Psychiatry: Assessment and Management

Psychiatric History

The psychiatric history and mental state assessment are undertaken together in the psychiatric interview.
This is a critical time for establishing rapport as well as systematically obtaining this information. In this chapter and the next, we present a format for written documentation; greater flexibility is clearly required during the actual interview. You should always do a physical examination too.

Introduction and presenting complaint

  • Patient’s name, age, occupation, ethnic origin, circumstances of referral (and, in the case of inpatients, whether voluntary or compulsory) and presenting complaint (in the patient’s own words).

History of the present illness

  • Start with open questions, e.g. ‘Can you tell me what has been happening?’
  • Establish when the illness first began (and, if a relapsing/remitting illness, when this illness episode began), e.g. ‘When did you last feel well?
  • What does the patient think might have caused the illness as a whole or this relapse/recurrence, and what makes it better or worse?
  • What has been the effect on daily life/relationships/work?
  • Depending on the presenting complaint, you will need to ask follow-up questions about other symptoms to help you make a diagnosis.
    Your questions should be guided by the diagnostic criteria for the individual disorders. For example, if the patient describes feeling anxious, you would ask questions to establish if the anxiety is situational and if panic attacks occur.
  • Enquire about mood, sleep and appetite, even if they appear normal, and whether there are risks of harm to self or others.
    Especially in psychosis or dementia, the patients’ views of events might differ from those of their family, friends or other collateral sources. In this case, you can record their accounts, followed by any collateral information available.

Previous psychiatric history

  • Dates of illnesses, symptoms, diagnoses, treatments.
  • Hospitalisations, including whether treatment was voluntary or compulsory.

Past medical/surgical history

  • Dates of any serious medical illnesses.
  • Dates of any surgical operations.
  • Dates of any periods of hospitalisation.

Drug history and allergies

  • All current medication.
    Note psychotropic medications that patients have received previously, their dosage and duration, and whether or not they helped.
    It may be necessary to obtain this information from the patients’ GP or hospital notes.

Family history

  • Parents’ and siblings’ physical and mental health, their frequency of contact with, and the quality of their relationship with the patient.
  • If a close relative is deceased, note the cause of death, the patient’s age at the time of death and their reaction to that death.
  • Ask about family history of psychiatric illness (‘nervous breakdowns’), suicide or drug and/or alcohol abuse, forensic encounters and medical illnesses.

Personal history

  • Early life and development: Include details of the pregnancy and birth (especially complications), any serious illnesses, bereavements, emotional, physical or sexual abuse, separations in childhood or developmental delays. Describe the childhood home environment (atmosphere and any deprivation). Note religious background and current religious beliefs/practices.
  • Educational history: Include details of school, academic achievements, relationships with peers (did they have any friends?) and conduct (whether suspended, excluded or expelled).
    Bullying and school refusal or truancy should be explored.
  • Occupational history: List job titles and duration, reasons for change; note work satisfaction and relationships with colleagues. The longest duration of continuous employment is a good indicator of premorbid functioning.
  • Relationship history: Document details of relationships and marriages (duration, gender of partner, children, relationship quality, abuse); sexual difficulties; in the case of women, menstrual pattern, contraception, history of pregnancies. Those who are in a long-term relationship should be asked about the support they receive from their partner and the quality of the relationship – e.g. whether there is good communication, aggression (physical or verbal), jealousy or infidelity.

Substance use

Alcohol, drug (prescribed and recreational) and tobacco consumption.

Forensic history

  • Any arrests, whether they resulted in conviction and whether they were for violent offences.
  • Any periods of imprisonment, for which offences and the length of time served.

Social history

  • Describe current accommodation, occupation, financial situation and daily activities.

Premorbid personality

  • A description of the patient’s character and attitudes before they became unwell (e.g. character, social relations). You could ask:
    • How would you describe yourself before you became unwell?
    • How would your friends describe you?
    • What do you enjoy doing?
    • How do you usually cope when things go wrong?

