Longer term management of self harm: summary of NICE guidance
BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7073 (Published 23 November 2011) Cite this as: BMJ 2011;343:d7073
- Tim Kendall, director 1, visiting professor2, consultant psychiatrist and medical director3,
- Clare Taylor, editor1,
- Henna Bhatti, research assistant1,
- Melissa Chan, systematic reviewer1,
- Navneet Kapur, professor of psychiatry and population health4, honorary consultant psychiatrist5
- On behalf of the Guideline Development Group
- 1National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London E1 8AA, UK
- 2University College London (Clinical, Educational and Health Psychology), London WC1E 7HB
- 3Sheffield Health and Social Care NHS Foundation Trust, Sheffield S10 3TH, UK
- 4Centre for Suicide Prevention, Centre for Mental Health and Risk, University of Manchester, Manchester M13 9PL, UK
- 5Manchester Mental Health and Social Care Trust, Manchester M21 9UN, UK
- Correspondence to: Professor T Kendall, National Collaborating Centre for Mental Health tim2.kendall{at}virgin.net
Self harm is common but its prevalence may be underestimated because many studies rely on self report. In a study of 17 countries an average of 2.7% of adults reported self harm.1 A survey in the United Kingdom of 15-16 year olds estimated that more than 10% of girls and 3% of boys had self harmed in the previous year.2 Self harm and psychiatric disorder are strongly associated.3 4 Importantly, once a person has self harmed, the likelihood that he or she will die by suicide increases 50 to 100 times,5 6 with 1 in 15 dying by suicide within nine years of the index episode.7 The UK suicide rate is 17.5 for males and 5.2 for females per 100 000 population,8 which is nearly 10 times the homicide rate. Understanding and helping people who self harm is therefore likely to be an important part of an effective suicide prevention strategy.
This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the longer term management of self harm.9 This guideline is intended to complement the earlier NICE guideline on the short term management of self harm (treatment within the first 48 hours after an episode of self harm).10
Recommendations
NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice.
General principles of care
When working with people who self harm:
-Aim to develop a trusting, supportive, and engaging relationship
-Be aware of stigma and discrimination sometimes associated with self harm and be non-judgemental
-Ensure that people are fully involved in decision making about their treatment and care
-Aim to foster people’s autonomy and independence whenever possible
-Maintain continuity of therapeutic relationships whenever possible
-Ensure that information about self harm is communicated sensitively to other team members.
[Based on qualitative evidence and the experience and opinion of the Guideline Development Group (GDG)]
Psychosocial assessment in community mental health services and other specialist mental health settings
Offer an integrated and comprehensive psychosocial assessment of needs and risks to understand and engage people who self harm, and initiate a therapeutic relationship. [Based on qualitative evidence and the experience and opinion of the GDG]
Assessment of needs should include:
-Skills, strengths, assets, and coping strategies
-Mental and physical health problems or disorders
-Social circumstances and problems
-Psychosocial and occupational functioning, and vulnerabilities
-Recent and current life difficulties, including personal and financial problems
-The need for psychological intervention, social care and support, occupational rehabilitation, and also drug treatment for any associated conditions
-The needs of any dependent children.
[Based on the experience and opinion of the GDG]
When assessing children and young people who self harm, follow the same principles as for adults (above), but also include a full assessment of their family, social situation, and child protection issues. [Based on the experience and opinion of the GDG]
When assessing the risk of repetition of self harm or risk of suicide, identify and agree with the person the specific risks for them, taking into account:
-Methods and frequency of current and past self harm
-Current and past suicidal intent
-Depressive symptoms and their relationship to self harm
-Any psychiatric illness and its relationship to self harm
-The personal and social context and any other factors preceding self harm, such as specific unpleasant affective states or emotions and changes in relationships
-Specific risk factors and protective factors (social, psychological, pharmacological, and motivational) that may increase or decrease the risks associated with self harm
-Coping strategies that the person has used either to successfully limit or avert self harm or to contain the impact of personal, social, or other factors preceding episodes of self harm
-Important relationships that may either be supportive or represent a threat (such as abuse or neglect) and may lead to changes in the level of risk
-Immediate and longer term risks.
