This involved selecting five random transcripts which were double coded and categorized, to generate an initial framework against which all subsequent transcripts were analysed. Themes and subthemes were generated from the data set, by reviewing the matrix and making connections within and between clinicians, codes and categories One child psychiatrist completed a 2-week logbook of the nature and outcomes of primary and secondary consultations (Objective 6). 51 (86%) clinicians attended CoP sessions and completed pre-post surveys, with 92% recommending COMPASS to peers. Clinicians reported increased confidence in the pharmacological and non-pharmacological management of all conditions, most notably for management of self-harm. They also reported increased knowledge of how to navigate the mental health system and prescribe medications. Qualitative analysis (n = 27 interviews) found that COMPASS increased clinician wellbeing and reduced feelings of professional isolation and burnout. Over the 2-week snapshot, the child psychiatrist consulted on 22 patients and referred all back to the community clinician. COMPASS is associated with improved clinician confidence to manage child and adolescent mental health concerns, navigate the mental health system, improved clinician wellbeing, and reduced need for ongoing mental health care by specialists.

Exploring General Practitioners' Management of Self-Harm in Young People: A Qualitative Study.

General practitioners (GPs) are key to the frontline assessment and treatment of young people after self-harm. Young people value GP-led self-harm care, but little is known about how GPs manage young people after self-harm. This study aimed to understand the approaches of GPs to self-harm in young people and explore their perspectives on ways they might help young people avoid repeat self-harm. We conducted semi-structured interviews with GPs from the National Health Service in England in 2021. GPs were recruited from four geographically spread clinical research networks and a professional special interest group. Data were analysed using reflexive thematic analysis. The study's patient and public involvement and community of practice groups supported participant recruitment and data analysis. Fifteen interviews were undertaken with a mean age of participants being 41 years and a breadth of experience in practice ranging from 1 to 22 years. Four themes were generated: GPs' understanding of self-harm; approaches to managing self-harm; impact of COVID-19 on consultations about self-harm; and ways to avoid future self-harm. Negative attitudes towards self-harm within clinical settings are well documented, but GPs said they took self-harm seriously, listened to young people, sought specialist support when concerned and described appropriate ways to help young people avoid self-harm. GPs felt that relationship-based care is an important element of self-harm care but feared remote consultations for self-harm may impede on this. There is a need for brief GP-led interventions to reduce repeat self-harm in young people. A study advisory group consisting of young people aged 16-25 years with personal experience of self-harm and parents and carers of young people who have self-harmed designed the recruitment poster of this study, informed its topic guide and contributed to its findings.

Healthcare practitioners' views of self-harm management practices in older adults in Ireland: A qualitative study.

To explore healthcare practitioners' views on management practices of self-harm in older adults. Semi-structured interviews were conducted with healthcare practitioners, including consultant psychiatrists, general practitioners, clinical psychologists, psychotherapists, clinical nurse specialists and social workers. Purposeful sampling was used to recruit participants in the Republic of Ireland ensuring diverse perspectives of healthcare practitioners were included. Healthcare practitioners were recruited advertising via professional and clinical research networks, social media, and snowballing methods. Interviews were audio-recorded, transcribed verbatim, and analysed using reflexive thematic analysis. We conducted interviews with 20 healthcare practitioners from April to July 2023. Three main themes were generated: first, a perceived greater risk of suicide, and increased awareness of complexity in older adults' self-harm presentations. Second, integrated care as an avenue for improving the management of self-harm in older adults. Third, the importance of safety planning in risk assessments of older adults. Healthcare practitioners viewed self-harm in older adults as complex, challenging, and associated with high suicide risk, approaching patients with care and caution. The need for integrated support and improved collaboration between relevant healthcare practitioners was identified. Suggestions were made for primary care having a lead role in identifying and managing older adults after self-harm. Increased mental health promotion and awareness of mental health and self-harm in this age group would help address current stigma and shame.

Emergency department staff experiences of working with people who self-harm: A qualitative examination of barriers to optimal care.

