Intended for healthcare professionals

Rapid response to:

Primary Care

General practice based intervention to prevent repeat episodes of deliberate self harm: cluster randomised controlled trial

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7348.1254 (Published 25 May 2002) Cite this as: BMJ 2002;324:1254

Rapid Response:

Intentional Self-Injury Patterns and Interventions

This study speaks to the frustrations and very real risks of patients presenting at hospital EDs with intentional self-injury.

What is interesting to me as a community based clinician are the study population exclusions noted below:

"Exclusions

We excluded cases of alcohol (taken alone) and illicit drug overdose, except where the casualty officer felt that the purpose of the act was self harm or suicide. We excluded patients who were under 16, of no fixed abode, or imprisoned; who had requested that nobody was to be informed of the episode or had harmed themselves deliberately in response to a psychotic hallucination or delusion; or whose episode of deliberate self harm was managed entirely in primary care."

While this study protocol make efforts to eliminate uncontrollable variables that influence impulsivity, cognition, and lifestyle, it eliminates the bulk of the self-harming population who repeat these behaviors and represent at EDs in varying frequencies and levels of injury. It is the bulk of folks who are the highest risk, repeat event admissions who cost EDs and health care tremendously in personnel, treatment costs and stress.

The pattern of self-harm beginning in adolescence frequently leads to concommitant and comorbid factors such as homelessness or drifting, alcohol and drug use which disinhibit and/or are acts of self-medication, and frequent hallucinatory (non-drug) or delusional experiences arising from previous trauma which is the substratum for a substantial number of repeat self-harm cases. There also are frequent problems with law enforcement as during episodes of derealization/depersonalization/loss of impulse control, self-harming individuals often are arrested and detained for legal infractions.

In my 20 years' experience the intervention offered in this study of: a letter to the primary physician, an invitation to receive follow-up care and a copy of guidelines would not be seen as "helpful" by most self-injuring patients. The balance of cases which are included in the study are usually situationally reactive in nature and also not likely to follow up. Those more dependent in personality might follow-up if this was done by a phone outreach so that they would feel more of a caring connection.

In the US, most EDs and primary care providers follow a protocol of a mandated mental health assessment as soon as medical stabilization is achieved. All cases of self-harm are seen as high risk and/or suicidal so that for those who refuse a voluntary assessment, an involuntary assessment at the ED will be sought (or in hospital if admission has been required). It is following this consult that a determination will be made regarding intervention and treatment. The medical/mental health collaboration is seen as an essential part of risk management. Also, the link is established between the patient and mental health provider/system that strengthens liklihood of followup within days. Medications, if indicated and accepted by the patient, are begun at the ED or within a few days in most cases. In the region where I work, there are no psychiatrists for 150 miles, so primary care providers initiate and monitor medications.

Medications AVOIDED include tricyclic antidepressants, benzodiazepines, and pain management opioids. Medications UTILIZED are usually SSRIs to start and often atypical antipsychotics such as risperidone if the individual enters follow-up treatment. Few primary care providers try to manage self-harming patients without mental health consult because of the risks and frustrations of repeat incidents. This relieves the tremendous burden medical providers carry in frontier areas such as Easterm Montana where the distances from medical center access are in the hundreds of miles.

In most cases, the effects of interventions support the collaboration and decrease the anger and frustrations of the providers thus maintaining compassionate patient care for individuals who challenge the patience of even the most experienced medical providers. It does not seem to make much of a deterrent in patients struggling with the addiction to self-injury to relieve psychic pain or thepatient in the throws of flashback to abuse.

It would be interesting to see a study of repeat self-injury patterns including those excluded.

Respectfully Submitted,

Aliceann Carlton, MACP, LCPC

Eastern Montana Community Mental Health Center

Competing interests: No competing interests

27 May 2002
Aliceann Carlton
Licensed Clinical Therapist
Eastern Montana Community Mental Health Center USA 59301