Deliberate Self-Harm

Quick Answer

One-liner: Deliberate self-harm (DSH) is intentional self-poisoning or self-injury requiring comprehensive psychosocial assessment, medical stabilization, and collaborative safety planning to prevent repeat episodes and suicide.

Deliberate self-harm affects 200-250 per 100,000 Australians annually presenting to emergency departments. It encompasses both suicide attempts (with intent to die) and non-suicidal self-injury (NSSI, without intent to die). The 1-year suicide completion rate after DSH presentation is 1-2%, with the highest risk in the first 3 months post-discharge. Emergency physicians must medically stabilize, perform comprehensive psychosocial assessment, avoid relying on risk stratification tools, engage psychiatric services, and ensure robust follow-up arrangements. Aboriginal and Torres Strait Islander peoples have 2-3 times higher rates of suicide and DSH, requiring culturally safe approaches.

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Neuroanatomy of mood regulation (prefrontal cortex, limbic system, HPA axis)
• Physiology: Neurotransmitter systems (serotonin, noradrenaline, dopamine) in depression and impulsivity
• Pharmacology: Antidepressants (SSRIs, TCAs, MAOIs), antipsychotics, benzodiazepines, naltrexone for NSSI

Fellowship Exam Relevance

• Written: Risk assessment approaches, limitations of scoring tools, safety planning, Indigenous health disparities, mental health legislation (involuntary treatment), capacity assessment
• OSCE: Communication with suicidal patient, breaking bad news to family, psychiatric history-taking, risk assessment documentation, involuntary treatment orders
• Key domains tested: Medical Expert, Communicator (empathy, non-judgmental approach), Health Advocate (addressing Indigenous disparities), Professional (ethical considerations, duty of care vs autonomy)

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Key Points

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Epidemiology

Australian/NZ Specific

• Australian suicide rate: 12.9 per 100,000 (2021) [9]
• Aboriginal and Torres Strait Islander suicide rate: 27.1 per 100,000 (2.1× non-Indigenous rate) [10]
• Māori suicide rate (NZ): 19.6 per 100,000 (1.5× non-Māori rate) [11]
• Highest rates: Remote/very remote Aboriginal communities (up to 3× national average) [12]
• Peak time: First 3 months post-discharge from psychiatric admission or ED visit [13]
• LGBTIQ+ youth: 5-6× higher suicide attempt rates than heterosexual peers [14]

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Pathophysiology

Mechanism

Suicide vs Non-Suicidal Self-Injury (NSSI)

Suicide Attempt

• Intent: To end one's life
• Lethality: Often high-lethality methods (hanging, jumping, firearms, severe overdose)
• Psychological state: Hopelessness, perceived burden, thwarted belongingness (Interpersonal Theory of Suicide) [15]
• Neurobiological: Reduced serotonergic function (5-HT1A receptor binding), HPA axis dysregulation, impaired executive function (ventromedial prefrontal cortex)

Non-Suicidal Self-Injury (NSSI)

• Intent: Emotional regulation, relief from overwhelming feelings, self-punishment (NOT to die)
• Lethality: Typically low-lethality (superficial cutting, burning, scratching)
• Psychological state: Emotional dysregulation, often borderline personality traits [16]
• Neurobiological: Endogenous opioid release (explains temporary relief), reduced pain sensitivity during episodes

CRITICAL DISTINCTION: NSSI is distinct from suicide attempt, BUT individuals with NSSI have 5-10× increased risk of future suicide attempts due to acquired capability for self-harm [17]

Pathological Progression

Predisposing factors (psychiatric illness, trauma, genetics) 
  → Precipitating stressor (relationship breakdown, job loss, trauma) 
    → Acute suicidal crisis (hopelessness, intent, plan, means) 
      → Self-harm act 
        → ED presentation 
          → Risk of repeat DSH (15-25%) or suicide completion (1-2%)

Why It Matters Clinically

• Assessment must distinguish intent: Suicidal intent vs emotional regulation vs manipulative behavior (though all require compassionate care)
• High-lethality methods predict completion: Even if patient appears "settled," hanging/jumping/firearms indicate high ongoing risk
• Post-discharge period is highest risk: Active follow-up (not passive referral) reduces repeat DSH by 20-30% [18]

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Clinical Approach

Recognition

DSH presentations to ED:

• Overt self-poisoning (overdose) or self-injury (cutting, hanging, jumping)
• Covert presentations: Vague somatic complaints, "accidental" overdose, repeated presentations with medically unexplained symptoms
• Police or ambulance brought with known suicide attempt
• Family/friends expressing concern about suicidal statements

Initial Assessment

Primary Survey

• A: Airway patency (especially if reduced GCS from overdose or hanging attempt)
• B: Respiratory rate/effort (opioid/benzodiazepine overdose, aspiration risk)
• C: Hemodynamic stability (tricyclic overdose, significant blood loss from cutting/stabbing)
• D: GCS, pupil size (toxidromes), agitation vs sedation
• E: Examine for injuries (lacerations, ligature marks, signs of trauma)

