Advances in Psychiatric Treatment (1995), vol. 1, pp.124-130

Assessment of deliberate self-harmin adults

David Owens & Allan House

Deliberate self-harm remains a common problemin the United Kingdom, with rates in the order of250-300 per 100 000 per year (Hawton & Fagg,1992). Since the suicide rate in the 12 months afterhospital attendance for deliberate self-harm isaround 1% (Hawton & Fagg, 1988), each yearapproximately 2-3 per 100 000 of the populationdie by suicide within a year of attending hospitalwith a non-fatal episode of deliberate self-harm.This is about a quarter of the overall suicide rateof 11 per 100000. There is therefore an easilydefinable group at risk of suicide who should bethe focus of a suicide prevention strategy.

Conscious of a need to improve services for self-harm patients, the Royal College of Psychiatristsrecently examined standards of care. The thenAudit Working Group of the College and itsLiaison Psychiatry Special Interest Group arrangeda consensus conference of mental health and publichealth professionals to consider and set standardsfor the hospital management of adult deliberateself-harm patients. Many of the steps towardsbetter care and the standards suggested below aredrawn from the agreed statement which resultedfrom that meeting (Royal College of Psychiatrists,1994). All those who are involved with servicesfor deliberate self-harm should examine therecommendations of the College closely.

Organisation of services

Despite the scale of deliberate self-harm, planningand delivery of services are in disarray locally andnationally. The situation in most places is much asdescribed in an audit carried out in one hospitalin the 1970s. Blake & Mitchell (1978) found widevariations in the aftercare arrangements made bythe ten separate consultant teams responsible for

the deliberate self-harm assessment service. Forexample, further follow-up was arranged foralmost all patients by one team but for less thanhalf by another. More contemporary figures fromaround the country vary just as much: referralsfor psychiatric care range between 21% (Hawton& Catalan, 1987) and 76% (Hamer et al, 1991).

Variations in the actions of clinicians areparalleled by inconsistencies in organisation ofservices. A survey around Yorkshire Regionrevealed that less than half of districts had writtenguidelines on management of deliberate self-harm,or had a named consultant psychiatrist withresponsibility for the service (Renvoize & Storer,1991, unpublished). A national survey of practicein the late 1980s suggested that there had been littlemovement towards the use of specific self-harmteams and only a quarter of health districtsreported use of multi-disciplinary assessment assuggested in the 1984 Department of Health andSocial Security guidelines (Butterworth & O'Grady,

1989).This is unfortunate because there is evidence that

staff other than psychiatrists can make satisfactorypsychosocial assessments of self-harm patients.These staff are most commonly social workers(Newson-Smith & Hirsch, 1979) and psychiatricnurses (Catalan et al, 1980). Non-psychiatricmedical staff have been shown to be competent inassessing in-patients (Gardner et al, 1977) andattenders in the accident and emergency (A & E)department (Gardner et al, 1982; Waterhouse &Platt, 1990; Owens et al, 1991).

Whatever the style of assessment and aftercare,self-harm services need to be planned, andresponsibilities defined. Because of the scale andimportance of deliberate self-harm, those whocommission and purchase hospital services areincreasingly likely to want specifications forminimum quality. Each hospital or Trust shouldtake a number of steps.

David Owens is Senior Lecturer in Psychiatry, Division of Psychiatry and Behavioural Sciences, University of Leeds, 15 Hyde Terrace,Leeds LS29LTAllan House is Senior Lecturer in Liaison Psychiatry, University of Leeds, and Consultant Liaison Psychiatrist, Leeds General Infirmary,Great George Street, Leeds LSI 3EX

Deliberate sei APT (1995), vol. 1, p. 125

Self-harm services planning group

A deliberate self-harm services planning groupshould be set up. A consultant and a nurse from A& E, general medicine and psychiatry are theobvious clinical members of the planning group,together with a social worker. Also essential are asenior manager and a representative of purchasers.The involvement of several distinct parts of thehospital or Trust points to inclusion of aninformation officer to help with service monitoring.