[Based on prospective cohort studies and the experience and opinion of the GDG]
Do not use risk assessment tools and scales to predict future suicide or repetition of self harm because the modest predictive value of those currently available makes them of limited usefulness in clinical practice. [Based on prospective cohort studies and on the experience and opinion of the GDG]
Care plans
Discuss, agree, and document the aims of longer term treatment in the care plan with the person who self harms. These aims may be to:
-Prevent escalation of self harm
-Reduce harm arising from self harm or reduce or stop self harm
-Reduce or stop other risk related behaviour
-Improve social or occupational functioning, quality of life or any associated mental health conditions.
Review the person’s care plan with them, including the aims of treatment, and revise it at agreed intervals of not more than one year.
[Based on the experience and opinion of the GDG]
Care plans should be multidisciplinary and developed collaboratively with the person who self harms and his or her family, carers, or significant others. Care plans should:
-Identify realistic and optimistic long term goals, including education, employment, and occupation
-Identify short term treatment goals (linked to the long term goals) and steps to achieve them
-Identify the roles and responsibilities of any team members and the person who self harms
-Include a jointly prepared risk management plan
-Be shared with the person’s general practitioner.
[Based on the experience and opinion of the GDG]
Risk management plans
A risk management plan should be a clearly identifiable part of the care plan and should:
-Outline how to deal with each of the long term and more immediate risks identified in the risk assessment
- Outline how to deal with the specific factors (psychological, pharmacological, social, and relational) identified in the assessment as associated with increased risk, with the agreed aim of reducing the risk of repetition of self harm and/or the risk of suicide
-Include a crisis plan outlining self management strategies and how to access services during a crisis when self management strategies fail
-Ensure that the risk management plan is consistent with the long term treatment strategy.
Inform the person of the limits of confidentiality and that information in the plan may be shared with other professionals.
[Both the above points are based on the experience and opinion of the GDG]
Interventions for self harm
Consider offering three to 12 sessions of a psychological intervention that is specifically structured for people who self harm with the aim of reducing self harm. The intervention should be tailored to individual need and could include cognitive behavioural, psychodynamic, or problem solving elements. Therapists should be trained and supervised in the therapy they are offering and be able to work collaboratively with the person to identify the problems causing distress or leading to self harm. [Based on very low to moderate quality randomised controlled trials and the experience and opinion of the GDG]
Do not offer drug treatment as a specific intervention to reduce self harm. [Based on evidence from randomised controlled trials and the experience and opinion of the GDG]
Treating associated mental health conditions
Provide psychological, pharmacological, and psychosocial interventions for any conditions associated with self harm—for example, the following conditions covered by published NICE guidance:
Overcoming barriers
Services for people who self harm vary considerably.18 In some, liaison psychiatrists provide a comprehensive treatment programme and train other healthcare professionals. Others may be limited to an emergency department and community mental health teams with no self harm training. Possible reasons for poor services include limited resources, lack of an evidence base for treatments, and the unpopularity of this group of service users among some clinical staff.19 People who self harm often report negative responses from staff in mental health services; primary and secondary physical healthcare; and particularly in emergency departments. This may be linked to professionals’ lack of understanding of self harming behaviour.20 A poor healthcare experience may prevent people from seeking help if they self harm in the future.21
Young people who self harm often come to the attention of school teachers and young people’s health advisers. Although these staff often receive training in how to deal with disclosures about self harm from young people, this aspect of work causes concern among staff, who often request further training from local healthcare professionals.
This guideline is intended to increase awareness and knowledge of self harm among frontline staff and service providers and lessen stigma, thereby reducing important barriers that prevent service users from receiving appropriate care. Although the evidence base is limited, the guideline will help inform better longer term management for people who self harm, enable increased access to psychological treatment, and reduce the harm that services can sometimes inflict, in terms of both inappropriate prescribing (see the box “Further information on the guidance”) and the discrimination and stigmatisation of people who self harm.
As a major factor in completed suicide, self harm can no longer be regarded as a marginal or shameful behaviour in people using mental health and other healthcare services.