MEDICAL STABILIZATION FIRST - psychiatric assessment only when GCS 15, medically stable, cooperative

History

Key Questions (Once Medically Stable)

Red Flag Symptoms

Examination

General Inspection

• Affect: Flat, tearful, agitated, hostile, incongruent (laughing when discussing serious harm)
• Behavior: Eye contact, rapport, cooperation vs evasiveness
• Speech: Slow/monotone (depression), pressured (mania), thought disorder (psychosis)
• Appearance: Self-care, evidence of intoxication, disheveled

Mental State Examination (MSE)

Physical Examination Specific Findings

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Investigations

Immediate (Resus Bay - If Overdose or Hemodynamically Unstable)

Standard ED Workup (All DSH Presentations)

Advanced/Specialist

Point-of-Care Ultrasound

• Limited role in DSH, primarily for:
  • Cardiac standstill if peri-arrest (massive TCA overdose, hanging with anoxia)
  • FAST scan if abdominal stab wounds
  • Pneumothorax if chest stab wounds

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Management

Immediate Management (First 10 Minutes)

1. MEDICAL STABILIZATION (0-5 min)
   - Airway: Protect if GCS <8 (intubate if required)
   - Breathing: High-flow O2 if SpO2 <94%, monitor RR
   - Circulation: IV access, 500mL crystalloid if hypotensive
   - Disability: GCS, glucose check, pupillary exam
   - Exposure: Remove clothing, full body exam for injuries/ingestions

2. TOXICOLOGY ASSESSMENT (5-10 min)
   - Identify toxidrome (anticholinergic, cholinergic, sympathomimetic, sedative)
   - ECG within 10 minutes (QRS, QT interval)
   - Paracetamol/salicylate levels
   - Contact Poisons Information Centre 13 11 26 if unclear

3. SAFETY (10 min)
   - 1:1 observation if agitated, psychotic, or ongoing high risk
   - Remove sharps, cords, bags from environment
   - Consider security presence if aggressive or absconding risk
   - Do NOT leave alone until mental state assessed

Resuscitation (if applicable)

Airway

• GCS <8: Rapid sequence intubation (consider TCA overdose if wide QRS - avoid suxamethonium if hyperkalemia)
• Protect from aspiration: Left lateral position if vomiting (activated charcoal risk)

Breathing

• Target SpO2 ≥94% (high-flow O2 if hypoxemic)
• Respiratory depression: Naloxone 400 mcg IV if opioid overdose, flumazenil CONTRAINDICATED (seizure risk in benzodiazepine-dependent patients)

Circulation

• Hypotension: 500mL boluses crystalloid, vasopressors if refractory (noradrenaline 0.05-0.2 mcg/kg/min)
• Arrhythmias: Sodium bicarbonate 1-2 mmol/kg IV for wide-complex tachycardia (TCA overdose)

Medications

Toxicology-Specific

Psychiatric Medications (Use Cautiously - Consult Psychiatry)

CAUTION: Do NOT sedate heavily if suicide risk assessment incomplete - impairs assessment and may increase risk if discharged

Paediatric Dosing

Ongoing Management

Medical Observation Period

• Overdose patients: Minimum 4h observation post-ingestion (longer for sustained-release, toxicity)
• Self-injury patients: Once medically cleared (wounds dressed/sutured, hemodynamically stable)

Psychiatric Assessment (Once GCS 15, Cooperative, Not Intoxicated)

COMPREHENSIVE PSYCHOSOCIAL ASSESSMENT - NOT ISOLATED RISK SCALE

Assessment Domains (NICE Guideline NG225) [20]

1. Needs assessment

   • Current mental state, suicidal ideation, intent, plan
   • Psychiatric history (diagnoses, previous admissions, medications)
   • Physical health problems
   • Social circumstances (housing, employment, relationships, financial)
   • Protective factors (children, religious beliefs, future plans)

2. Risk assessment

   • Previous self-harm (number, frequency, methods, lethality escalation)
   • Current suicide intent and plan
   • Access to means (medications, firearms, heights)
   • Alcohol and substance use
   • Recent stressors or losses
   • Support network

3. Understanding of episode

   • Precipitants and motivation
   • Expectation of lethality
   • Preparatory acts (note, giving away possessions)
   • Feelings about surviving

4. Capacity assessment

   • Does patient understand their situation?
   • Can they retain and weigh information?
   • Can they communicate a decision?
   • If lacks capacity + high risk = involuntary admission

Risk Stratification Tools - Use with EXTREME CAUTION

Manchester Self-Harm Rule (MSHR) [23]

• Positive if ANY of:

  1. Previous self-harm
  2. Psychiatric treatment (current or previous)
  3. Current psychiatric treatment
  4. Cutting as method (in original study; now interpreted as high-lethality method)