A designated clinical team

Two aspects of the work have led some hospitalsto set up a designated, multi-disciplinary deliberate self-harm clinical team - staffed by a varietyof psychiatrists, nurses, social workers and others.First, such teams can coordinate and deliverprompt services for the hundreds of patients to beassessed across the different settings in thehospital. Second, interventions following self-harmdiffer from those used in general psychiatricpractice. Although identifying and institutingtreatment for severe mental illness is among themost important tasks in the assessment ofdeliberate self-harm patients, in a majority of

patients the precipitating events are psychosocialproblems which are not amenable to routinetreatments for mental illness. Self-harm clinicalteams must offer psychosocial interventions, oftenbased around helping patients to learn new waysto solve problems, through a mixture of cognitive-behavioural and counselling techniques.

Specialist multi-disciplinary teams can improvequality of care for deliberate self-harm patients andeach planning group should consider setting oneup. A specialist team may not be feasible in smalldistricts, particularly in rural areas. In thosecircumstances sectorised multi-disciplinary mentalhealth teams may more appropriately offer theassessment and aftercare. In larger hospitals it isdifficult for multiple sector mental health teamsto offer the full range of interventions swiftly andto communicate adequately with the relevantdepartments. In either case - special teams orregular mental health services - the planning groupmust ensure the support of psychiatric colleaguesso that the general adult psychiatric serviceprovides necessary backup (for example, out-of-hours and holiday cover) for the assessment of self-harm patients in A & E and on in-patient wards.

Policy on direct discharge

Published reports from around the country revealthat in many hospitals between a quarter and a

half of all self-harm patients are discharged directlyfrom the A & E department (Owens, 1990). A highproportion of these patients are not assessed byspecialist mental health staff before their discharge.Often this practice is not openly acknowledged;discharge without specialist referral will occurfrom some A & E departments, but there shouldalways be a written policy, and cases should bedocumented so that rates of discharge and referralcan be monitored and audited.

Recovery time

Some patients will need time to recover theirequanimity before a decision can be made aboutwhat to do next. Sometimes a relative or otherinformant is awaited, or there may be social needswhich must be organised. It is therefore importantthat there are facilities to allow some patients timeeither in A & E or a medical ward for a degree ofrecovery. Short-stay wards may be a useful settingfor brief admissions; patients should not spendmany hours in A & E.

Training and supervision

Opinions vary on how best to carry out psycho-social assessment of patients who attend hospitalas a result of deliberate self-harm (usually self-poisoning, less often self-injury). Although therehas been a good deal of argument about whoshould carry out such assessments, these issueswere largely resolved before the latest set of officialguidelines were issued ten years ago (Departmentof Health and Social Security, 1984). In particular,evidence was accepted that in some circumstancesadequate assessment could be carried out by non-psychiatrists (Black & Pond, 1980). As the currentguidance stands, "the consultant who has charge

of the patient whether in the Accident andEmergency department or in a ward will beresponsible for ensuring that a full physicalassessment is made and that before patients aredischarged from hospital, a psychosocial assessment is carried out by staff specifically trained forthis task" (Department of Health and Social

Security, 1984).In reality, patients are often not assessed by staff

with adequate training and supervision inpsychosocial assessment before their discharge.Even when patients are referred for specialistpsychiatric assessment, whether in A & E or on anin-patient ward, they are frequently seen by juniorpsychiatrists with indifferent supervision.

~Th± s One

APT (1995), vol. 1, p. 126 Owens & House

Non-specialist staff

Where A & E and other non-psychiatric medicalstaff undertake psychosocial assessment of self-harm patients they should undergo post-qualification training. The planning group for eachhospital should arrange for newly appointed A & Eand general medical staff to receive training beforethey are expected to carry out this task, probablywithin days of taking up a post.

As well as training, A & E medical staff whocarry out assessments need supervision by seniorstaff who have themselves had designated trainingin psychiatry. It is now commonplace for thoseappointed as consultants in A & E to have spent aperiod of post-qualification training in psychiatry,but where they have not, appropriate supervisionneeds to be identified. If physicians opt toundertake psychosocial assessment of in-patientswithout calling in the specialist self-harm team ora psychiatrist, that assessment then becomes amajor part of the patient's management and must

be dealt with by the medical team as a whole(involving nurses, senior doctors and other staff)and not by an unsupervised house officer.