The Mental State Examination

Appearance and behaviour

Here you should note:

  • Their general health, build, posture, unusual tattoos or clothing, piercings, injection sites, lacerations (especially on the forearm).
  • Whether they have good personal hygiene?
  • Whether they are tidily dressed/well-kempt or unkempt?
  • Their manner, rapport, eye contact, degree of cooperation, facial expression, whether responding to hallucinations.
  • Motor activity may be excessive (psychomotor agitation) or decreased (psychomotor retardation).
  • Abnormal movements may be antipsychotic side effects such as
    • tremor
    • bradykinesia: slowness of movement
    • akathisia: restlessness
    • tardive dyskinesia: usually affects the mouth, lips and tongue (e.g. rolling the tongue or licking the lips)
    • dystonia: muscular spasm causing abnormal face and body movement or posture.
  • Other abnormal movements include:
    • tics
    • chorea
    • stereotypy: repetitive, purposeless movement (e.g. rocking in people with severe learning disability)
    • mannerisms: goal-directed, understandable movements (e.g. saluting)
    • gait abnormalities.

Speech

Describe tone (variation in pitch), rate (speed) and volume (quantity). In pressure of speech, rate and volume are increased and speech may be uninterruptible. In depression, tone, rate and volume are often decreased.

  • ‘Normal’ speech can be described as ‘spontaneous, logical, relevant and coherent’.
  • ‘Circumstantial’ speech takes a long time to get to the point.
  • Perseveration (repeating words or topics) is a sign of frontal lobe impairment.
  • Neologisms (made up words e.g. ‘headshoe’ to mean ‘hat’) can occur in schizophrenia.

Thought form

  • Normal speech consists of a series of phrases/statements connected by their meanings:
    I am reading this book ⇒ because I want to pass my exam.
  • In flight of ideas there is an abnormal connection between statements based on a rhyme or pun rather than meaning:
    I read this book ⇒ because it was red and blue ⇒ I feel blue.
  • In ‘loosening of associations’ there is no discernible link between statements:
    I am reading ⇒ climate change ⇒ where’s the piano?
  • If you think a patient has abnormal thought form, record some examples of what they say.
  • In thought block, the patient’s subjective experience of thought is abnormal (thoughts disappear: ‘my mind goes blank’).

Mood and affect

  • Mood is the underlying emotion; report subjective mood (in patient’s own words) and objective mood (described as dysthymic (low), euthymic (normal) or hyperthymic (elated)).
  • Affect is the observed (and often more transient) external manifestation of emotion. Mood has been compared to climate and affect to weather. An abnormal affect may be described as:
    • blunted/unreactive (lacking normal emotional responses – e.g. negative symptoms of schizophrenia)
    • labile (excessively changeable)
    • irritable (which may occur in mania, depression)
    • perplexed
    • suspicious; or
    • incongruous (grossly out of tune with subjects being discussed – e.g. laughing about bereavement).
  • Where no abnormality is detected, affect is described as reactive (appropriate response to emotional cues).

Disorders of thought content

Record:

  • Negative (depressed) cognitions (e.g. guilt, hopelessness).
    • Ruminations (persistent, disabling preoccupations) that may occur in depression or anxiety (e.g. worrying about redundancy, illness or death).
    • Obsessions and phobias.
    • Depersonalisation or derealisation: these often occur with anxiety; they are not psychotic phenomena.
    • Depersonalisation – feeling detached, unreal, watching oneself from the outside: ‘as if cut off by a pane of glass’.
    • Derealisation – the world or people in it seeming lifeless: ‘as if the world is made out of cardboard’.
  • Abnormal beliefs. These are:
    • overvalued ideas: acceptable and comprehensible but pursued by the patient beyond the bounds of reason and to an extent that causes distress to them or others (e.g. an intense, non-delusional feeling of responsibility for a bereavement)
    • ideas of reference: thoughts that other people are looking at or talking about them, not held with delusional intensity
    • delusions: fixed, false, firmly held beliefs, out of keeping with the patient’s culture and unaltered by contrary evidence.

Ask about suicidal or homicidal ideation, plans and intent:

Perception

  • Ask ‘Have you seen or heard things that other people can’t see or hear? Can you tell me more about that?’
  • Illusions are misinterpretations of normal perceptions (e.g. interpreting a curtain cord as a snake). They can occur in healthy people.
  • Hallucinations are perceptions, in the absence of an external stimulus, that are experienced as true and as coming from the outside world. They can occur in any sensory modality, although auditory and visual are the most common. Some auditory hallucinations occur in normal individuals when falling asleep (hypnagogic) or on waking (hypnopompic).
  • Pseudohallucinations are internal perceptions with preserved insight (e.g. ‘A voice inside my head tells me I’m no good.’

