Self-harm / Suicidal thoughts / Suicide ✅

⚠️ Key exam pearl: Self-harm and suicidal thoughts require a compassionate, non-judgemental, person-centred assessment. Do not rely on “low / medium / high risk” scores to decide who is safe for discharge. NICE recommends a psychosocial assessment, collaborative safety planning, treatment of physical injury or overdose, and clear follow-up.

📖 Overview

• Self-harm: Intentional self-poisoning or self-injury, irrespective of the apparent purpose.
• Suicidal thoughts: Thoughts about ending one’s life, which may range from fleeting thoughts to active plans or intent.
• Suicide attempt: Self-harm with at least some intent to die.
• Suicide: Death caused by self-injurious behaviour with intent to die.

Self-harm is often a sign of severe distress rather than “attention seeking”. It may be linked to depression, trauma, anxiety, personality disorder, psychosis, substance misuse, neurodevelopmental conditions, relationship stress, pain, isolation or social adversity.

🧠 Why Self-harm Happens

• To reduce overwhelming emotional distress
• To communicate distress when words feel impossible
• To regain a sense of control
• As a response to trauma, shame, anger, loneliness or hopelessness
• As part of suicidal thinking or planning
• During intoxication, impulsivity, psychosis or severe mood disorder

🚩 Immediate Safety Concerns

• Current suicidal intent or a clear plan
• Access to means, such as medication, ligatures, weapons or high places
• Recent self-poisoning, hanging, strangulation, drowning attempt or serious injury
• Persistent wish to die, hopelessness or inability to agree to a safety plan
• Psychosis, severe depression, mania, severe agitation or intoxication
• Domestic abuse, safeguarding concerns, exploitation or severe social isolation
• Recent discharge from psychiatric inpatient care
• Previous suicide attempt, especially if recent or medically serious

☎️ Emergency Advice

• Immediate risk to life: Call 999 or attend the nearest Emergency Department.
• Urgent mental health crisis: Call NHS 111 and select the mental health option where available.
• Samaritans: Call 116 123 free, 24 hours a day.
• Do not leave the person alone if there is immediate danger or active suicidal intent.
• Remove or reduce access to obvious means of harm if this can be done safely.

🩺 Initial Assessment

• Physical health first: Assess and treat injury, overdose, poisoning, intoxication, strangulation, hypothermia or bleeding.
• ABCDE approach: Use standard emergency assessment if acutely unwell.
• Pregnancy test: Consider in females of reproductive age when clinically relevant.
• Overdose: Identify substance, dose, timing, co-ingestants and need for toxicology advice.
• Safeguarding: Consider children, vulnerable adults, domestic abuse, coercion, exploitation and neglect.
• Capacity and consent: Assess decision-making capacity if the person refuses assessment or treatment.

🧾 Psychosocial Assessment

NICE recommends that a mental health professional should complete a psychosocial assessment as early as possible after self-harm. This should not be delayed until all physical treatment is complete if the person is able to engage.

• Build a therapeutic, non-judgemental relationship
• Explore what happened before, during and after the episode
• Ask about suicidal thoughts, intent, planning and access to means
• Assess current mental state, mood, psychosis, intoxication and agitation
• Ask about previous self-harm or suicide attempts
• Identify triggers, protective factors, coping strategies and support networks
• Assess social context: housing, relationships, employment, finances, caring responsibilities and isolation
• Assess trauma, abuse, bullying, discrimination and domestic violence
• Consider physical illness, chronic pain, frailty and cognitive impairment
• Develop a shared plan for safety, follow-up and ongoing care

❌ Do Not Use Risk Scores to Decide Discharge

• Do not use risk assessment tools or scales to predict future suicide or repeated self-harm.
• Do not use risk scores to decide who should receive treatment or who should be discharged.
• Tools may help structure conversation, but clinical care should be based on individual needs, formulation, safety planning and follow-up.

👧 Children and Young People

• Assessment should be by a mental health professional experienced in children and young people.
• Ask about home, school, peers, bullying, social media, exploitation, abuse and safeguarding.
• Consider neurodevelopmental conditions, learning disability, eating disorders and substance misuse.
• Involve parents or carers where appropriate, while respecting confidentiality and safeguarding duties.
• If admitted to hospital, ensure age-appropriate care and access to CAMHS or equivalent crisis services.