Specialist staff

In many cases, however, a specialist mental healthworker will be called to A & E or an in-patientward in order to assess deliberate self-harmpatients. This person should be suitably trainedand supervised, but need not be a psychiatrist.There are numerous services in which nurses andsocial workers act as specialist assessors. Whateverthe professional background of the specialistassessor, there are minimum standards for theirtraining. Someone new to the task should undertake observed assessments, i.e. under directsupervision, until judged competent. Newspecialist staff should be provided with or directedto relevant literature.

During the first six months of carrying outspecialist assessments, every case should besupervised, and the management should bediscussed in detail with a designated supervisor.Out of hours, when cases can be particularlycomplex, self-harm assessments by new staffshould routinely be discussed with the on-dutyconsultant or senior registrar. Rotational seniorhouse officers who have previously undertakenwork of this kind do not need to discuss every casein detail but they should routinely discuss, overthe telephone or face-to-face, the management witha designated supervisor. Psychiatric registrars

should have the experience to decide when todiscuss management with a more senior person.

The planning group should set a policy forsupervision of non-medical staff once they areadequately trained for self-harm assessments.These arrangements will vary according to theexperience of the specialist nurse or social worker,and the views of senior psychiatrists - both in theplanning group and within adult psychiatry in thedistrict.

Tricky areas of clinical responsibility arise whenspecialist staff are asked to make an assessment.First, is the specialist providing advice to the A & Eor medical team, or acting autonomously andmaking management decisions? Second, is atraining-grade doctor or a non-medical specialistacting independently or on behalf of a consultantpsychiatrist? Local views on these issues will vary.The essential thing is written guidance, preferablyagreed across the service; another job for thedeliberate self-harm services planning group.

Assessment of patients

The purpose of psychosocial assessment is toidentify among self-harm patients those who havea psychiatric illness, high suicide risk, co-existingproblems (for example alcohol or drug problems),and those in social crisis. Those with mental illnessor a substance use problem may need prompt andeffective psychiatric treatment, and where otherpsychosocial problems are identified patientsshould have access to various forms of social andpsychological help.

The first task in A & E and on a medical or short-stay ward will usually be to provide promptassessment and effective treatment of the patient's

physical condition in order to minimise risk ofdeath and disability. However, not far behind inimportance and urgency are detection of suiciderisk and of severe mental illness. Patients in A & Einclude some who may leave the hospital precipitately due to an abnormal mental state. Therefore,when the presenting complaint is deliberate self-harm, prior to any consultation a member of theA & E staff (probably a nurse) should answer threequestions immediately after the patient's arrival :

(a) Is the person physically fit to wait?(b) Is there obvious distress?(c) Is the person likely to wait until seen by the

accident and emergency doctor?This process should lead to rapid medical

assessment for some patients and for some arequest for psychosocial assessment in A & E.

Deliberate self-harm APT (1995), vol. 1, p. 127

Nurses on general medical and short-stay wardsshould be trained in the nursing of suicidal patientsand be able to produce a nursing care-plan whichassesses immediate risk and recognises that riskfluctuates.

When a psychosocial assessment is undertakenin A & E or on a ward, the physical environmentneeds to be adequate. Each patient should beinterviewed in a setting which accords with privacy,confidentiality and respect. There should be adesignated room to which patients can be directedfor the necessary interview. In A & E the roomshould be close to, or part of, the main receivingarea and should have a suitable security system.Psychosocial assessment should be carried out insuch a room unless it is inappropriate (forexample,when a patient is threatening and abusive and it isnecessary for other staff to be present or immediately available).

Information to be documented

Whether psychosocial assessment is carried out byA & E medical staff, psychiatrists or specialist non-medical staff, it should be systematic. Theinformation in Box 1 should always be collectedand documented in either A & E or standardhospital casenotes. A pre-printed checklistprepared by the planning group may assist withthis task.

