Mental Health
Question 171 of 180
A 15 year old girl is brought to the Emergency Department by her mother. She has reported to her mother that she has been self harming for the past 2 months. Which of the following is NOT a risk factor for self-harm?
Answer:
Risk factors for self-harm include:- Age — self-harm rates peak in 16 to 24-year-old women and 25 to 34-year-old men. Suicide rates are highest in both men and women aged 45–49 years.
- Socio-economic disadvantage.
- Social isolation.
- Stressful life events, for example relationship difficulties, previous experience in the armed forces, child maltreatment, or domestic violence.
- Bereavement by suicide.
- Mental health problems, such as depression, psychosis or schizophrenia, bipolar disorder, post-traumatic stress disorder, or a personality disorder.
- Chronic physical health problems.
- Alcohol and/or drug misuse.
- Involvement with the criminal justice system (with people in prison being at particular risk).
Self Harm and Suicide
Complex Situations (SLO7) / Mental Health
Last Updated: 6th September 2022
Self-harm refers to an intentional act of self-poisoning or self-injury, irrespective of the motivation or apparent purpose of the act, and is an expression of serious emotional distress. Self-harm includes suicide attempts as well as acts where little or no suicidal intent is involved (for example, where people harm themselves to reduce internal tension, communicate distress, or obtain relief from an otherwise overwhelming situation).
- The majority of self-poisoning episodes involve prescribed or over-the-counter medication, and a minority involve illicit drugs, other household substances, or plant material.
- The majority of self-injury episodes involve cutting.
- Less common methods include burning, hanging, stabbing, drowning, swallowing objects, insertion, shooting, and jumping from heights or in front of vehicles.
Risk factors
Risk factors for self-harm include:
- Age — self-harm rates peak in 16 to 24-year-old women and 25 to 34-year-old men. Suicide rates are highest in both men and women aged 45–49 years.
- Socio-economic disadvantage.
- Social isolation.
- Stressful life events, for example relationship difficulties, previous experience in the armed forces, child maltreatment, or domestic violence.
- Bereavement by suicide.
- Mental health problems, such as depression, psychosis or schizophrenia, bipolar disorder, post-traumatic stress disorder, or a personality disorder.
- Chronic physical health problems.
- Alcohol and/or drug misuse.
- Involvement with the criminal justice system (with people in prison being at particular risk).
It is thought that the overall higher rate of suicide in men despite the higher rate of self-harm in women may be due to the choice of more lethal methods (firearms and hanging vs cutting or poisoning).
Risk assessment
- When assessing the risk of suicide, ask the person:
- Do you have thoughts about death or suicide?
- Do you feel that life is not worth living?
- Have you made a previous suicide attempt?
- Is there a family history of suicide?
- If the answer to any of these questions is yes, ask about their plans for suicide:
- Have you considered a method?
- Do you have access to the materials?
- Have you made any preparations (for example, written a note)?
- Also ask about any protective factors (including coping strategies, supportive relationships, dependent children, religious beliefs), for example:
- What keeps you from harming yourself?
- Is there anything that would make life worth living?
- Identify risk factors that increase the risk of suicide — these include:
- Previous suicide attempts or self-harm. Consider history and frequency of any past self-harm, medical seriousness, use of violent methods, evidence of planning, such as suicide note or changes to will, and precautions taken to prevent rescue.
- Active mental illness.
- Family history of mental disorder, suicide or self-harm.
- Low socioeconomic status.
- Male gender.
- Being unemployed.
- Physical health problems.
- Living alone.
- Being unmarried.
- Abusive or violent relationships.
- Drug/alcohol dependence.
- Feelings of hopelessness.
- Exposure to suicidal behaviour.
- High risk groups include:
- Young and middle-aged men.
- People in contact with the criminal justice system.
- Specific occupational groups, for example, doctors, nurses, veterinary workers, farmers, agricultural workers.
- If there is a risk of self-harm or suicide:
- Assess whether the person has adequate social support and is aware of sources of help.
- Assess whether there are any dynamic risk factors that can be treated (for example, mental illness, use of alcohol or illicit drugs).
- Arrange help appropriate to the level of risk.
- Advise the person to seek further help if the situation deteriorates.
- Assess for any safeguarding concerns in children, young people, or vulnerable adults dependent for their care on the person presenting with an episode of self-harm.
- If a person with depression presents considerable immediate risk to themselves or others, refer them urgently to specialist mental health services.
- If the person is considered at low risk, discuss and/or create a safety plan with them, detailing steps they should take if their situation deteriorates.
Modified SAD PERSONS scale
Modified SAD PERSONS Scale:
- Sex (male) – 1 point
- Age (< 19 or > 45 years) – 1 point
- Depression or hopelessness – 2 points
- Previous suicidal attempts or psychiatric care – 1 point
- Excessive alcohol or drug use – 1 point
- Rational thinking loss (psychotic or organic illness) – 2 points
- Single, widowed or divorced – 1 point
- Organised plan – 2 points
- No social support – 1 point
- Stated future attempt – 2 points
This score is then mapped onto a risk assessment scale as follows:
- 0–5: May be safe to discharge (depending upon circumstances)
- 6-8: Probably requires psychiatric consultation
- >8: Probably requires hospital admission
Consent
- Ensure any person who has self-harmed gives informed consent for management, wherever possible.
- If a person declines or refuses management that is perceived to be in their best interests, assess their mental capacity, to help decide whether they are unable to make an informed decision about whether to accept or refuse treatment. Mental capacity should be assumed in a person aged 16 years or over, unless there is evidence to the contrary. If possible, gather additional information from family, carers, and significant others, if the person allows.
- If a person refuses treatment, determine the reason(s) why. Provide information about the potential consequences of not receiving hospital treatment and assessment.
- If a person is judged to have diminished capacity and/or the presence of a significant mental health disorder, refer for an urgent mental health assessment or hospital admission, depending on clinical judgement. Healthcare professionals have a duty to act in the person's best interests. This may include taking the person to hospital for further assessment and treatment against their wishes.
- If there is uncertainty about whether a person has capacity to make informed decisions, seek advice from a psychiatrist who has experience in assessing capacity.
- If the person is judged to have capacity, and does not have signs of a mental disorder, by law they have the right to refuse hospital admission and/or to refuse lifesaving treatment. Take all steps to persuade them to attend hospital or have treatment. If the person allows, involve family and carers. Seek advice from senior staff. Clearly document their wishes and that these are against medical advice.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