• If MSHR positive: Sensitivity 94% for repeat DSH or suicide within 6 months

• If MSHR negative: Only 6% risk of adverse outcome

• Problem: 75% of patients screen positive (low specificity), overwhelming services

Clinical Risk Factors for Suicide Completion [24]

Safety Planning (CRITICAL COMPONENT)

Collaborative Safety Planning > "No-Harm Contracts" [25]

Develop written safety plan with patient including:

1. Warning signs: Thoughts, feelings, behaviors that precede suicidal crisis
2. Internal coping strategies: Exercise, music, distraction techniques
3. Social supports: People/places that provide distraction or support (name + phone)
4. Professional contacts: Crisis team, GP, mental health service (name + phone)
5. Means restriction: Remove/secure medications, firearms, sharps
6. Emergency contacts: 000, Lifeline 13 11 14, Beyond Blue 1300 22 4636

Provide written copy to patient and document in notes

Definitive Care

Psychiatric Consultation

MANDATORY for all DSH presentations (may be delayed until sober/medically cleared)

• Psychiatry consult to assess:
  • Need for admission (voluntary vs involuntary)
  • Diagnosis and treatment plan
  • Medication initiation/optimization
  • Follow-up arrangements

Involuntary Treatment (Mental Health Act)

Criteria (varies by state/territory, general principles):

• Mental illness present
• Risk of harm to self or others
• Treatment required and patient refuses
• No less restrictive alternative

Documentation:

• Medical practitioner examination and recommendation
• Second opinion (usually psychiatrist or second doctor)
• Specific forms (e.g., NSW Mental Health Act Form 1, VIC Assessment Order)

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Disposition

Admission Criteria (Psychiatric Inpatient Unit)

ICU/HDU Criteria

• ICU: Intubated, hemodynamically unstable, severe toxicity requiring antidote infusions (N-acetylcysteine, sodium bicarbonate, fomepizole), rhabdomyolysis with AKI
• HDU: Moderate toxicity, QRS/QT prolongation requiring cardiac monitoring, frequent observations (q15-30min)

Discharge Criteria (Emergency Department)

Safe discharge requires ALL of:

• Medically stable (no ongoing toxicity, wounds managed)
• GCS 15, sober, cooperative
• Psychiatric assessment completed
• LOW ongoing suicide risk (no intent, plan, or means; good insight; protective factors present)
• Adequate social supports (family/friends aware, can supervise)
• Follow-up arranged (GP, mental health team, crisis team within 48-72h)
• Safety plan completed and provided in writing
• Means restriction discussed (remove medications, sharps, firearms)
• Patient agrees to return if ideation worsens
• NOT safe to discharge if: ongoing intent, high-lethality method, psychosis, no supports, refuses follow-up

Follow-up

Active Follow-Up (NOT Passive Referral)

Discharge Plan Components

• GP letter: Detailed summary of presentation, risk assessment, safety plan, follow-up required
• Mental health referral: Community mental health team, private psychiatrist/psychologist
• Crisis contacts: 24/7 crisis team, Lifeline 13 11 14, Beyond Blue 1300 22 4636, Kids Helpline 1800 55 1800 (age <25)
• Medication: If starting antidepressants, provide only 1 week supply (overdose risk), weekly dispensing thereafter
• Family education: Warning signs, crisis response, means restriction
• Social supports: Accommodation (if homeless), financial counseling, domestic violence services if applicable

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Special Populations

Paediatric Considerations (Age <18 Years)

• Peak age for DSH: 15-19 years (especially females)
• Common methods: Overdose (paracetamol, ibuprofen), superficial cutting
• Assessment: Include family/caregivers, school issues, bullying, social media, LGBTIQ+ identity, body image
• Child protection: MANDATORY reporting if abuse/neglect suspected (all states/territories)
• Admission threshold: Lower - most require admission unless very low risk with excellent family supports
• Follow-up: Child and Adolescent Mental Health Services (CAMHS), school counselor, headspace (age 12-25)

Pregnancy

• Suicide is leading cause of indirect maternal mortality (20% of pregnancy-related deaths) [27]
• Perinatal period is HIGH RISK: Postpartum psychosis (especially postpartum week 2-4)
• Medication considerations: SSRIs generally safe (sertraline, fluoxetine preferred), avoid paroxetine (cardiac malformations)
• Social supports: Perinatal mental health team, maternal child health nurse
• Child protection: Notify if risk to newborn

Elderly (Age greater than 65 Years)

• Highest suicide completion rate: Especially males greater than 75 years (30-40 per 100,000) [28]
• Higher intent: Less impulsive, more planning, higher lethality methods
• Risk factors: Bereavement, chronic pain, terminal illness, social isolation
• Cognitive assessment: Screen for dementia, delirium (impairs risk assessment)
• Polypharmacy: Higher overdose risk, complex medication interactions
• Disposition: Lower threshold for admission (frailty, reduced resilience)