The most important information is level ofconsciousness. If the drugs or alcohol taken haveimpaired the patient's consciousness then much

of the assessment is rendered unreliable or maybe impossible to carry out. Where an intoxicateddeliberate self-poisoning patient wants to leaveA & E or a ward without assessment, staff nevertheless have an obligation to carry out as muchassessment as is possible - and to take appropriateaction, especially if the patient continues to expresssuicidal intent.

It is particularly important for A & E andmedical staff to recognise that deliberate self-harmpatients with impaired consciousness must be able

Box 1. Information to be collected anddocumented during assessment

Conscious levelPsychiatric history and mental state exam

inationSocial situation and eventsRiskAlcohol and drug useDecisions takenSpecific arrangements for any follow-up

to stay in hospital until fully assessed, even ifassessment needs to be delayed for physical,psychiatric or social reasons. If monitoring revealsthat discharge of in-patients who have not undergone specialist assessment is commonplace,regular meetings between general medical staffand the specialist self-harm team should be held.

Where the patient's condition and the physical

surroundings permit adequate psychosocialassessment, assessing risk may be the most difficulttask. In this article we have concentrated on theimportance of proper procedures for self-harmassessment. Assessment of risk in individualpatients is a topic which warrants a separatearticle; only a few remarks about it are includedhere, with useful references for further reading.

Risk assessment

There are available lists of risk factorswhich predictrepetition of self-harm or subsequent suicide(Hawton & Catalan, 1987; Williams & Morgan,1994). However, although factors such as psychiatric history, past episodes of self-harm, oradvancing age may indicate increased risk amonggroups of patients, predictive values of all riskfactors are poor, and consequently of limitedclinical value (Owens etal, 1994).In the assessmentof the risk for an individual patient attention needsto be paid to three key areas: suicidal intent at thetime of the self-harm, present psychiatric state, andsocial support.

Suicidal intent has been studied closely by Becket al (1974)and their intent scale is widely used inclinical practice; it is reproduced in the excellentbook on self-harm by Hawton & Catalan (1987).Assessing the present psychiatric state requires afull history and mental state examination.Particular attention needs to be paid to indicationsof depressive features, especially hopelessness.Adverse social circumstances add to despair andit is essential to enquire into the extent of thepatient's social support. Useful guides to interviewing self-harm patients, with specificquestionsabout intent, present state and social support, areincluded in one of the Health of the Nationpublications - a review on the theme of suicideprevention, carried out by the Health AdvisoryService (Williams & Morgan, 1994). Table 1 setsout some examples of important questions aboutintent, psychiatric state and social support.

Certain groups of patients can be particularlydifficult to assess. For patients aged over 65 years,and those with a learning disability, referral to thespecialist service as a matter of routine isrecommended. Some would advocate routine

APT (1995), vol. 1, p. 128 Owens & House

Table 1. Estimating risk of further suicidal behaviour: examples of enquiry'

Risk factors

Suicidal intentof self-harm episode

Present psychiatric state

Social support

Past psychiatric contact or admission, previous self-harm, advancing age,living alonePremeditation, risk of discovery, calls for assistance, patient's stated intent, actuallethality of method and patient's perception

Recent history of depressive features, guilt, hopelessness, desperation,suicidal thoughts or plansHousing, employment, support from family or partner, isolation or solitude,professional helper (for example, social worker)

1. These are only examples - see text for references to more complete lists.

referral to specialists of all deliberate self-harmpatients aged under 18 years.

In many hospitals a large proportion of self-harmpatients are discharged directly from A & E. Theevidence is that those who return home are, ingeneral, a group whose risk of further suicidalbehaviour is lower than those who are admittedto medical or short-stay wards; they are youngerand have less history of self-harm or of psychiatriccare (Owens et al, 1991). Where the patientsdischarged from A & E are being selectedappropriately, there must be a correspondingconcentration of morbidity and risk within theremainder who are admitted to medical or short-stay beds. This in turn will make the task ofassessing these patients more difficult.

