Self-Harm in Adults

Quick Reference

Critical Alerts

Critical Alert: SAFETY FIRST: Medical stabilization takes priority. Treat overdose, wounds, and poisoning before psychiatric evaluation.

Critical Alert: UNIVERSAL ASSESSMENT: Every patient presenting with self-harm requires formal suicide risk assessment—do not assume non-suicidal intent based on method or appearance.

Critical Alert: DIRECT QUESTIONING: Asking directly about suicidal thoughts does NOT increase risk of suicide. Evidence consistently demonstrates that asking reduces distress and facilitates help-seeking. [1]

Critical Alert: HIGH-RISK OBSERVATION: Patients assessed as high risk require continuous 1:1 observation until comprehensive psychiatric evaluation is completed.

Critical Alert: MEANS RESTRICTION: Actively counsel on restricting access to lethal means—this is one of the most effective suicide prevention interventions. [2]

Key Risk Factors for Suicide Following Self-Harm

Emergency Intervention by Risk Level

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Overview

Self-harm refers to intentional self-inflicted injury regardless of suicidal intent. This encompasses a spectrum from non-suicidal self-injury (NSSI)—where the intent is emotional regulation rather than death—to suicide attempts with clear intent to die. Understanding this distinction is clinically important but should never lead to underestimation of risk, as NSSI independently increases future suicide risk. [3]

Self-harm represents a major public health concern. Globally, approximately 800,000 people die by suicide annually, making it the 10th leading cause of death in high-income countries. [4] Hospital presentations for self-harm have increased substantially, with emergency department visits for intentional self-harm rising by over 40% in the past two decades. [5] The lifetime prevalence of NSSI is approximately 17% among adolescents and 5-6% among adults, while lifetime prevalence of suicide attempts is 2.7% globally. [6]

The assessment and management of self-harm requires a comprehensive biopsychosocial approach. Beyond immediate medical management of injuries or overdose, the clinician must conduct thorough risk assessment, identify underlying psychiatric conditions, address psychosocial stressors, and implement evidence-based interventions including safety planning and connection to appropriate ongoing care. [7]

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Definition and Terminology

Core Definitions

Self-harm is defined as intentional self-poisoning or self-injury, irrespective of the apparent purpose of the act. This term is preferred in UK and European literature as it avoids assumptions about intent. [8]

Non-suicidal self-injury (NSSI) refers to the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned. Common methods include cutting, burning, hitting, and scratching. NSSI is included as a condition for further study in DSM-5. [9]

Suicidal ideation (SI) encompasses thoughts about ending one's own life, ranging from passive wishes ("I wish I were dead") to active planning with intent and method.

Terminology Table

Clinical Pearl: The terms "parasuicide," "deliberate self-harm," and "suicide gesture" are falling out of favor as they may minimize the clinical significance of self-harm. The preferred terminology is "self-harm" with explicit assessment of intent. [8]

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Epidemiology

Prevalence and Incidence

Self-harm is substantially more common than completed suicide, representing a significant burden on emergency and mental health services. Data from the Multicentre Study of Self-Harm in England demonstrate an incidence of approximately 400 per 100,000 population per year presenting to hospital. [10]

Demographics

Sex differences: Females present to hospital for self-harm at approximately 1.5 times the rate of males. However, males account for approximately 75% of completed suicides. This "gender paradox" reflects differences in method choice, with males more commonly using high-lethality methods. [4]

Age distribution: Peak rates of self-harm presentation occur in females aged 15-24 years and males aged 25-34 years. Suicide rates increase with age, particularly in males, with the highest rates in those aged over 75 years. [4]

Socioeconomic factors: Self-harm rates are strongly associated with social deprivation, unemployment, and lower educational attainment. Rates are approximately three times higher in the most deprived areas compared to the least deprived. [10]

Trends

Hospital presentations for self-harm have increased substantially over the past two decades. Data from the UK Multicentre Study demonstrate a 73% increase in self-harm presentations among young females aged 16-24 years between 2000 and 2014. [13] More recent data suggest continued increases, particularly during and following the COVID-19 pandemic. [5]

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Aetiology and Risk Factors

Biopsychosocial Framework

Self-harm results from complex interactions between biological vulnerabilities, psychological factors, and social/environmental stressors.