For people who seek help for self-harm, emergency departments (ED) are often the first point of contact, making them a suitable setting for intervention. In Australia, base rates of self-harm presentations to ED are increasing, while the quality of care these people receive is often considered sub-optimal. This study used qualitative interviews to explore potential barriers ED staff face in delivering best possible self-harm care. Seventeen staff across two EDs in the state of Victoria, Australia, were interviewed regarding their perceptions of barriers to providing optimal self-harm care and suggestions for improvement. Three themes were identified: (1) system-related challenges when managing self-harm in ED, including the shortage of hospital resources, challenges of ED as a physical environment, and insufficient education, training and guidelines about self-harm care for staff; (2) human-related challenges regarding management of self-harm in ED, which encompassed the nature of a person's circumstances and presentation, and staff attitudes towards self-harm; and (3) staff suggestions for improving self-harm care in ED. Specific recommendations that were proposed based on these findings included introducing a separate ED area for mental health-related presentations, provision of specialised education and training about self-harm care to staff, better implementation of guidelines on treating self-harm in ED, and employing mental health educators to provide on-the-floor mentoring to nurses. The relevance of these barriers and recommendations to the wider healthcare sector is also discussed. Together, these findings may inform improvements to the quality of care provided to those who engage in self-harm.

Developing a clinical decision support system software prototype that assists in the management of patients with self-harm in the emergency department: protocol of the PERMANENS project.

Self-harm presents a significant public health challenge. Emergency departments (EDs) are crucial healthcare settings in managing self-harm, but clinician uncertainty in risk assessment may contribute to ineffective care. Clinical Decision Support Systems (CDSSs) show promise in enhancing care processes, but their effective implementation in self-harm management remains unexplored. PERMANENS comprises a combination of methodologies and study designs aimed at developing a CDSS prototype that assists clinicians in the personalized assessment and management of ED patients presenting with self-harm. Ensemble prediction models will be constructed by applying machine learning techniques on electronic registry data from four sites, i.e., Catalonia (Spain), Ireland, Norway, and Sweden. These models will predict key adverse outcomes including self-harm repetition, suicide, premature death, and lack of post-discharge care. Available registry data include routinely collected electronic health record data, mortality data, and administrative data, and will be harmonized using the OMOP Common Data Model, ensuring consistency in terminologies, vocabularies and coding schemes. A clinical knowledge base of effective suicide prevention interventions will be developed rooted in a systematic review of clinical practice guidelines, including quality assessment of guidelines using the AGREE II tool. The CDSS software prototype will include a backend that integrates the prediction models and the clinical knowledge base to enable accurate patient risk stratification and subsequent intervention allocation. The CDSS frontend will enable personalized risk assessment and will provide tailored treatment plans, following a tiered evidence-based approach. Implementation research will ensure the CDSS' practical functionality and feasibility, and will include periodic meetings with user-advisory groups, mixed-methods research to identify currently unmet needs in self-harm risk assessment, and small-scale usability testing of the CDSS prototype software. Through the development of the proposed CDSS software prototype, PERMANENS aims to standardize care, enhance clinician confidence, improve patient satisfaction, and increase treatment compliance. The routine integration of CDSS for self-harm risk assessment within healthcare systems holds significant potential in effectively reducing suicide mortality rates by facilitating personalized and timely delivery of effective interventions on a large scale for individuals at risk of suicide.

Mortality and suicidality in veterans health administration patients with newly-identified early episode psychosis

Within the Veterans Affairs (VA), management of self-harm is a major clinical priority. However, there is limited information on risks for self-harm among VA patients with emerging psychotic disorders relative to VA patients with other emerging mental health conditions. Using information from fiscal years 2010 through 2018, a national cohort of VA patients 30 or younger was classified based on mental health diagnoses into three groups: 1) early episode psychosis (EEP), 2) non-early episode psychosis mental health (non-EEP MH), or 3) no mental health (no MH). Analyses focused on cohort members' risk for all-cause mortality, suicide mortality, and non-fatal suicide attempts (NFSA) during the year following initial diagnosis of mental health conditions (or first year of VA care, for the no MH group). In unadjusted analyses, the EEP group had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the non-EEP MH and no MH groups and the non-EEP MH had elevated rates of all-cause mortality, suicide mortality, and NFSA relative to the no MH group. After adjusting for demographics and care receipt, EEP status was unrelated to all-cause mortality but associated with increased suicide mortality risk and NFSA. Non-EEP MH status was associated with reduced risk of all-cause mortality but increased risk for NFSA. In the year following first diagnosis, VA patients with EEP are at increased risk for suicide mortality and self-harm even after accounting for other risk factors. Clinical services targeting this crucial time can help promote safety for this vulnerable group.

