120 Chapter 12
Box 12.1Characteristics suggesting serious suicidal intent
1 Carried out in isolation.
2 Timed so that intervention unlikely.
3 Precautions taken to avoid discovery.
4 Preparations made in anticipation of death.
5 Other people informed beforehand of the individual’s intention.
6 Extensive premeditation.
7 Suicide note left.
8 Failure to alert other people following the episode.effects of the overdose have worn off. The assessment should cover the
following areas:
1 The circumstances of the self-harm and the degree of suicidal intent (see
Box 12.1).
2 Possible precipitating factors in the preceding days.
3 Predisposing factors: previous and current life circumstances, family
history, models for suicidal behaviour.
4 History and mental state examination to evaluate current psychiatric
state and suicide risk. Have suicidal talk or behaviour been escalating
progressively?
5 Was the episode of self-harm typical of a long-standing difficulty in
coping with stress or obtaining support in a more adaptive way?
6 Attitude of individual and family to professional help.
Management
Parents should be advised to lock away potentially poisonous medicines
and guns, and to limit the individual’s access to alcohol and drugs. When
DSH is an out-of-character response to acute stress in an otherwise well-
adjusted individual, referral back to the family doctor is usually all that
is necessary. At the other extreme, psychiatric admission is occasionally
necessary for further assessment, for treatment of a major psychiatric
disorder, or because of continuing high suicide risk. Between these two
extremes, people who have harmed themselves are commonly offered
out-patient treatment, though many never turn up. Associated psychiatric
disorders, such as depression and conduct disorder, can be treated in the
normal way, as described elsewhere in this book.
As regards the self-harm itself, there is no strong evidence that any
intervention makes a significant difference to recurrence rates or long-
term psychosocial adjustment. Nevertheless, many clinicians feel the need
to administer something. A family approach may seem indicated, though
the families are usually difficult to engage or change. Some families dismiss
the episode as trivial; they should be encouraged to regard the episode as
a serious challenge to solve problems or reduce stresses. Brief individual
therapy may be helpful, particularly if it is focused on improving the
individual’s capacity to solve problems and handle stresses in a more