Cognition

Note at least the level of consciousness, memory, orientation, attention and concentration. More formal testing is needed for those who may have cognitive impairment and everyone aged 65 and over. This may involve completing a Mini-Mental State Examination (MMSE) with additional tests of frontal lobe function.
You should test:

  • memory (e.g. repeating a list of three or more objects or an address – immediately and after 5 minutes)
  • orientation in time (day, date, time), place, person (e.g. knowing their name, age and identity of relatives)
  • attention and concentration (e.g. counting backwards)
  • dyspraxia (e.g. drawing intersecting pentagons)
  • receptive dysphasia (following a command)
  • expressive dysphasia (naming objects)
  • executive (frontal lobe) functioning tests such as:
  • approximation (e.g. height of a local landmark)
  • abstract reasoning (e.g. finding the next number or shape in a sequence)
  • verbal fluency (can they think of >15 words beginning with each of the letters F, A or S in a minute?)
  • proverb interpretation.

Insight

  • The patient’s understanding of their condition and its cause as well as their willingness to accept treatment.

Diagnosis and Classification in Psychiatry

History

  • Before the 1950s, diagnoses were unreliable and had meanings that varied across the world. In the 1960–1970s ‘antipsychiatrists’, including R. D. Laing and Thomas Szasz, suggested that psychiatric diagnoses should be abandoned, together with the concept of mental illness.
  • The International Classification of Diseases (ICD) is a system developed by the World Health Organization (WHO) aimed at improving diagnosis and classification of disorders. The mental health section is currently in its tenth edition (ICD-10). Look online at some of the diagnostic criteria (http://apps.who.int/classifications/apps/icd/icd10online/). ICD 11 is scheduled for publication in 2017.
  • The American Psychiatric Association developed its own classificatory system, the Diagnostic and Statistical Manual of Mental Disorders (DSM); the current classification, DSM 5 was released in May 2013.
  • ICD-10 and DSM-5 are broadly similar. Figure 3.1 shows the main differences.

The concept of mental illness

  • In medicine, a distinction is made between disease (objective physical pathology and known aetiology) and illness (subjective distress). Psychiatric conditions without known organic cause, such as depression, are described as illnesses or disorders not diseases since in many there is no demonstrable pathology. New techniques (e.g. neuroimaging) may identify definable psychiatric diseases.
  • The concept of mental illness is useful in defining a level of subjective distress greater in severity or duration than occurs in normal human experience. The legislation in many countries requires psychiatrists to diagnose defined ‘mental illness’ when certifying the need for compulsory hospital treatment and in forensic (legal) psychiatry.
  • Diagnostic criteria set thresholds to define the level of symptoms that constitute mental illness. These thresholds can be controversial. For example, compared to DSM-IV, DSM-5 criteria for ADHD are more inclusive – requiring symptoms before age 12 rather than age 7. In the USA, 20% of boys aged between 14 and 17 have been diagnosed with ADHD and 2/3 take medication. Critics claim this as the medicalization of childhood, proponents that it is right that those who may benefit from treatment receive it.
  • Decisions about what constitutes mental illness change over time, influenced by:
    1. Latest research findings e.g. gambling disorder is newly classified in DSM-5 among substance abuse/addictions as it has been found to have more in common with these disorders than with impulse control disorders where classified in DSM-IV.
    2. Sociopolitical thinking: homosexuality was removed from the DSM in the 1970s. DSM-IV, gender identity disorder was changed to gender dysphoria in DSM-5 because ‘gender incongruence’ rather than cross-gender identification per se is considered a disorder.

Aims of classification in psychiatry

  • To identify groups of patients who are similar in their clinical features, course of disease, outcome and response to treatment, aiding individual clinical management.
  • To provide a common language for communication between patients, professionals and researchers.
  • To improve the reliability (reproducibility among different settings) and validity (correctness) of diagnoses. Validity is more difficult to confirm but attempts have been made, including the examination of consistency of symptom patterns and demonstration of consistent treatment responses, long-term prognoses, genetic and biological correlates.

Categorical versus Dimensional

  • ICD-10 and DSM-5 are categorical systems. They describe a group of discrete conditions. They give operational definitions specifying inclusion and exclusion criteria. These state which symptoms must be present for each diagnosis to be made (often quantifying their number and requiring a minimum duration).
  • Dimensional systems use a continuum rather than categories and have been used mainly to classify personality.
    For example, Hans Eysenck proposed three dimensions of personality: introversion/extroversion, neuroticism (mental distress in which ability to distinguish between symptoms originating from patient’s own mind and external reality is retained; includes most depressive and anxiety disorders) and psychoticism (severe mental disturbance characterised by a loss of contact with external reality). DSM-5 includes a suggested model for defining personality disorders that allows dimensional assessment of traits in its section for further study, although the main manual still defines personality disorders categorically.