Accident and emergency staff must haveimmediate access to telephone advice, either froma psychiatrist whose designated duties includeattendance at A & E, or from another designatedself-harm health specialist (a nurse or socialworker) who is equipped to undertake psycho-social assessment and management. A request foremergency attendance should result in the promptarrival of a member of the self-harm specialist teamor a duty psychiatrist. There should also beavailable social services assistance for those self-harm patients who have significant social difficulties (for example, homelessness).

If all in-patients are referred for specialistassessment, there will be no need for the generalmedical staff to do more than make the initialassessment of immediate risk and disturbance ofmental state. The system for referring patientsshould be efficient and clearly understood byphysicians, nurses and others on medical wards,psychiatric clerical staff, and those who undertakethe assessment.

Patients should be seen for assessment on thesame working day provided that the referral ismade from the ward during the first part of themorning. At weekends and public holidays insmall hospitals it may not be possible to arrangefor a daily round of routine assessment. However,when a psychiatric emergency arises with adeliberate self-harm patient - as it does from time

to time - it should be agreed policy that a memberof the self-harm specialist team or a dutypsychiatrist will attend any hospital ward withinone hour of an urgent request for consultation fromthe medical team in charge of the patient's care.

Where there is no designated self-harm team,the rota for routine assessments of self-harmpatients should name the consultant team responsible for the assessment rather than the names oftrainee psychiatrists. This step helps to emphasisethat assessment of deliberate self-harm patientsshould be a scheduled team activity with adequatetime and supervision set aside.

Intervention

It is unfortunate that neither officialguidelines norresearch findings have led to uniformly highstandards of service,because the research evidencestrongly suggests that psychiatric intervention canimprove psychiatric and social function afterdeliberate self-harm; whether it can reducerepetition rates or suicide rates is not yet clear.Sixrandomised controlled trials of psychosocialaftercare have been undertaken in the UK.Although they used widely differing interventions,each showed significant improvements amongthose receiving the psychosocial intervention,compared with the patients receiving routine care.The studies, their interventions, and findings aresummarised in Table 2.

In the two earliest studies repetition rates weresimilar in those receiving new and establishedinterventions. The four more recent studies foundmarkedly less repetition among those receiving thenew intervention. All six studies were however fartoo small to ensure a definite answer on loweringrepetition (House et al, 1992);and intervention toreduce suicide following non-fatal self-harmcannot be demonstrated without a study of manythousands of patients. In the likelihood of acontinued lack of such a study, demonstrableimprovements in outcomes such as repetition

Deliberate self-harm APT (7995), vol. 1, p. 129

might be taken as a reasonable proxy measure ofreduction in suicides. Webadly need more researchfindings about the interventions best suited fordeliberate self-harm patients.

In the meantime, what should be done? In apractical way Hawton & Catalan's book indicateshow the specialist deliberate self-harm counsellorsin Oxford approach the real problems encounteredby their patients. The authors describe how toformulate problems and tackle them with briefpsychotherapeutic and social interventions.Further description of problem-solving after self-harm is provided by Salkovskis et al (1990) in areport of a small but successful intervention studyusing cognitive-behavioural techniques. From apreliminary study (Morgan etal, 1993)it also seemspossible that further self-harm may be reduced bygiving the patient written guidance on how to gainaccess to psychiatric help at times of crisis. Thecard given to deliberate self-harm patients inBristol is reproduced in the Health AdvisoryService document referred to previously (Williams& Morgan, 1994).

Aftercare

One of the established findings about aftercare forself-harm patients is the tendency of many todefault from follow-up appointments. In a recentstudy in our hospital of almost 200 self-harmpatients who repeated within one year of an indexepisode, their median time to repetition was 12weeks; a quarter had repeated by only three weeks

from the index episode (Gilbody et al, submittedfor publication). This means that where any kindof follow-up appointment is arranged, it must bevery prompt to be effective,probably within sevenworking days of discharge from hospital.