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

Epidemiology

• Suicide rate 2.1× higher in Aboriginal and Torres Strait Islander peoples (27.1 vs 12.9 per 100,000) [10]
• Youth disproportionately affected: 15-24 year age group 4× non-Indigenous rate [29]
• Māori suicide rate (NZ): 19.6 per 100,000 (1.5× non-Māori) [11]
• Remote communities: Up to 3× higher rates due to social determinants (historical trauma, poverty, unemployment, substance use) [12]

Cultural Safety

• Non-judgmental, empathetic approach: Acknowledge historical trauma, racism, discrimination
• Aboriginal Liaison Officers: Involve early (available in most tertiary hospitals)
• Family-centered care: Include family/community in assessment and planning (with consent)
• Communication: Use interpreter if language barrier, allow time for storytelling
• Holistic assessment: Social determinants (housing, employment, racism experiences), connection to culture/country, stolen generations impacts
• Cultural protocols: Understand local customs (e.g., eye contact norms, use of name after death)

Discharge Planning

• Community-led services: Aboriginal Medical Services (AMS), community-controlled health organizations
• Continuity: Same clinician where possible (rapport and trust critical)
• Transport: Arrange if remote/rural (RFDS, community transport)
• Outreach: Home visits more acceptable than clinic attendance in some communities

Resources

• 13YARN (13 92 76): Aboriginal and Torres Strait Islander crisis support
• Lifeline's First Nations line: 13 11 14 (ask for Indigenous counselor)
• Headspace Indigenous services: For youth 12-25 years

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Psychiatric History - Deliberate Self-Harm

Format: History Time: 11 minutes Setting: ED cubicle

Candidate Instructions:

You are the ED registrar. A 28-year-old woman has presented after taking an overdose of 20 paracetamol tablets 3 hours ago. She is medically stable and N-acetylcysteine has been commenced. Please take a focused psychiatric history to assess her suicide risk and determine appropriate disposition. You will be marked on your ability to establish rapport, gather relevant information, and demonstrate a structured approach to risk assessment.

Examiner Instructions: The candidate should demonstrate:

• Non-judgmental, empathetic approach
• Systematic exploration of suicidal ideation, intent, plan
• Assessment of precipitants, protective factors, supports
• Previous psychiatric and self-harm history
• Capacity assessment (implicit or explicit)

The patient (actor) will disclose:

• Overdose followed argument with partner (relationship of 5 years)
• Previous episode of self-harm 2 years ago (cutting)
• Diagnosed with depression, on sertraline 100mg daily
• Denies current suicidal ideation, regrets overdose
• Has supportive family (mother lives nearby)
• Works as teacher, no current work stressors

Candidate should NOT rely on screening tools (SAD PERSONS) but perform comprehensive assessment.

Actor/Patient Brief: You are Sarah, a 28-year-old primary school teacher. You took 20 paracetamol tablets 3 hours ago after a heated argument with your partner of 5 years about moving in together (you want to, he doesn't). You immediately regretted it and told your mother, who brought you to hospital.

Background:

• You have depression (diagnosed 2 years ago, on sertraline 100mg)
• You cut your wrists 2 years ago during a previous relationship breakdown (superficial, no stitches)
• You see a psychologist monthly
• You live alone, mother lives 10 minutes away (very supportive)
• You love your job as a teacher
• You do NOT currently want to die, you regret taking the tablets

If asked directly:

• "Were you trying to end your life?" → "I don't know, I just wanted the pain to stop"
• "Do you have thoughts of harming yourself now?" → "No, I regret it, I want to get better"
• "What stopped you from taking more?" → "I thought of my mother and my students"
• "Can you keep yourself safe?" → "Yes, I'll stay with my mum tonight"

Be cooperative but tearful. Show regret. Allow candidate to build rapport.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Distinguishes intent vs impulsivity
  • Explores protective factors (not just risk factors)
  • Non-judgmental language ("What happened?" not "Why did you do this?")
  • Addresses safety planning collaboratively

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Station 2: Communication - Breaking Bad News to Family After Suicide Attempt

Format: Communication Time: 11 minutes Setting: Relatives' room

Candidate Instructions:

You are the ED registrar. A 17-year-old male was brought to ED 2 hours ago after a hanging attempt. He was resuscitated but remains intubated in ICU with severe hypoxic brain injury (GCS 3T). The prognosis is very poor. His mother has just arrived from interstate and is unaware of the severity. Please speak with her to explain the situation. You will be marked on your ability to break bad news sensitively and respond to her emotional distress.

Examiner Instructions: Candidate should demonstrate:

• Structured approach (SPIKES or similar)
• Clear, jargon-free language
• Empathy and acknowledgment of grief
• Ability to manage strong emotions
• Honesty about prognosis without destroying hope prematurely
• Offer of support (chaplain, social work, family presence)

The mother (actor) will be distressed, may cry, may ask "Is he going to die?" Candidate should be honest but compassionate.

