Psychiatry - self-harm and suicidal behaviour
Description
- Self-harm: intentional self-injury with or without suicidal intent (coping mechanism, communication of distress, or suicide attempt)
- Suicidal behaviour: spectrum from ideation (passive/active) -> plan -> attempt -> completed suicide
Epidemiology
- Self-harm most common in adolescents/young adults, F>M for non-fatal self-harm; completed suicide M>F (higher lethality of method)
- Suicide a leading cause of death in young Australians
- Highest-risk groups: prior attempt (strongest single predictor), psychiatric illness, substance use, chronic pain/illness, Indigenous Australians, LGBTQ+ youth, rural/remote (means access), post-discharge from psychiatric admission
Aetiopathogenesis
- Multifactorial - psychiatric illness (depression, psychosis, personality disorder, substance use), psychosocial stressors (relationship breakdown, financial, legal, bereavement), access to lethal means, social contagion/exposure
- Self-harm without suicidal intent often functions as emotional regulation - distinct psychological driver from an attempt with intent to die
Diagnosis
- Move away from fixed risk-stratification tools/checklists (e.g., labelling "low/medium/high risk") as a sole basis for disposition decisions - poor predictive validity
- Instead: collaborative, detailed clinical assessment - explore intent, method, lethality, planning, protective factors, access to means, ongoing ideation, the patient's own understanding of their risk
- Assess for underlying/precipitating psychiatric illness, substance use, psychosocial stressors
- Involve family/carers where appropriate and consented
Management
1. Immediate safety
- Means restriction counselling (remove/limit access to medications, firearms, other lethal means) - one of the few interventions with clear evidence of benefit
- Collaborative safety planning (not a rigid checklist) - warning signs, coping strategies, support contacts, professional/crisis contacts
- Admission if acute high-lethality risk, ongoing intent, or inadequate supports - least restrictive setting consistent with safety
2. Ongoing care
- Treat underlying psychiatric illness (depression, psychosis, substance use) - specific evidence-based therapy (DBT for recurrent self-harm/borderline personality disorder)
- Close follow-up post-discharge - highest risk period is the weeks immediately following a psychiatric admission/ED presentation
- Involve family/community supports, address modifiable psychosocial stressors
3. Documentation and communication
- Document assessment reasoning narratively rather than reducing to a risk category label
- Clear handover and follow-up plan given transition periods carry the highest risk
Associations
- Depression, psychotic disorders, personality disorder (esp. borderline), substance use disorder
- Chronic pain, chronic illness, LGBTQ+ discrimination/minority stress
- Bereavement by suicide (postvention support needed for family/friends)
Natural history & complications
- Prior self-harm/attempt is the strongest predictor of future attempts and completed suicide
- Risk fluctuates - a "low risk" assessment today does not predict low risk indefinitely; risk is dynamic and situational
- With appropriate treatment of underlying conditions and psychosocial support, most people who self-harm do not go on to die by suicide
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