On leaving hospital, the patient should be givenwritten information about how to seek furtherhelp, together with written details of the treatmentplan and who to contact if in doubt about thearrangements. Whoever makes the decision todischarge the patient should ensure that thepatient's GP is contacted promptly, often teleph

oning during the next 24 hours. A discharge letter,including all the information in Box 1, should besent out within a few days. To assist both GP andpatient, the letter should record whether the GPagreed to see the patient, and what action thepatient was told to take in order to see the GP.

It should be standard practice for a relative orother informant to be contacted, in order to obtaindetails about the circumstances of the self-harmevent, and to discuss any aftercare or discharge.Where medical or A & E staff undertake psycho-social assessments, they need to be able to producea practical management plan which showsawareness of local facilities (such as psychiatricclinics, social work services, and voluntaryservices).

References

Beck, A. T., Schuyler, D. & Herman, J. (1974) Development ofsuicidal intent scales. In ThePredictionofSuicide(eds A. T. Beck,H. L. P.Resnick & D. J. Lettierite). Maryland: Charles Press.

Table 2. Six randomised treatment trials in deliberate self-harm: Details of methods ami outcome

Study

Chowdhuryfia/(1973)Gibbons et ni(1978)

Hawton et ai(1981)

Hawton et ai(1987)

Salkovskis et al(1990)

Morgan et ai(1993)

u Nature of intervention

197 General psychiatry

400 Task-centred social work

96 Brief problem-orientedcounselling (Domiciliaryv. out-patient care)

80 Brief problem-orientedcounselling (Out-patientv. general practitioner care)

20 Problem-solving therapy

Repetition rateTreatment Control

24%

14%

10%

7%

0%

23%

15%

15%

15%

38%

212 Giving of a card setting out help 5% 11%available (if despairing or closeto further self-harm)

Other outcomes(benefits seen in treatment group)

More improvement in social circumstances

Less psychiatric contact;more satisfaction with services;more improvement in social problemsMore improvement in socialadjustment

More improvement in target problems (inwomen); more improvement in symptoms(General Health Questionnaire) and mood(Beck Depression) scores; more improvement in social adjustmentMore improvement in mood (Beck Depression) scores; greater reduction inhopelessnessFewer patients who either threatened orcarried out further self-harm

APT (1995), vol. 1, p. 130 Owens & House

Black, D. & Pond, D. (1980) Management of patients after self-poisoning. British Medical Journal, 281, 1141.

Blake, D. R. & Mitchell, J. R. A. (1978) Self-poisoning:management of patients in Nottingham, 1976.British MedicalJournal, i, 1032-1035.

Butterworth, E. & O'Grady, T.J. (1989)Trends in the assessmentof cases of deliberate self-harm. Health Trends,21, 61.

Catalan, ]., Marsack, P.,Hawton, K., et al. (1980) Comparison ofdoctors and nurses in assessment of deliberate self-poisoningpatients. PsychologicalMedicine, 10, 483-491.

Chowdhury, N., Hicks, R. C. & Kreitman, N. (1973) Evaluationof an aftercare service for parasuicide (attempted suicide)patients. Social Psychiatry, 6, 67-81.

Department of Health and Social Security (1984) The Management of DeliberateSelf-harm(HN(84)25). London: Departmentof Health and Social Security.

Gardner, R., Hanka, R., O'Brien, V.C., et al (1977) Psychologicaland social evaluation in cases of deliberate self-poisoningadmitted to a general hospital. BritishMedicalJournal, ii, 1567-1570.

, , Roberts, S. J., et al (1982) Psychological and socialevaluation in cases of deliberate self-poisoning seen in anaccident department. British Medical Journal, 284, 491—493.

Gibbons, J. S., Butler, P., Urwin, P.,et al (1978) Evaluation of asocial work service for self-poisoning patients. British Journalof Psychiatry, 133, 111-118.

Gilbody, S., House, A. & Owens, D. Early repetition of deliberateself-harm. Submitted for publication.

Hamer, D., Sanjeev, D., Butterworth, E., et al (1991) Using theHospital Anxiety and Depression Scale to screen forpsychiatric disorders in people presenting with deliberateself-harm. British Journal of Psychiatry, 158, 782-784.