Actor/Patient Brief: You are Margaret, a 52-year-old mother. Your son James (age 17) has been struggling with depression for 6 months. You live interstate and were visiting him at his father's house (divorced 5 years ago). You received a call 2 hours ago saying James was in hospital but no details. You are very anxious and expect he has attempted suicide (he has tried before - overdose 3 months ago).

Emotional state:

• Initially anxious, asking rapid questions
• When told prognosis is poor, become tearful and distressed
• May ask: "Can I see him?"
  • "Will he wake up?"
  • "Is this my fault?"

If asked:

• "Did you know he was suicidal?" → "Yes, he's been depressed for months, I've been so worried"
• "Has he done this before?" → "Yes, he took an overdose 3 months ago, but he recovered"
• "What was happening in his life?" → "Bullying at school, his father and I divorced, he was seeing a psychologist"

Be realistic - you suspected this might happen. Show grief but also strength.

Marking Criteria:

• "ICU team will assess over next 24-48h"), avoids false reassurance | /2 | | Support | Offers to see James, provides ICU contact, mentions chaplain/social work, family presence encouraged | /1 | | Closure | Summarizes, checks understanding, provides contact for questions | /1 | | Total | | /11 |

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Balances honesty with compassion
  • Does NOT say "he will definitely die" (too blunt) but also does NOT give false hope
  • Manages mother's guilt ("Is this my fault?") with reassurance ("Depression is an illness, you sought help for him")
  • Recognizes this is bereavement conversation (even if patient still alive, loss of "who he was")

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Station 3: Practical Procedure - Involuntary Treatment Order

Format: Communication / Documentation Time: 11 minutes Setting: ED resus bay

Candidate Instructions:

You are the ED registrar. A 45-year-old male presented 2 hours ago after taking a large overdose of aspirin and paracetamol. He is medically stable and has been cleared for psychiatric assessment. The psychiatric registrar has assessed him and found ongoing high suicide risk with intent, plan, and means. The patient is demanding to leave and refuses voluntary admission. The psychiatric registrar has asked you to complete the medical section of an involuntary treatment order (Mental Health Act). Please explain to the patient why you are detaining him, and complete the required documentation. You will be marked on your communication and legal/ethical understanding.

Examiner Instructions: Candidate should demonstrate:

• Understanding of Mental Health Act criteria (mental illness, risk of harm, treatment required, no less restrictive option)
• Clear explanation to patient (avoiding jargon)
• Empathy while maintaining boundaries
• Documentation skills (if form provided)

The patient (actor) will be hostile, deny mental illness, threaten legal action. Candidate must remain calm and professional.

Actor/Patient Brief: You are John, a 45-year-old man. You took a large overdose 6 hours ago because your wife left you and you lost your job. You have been treated medically and feel physically better. You want to leave hospital and "sort things out yourself." You deny being mentally ill ("I'm just having a bad time"). You are angry at being kept in hospital against your will.

If asked:

• "Do you still want to harm yourself?" → "That's none of your business, I just want to leave"
• "We're concerned you're at risk" → "You can't keep me here, I'm not crazy, I'll sue you"
• "Have you seen a psychiatrist before?" → "No, I don't need one"

Be hostile but not physically aggressive. Interrupt candidate, raise voice, use dismissive language.

Marking Criteria:

Expected Standard:

• Pass: ≥6/11
• Key discriminators:
  • Does NOT argue with patient or become defensive
  • Uses phrases like "I understand you don't want to be here, but my duty of care requires me to keep you safe"
  • Explains "mental illness" in plain language (severe depression, not "crazy")
  • Understands this is time-limited order (24-72h depending on state) with regular reviews

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SAQ Practice

Question 1 (6 marks)

Stem: A 19-year-old female presents to ED with superficial lacerations to both forearms. She states she "just wanted to feel something" and denies suicidal intent. This is her 8th presentation for self-harm in the past year.

Question: Outline your approach to assessing this patient's risk of future suicide. (6 marks)

Model Answer:

1. Comprehensive psychosocial assessment - NOT isolated risk scores (SAD PERSONS have poor validity) (1 mark)
2. Distinguish NSSI from suicide attempt - This presentation appears to be non-suicidal self-injury (emotional regulation, no intent to die), but NSSI patients have 5-10× increased suicide risk (1 mark)
3. Previous self-harm history - 8 presentations in 1 year = very high risk (previous DSH is single strongest predictor of future DSH and suicide, 40× general population) (1 mark)
4. Current suicidal ideation - Ask directly: "Do you have thoughts of ending your life? Do you have a plan? Do you have access to means?" (1 mark)
5. Psychiatric assessment - Screen for depression, borderline personality disorder, substance use, trauma history (1 mark)
6. Protective factors - Social supports, reasons for living, future plans, engagement with mental health services (1 mark)

Examiner Notes:

• Accept: Mention of mental state examination, capacity assessment, involvement of psychiatric services
• Do not accept: Using SAD PERSONS score as sole determinant, discharging without psychiatric assessment, labeling as "attention-seeking"

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Question 2 (8 marks)

Stem: A 62-year-old male farmer from a remote community presents after a self-inflicted gunshot wound to the abdomen. He is hemodynamically stable after laparotomy. He has no previous psychiatric history. He states he "didn't mean to do it, gun went off accidentally while cleaning it."