Comorbidity

  • Psychiatric diagnoses are made in ICD-10 (and to a lesser extent in DSM-5) using a diagnostic hierarchy, which is often illustrated as a triangle.
  • Organic disorders are at the top of the triangle and take precedence when making diagnoses. For example, if a person with dementia is agitated and anxious, the anxiety would be classified as a neuropsychiatric symptom of the dementia rather than being diagnosed separately as anxiety disorder.
  • Similarly, a person who met criteria for both a depressive episode and generalised anxiety disorder would be diagnosed with depression alone.
  • Comorbidity (co-occurrence of two psychiatric disorders) is allowed in either system if a person is experiencing symptoms not explained by one diagnosis alone. For example, a person with an emotionally unstable personality disorder may be diagnosed with depression.

Risk Assessment and Management in Psychiatry

Clinicians need to balance the need to reduce risk as far as possible with the duty to respect patients’ rights and freedom; risk cannot be eliminated completely. This continuing process is called risk assessment and management.

Risk assessment

  • All psychiatric patients should have a risk assessment to assess the level of risk they pose to themselves and to others (specific named people or risk of indiscriminate violence).
  • This needs to be reviewed regularly since degree of risk is sensitive to changing circumstances and to a patient’s changing mental state.
  • Past behaviour is the best indicator of future behaviour and should be considered in addition to the current episode history and mental state.
  • History from informants (e.g. family, hostel staff) and a review of case notes and other documentation are critical to ensure all important information is considered.
  • Assess patients in as safe an environment as possible – assessment areas should have appropriate alarm facilities and easily available exit routes. Consider potential access to harmful agents (firearms, knives, other weapons, incendiary devices, objects that can be used as weapons). Where risk behaviour is anticipated, ensure that senior staff and appropriate security/support staff are present where possible.

Risk of self-harm

From the psychiatric interview and case notes, document:

  • current suicidal thoughts, plans and intent;
  • anything that prevents the patient acting on these thoughts (e.g. family, religion);
  • previous episodes of deliberate self-harm (circumstances, method and management);
  • factors predisposing to deliberate self-harm or actual suicide, which include:
    • a family history of suicide
    • social isolation
    • substance misuse
  • any history of previous disengagement from statutory or voluntary support services, and whether the patient is now willing to engage with such services.
    In the mental state examination, look for these risk factors:
  • thoughts of hopelessness and worthlessness.
  • command hallucinations inciting self-harm.

Risk of harm to others

From the psychiatric interview and case notes, document:

  • acts or threats of violence (to whom directed, frequency, severity, methods used and most serious harm resulting);
  • deliberate arson;
  • sexually inappropriate behaviour;
  • episodes of containment (compulsory detention, treatment in special hospital, secure unit, locked ward, prison or police station);
  • extent of compliance with previous and current psychiatric treatment and aftercare; note past or current episodes of disengagement from psychiatric follow-up.
    Document the following because they can increase risk:
  • recent discontinuation of prescribed drugs;
  • change in use of recreational drugs;
  • alcohol or drug misuse (or any other disinhibiting factors);
  • impulsive or unpredictable behaviour;
  • recent stressful life events, changes in personal circumstances, lack or loss of social support, because these may indicate ‘social restlessness’ (frequent changes of relationships, work or domicile).
    In the mental state examination, look for:
  • expressed violent intentions or threats;
  • irritability, disinhibition, suspiciousness;
  • persecutory delusions (especially with specific person or people involved);
  • delusions of control or passivity phenomena;
  • command hallucinations.

Risk of self-neglect and accidental harm

People with mental illness may lack the motivation (e.g. because of severe depression, chronic schizophrenia) or skills (dementia, learning disability) to care for themselves and/or to arrange access to necessary services (e.g. heating, lighting, housing and health care). This can result in serious health risks from:

  • malnutrition (forgetting to eat, eating out-of-date food);
  • failure to access health care or living in squalid conditions;
  • falls owing to physical frailty or alcohol or drug intoxication;
  • failure to take adequate safeguards against fire (cigarette-burned bedclothes indicate such a risk) or explosion (from leaving the gas on);
  • wandering (leaving the house and being unable to find the way home, or going out at inappropriate times such as middle of night), poor road safety;
  • accidentally taking too much or too little medication;
  • vulnerability to crime through leaving the front door open, persistently losing door key or inviting strangers in.