Evaluation of a national clinical programme for the management of self-harm in hospital emergency departments: impact on patient outcomes and the provision of care

BackgroundEmergency departments are important points of intervention, to reduce the risk of further self-harm and suicide. A national programme to standardise the management of people presenting to the emergency department with self-harm and suicidal ideation (NCPSHI) was introduced in Ireland in 2014. The aim of this study was to evaluate the impact of the NCPSHI on patient outcomes and provision of care.MethodsData on self-harm presentations were obtained from the National Self-Harm Registry Ireland from 2012 to 2017. The impacts of the NCPSHI on study outcomes (3-month self-harm repetition, biopsychosocial assessment provision, admission, post-discharge referral, and self-discharge) were examined at an individual and aggregate (hospital) level, using a before and after study design and interrupted time series analyses, respectively. The 15 hospitals that implemented the programme by January 2015 (of a total of 24 between 2015 and 2017) were included in the analyses.ResultsThere were 31,970 self-harm presentations during the study period. In hospitals with no service for self-harm (n = 4), risk of patients not being assessed reduced from 31.8 to 24.7% following the introduction of the NCPSHI. Mental health referral in this hospital group increased from 42.2 to 59.0% and medical admission decreased from 27.5 to 24.3%. Signs of a reduction in self-harm repetition were observed for this hospital group, from 35.1 to 30.4% among individuals with a history of self-harm, but statistical evidence was weak. In hospitals with a pre-existing liaison psychiatry service (n = 7), risk of self-discharge was lower post-NCPSHI (17.8% vs. 14.8%). In hospitals with liaison nurse(s) pre-NCPSHI (n = 4), medical admission reduced (27.5% vs. 24.3%) and there was an increase in self-harm repetition (from 5.2 to 7.8%. for those without a self-harm history).ConclusionThe NCPSHI was associated with improvements in the provision of care across hospital groups, particularly those with no prior service for self-harm, highlighting the need to consider pre-existing context in implementation planning. Our evaluation emphasises the need for proper resourcing to support the implementation of clinical guidelines on the provision of care for people presenting to hospital with self-harm.

Exploring gender differences in risk factors for self-harm in adolescents using data from the Millennium Cohort Study

BackgroundSelf-harm is common in young people and girls have consistently higher rates of self-harm than boys. Differences in exposure and reactions to risk and protective factors, adverse events and problematic interpersonal relationships, and levels of wellbeing could contribute to the gender difference. This study aims to explore gender differences in risk factors associated with self-harm, to provide the foundation for developing more gender-sensitive approaches to self-harm management. MethodsData were analysed from 11,196 young people recruited to the Millennium Cohort Study, surveyed around age 14. We examined gender differences in the prevalence of key psychological and social risk factors for self-harm, including family and peer relationships, emotional wellbeing, and bullying and victimisation. We utilised modified Poisson regression to estimate gender-specific risks. ResultsAt age 14 self-harm prevalence was 15.4 % with a ratio of 2.6 females to 1 male. Differential exposure to recorded psychosocial risk factors explained a third of the gender difference in risk of self-harm. Intense social media use and not confiding in family members were associated with a greater likelihood of self-harm in girls than boys. Bullying others and same-sex attraction were more strongly associated with self-harm in boys than girls. LimitationsSelf-harm data were obtained by self-report therefore subject to misclassification. The cross-sectional design does not enable us to establish causation. ConclusionsUnhappiness and dissatisfaction are common in adolescence. Our findings suggest the need for further research into young people's experiences to explore why rates differ and inform the development of gender-specific approaches to self-harm management.

Caring for Male Prisoners Who Self-Harm: Perceptions, Attitudes and Experiences of Custodial Prison Staff and Male Prisoners in England

The aims of this research were to explore custodial prison staff and male prisoners’ perceptions toward self-harm, prison system responses and environmental impacts on self-harm. Four staff focus groups (thematic analysis) and 12 semi-structured interviews with male prisoners (interpretative phenomenological analysis) took place in three prisons in England. Prison staff attributed manipulative intention to self-harm; self-harming prisoners felt misunderstood. The prison environment and formal response processes were barriers for care access and provision. Recommendations include staff training in understanding and management of self-harm, supported by a care-focused culture, and fostering safety, security, empowerment and value for both prisoners and staff.

