Mental Health

Self-harm and suicide risk

Intentional self-poisoning or self-injury irrespective of apparent purpose, requiring concurrent physical care, compassionate psychosocial assessment, individualised safety planning and coordinated aftercare.

In a nutshell

Treat self-harm as intentional self-poisoning or injury regardless of apparent purpose. Manage physical emergencies and psychosocial care concurrently, assess privately and compassionately, formulate needs and safety without risk scores or global categories, agree means restriction and a written safety plan, and arrange coordinated aftercare before discharge.

Classic presentation

A person presents after intentional self-poisoning or injury; the method or stated motive cannot determine safety, so assess physical consequences, current suicidal ideation, intent, means, psychosocial context, safeguarding and support.

Key points

Self-harm and suicidal intent overlap but are not identical; ask directly about intent, plans, means, precautions and current safety.
Treat physical consequences and arrange psychosocial assessment concurrently; intoxication or an alcohol level should not be used to delay assessment, but inability to participate requires regular review.
Do not use risk tools, numerical scales or global low/medium/high categories to predict suicide or decide treatment or discharge.
Explore the person's reasons, functions, values, wishes, historic and current factors, future stressors, strengths, protective factors, comorbidities and support.
A written safety plan should include warning signs, coping strategies, supportive contacts, crisis services, emergency actions and collaborative restriction of access to methods.
Before discharge, psychosocial assessment, further-management planning and aftercare arrangements must be in place; ongoing safety concern warrants initial aftercare within 48 hours of assessment.
Treat coexisting depression, psychosis, substance use, trauma, pain and social problems; do not prescribe medication as a specific anti-self-harm treatment.

First-line investigation

Concurrent physical assessment and private psychosocial assessment with collateral where appropriate, followed by an individualised risk formulation rather than a numerical score.

Management

Stabilise and protect

Use ABCDE and current poisoning or injury pathways, place the person in a safe private environment and restrict access to dangerous means collaboratively where possible.^1,3
Start psychosocial assessment at the earliest opportunity alongside physical treatment; do not wait for completion of medical care or an alcohol level.^1,6

Formulate needs and safety

Explore the act, intent, functions, means, plans, precautions, historical/current/future factors, protective factors, comorbidity, safeguarding, capacity, support and preferences in a private, compassionate assessment.^1,2
Do not use risk tools or global categories; use a clinical formulation of immediate and longer-term psychological and physical safety.^1,6

Create a collaborative plan

Agree a written safety plan with warning signs, coping strategies, supportive contacts, crisis services, emergency actions and collaborative restriction of access to methods.^1,2
Treat underlying depression, psychosis, substance use, trauma, pain or social problems; do not offer medication specifically to reduce self-harm.^1,5

Use admission and specialist escalation appropriately

Admit or seek urgent senior mental-health care when physical care, safeguarding, severe distress/intoxication or inability to engage means safety cannot be managed otherwise.^1,3
Escalate recurrent, escalating, refractory or high-risk presentations to liaison, crisis, community or specialist services and identify a named coordinator.¹

Discharge only with coordinated aftercare

Before discharge, confirm psychosocial assessment, a joint further-management plan, appropriate discharge planning and specified aftercare with clear written primary-care communication.¹
Agree aftercare purpose, format, frequency and contacts; if safety concerns remain, provide initial aftercare within 48 hours of the psychosocial assessment and review the plan as circumstances change.^1,4

Exam traps

A low-lethality method or denial of suicidal intent does not remove the need for psychosocial assessment.
A calm patient or a normal alcohol level is not a reason to delay or downgrade assessment; if the patient cannot engage, review regularly and reassess.
Risk-scoring tools and global low/medium/high labels must not decide treatment, admission or discharge.
Do not discharge from general hospital before psychosocial assessment, a further-management plan, appropriate discharge planning and aftercare arrangements are specified.
Harm minimisation can be considered only within ongoing collaborative care and is not safer self-harm advice, a substitute for treatment or a reason to withhold emergency care.
Medication is used for coexisting conditions, not offered as a specific intervention to reduce self-harm.
Frequent presentations require a coordinated multidisciplinary review and named point of contact, not punitive responses or repeated generic assessments.

Illustrations

Psychosocial assessment structureA private, collaborative assessment map covering the act, intent, means, functions, historical and current factors, future stressors, strengths, protective factors, coexisting conditions and support.PassFinals · original

Risk formulation rather than risk scoreComparison diagram showing why a global low/medium/high score is insufficient and how individual needs, immediate safety, longer-term safety, protective factors and context inform a collaborative formulation.PassFinals · original

Collaborative safety planWritten safety-plan layout showing warning signs, coping strategies, supportive contacts, crisis services, emergency actions and agreed restriction of access to self-harm methods.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.