Vulnerability to abuse

  • Abuse is defined as a single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust and which causes harm or distress to a vulnerable (e.g. older or learning disabled) person. Abuse may be verbal, psychological, physical, financial, sexual or through neglect.
  • People living in institutions may be at particular risk.
  • Abuse also occurs in private homes and this may relate to high levels of stress in family carers. Carers are sometimes at the receiving end of verbal or physical abuse and this should also be enquired into.

Managing violence

Immediate management

  • For community patients, consider whether admission is necessary, and, if so, whether this should be under the Mental Health Act, possibly to a psychiatric intensive care unit (PICU) or secure unit.
  • All staff working in psychiatry should be trained in ‘breakaway’ techniques for escaping from violent situations. Nursing staff in psychiatric units are trained in safe methods of control and restraint of patients, the first stage of which is always to try to manage the situation by ‘talking down’.
  • Medication can be used to treat any underlying psychiatric disorder and (in patients with high levels of arousal) for sedation or tranquilisation; usually benzodiazepines and/or antipsychotic medication are used.
  • Very occasionally, it is necessary to manage violent and aggressive patients in seclusion for short periods of time to ensure the safety of staff and other patients.

Preventing future violence

  • Level of monitoring should be specified for patients in the community and for those in hospital.
  • Communication between agencies (particularly Health, Probation and Social Services) is crucial, especially for high-risk patients.
  • Care plans and their implementation must be negotiated by all involved parties (including the patients themselves, their families and other informal carers) and fully documented.
  • Document all incidents and new information that may suggest a change in risk. Even if a piece of information seems insignificant, it may not be when considered together with information from other sources or time points.

Breaking confidentiality

  • Patients have a right to expect that information about them will be held in confidence by their doctors.
  • If professionals are aware of a specific threat to a named individual, they have a duty to ensure that the person concerned is informed.
  • In very rare circumstances, disclosure of patients’ information may be justified in the public interest, even if the patients withhold their consent (e.g. if disclosure may assist in the prevention, detection or prosecution of a serious crime).
  • Professionals also have a responsibility to report significant abuse that may cause, or has caused, harm to children and vulnerable adults (people with dementia or learning disabilities, or others who cannot make decisions about their own welfare) to appropriate agencies (Social Services or, in very serious cases, the police).
  • Seek senior advice if in any doubt about breaking confidentiality.

Suicide and Deliberate Self-harm

Suicide

Epidemiology

  • There are about 8 suicides per 100â•›000 people per year in UK (1% of all deaths).
  • UK suicide rates have fallen in the past decade with a small increase in the period 2010–2014, probably as a result of the global economic crisis.
  • Suicides worldwide are more common in men than women; in the UK the highest suicide rates are in middle aged (aged 40–50) men, and around three-quarters of victims are men.
  • The most frequently used methods vary between countries and by gender. In the USA, most deaths involve firearms; in the UK hanging is more common in men, hanging and self-poisoning in women. Other methods include jumping in front of a train or car and exsanguination; worldwide, pesticide ingestion is common. Firearms are more often used by male suicide victims.

Aetiology

The aetiology of any suicide is likely to be a complex interplay of factors, but the following are often important:

  • Mental illness: Retrospective ‘psychiatric autopsy’ studies have suggested that a current psychiatric diagnosis can be made in almost all suicides. Recent UK statistics show:
    • Just under 20% of all mental health patient suicides were within three months of discharge from inpatient psychiatric care, 10% happened in current inpatients, 8% in those in contact with Crisis Resolution and home treatment teams (CR/HTT). Disorders frequently implicated include:
      – substance misuse – 56% had a history of alcohol or drug misuse;
      – schizophrenia – 16% had this diagnosis;
      – severe mental illness and substance misuse diagnoses – 15%;
      – personality disorder – the primary diagnosis in 8% of suicides, 71% of whom had comorbid depression or substance misuse;
      – depression – very commonly implicated, often comorbid with other disorders.
    • Suicide rates are also particularly high in prisons because of high rates of mental illness, deprivation and stress.
      Other risk factors include:
  • Chronic painful illnesses.
  • Availability of means: removing potential ligature points from inpatient wards, restrictive firearm legislation and reducing paracetamol and aspirin pack sizes have reduced suicide rates.
  • Family history of suicide.
  • Lack of social support or recent adverse life events (loss of job, bereavement, divorce or other loss of relationship).
  • At a biological level, expression of Brain Derived Neurotrophic Factor (BDNF) is reduced in the brains of people who have committed suicide.
  • Countries where Finno-Ugrian (Finnish and Hungarian) ethnicities prevail show some of the highest suicide rates in Europe and worldwide, suggesting there may be genetic susceptibility factors (relating to heritable behavioural and personality traits, such as aggression, depression and impulsivity).