Question: What features of this case indicate high ongoing suicide risk, and what disposition would you recommend? (8 marks)

Model Answer:

High-risk features (5 marks):

1. High-lethality method - Firearms indicate very high intent (90% fatal if not interrupted) (1 mark)
2. Minimization - "Accidental discharge" is likely denial/minimization of suicide attempt (1 mark)
3. Demographics - Male, age greater than 60, rural = highest risk group (3× urban suicide rate in rural males greater than 60) (1 mark)
4. Occupation - Farmer = access to means (firearms, chemicals), financial stressors, social isolation (1 mark)
5. No psychiatric history - 50% of suicide deaths occur in people with no prior contact with mental health services (suggests first attempt may be fatal) (1 mark)

Disposition (3 marks):

1. Psychiatric admission (voluntary or involuntary) for stabilization and comprehensive assessment over days (not hours) (1 mark)
2. Involuntary if refuses - High lethality method + minimization + ongoing risk justifies Mental Health Act detention (1 mark)
3. If discharged (strongly discouraged): Daily crisis team contact, removal of firearms (notify police firearms registry), 24/7 family supervision, urgent psychiatry follow-up within 48h (1 mark)

Examiner Notes:

• Accept: Mention of rural/remote risk factors, need for means restriction (firearms removal), involvement of GP
• Do not accept: Accepting "accidental" explanation without further assessment, discharging without psychiatric consult

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Question 3 (6 marks)

Stem: A 16-year-old Aboriginal girl presents with recurrent superficial cutting to her forearms. She has presented 6 times in the past 3 months. She is withdrawn and will not engage with ED staff.

Question: What culturally safe strategies would you use to engage this patient and plan her ongoing care? (6 marks)

Model Answer:

1. Involve Aboriginal Liaison Officer early - Provide culturally safe support, build rapport, explain hospital processes (1 mark)
2. Non-judgmental, trauma-informed approach - Acknowledge historical trauma (stolen generations), allow time for storytelling, avoid rapid-fire questions (1 mark)
3. Family involvement - Ask if she wants family/elder present (with consent), family-centered care is culturally appropriate (1 mark)
4. Holistic assessment - Social determinants (housing, education, racism experiences), connection to culture/country/community, protective factors (family, elders, culture) (1 mark)
5. Community-led follow-up - Aboriginal Medical Service (AMS), community-controlled health organization, cultural healing programs (art, land connection) (1 mark)
6. Continuity of care - Same clinician where possible (trust and rapport critical), outreach/home visits more acceptable than clinic attendance in some communities (1 mark)

Examiner Notes:

• Accept: Mention of 13YARN crisis line, Headspace Indigenous services, mandatory reporting if abuse suspected
• Do not accept: "Cultural competence training" without specific actions, discharging without culturally appropriate follow-up

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Question 4 (8 marks)

Stem: You are the doctor in a remote rural ED. A 22-year-old woman presents after taking 30 paracetamol tablets 8 hours ago. Her 4-hour paracetamol level is above the treatment line and N-acetylcysteine is commenced. She is medically stable but psychiatrically high-risk with ongoing suicidal ideation. The nearest tertiary hospital is 500km away.

Question: Outline your management plan including disposition options and retrieval considerations. (8 marks)

Model Answer:

Medical management (2 marks):

1. Continue N-acetylcysteine - 21-hour protocol, monitor LFTs q12h for hepatotoxicity (1 mark)
2. 1:1 observation - Suicide risk + receiving medical treatment = cannot leave (1 mark)

Psychiatric management (3 marks):

1. Telehealth psychiatric consultation - State mental health line or HealthDirect for risk assessment and advice (1 mark)
2. Safety measures - Remove sharps/medications from room, family or nurse 1:1 supervision (1 mark)
3. Involuntary detention - If she attempts to leave during medical treatment, detain under Mental Health Act (ongoing suicide risk + lacks capacity to refuse life-saving treatment) (1 mark)

Disposition options (3 marks):

1. Option 1: Retrieval to tertiary center (preferred if high psychiatric risk) - Contact RFDS or state retrieval service, provide nursing escort during transfer, continue NAC infusion en route (1 mark)
2. Option 2: Admit locally - If intermediate risk and local resources allow: continue NAC, daily telehealth psychiatry reviews, transfer if deteriorates medically or psychiatrically (1 mark)
3. Factors favoring retrieval - Ongoing high suicide risk, lack of local mental health services, medical complications (rising ALT), patient request (1 mark)

Examiner Notes:

• Accept: Mention of delayed NAC efficacy (8h post-ingestion = reduced efficacy to 65%), contact Poisons Information Centre, GP follow-up if discharged
• Do not accept: Discharging patient before NAC complete, failing to consider retrieval for high psychiatric risk