Further information on the guidance
In this, the first NICE guideline to provide guidance on the longer term management of self harm, the Guideline Development Group (GDG) made a recommendation that drugs should not be prescribed as a specific treatment to reduce self harm because there was insufficient evidence to determine whether drug interventions would reduce the likelihood of repeated episodes. However, many people who self harm are prescribed psychotropic medication,22 often to treat associated conditions such as depression. The GDG was concerned about the need for safe prescribing in a population at risk of overdose. It therefore advised that, when prescribing a psychotropic medication for an associated condition, prescribers should consider the toxicity of the drug in overdose and, when offering antidepressants, choose selective serotonin reuptake inhibitors because they are less potentially lethal than other antidepressants, and avoid tricyclic antidepressants such as dosulepin.
Harm reduction (that is, reducing the harmful aspects of an episode of self harm rather than stopping the self harming altogether) is a controversial concept in the management of self harm and was much debated by the GDG. For some people—for example, those for whom self harm is a coping mechanism that helps to prevent suicide—stopping self harm may not be achievable in the short term, and therefore healthcare professionals may want to consider a programme of harm reduction, either aiming to reduce the frequency of the episodes or to reduce the harm associated with the act itself. Several clinical, ethical, and legal complexities are associated with this strategy, and healthcare professionals need to consider these and other factors, including what the self harm means to the individual, how that person can retain his or her autonomy, and how the risks can be minimised. The GDG found no evidence for or against harm reduction in people who self harm, but given that it found evidence supporting the approach in substance misuse, the group suggested that professionals might consider such strategies for some people who self harm.
Methods
This guideline was developed by the National Collaborating Centre for Mental Health using NICE guideline methods (www.nice.org.uk/guidelinesmanual). The guideline review process involved comprehensive and systematic literature searches to identify relevant evidence for the clinical and economic reviews, with critical appraisal of the quality of the identified evidence. A multidisciplinary team of healthcare professionals and patient and carer representatives (the GDG) was established to review the evidence and develop the subsequent recommendations. The guideline then went through an external consultation with stakeholders. The GDG considered the stakeholders’ comments, reanalysed the data where necessary, and modified the guideline as appropriate.
NICE has produced three different versions of the guideline: a full version; a summary version known as the “NICE guideline”; and a version for people who self harm, their families and carers, and the public. All these versions, as well as a pathway that integrates both guidelines on self harm, are available from the NICE website. Further updates of the guideline will be produced as part of NICE’s guideline development programme.
Future research and remaining uncertainties
Does the provision of training in assessing and managing self harm improve outcomes compared with no additional specialist training?
Does the provision of psychosocial assessment with a validated risk scale, compared with psychosocial assessment alone, improve outcomes for people who self harm?
Does the provision of a psychological therapy with problem solving elements, compared with treatment as usual, improve outcomes? What is the differential effect for people with a history of self harm, compared with people who self harm for the first time?
Does the provision of potentially cheap, low intensity or brief psychosocial interventions, compared with treatment as usual, improve outcomes for people who self harm?
What are the different approaches in the NHS to harm reduction for people who self harm?
Notes
Cite this as: BMJ 2011;343:d7073
Footnotes
This is one of a series of BMJ summaries of new guidelines based on the best available evidence; they highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.
The members of the Guideline Development Group were Navneet Kapur (chair), Tim Kendall (facilitator), Benedict Anigbogu, Gareth Allen, Simon Baston, Henna Bhatti, Andrew Briggs, Stephen Briggs, Anthony Cox, Melissa Chan, Matthew Dyer, Jonathan Evans, Paul Gill, Naomi Glover, Marie Halton, Kate Hunt, Suzanne Kearney, Katherine Leggett, Nick Meader, Rory O’Connor, Richard Pacitti, Sarah Stockton, Michaela Swales, Clare Taylor, and Alison Wood.
Contributors: All authors contributed to the conception and drafting of this article and revising it critically. They have all approved this version. TK is the guarantor.
Funding: The National Collaborating Centre for Mental Health was commissioned and funded by the National Institute for Health and Clinical Excellence to develop this guideline and summary.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: (1) TK, CT, and HB had support from the National Collaborating Centre for Mental Health (NCCMH) for the submitted work; (2) TK, CT, HB, and MC have been employed by the NCCMH in the previous three years; TK receives funding from NICE to support guideline development at the NCCMH; NK is employed by the University of Manchester and Manchester Mental Health and Social Care Trust and was supported by the NCCMH in carrying out this work. He has received funding from a variety of non-industry sources (for example, Department of Health, other government departments, and charities) to carry out research into suicidal behaviour; (3) no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.