Preliminary evaluation of a multidisciplinary pathway for people who self-harm in acute inpatient mental health care

Background/aims Inpatient mental health settings are required to provide biopsychosocial interventions to support service users who self-harm. This is important as self-harm has been associated with increased admissions and risk of suicide. A multidisciplinary self-harm pathway was developed in an acute inpatient mental health ward for adult women to help staff support patients who self-harm. The aim of this project was to evaluate the pathway in relation to service user distress, confidence in managing mental health, therapeutic alliances with the ward team and self-harm incidents on the ward. Methods Data were collected from the record-keeping systems and from questionnaires completed before and after the pathway was introduced. Results The pathway was well received by service users and contributed to improvements in distress, confidence and to more effective management of self-harm. Conclusions The self-harm pathway was found to be a useful framework within which to structure psychosocial interventions for self-harm and least restrictive practice.

Staff perceptions of barriers to self-harm care in the emergency department: A cross-sectional survey study

BackgroundEmergency departments (EDs) are often the first point of contact for people with self-harm; however, they do not always receive optimal care. The study objective was to examine the perspectives of ED staff who respond to self-harm presentations, perceived barriers to providing optimal, guideline-concordant care, and staff’s familiarity with existing guidelines. MethodsAn online cross-sectional survey comprising purpose-designed questions concerning self-harm in the ED was completed by 131 staff (83.2% nurses) from two hospitals in Victoria, Australia. Survey results were analysed using Stata version 16 and frequencies and percentages were calculated. ResultsRespondents reported knowledge of how to appropriately manage a person presenting with self-harm. However, lack of space (62.3%) and time (78.7%) to conduct the appropriate assessments, lack of self-harm training (71.8%), and limited awareness of or access to guidelines and recommendations for self-harm management within the ED (63.6%), were identified as primary barriers to their ability to appropriately manage these presenters. ConclusionsImprovements to the ED environment and processes, as well as the provision of regular self-harm specific education and training for all ED staff are needed. Implementation of best-practice standards should prioritise guideline-concordant care, with a particular focus on the education needs of nursing staff.

AKT answer relating to self-harm management in young persons

AKT answer relating to self-harm management in young persons

AKT question relating to self-harm management in young persons

AKT question relating to self-harm management in young persons

A comparison of daytime and out of hour mental health presentations to Beaumont Hospital Emergency Department between 2018 and 2020.

In 2018, there were more than 12,000 self-harm presentations to emergency departments (EDs) in Ireland with 50% occurring between 7p.m. and 3a.m. There is evidence that the assessment quality and follow-up is variable across clinicians. To address this, The National Clinical Programme for the Management of Self-Harm in the ED (NCPSH 2016) was developed to set clear standards. Our aim was to compare diagnosis and management of patients presenting to Beaumont Hospital (BH) ED, across a 3-year period, by the on-site Liaison Psychiatry Service, during normal working hours, to the off-site on call service outside of normal working hours (OOH). This is a retrospective audit of BH ED patients referred for psychiatric assessment between 2018 and 2020, using patient electronic records for data collection, and Pearson's chi square testing for group differences. Post hoc analysis was performed using adjusted residuals and Bonferroni correction. Of 3659 psychiatric referrals to Beaumont ED from 2018 to 2020, alcohol-related disorders were the most common diagnosis and were diagnosed more frequently during normal working hours (n = 592, 16.2%; 22.9% normal hours vs 8.5% OOH, p < 0.001), while personality disorder was diagnosed more frequently out of hours. (n = 432, 11.8%; 9.6% normal hours vs 14.4% out of hours, p < 0.001). There was a statistically significant difference in referral to voluntary services out of hours (7.2% normal hours vs 0.3% OOH). In contrast to previous findings, our study found higher rates of alcohol-related disorders diagnosed during normal hours vs OOH. Furthermore, voluntary and addiction services were under-utilised OOH and this presents an important teaching opportunity.

Management of self-harm, suicidal ideation and suicide attempts.