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Australian Guidelines

ARC/ANZCOR

• Not applicable - Deliberate self-harm is psychiatric/toxicological, not resuscitation topic
• If cardiac arrest from overdose or hanging: Follow ARC adult cardiac arrest algorithm (see related topics)

Therapeutic Guidelines

Therapeutic Guidelines: Psychotropic [40]

• First-line antidepressant for suicidal depression: Sertraline 50-200mg daily (safest in overdose)
• Avoid TCAs in high-risk patients (cardiotoxic in overdose)
• Avoid citalopram greater than 40mg (QT prolongation, fatal in overdose greater than 600mg)
• Antipsychotics for agitation: Olanzapine 5-10mg PO/IM (less extrapyramidal side effects than haloperidol)

Therapeutic Guidelines: Toxicology [41]

• Paracetamol: NAC if level greater than 150mg/L at 4h or greater than 10g ingested (or unknown time/dose)
• Salicylate: Sodium bicarbonate for pH <7.2 or salicylate greater than 500mg/L
• Activated charcoal: Within 1h of ingestion, only if cooperative and GCS 15

State-Specific

New South Wales

• Mental Health Act 2007: Schedule 1 Form (medical practitioner assessment), Schedule 2 Form (ambulance officers), involuntary detention up to 72h [42]
• NSW Mental Health Line: 1800 011 511 (24/7 telehealth psychiatric consultation)

Victoria

• Mental Health Act 2014: Assessment Order (up to 24h), Temporary Treatment Order (up to 28 days) [43]
• Centre for Psychiatric Risk Management (CPRM): 1300 794 991 (psychiatric consultation and bed coordination)

Queensland

• Mental Health Act 2016: Recommendation for Assessment (up to 6h), Emergency Examination Authority (up to 12h) [44]
• Mental Health Alcohol and Other Drugs Branch: 1300 642 255 (telehealth)

ACEM Policy

• ACEM Statement on Mental Health in Emergency Departments (2022): Recommends 24/7 access to psychiatric consultation, dedicated mental health spaces, training in mental health assessment for ED staff [45]

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Remote/Rural Considerations

Pre-Hospital

Ambulance Management

• Scene safety: Remove means (medications, weapons, sharps) before transport
• Medical stabilization: Airway protection if reduced GCS, IV access, monitor vital signs
• Mental Health Act: Paramedics can detain under Schedule 2 (NSW) or equivalent if immediate risk
• Communication: Notify ED of high-risk arrival (prepare 1:1 observation, remove sharps from room)

Police Involvement

• Welfare check: Police can detain under Mental Health Act if immediate risk to self
• Firearms: If firearm involved, police must secure weapon and notify firearms registry (patient's license revoked pending psychiatric assessment)
• Domestic violence: If self-harm in context of family violence, police issue Apprehended Violence Order (AVO)

Resource-Limited Setting

Modified Approach When No Psychiatric Services

1. Telehealth psychiatric consultation - Mandatory in all rural/remote DSH cases

   • NSW Mental Health Line: 1800 011 511
   • QLD Mental Health Line: 1300 642 255
   • VIC Mental Health Triage: Local area mental health service
   • HealthDirect: 1800 022 222 (after-hours)

2. GP as primary mental health provider

   • GP Mental Health Treatment Plan: Up to 10 Medicare-rebated psychology sessions
   • Medication: GP can initiate SSRIs (sertraline 50mg daily), avoid TCAs
   • Safety planning: Collaborate with GP for ongoing monitoring

3. Nursing staff 1:1 observation

   • If no mental health nurses, use general nurses or family member
   • Provide education: Engage patient, watch for absconding, remove sharps
   • Duration: Until psychiatric consult complete (may be hours if waiting for telehealth)

4. Local supports

   • Community mental health team: If available (visit weekly/fortnightly)
   • Aboriginal Health Worker: If Indigenous patient
   • School counselor: If adolescent patient
   • Church/community groups: Pastoral care (with consent)

Retrieval

RFDS Retrieval Criteria for DSH

Absolute indications:

• Ongoing high suicide risk + lacks capacity + refuses voluntary admission (requires tertiary psychiatric unit)
• Medical complications requiring tertiary care (paracetamol hepatotoxicity, ICU-level monitoring)
• Severe psychiatric illness (psychosis, mania) requiring involuntary admission
• Safeguarding concerns requiring statutory child protection + tertiary resources

Relative indications:

• Recurrent DSH with inadequate local supports
• Request from telehealth psychiatrist
• Young age (<16 years) with moderate-high risk

RFDS Contacts

• RFDS Central Operations: 1300 137 327 (NT, SA, QLD)
• RFDS Western Operations: 1800 625 800 (WA)
• State retrieval services:
  • "NSW: NSW Ambulance Aeromedical 1300 008 001"
  • "VIC: Air Ambulance Victoria 1300 368 661"
  • "QLD: Retrieval Services Queensland 1300 799 127"

