Clinical Notes : Mental Health

31. Deliberate Self Harm


Self-inflicted injury that is not associated with an implicit or explicit intent to die.

Examples of self-harm behaviours include burning/cutting after an emotionally upsetting event or burning/cutting as a method of manipulation or threat.



  • 3-5% population and increasing

  • 25% repeat self harm within 4 years (highest within first year)

  • Long-term suicide risk is high 3-7% following DSH

    • 49 x higher compared to general population

    • 100 x higher in the first year

  • Most at risk :

    • females age 15-24 (RR 3.75)

    • male low socioeconomic class (RR 2.17)



  • Ensure safe environment while waiting to be seen

    • Someone present at home

    • Public waiting room at OOH service

  • Sensitive and compassionate approach

    • Where possible, the person should be seen alone initially to maintain confidentiality

    • Non-judgemental interaction

    • Mind clinician’s own body language

  • Psychological assessment at initial presentation

    • Ask the patient what would make them feel safe

  • Psychological assessment and risk of further self-harm assessment

    • feelings of hopelessness,

    • level of understanding of own self-harm,

    • level of emotional distress,

    • associated mental health disorder, such as depression or schizophrenia.

  • Suicide risk assessment

    • Clearly document the risk

    • Note : asking about suicide ideation does not increase the risk/incidence of suicide

  • Physical risk assessment

    • E.g  acute bleeding following self-cutting, or risk of acute liver failure following paracetamol ingestion


Refer to A&E

  • Cases of self-poisoning

    • Patient often not a reliable witness with regard to quantity and type of drug ingested

  • All patients deemed at risk of suicide

    • Consideration to mode of transport is essential if at risk of suicide and reluctant to attend other services



  • Allow patient choice regarding treatment plan, loss of control can play a part in self harm and so giving patients choice and supporting that choice can be important

  • Physical

    • Injuries should be treated with adequate analgesia/ local anaesthetic

  • Psychological

    • Referral based upon assessment of risk

  • Pharmacological

    • No pharmacological interventions have been shown to be of benefit


Calm Harm

Award-winning app using the basic principles of Dialectical Behavioural Therapy (DBT).


Calm Harm provides tasks to help resist or manage the urge to self-harm. 


The app is an aid in treatment but does not replace it.

The epidemiology of self-harm in a UK-wide primary care patient cohort, 2001–2013

Matthew J. Carr, Darren M. Ashcroft, Evangelos Kontopantelis, Yvonne Awenat, Jayne Cooper, Carolyn Chew-Graham, Nav Kapur, and Roger T. Webb

BMC Psychiatry. 2016; 16: 53.

Published online February 2016




NICE Quality standard QS34. June 2013


Better services for people who self-harm- Quality standards for healthcare professionals.

Royal College of Psychiatrists. College Report CR158

June 2010

February 2006




Royal College of Psychiatrists.

February 2016



Saving Lives and reducing Harmful Outcomes : Care Sysytems for Self-Harm and Suicidal Behaviour

National Guidelines for the Assessment and Management of Patients Presenting to Irish Emergency Departments following self-harm. HSE

March 2012


Ireland notes.png

There should be a single point of contact for ED staff to access MH services for patients and the referral procedure should be a simple one. Services should be available in the ED that span the entire age range and are provided irrespective of the catchment area /address of the patient.



Liaison Psychiatry: During agreed hours for adults, this should be the Liaison Psychiatry team based on-site as there is consensus in Ireland and elsewhere that mental health service delivery to acute/emergency medical patients is best provided by a specialist ‘Liaison’ mental health team based on-site.

Out-of-hours in all 24/7 EDs, there should be mental health staff available on-site, supported by a Consultant on-call.


Children & Adolescents:

Timely access to MH services must be available at all times for children and adolescents attending the ED in crisis.

All major EDs should have defined access to assessment by Child and Adolescent Mental Health services (CAMHS) via a simple referral procedure. Ideally this should be a dedicated Liaison CAMHS supported by the on-call CAMHS.

This service should be accessible 24/7 via a single point of contact.

In any event, the MH service responsible for assessment of 16 and 17 year-olds in the ED should be explicit.

In addition to this it is essential that there should access to child protection services including out of hours and weekends.


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