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Figure 5 . Healed scars from a prior self-harm . |
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and suicide . 45 Group self-harm and suicide attempt clinical profiles also overlap : earlier onset and longer duration of self-harm pose increased risk for suicide attempts in adolescents ; while concurrent self-harm and mood disorders do the same for suicide attempts in adults . Those hospitalised with medically serious suicide attempts constitute the minority of clinical presentations , with most patients managed in the community , after ( often ) hospital-based mental health review and medical treatment . 46
However , most adolescent suicidal behaviours remain unknown to clinical services . 47 These behaviours occur in relation to common mental health problems ( for example , anxiety , depression and eating disorders ) and stressful life events , including academic and exam pressures , problematic family relationships or conflicts , separation / loss , offline and / or online bullying and peer pressure , caring for loved ones with physical / mental disabilities and abuse / trauma . 48
GPs ’ pivotal role
GPs can have key roles in detecting
emergent suicidal ideation or non-suicidal self-injury , assessing and managing acutely suicidal youth , referral to specialist care and aftercare support following suicide attempts . While GPs are enablers to self-harming youth to access help , they may feel unprepared , with practical and resourcing problems challenging their effectiveness ( see later ). Although time-poor , GPs offer the advantage of avoiding the stigma of mental health issues while providing holistic patient care . 49
GPs also may encounter , and through their informed awareness , be positioned to address community myths about suicide that complicate help-seeking . These include assumptions that asking questions or talking about suicide with children and adolescents will increase the probability of its occurrence , that those who talk about it will not do it and that intervention is fruitless once an individual decides to complete suicide . 50
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Avoiding direct questioning of young people about suicidal ideas or behaviour has no empirical basis . 44 Suicidal intent fluctuates , particularly with young people , where impulsivity and substance abuse co-occur with suicidal behaviour . There is also often a misunderstanding of the overlaps and the differences between different forms of self-harm ( non-suicidal self-injury and suicidality ), which can result in panic or draconian responses by schools and families .
Supportive organisational cultures , practices and terminologies
Safety in managing suicidality includes
effective supportive organisational protocols and policies and culture regarding suicidal behaviours . Pressures that detract from careful listening ( for example , organisational demands for quick processing , obsessive reliance on checklists ) require identification and modification or resistance .
Suicide attempts elevate future suicide risk and suicide attempt survivors want a sustained helpful relationship . Interpersonal and systemic factors in EDs often prevent effective intervention . Youth suicide attempters ’ aversive experiences often thwart their engagement and preparedness to return in future suicidal crises , thereby increasing reattempt risks . 51 , 52 Such experiences can be mitigated by staff training . 52
GPs ’ receipt of information about suicidal behaviours and their unique positioning means that they are ‘ interested parties ’ who have a valuable role . Even if mental health staff undertake the primary follow-up , GPs , whatever their confidence about mental health , may approach their patients or be approached to offer support .
In caring for suicidal people , some terminologies are acceptable while others have been or should be phased out . These include deliberate self-harm ( though the term ‘ intentional selfharm ’ is used in ICD-10 ); parasuicide , ‘ failed attempt ’ and suicide gesture ; and the often-used phrases ‘ completed ’ suicide ( suicide does not fulfil or make things complete ) or ‘ committed suicide ’ ( suicide is not a crime ).
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Creating and sustaining engagement at assessment and follow-up
Content and process are both important in assessment . 53 Assessment aims to minimise foreseeable risk ,
diagnose and treat underlying conditions and mobilise strengths and supports . Assessment also aims to engage the patient , enable shared understanding of the problem and management , while providing a sense of containment and hope .
The young person is preferably interviewed alone in a quiet , safe and well-provided environment . Listening carefully and attentively to the narrative / story helps create trust , equality and reliable information .
Cognitive analytic therapy , a time-limited collaborative program for considering how a person thinks , feels and acts and underlying events and relationships ( often from childhood or earlier in life 54 ) underpins therapeutic assessment , which is a brief intervention designed to increase treatment engagement of adolescents with self-harm . 55 Therapeutic assessment seems to increase adherence with subsequent treatment compared with usual care . 47
Where patients are non-forthcoming , barriers to trust need attention : for example , the mode of referral and consent for treatment ; language / communication difficulties ; confidentiality concerns ; and negative beliefs or experiences . These include stigma and / or adverse experiences regarding mental health problems and services and / or fear of not being taken seriously or treated respectfully . Survivors and service users define what matters : active listening , respect , non-pejorative language , flexibility , continuity and engendering hope , plus the clinician recognising the meaning of the behaviours . 56 It is important to understand the overlaps and the differences between non-suicidal self-injury and suicidality . Nevertheless , confidentiality cannot be absolute if safety is at stake . But one may distinguish session detail and medical opinions , determine collaboratively what responsible adults need to hear , and
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Box 2 . Indications for more intensive psychiatric care
• High lethality ( medically serious ) suicide attempt .
• Suicide attempt involving preparation , concealment or belief that the attempt would be serious .
• Ongoing ( pressing ) suicidal thoughts , wishes , intentions , plans .
• Inability to openly and honestly discuss the suicide attempt .
• Inability to discuss safety planning .
• History of past suicide attempts .
• Escalating suicidal actions .
• Lack of alternatives for adequate monitoring and treatment .
• Psychiatric disorders ( eg , unipolar major depression , bipolar disorder , psychotic disorders , or substance use disorders ), underlying suicidal ideation and behaviour .
• Agitation .
• Impulsivity .
• Severe hopelessness .
• Poor social support .
gain permission to obtain a collaborative history . Confidentiality may be more ‘ watertight ’ for those aged over 16 years .
Re-referral and hospitalisation
Indications for more intensive psychiatric
care , such as ( re- ) referral for mental health care and / or hospitalisation are listed in box 2 . 57
Does hospitalisation prevent suicide ?
Although clinicians admit some suicidal
young people to hospital , outpatient follow-up is more common . 46 Inpatient psychiatric care is generally associated with very high suicide risk in the months post-attempt and post-discharge . 58 Debate exists regarding the source of such risk : evidence is still insufficient to decide whether this depends on the patient populations ’ high pre-existing risk , or traumatic experiences / exposures in ( some ) psychiatric hospitals , or in problematic aftercare . 58 The latter two categories are understudied : young people involuntary hospitalised often have a negative view of their experience , become unlikely to share their suicidal states with treating staff and report reduced likelihood of openness in future encounters . 59 As key contacts , GPs have an important potential role in engaging young people leaving psychiatric hospitals ( and ED post-suicide
attempt ), evaluating their suicide risk status , listening to their experiences and connecting them to treatments .
Documentation
From a medicolegal viewpoint , evidence pertaining to risk should be collected , contemporaneously documented and evaluated , and standards of care must be reasonable and prudent . In Australia , current national data sets cannot easily identify suicidal behaviours or their treatments ; a potential solution is to co-create the medical record with the young person and have primary care and medical records staff trained for consistent recording . 56
Addressing acute risk and safety planning
Safety planning involves working
with the patient and those close to them to marshal and combine strategies to address risk and maximise the patient ’ s wellbeing ( see figure 6 ). The value of addressing factors to mitigate suicidal risk , such as sobriety , healthy sleep and promotion of positive affect , is understudied . 60 The Beyond Now suicide safety plan app provides one example ; the strategies can be collaboratively listed and these solutions tested with one ’ s GP ( see table 2 ).
Effective treatments
PSYCHOTHERAPIES These are first-line treatment for
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