The consultation on the updated National Institute for Health and Care (NICE) guideline on the assessment, management and prevention of self-harm closed on 1 March 2022. Once finalised, it will mark the first update to NICE guidance on self-harm for over 10 years (NICE, 2011, 2022).
Self-harm is defined as any act of intentional self-injury or self-poisoning, regardless of the specific purpose behind the act (NICE, 2022). An individual may self-harm for a variety of reasons, but it is primarily used as a means of coping with difficult emotions, overwhelming situations or traumatic memories. Therefore, this behaviour is often linked to mental health conditions such as post-traumatic stress disorder, schizophrenia and depression (Mind, 2020).
The draft guideline, released in January 2022, emphasises that self-harm is ‘everyone's business’ (NICE, 2022). Indeed, with the difficulties many face in accessing specialist mental health services, combined with the stigmatised nature of self-harm that may cause individuals to be apprehensive about seeking medical help, it is crucial that all health and social care professionals know how to recognise and address this behaviour (NICE, 2022).
Prevalence, risks and costs of self-harm
Compiling accurate statistics about self-harm incidence is challenging as it is often a hidden behaviour, with only a small minority of patients who have self-harmed being seen in a hospital setting. However, prevalence rates are high, with around 16.7% of women and 4.8% of men self-harming at some point in their lives (Royal College of Psychiatrists, 2020a). These rates are believed to be increasing, particularly among young people aged 17–19 years, with about 21.5% of girls and 9.7% of boys engaging in self-harm in this age group (NICE, 2022).
Despite the proportion of people who self-harm presenting to hospital being low, it is still one of the most common reasons for emergency department attendance in the UK, with treatment and management costing the NHS around £162 million per year (Tsiachristas et al, 2017). As well as the impact on physical health, such as serious injury, organ damage and accidental death, self-harm can also exacerbate existing mental health conditions, increase social isolation because of feelings of guilt and/ or shame, and significantly increase the risk of suicide (Better Health, 2019; Royal College of Psychiatrists, 2020a).
Common perceptions and media portrayals of self-harm often attribute it to adolescents but, although prevalence rates are high in this age group, self-harm can occur in any demographic group. Research has shown that socioeconomic deprivation, social isolation, chronic illness, and alcohol and/or drug misuse are all risk factors for self-harm (NICE, 2020). Exposure to self-harm through family, friends and the media may also increase the risk, especially among young people (Pollock et al, 2021).
‘One of the most prominent themes in the NICE (2022) draft guideline is the emphasis on the role of primary care in treating self-harm and preventing recurrence.‘
Emphasising the role of primary care
One of the most prominent themes in the NICE (2022) draft guideline is the emphasis on the role of primary care in treating self-harm and preventing recurrence. The document states that individuals who have self-harmed should be regularly reviewed by their GP, who should assess the patient and provide signposting to suitable non-NHS support services. They should also manage and review medication, taking any history of self-poisoning into account when prescribing drugs that may be overdosed on or abused (NICE, 2022).
For individuals who contact ambulance services for self-harm, it is recommended that staff assess the patient and, if they do not require emergency care, refer them to their GP or a specialist mental health service, rather than taking them to hospital. For those who do present to the emergency department, the guideline states that a full psychosocial assessment should be performed by a mental health specialist (NICE, 2022).
This focus on primary care can be seen as part of a wider trend of attempts to relieve the pressure on acute services (The King's Fund, 2015). However, this may raise some challenges if GPs and nurses do not feel that they have the appropriate training or capacity to play such a prominent role in the management of patients who self-harm. Mental health-specific education for GPs is limited, and many believe that more training in this field would be useful (Mind, 2018). Mughal et al (2020) found that GPs often did not feel confident about assessing patients who self-harm, and reported that time constraints and large caseloads limited their ability to perform a proper assessment. This is notable, as the NICE (2022) guideline states that GPs and community pharmacy staff should assess patients' thoughts, intent and behaviours around self-harm during follow up, which they may not feel prepared for. Of patients who present to hospital for self-harm, around half will have presented to their GP in the previous month (NICE, 2022), which arguably suggests that the services currently provided in primary care are not sufficient to prevent recurrence or escalation of harm.
Although the draft guideline states that any person who discloses self-harm to a health or social care professional should be considered for referral to specialist mental health services, waiting times for these services are usually long (Royal College of Psychiatrists, 2020b). Therefore, the GP or other primary care services will likely remain the main port of call for these patients for some time.
Mughal et al (2020) recommended that GPs needed more training in mental health and self-harm management, with more communication channels between GPs and mental health services, and more access to specialist support for self-harm. This is also an area that needs more research to allow optimal management of self-harm within primary care.
Making self-harm everyone's business
The NICE (2022) draft guideline contains several sections that champion person-centred, holistic care, particularly in terms of attitudes towards self-harm and mental health. First, it emphasises that mental health assessments following self-harm should not be delayed until after physical injuries have been treated (unless the person is incapacitated), to avoid prioritising physical health needs at the expense of mental health needs. Second, it prohibits the use of punitive measures against patients who frequently attend the emergency department for self-harm, stating instead that they should have a multidisciplinary review arranged. Third, the guideline recommends that all training regarding self-harm should highlight the need to involve the individual in all care decisions, and to be culturally and socially sensitive (NICE, 2022).
However, it is not only health and social care professionals that need to be aware of self-harm. The guidance provides information and tools for addressing self-harm in the community and criminal justice settings. Particular emphasis is placed on identifying and responding to self-harm in educational settings, with the guideline recommending that all schools have a designated lead responsible for implementing self-harm guidance and ensuring that it is up to date (NICE, 2022). As well as easing pressure on healthcare services, this may help to shift the focus of mental health care towards prevention and recovery, rather than crisis management alone (The King's Fund, 2015).
Conclusions
The publication of new national guidance on the management of self-harm for the first time in 11 years is significant in itself. The draft certainly suggests a prominent role for GPs and other primary care services; given the pressures facing acute and mental health services, and the prominence of self-harm in the community, this is understandable. However, the author hopes that the general practice perspective will be acknowledged, and adequate training and support provided. By ensuring that self-harm is ‘everyone's business’, it may be possible to make care more consistent and joined up, providing multiple channels through which individuals can access support.