👵 Older Adults

• Self-harm in older adults is associated with a higher risk of later suicide.
• Assess depression, loneliness, bereavement, cognitive impairment, frailty, pain and physical illness.
• Explore carer stress, loss of independence, alcohol use, medication burden and access to means.
• Consider delirium, dementia and safeguarding concerns.

🧩 Neurodiversity and Learning Disability

• Adapt communication to the person’s needs.
• Allow extra time and use clear, concrete language.
• Consider sensory distress, communication difficulties, masking, bullying and carer strain.
• Involve carers or advocates where appropriate and with consent, unless safeguarding concerns override this.

🛡️ Safety Planning

A safety plan is a collaborative, practical plan for what the person will do if distress or suicidal thoughts increase. It should be personalised, accessible and shared with relevant professionals and carers where appropriate.

• Identify warning signs and triggers
• List coping strategies that have helped before
• Identify people and places that provide distraction or support
• Include emergency contacts and crisis numbers
• Plan how to reduce access to means of self-harm
• Agree what to do if the person feels unable to stay safe
• Include follow-up arrangements and who is responsible for each action

💊 Safer Prescribing

• Consider overdose toxicity when prescribing, especially with tricyclic antidepressants, opioids, sedatives and large quantities of medication.
• Prescribe smaller quantities if appropriate and arrange closer review.
• Consider supervised dispensing, blister packs or family/carer support if safe and appropriate.
• Review alcohol and recreational drug use because these can increase impulsivity and overdose risk.
• Communicate medication changes clearly between primary care, mental health teams and pharmacy.

🧠 Psychological Treatment

• Offer treatment based on the person’s needs, mental health diagnosis and formulation.
• For adults who self-harm, consider a structured, person-centred, CBT-informed psychological intervention tailored to self-harm.
• For children and young people with frequent self-harm and emotional dysregulation, specialist services may consider DBT adapted for adolescents.
• Treat associated conditions such as depression, PTSD, psychosis, anxiety, eating disorder, substance misuse or personality disorder according to relevant guidance.

🏥 When to Refer or Admit

• Immediate danger to life or medically serious self-harm
• Ongoing suicidal intent, plan or inability to stay safe
• Severe depression, psychosis, mania, severe agitation or intoxication
• Safeguarding concerns, domestic abuse or exploitation
• Lack of safe supervision or severe social isolation
• Diagnostic uncertainty or complex comorbidity
• Need for specialist mental health assessment or crisis team involvement

🔄 Follow-up and Aftercare

• Provide clear written and verbal information about what to do in a crisis.
• Ensure the person knows who will contact them, when, and how.
• Share care plans between relevant services, including GP, crisis team, liaison psychiatry and community mental health teams.
• Arrange timely follow-up after discharge, especially after hospital attendance or psychiatric discharge.
• Involve family, carers or trusted people where appropriate and with consent.

⚖️ Confidentiality and Information Sharing

• Respect confidentiality, but explain its limits where there is serious risk of harm.
• With consent, involve family, carers or trusted people in safety planning and aftercare.
• If a person is at serious risk, information may need to be shared to protect life, even without consent.
• Document the reasoning for decisions about confidentiality, capacity and information sharing.

📌 Important Communication Points

• Use calm, compassionate and non-judgemental language.
• Ask directly about suicidal thoughts - this does not “put the idea in someone’s head”.
• Avoid phrases such as “attention seeking”, “failed attempt” or “cry for help”.
• Validate distress while maintaining hope and practical next steps.
• Do not discharge someone solely because they deny suicidal intent if the wider picture suggests serious concern.

✅ Key Takeaways

Self-harm is a marker of distress and future suicide risk, but management should not be reduced to a risk score. NICE emphasises compassionate care, early psychosocial assessment, physical treatment, safeguarding, safety planning, safer prescribing and coordinated aftercare. The safest approach is to understand the person’s story, identify modifiable risks, strengthen protective supports, and ensure clear crisis and follow-up arrangements.

📚 References

• NICE NG225: Self-harm - assessment, management and preventing recurrence
• NHS: Help for suicidal thoughts
• NHS: Where to get urgent help for mental health