Suicide prevention strategies

  • Detect and treat psychiatric disorders.
  • Be alert to risk and respond appropriately to it. A large proportion of people who commit suicide have consulted their general practitioners (GPs) in the previous few weeks.
  • Prescribe safely – e.g. prescribing of co-proxamol must take account of the fact that an overdose of relatively few tablets may be lethal, especially if consumed with alcohol.
  • Give urgent care at appropriate level of patients with suicide intent – CR/HTT or hospitalization (consider detention under the Mental Health Act) if patients considered unsafe outside hospital even with intensive support.
  • Provide careful management of deliberate self-harm (DSH) because there is a high risk of repetition including completed suicide (see next section).
  • Act at the population level, tackling unemployment and reducing access to methods of self-harm.

DSH

Epidemiology and correlates

  • DSH is a much (20–30 times) more common event than completed suicide, with an annual incidence of 2–3/1000 in the UK.
  • DSH significantly increases the risk of completed suicide.
    A third of suicide victims have self-harmed at least once in the past.
  • Most cases involve drug overdose or physical self-injury (e.g. cutting or stabbing).
  • Unlike completed suicide, DSH is more frequent in women, the under-35s, lower social classes and the single or divorced.
  • Like suicide, DSH is associated with psychiatric illness, particularly depression and personality disorder.
  • In borderline personality disorder, repetitive self-harm (commonly superficial wrist cutting) may be carried out to relieve tension rather than because of a wish to die.

Assessment

  • The immediate priority is medical stabilisation. Subsequent psychiatric assessment first involves establishing rapport with the patient and adopting a non-judgemental approach.
  • DSH is often precipitated by undesirable life events. In most cases, its motive can be understood in terms of one or more of:
    • a desire to interrupt a sequence of events seen as inevitable and undesirable
    • a need for attention
    • an attempt to communicate
    • a true wish to die.
  • The latter, although probably the single best indicator of high subsequent risk of suicide, is seldom unequivocal or stable.
    Relevant interview topics include:
  • identification of motive(s), acute and chronic problems and associated coping strategies;
  • screening for current psychiatric illness;
  • screening for indicators of high risk: leaving a suicide note, making a will, continued determination to die, marked feelings of hopelessness and an attempt carefully prepared with precautions taken to prevent discovery and high lethality risk, either objectively or as imagined by the patient;
  • social history: risk is higher in older, male, unemployed or socially isolated individuals;
  • history of self-harm; risk of repeated non-fatal DSH is highest in subjects of low social class, with antisocial or emotionally unstable personality disorder, no work and/or a criminal record, and in those who abuse substances.

Options for DSH management

  • The objectives of DSH management are to:
    • decrease risk of repetition and of completed suicide
    • initiate or continue treatment of any underlying psychiatric illness
    • address ongoing social difficulties.
  • A good first step is to agree with patients what their problems are and what immediate interventions are both feasible and acceptable to them.
  • Ensure that they know who they can turn to if suicidal intent returns (e.g. A & E). Inpatient admission is needed for a minority; compulsory admission may be indicated where a patient has active suicidal intent.
  • Crisis Resolution Team referral may be necessary if suicidal ideation is present.
  • Think about reducing access to means of suicide if possible – for example, by encouraging patients to dispose of unneeded tablets from the home, and by prescribing antidepressants of lower lethality (e.g. SSRIs rather than tricyclics) and in small batches.
  • Consider psychological therapy and encouraging engagement in self-help and community social and support organisations.
    Dialectical behaviour therapy can reduce repetitive self-harm in emotionally unstable personality disorder.

Outcome

  • A fifth of people who self-harm repeat their act within a year.
  • Risk of actual suicide within a year is 1–2%; this is 100 times higher than in the general population.
  • Prior DSH (particularly in people with depression, bipolar disorder or schizophrenia) is the best predictor of future completed suicide.