The strategic location of primary care providers (PCPs) in clinics, private general practices and emergency departments is critical to the detection and appropriate management of patients with suicidal behaviour. Their position within the primary care setting and responsibility for preventive and promotive care require PCPs to possess good clinical skills and evidence-based knowledge to assist patients presenting with suicidal ideation and behaviour. The objective of this article is to provide guidelines for the management of suicidal behaviour within the primary care setting, with the goal of reducing deaths from suicide, and the frequency and intensity of suicide attempts. The priority in the management of patients presenting at health facilities following suicide attempts is medical resuscitation and stabilisation. As soon as the patient is medically stable, a thorough suicide risk assessment, which evaluates suicidal ideation/intent, preceding circumstances, predisposing and protective factors, should be conducted. An assessment of current and ongoing suicide risk will assist in determining the safest place to manage the patient. For those with a low level of suicide risk, outpatient management may be considered in the presence of a good social support system at home and a well-documented safety plan. Measures should be put in place to address the modifiable psychosocial risk factors for suicide, whilst appropriate pharmacotherapy is instituted for co-existing mental illness. Post-discharge care such as referral to psychologist, psychiatrist or social worker should be initiated by the primary care practitioner to ensure continuity of care. Support and psycho-education should also be extended to immediate family members of patients with suicidal behaviour for their own well-being and their ability to support the patient.

Making self-harm everyone's business: a consideration of the new national guideline

This article discusses the National Institute for Health and Care Excellence's consultation and draft guideline on self-harm management, placing the recommendations in the context of ongoing pressures on NHS services and the UK's growing mental health crisis

Making self-harm everyone's business: a consideration of the new national guideline

This article discusses the National Institute for Health and Care Excellence's consultation and draft guideline on self-harm management, placing the recommendations in the context of ongoing pressures on NHS services and the UK's growing mental health crisis.

Prevalence, Response and Management of Self-harm in School Children Under 13 Years of Age: A Qualitative Study

Research suggests that the incidents of self-harm among young people are increasing and age of onset of self-harm is decreasing. There is limited understanding of how widespread the problem of self-harm among younger school students is, and how schools respond to these incidents. This study used an in-depth qualitative approach to understand self-harm in children under 13, and how elementary schools respond including typical actions, support for the child and parental involvement. School psychologists in New South Wales, Australia (n = 17; 78% females), completed in-depth interviews detailing types of self-harm, prevalence and frequency, and how these incidents were managed, including student intervention approaches and participation of parents. Thematic analysis of interviews was conducted. Psychologists estimated the prevalence of self-harm in their schools was 6.5% and was increasing, with an average age of onset of 10.8 years. Self-harm was most often understood as a coping mechanism associated with anxiety, stress and being bullied. Six themes emerged from the interviews. School psychologists reported that self-harm occurs less frequently in primary school children than high school children, but noted these behaviours still require early intervention. Participants felt they were limited in the support they can provide students who self-harm, and wanted more training for all school staff and parents in identifying and responding to student self-harm. School psychologists are important in identification and management of self-harm, and they report they need further support in helping children who are engaging in self-harm behaviours. Upskilling teachers and parents may assist in reducing rates of self-harm among children.

The potential of general practice to support young people who self-harm: a narrative review.

BackgroundSelf-harm in young people is a growing public health concern. Young people commonly present to their GP for help with self-harm, and thus general practice may be a key setting to support young people who have self-harmed.AimTo examine the potential of general practice to support young people aged 10–25 years who have harmed themselves.Design & settingA narrative review of published and grey literature.MethodThe Scale for the Assessment of Narrative Review Articles (SANRA) was used to guide a narrative review to examine the potential of general practice to support young people who have self-harmed. The evidence is presented textually.ResultsThe included evidence showed that GPs have a key role in supporting young people, and they sometimes relied on gut feeling when handling uncertainty on how to help young people who had self-harmed. Young people described the importance of initial clinician responses after disclosing self-harm, and if they were perceived to be negative, the self-harm could become worse.ConclusionIn context of the evidence included, this review found that general practice is a key setting for the identification and management of self-harm in young people; but improvements are needed to enhance general practice care for young people to fulfil its potential.

Primary care clinical management following self-harm during the first wave of COVID-19 in the UK: population-based cohort study

ObjectivesA substantial reduction in self-harm recorded in primary care occurred during the first wave of COVID-19 but effects on primary care management of self-harm are unknown. Our objectives were to...