CG133 Self-harm: risk assessment podcast with Professor Navneet Kapur
Professor Navneet Kapur discusses the risk assessment process recommended with the guideline.
This podcast was added on 23 Nov 2011
Podcast with Professor Nav Kapur: NICE clinical guideline on ‘Self-harm: longer term management’ CG133
Interviewer: Hello and welcome to the NICE podcast about the NICE clinical guideline; Self-harm: longer-term management. This podcast will focus on carrying out a risk assessment with people who self harm.
I am Alexa Biesty, implementation lead for this guideline and with me is Professor Nav Kapur, Professor of Psychiatry and Population Health, University of Manchester and Honorary Consultant psychiatrist, Manchester Mental Health and Social Care Trust. Also chair of the guideline development group for this guideline.
Q1 Interviewer: Could you please start by explaining why self-harm is important?
NK: Yes, thanks Alexa. I think it is important to first of all define what we mean by self-harm and when we talk about self-harm we are really talking about, self-poisoning so primarily overdose, and self-injury and that is primarily cutting. And it is a major problem, it’s very common. We know from research that about one in ten girls aged fifteen to sixteen have harmed themselves in the previous twelve months and the corresponding figure for boys is about one in twenty. So it is common out in the community, it is also common in hospital. It is one of the reasons why people come to hospital, come to the emergency room. And probably the most pressing thing about self-harm is its consequences. Not only does it lead to distress for the individual, not only does it have quite a big economic impact if you think about it on a society wide basis but it is also associated with future risks. So sometimes people may think self-harm is an attention seeking behaviour or not serious, but what we know is maybe one in fifty or one in a hundred people after they have self-harmed and presented to hospital might die by suicide. So it’s a problem we do need to take seriously.
Q2 Interviewer: The guideline indicates that a psychosocial assessment should be carried out with people who self-harm. What do you mean by psychosocial assessment?
NK: Really when we talk about psychosocial assessment we are referring to a really detailed assessment of mental and physical healthcare needs, enquiring about the person’s social circumstances and getting a handle on the immediate precipitants for the self-harm episode, so the kind of problems people have been having. Another important element of a psychosocial assessment is an assessment of risk so what might be the immediate risk for this individual, what might be the longer term risks.
Q3 Interviewer: Ok thank you. When assessing the risks of repetition of self-harm or risk of suicide, the specific risks should be identified and agreed with the person who has self-harmed. What should be taken into account when identifying these risks?
NK: So risk assessment is a really complex process. A lot has been written about risk assessment. What the guideline shows (what we did as part of the guideline was review all of the relevant research literature) is that past self harm and mental health history especially depression are particularly important risks to take into account. But there are other things as well. Things like methods and patterns of current and past self-harm, psychological symptoms, social circumstances, coping strategies that the person might have found helpful in the past and relationships - relationships, tend to be an important part of the context within which people may hurt themselves.
Q4 Interviewer: The guideline recommends that risk assessment tools and scales should not be used to predict future suicide or repetition of self-harm. They also cannot be used to determine who should and should not be offered treatment or who should be discharged. Why does the guideline recommend this?
NK: This is quite a controversial area but there are two main reasons why the guideline suggested that the tools shouldn’t be used. The first is that suicide following self-harm and even repetition is quite rare in overall population terms and that means that it is difficult to predict which individual’s might have a poor outcome and which individual’s wont. The second thing is that the tools themselves, when you look at how they perform in terms of prediction, are not that good. As part of this guideline we have reviewed all the risk assessment tools out there, particularly in terms of something called positive predictive value. That is a measure of, if someone scores highly on a scale or tool, how likely are they in actual fact to repeat or to have a bad outcome? We have found that the positive predictive values of the scales are actually quite poor. What we are not saying is that tools cannot be used at all. We do say in the guideline that they might be used as a prompt or a supplement to routine assessment. So what we are trying to do as part of this guideline is get away from the notion of risk prediction and move instead to risk assessment. And we are trying to get away from the idea of these risk tools and really trying to encourage staff to develop risk skills.
Q5 Interviewer: And what treatments does the guideline recommend for treating self-harm?
NK: Well the evidence is not that extensive in this area, but one of the things we did find was that psychological treatments, talking treatments based on cognitive behavioural therapy, interpersonal therapy or problem solving therapy can benefit some individuals following self-harm and we found a reduction in the rate of repeat self-harm attempts of about a quarter. The other thing we found is that probably drugs or medication on their own should not be used solely as a treatment to reduce repeat self-harm. Of course self-harm is a complicated behaviour with a wide variety of underlying causes and you might use drug or other treatments to treat the underlying conditions and a lot of the other NICE guidance covers the treatments of those underlying conditions.
Interviewer: Thank you very much Professor Kapur. We hope that you will find the information in this podcast useful in helping you implement this NICE clinical guideline. For more information about the NICE clinical guideline on self-harm: longer-term management, including the implementation tools which can be adapted for local use please visit our website www.nice.org.uk
This resource should be used alongside the published guidance. The information does not supersede or replace the guidance itself.
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This page was last updated: 19 September 2012