Retrieval Preparation

• Medical: IV access, continuous ECG/SpO2 if overdose, NAC infusion if paracetamol
• Psychiatric: 1:1 nursing escort, sedation if required (olanzapine 5-10mg IM, avoid heavy sedation)
• Documentation: Comprehensive handover (event, investigations, psychiatric assessment, capacity, involuntary order if applicable)
• Communication: Phone handover to receiving psychiatry team

Transfer Time Considerations

• Average RFDS response: 1-3h (depends on distance, weather, aircraft availability)
• Road retrieval: May be faster for distances <200km (1-2h vs 2-3h for aircraft activation + flight)
• Maintain safety during wait: 1:1 observation, secure room, consider light sedation if agitated

Telemedicine

Telehealth Psychiatric Assessment Quality

• Advantages: Immediate access to psychiatrist, avoid retrieval delays, cost-effective
• Limitations: Lacks non-verbal cues, rapport harder to establish, patient may refuse video (feels impersonal)
• Best practice:
  • Use video (not phone only) if possible
  • ED doctor present during call (continuity, build on telehealth assessment)
  • Provide private space (not open ED area)
  • Allow 30-60min for comprehensive assessment (not rushed)

Post-Discharge Telehealth Follow-Up

• Evidence: Telehealth CBT is non-inferior to face-to-face for mild-moderate depression [46]
• Limitations: High-risk patients need face-to-face (rapport, safety assessment, medication monitoring)
• Hybrid model: Telehealth for weekly check-ins, face-to-face monthly with GP/psychiatrist

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References

Guidelines

1. Australian Institute of Health and Welfare. National Hospital Morbidity Database. Canberra: AIHW, 2021. Available from: https://www.aihw.gov.au
2. Carter G, Page A, Large M, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm. Aust N Z J Psychiatry. 2016;50(10):939-1000. PMID: 27650687
3. National Institute for Health and Care Excellence. Self-harm: assessment, management and preventing recurrence. NICE Guideline NG225. London: NICE, 2022. Available from: https://www.nice.org.uk/guidance/ng225

Key Evidence

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5. Australian Bureau of Statistics. Causes of Death, Australia, 2021. Canberra: ABS, 2022. Cat no. 3303.0.
6. Hawton K, Saunders KE, O'Connor RC. Self-harm and suicide in adolescents. Lancet. 2012;379(9834):2373-2382. PMID: 22726518
7. Möller-Leimkühler AM. The gender gap in suicide and premature death or: why are men so vulnerable? Eur Arch Psychiatry Clin Neurosci. 2003;253(1):1-8. PMID: 12664306
8. Bergen H, Hawton K, Waters K, et al. Epidemiology and trends in non-fatal self-harm in Oxford: update to 2014. Soc Psychiatry Psychiatr Epidemiol. 2016;51(9):1303-1312. PMID: 27438799
9. Australian Bureau of Statistics. Intentional self-harm (suicide) deaths in Australia. Canberra: ABS, 2022. Available from: https://www.abs.gov.au
10. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander health performance framework 2020: suicide and self-harm. Canberra: AIHW, 2020. PMID: N/A (grey literature)
11. Ministry of Health New Zealand. Suicide web tool. Wellington: MOH, 2021. Available from: https://www.health.govt.nz
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13. Chung DT, Ryan CJ, Hadzi-Pavlovic D, et al. Suicide rates after discharge from psychiatric facilities: a systematic review and meta-analysis. JAMA Psychiatry. 2017;74(7):694-702. PMID: 28564699
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15. Van Orden KA, Witte TK, Cukrowicz KC, et al. The interpersonal theory of suicide. Psychol Rev. 2010;117(2):575-600. PMID: 20438238
16. Klonsky ED. The functions of deliberate self-injury: a review of the evidence. Clin Psychol Rev. 2007;27(2):226-239. PMID: 17014942
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20. National Collaborating Centre for Mental Health. Self-harm: longer-term management. NICE Clinical Guideline 133. London: NICE, 2011. PMID: 22536615
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29. Robinson J, Too LS, Pirkis J, et al. Spatial suicide clusters in Australia between 2010 and 2012: a comparison of cluster and non-cluster among young people and adults. BMC Psychiatry. 2016;16:417. PMID: 27899101
30. Rudd MD, Mandrusiak M, Joiner TE Jr. The case against no-suicide contracts: the commitment to treatment statement as a practice alternative. J Clin Psychol. 2006;62(2):243-251. PMID: 16342288
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39. Royal Flying Doctor Service. Annual Report 2020-21. Sydney: RFDS, 2021. Available from: https://www.flyingdoctor.org.au
40. Therapeutic Guidelines Limited. Psychotropic: Depression. Melbourne: TGL, 2023. Available from: https://tgldcdp.tg.org.au
41. Therapeutic Guidelines Limited. Toxicology and Toxinology. Melbourne: TGL, 2023. Available from: https://tgldcdp.tg.org.au
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