Hawton, K., Bancroft, J., Catalan, J., et al. (1981) Domiciliaryand out-patient treatment of self-poisoning patients bymedical and non-medical staff. PsychologicalMedicine,11,169—177.

& Catalan, J. (1987) Attempted Suicide: a Practical Guide toits Nature and Management (2nd edn). Oxford: OxfordUniversity Press.

& Fagg, J. (1988) Suicide, and other causes of death,following attempted suicide. BritishJournal ofPsychiatry, 152,359-366.

& (1992) Trends in deliberate self poisoning and selfinjury in Oxford, 1976-90. British Medical Journal, 304,1409-1411.

, McKeown, S., Day, A., et al (1987) Evaluation of out-patientcounselling compared with general practitioner carefollowing overdoses. PsychologicalMedicine, 17, 751-761.

House, A., Owens, D. & Storer, D. (1992) Psychosocialintervention following attempted suicide: is there a case forbetter services? International ReviewofPsychiatry, 4,15-22.

Morgan, H. G., Jones, E. M. & Owen, J. H. (1993) Secondaryprevention of non-fatal deliberate self-harm. The green cardstudy. British Journal of Psychiatry, 163, 111-112.

Newson-Smith, J. G. B. & Hirsch, S. R. (1979) A comparison ofsocial workers and psychiatrists in evaluating parasuicide.British Journal of Psychiatry, 134, 335-342.

Owens, D. (1990) Self-harm patients not admitted to hospital.Journal of the Royal College of Physicians of London, 24, 281-283.

, Dennis, M., Jones, S., et al (1991) Self-poisoning patientsdischarged from accident and emergency: risk factors andoutcome. Journal of the Royal Collegeof Physicians of London,25, 218-222.

, , Read, S., et al (1994) Outcome of deliberate self-poisoning: an examination of risk factors for repetition. BritishJournal of Psychiatry , 165, 797-801.

Renvoize, E. & Storer, D. (1991) The assessment and management of deliberate self-harm patients attending Accident andEmergency departments, and admitted to general hospitalwards, in the Yorkshire Region. Unpublished report.

Royal College of Psychiatrists (1994) The General HospitalManagement of Adult Deliberate Self-Harm: a ConsensusStatement on Standards for Service Provision. (Council ReportNumber 32.) London: Royal College of Psychiatrists.

Salkovskis, P. M., Atha, C. & Storer, D. (1990) Cognitive-

behavioural problem solving in the treatment of patients whorepeatedly attempt suicide: a controlled trial. British Journalof Psychiatry, 157, 871-876.

Waterhouse, j. & Platt, S. (1990) General hospital admission inthe management of parasuicide. A randomised controlled trial.British Journalof Psychiatry, 156, 236-242.

Williams, R. & Morgan, H. G. (1994) Suicide Prevention: theChallengeConfronted. A Manual of Guidancefor PurchasersandProvidersofMental HealthCare.London: HMSO.

Multiple choice questions

1 Current Department of Health guidelines onmanagement of deliberate self-harma are largely adhered to across the UKb recommend multi-disciplinary assessment of

patientsc have led extensively to the setting-up of self-

harm assessment teamsd allow for psychosocial assessments by non-

psychiatric medical staffe allow for psychosocial assessments by non-

medical health professionals2 Discharge of deliberate self-harm patients

directly from A & E departmentsa accounts for between a quarter and a half of

patients at some hospitalsb is a local policy which rests with the A & E

consultantc runs contrary to the current Department of

Health guidelinesd is usually only undertaken after patients have

received psychosocial assessment by staffspecially trained for that task

e has not proved to be unsafe when examinedin research studies

3 Research into psychosocial intervention following deliberate self-harma has shown psychosocial intervention to be

ineffectiveb has shown that psychosocial intervention can

reduce subsequent suicidec has shown that psychosocial intervention can

reduce repetition of self-harmd has shown demonstrable psychosocial

benefits from psychosocial intervention inseveral clinical trials

e has led to improved services for self-harmpatients

MCQanswers1a

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T2a

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