Biological Factors

Exam Detail: Neurobiological Correlates

Neuroimaging studies have identified structural and functional abnormalities in individuals with suicidal behavior:

• Prefrontal cortex: Reduced gray matter volume and activity, associated with impaired decision-making and impulse control
• Amygdala: Heightened reactivity to negative emotional stimuli
• Anterior cingulate cortex: Abnormalities in error monitoring and conflict resolution
• Orbitofrontal cortex: Altered reward processing and behavioral inhibition

The serotonergic system is most strongly implicated, with reduced serotonin transporter binding and blunted serotonin synthesis capacity. This may underlie the impulsivity and aggression associated with suicidal behavior. [14]

Psychological Factors

Social and Environmental Factors

Psychological Models

Interpersonal Theory of Suicide (Joiner)

This influential model proposes that suicide capability requires the simultaneous presence of: [15]

1. Thwarted belongingness: Unmet need for social connectedness ("I am alone")
2. Perceived burdensomeness: Belief that one is a burden on others ("I am a burden")
3. Acquired capability: Reduced fear of death and elevated pain tolerance, often acquired through repeated exposure to painful or provocative experiences (including NSSI)

Clinical Pearl: NSSI may contribute to "acquired capability" for suicide by habituating the individual to self-inflicted pain and injury. This is one mechanism by which NSSI increases future suicide risk, even in the absence of initial suicidal intent.

Integrated Motivational-Volitional Model (O'Connor)

This three-phase model describes the pathway to suicidal behavior: [16]

1. Pre-motivational phase: Background factors and triggering events
2. Motivational phase: Development of suicidal ideation through defeat/entrapment perceptions
3. Volitional phase: Transition from ideation to action, moderated by capability factors

This model emphasizes that most people with suicidal ideation do not attempt suicide—understanding factors that facilitate transition to action is crucial.

Psychiatric Comorbidity

The vast majority of individuals who die by suicide have a diagnosable psychiatric disorder. Key associations include:

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Methods of Self-Harm

Overview of Methods

The method of self-harm provides important clinical information but should not be used to infer suicidal intent or predict future risk. Method availability strongly influences choice. [17]

Self-Poisoning (Overdose)

Self-poisoning accounts for the majority of hospital presentations for self-harm. Common substances include:

Medications:

• Acetaminophen (paracetamol): Most common; serious hepatotoxicity risk
• Non-steroidal anti-inflammatory drugs
• Antidepressants (particularly TCAs, SSRIs in combination)
• Benzodiazepines
• Opioids (increasingly common)
• Antipsychotics

Other substances:

• Alcohol (often in combination)
• Illicit drugs
• Household products

Critical Alert: STAGGERED OVERDOSE: Patients may take multiple doses over several hours or days. This pattern is associated with worse outcomes in acetaminophen poisoning and requires specific management protocols.

Non-Suicidal Self-Injury (NSSI)

NSSI serves specific psychological functions, most commonly: [9]

1. Affect regulation: Rapid relief from intense negative emotions (most common)
2. Self-punishment: Response to self-directed anger or guilt
3. Anti-dissociation: Generation of feeling when experiencing numbing/depersonalization
4. Interpersonal influence: Communication of distress (less common than perceived)
5. Sensation-seeking: In context of emotional numbness

Common methods and locations:

• Cutting: Forearms, thighs, abdomen
• Burning: Cigarettes, heated objects
• Scratching/picking: Arms, hands
• Hitting/banging: Head, limbs against hard surfaces

Clinical Pearl: Understanding the function of NSSI guides treatment. If the primary function is affect regulation, treatment focuses on developing alternative emotion regulation strategies (central to DBT). If the function is anti-dissociative, grounding techniques are prioritized.

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Clinical Presentation

History Taking

A comprehensive psychiatric history is essential. Key domains include:

Presenting Episode

About the self-harm act:

• What method(s) were used?
• What was the timing and sequence of events?
• Where did it occur and who was present?
• Was there planning or was it impulsive?
• Were precautions taken against discovery?
• Did they seek help afterward or expect to be discovered?
• What substances were involved (type, quantity, timing)?

About intent:

• "Did you want to die?"
• "Did you expect to die?"
• "Are you disappointed to have survived?"
• "What did you hope would happen?"
• "What, if anything, stopped you from doing more?"

About current mental state:

• Ongoing suicidal ideation?
• Current plan or intent?
• Reasons for living vs. reasons for dying?
• Hopelessness about the future?

Current Suicidal Ideation

Use structured questioning to assess:

Psychiatric History

• Previous self-harm or suicide attempts (strongest predictor)
• Psychiatric diagnoses and hospitalizations
• Current treatment and medication
• Engagement with mental health services
• History of trauma or abuse

Medical History

• Chronic medical conditions (pain, disability, terminal illness)
• Recent diagnoses or health deterioration
• Medications (assess lethality of available medications)

Substance Use

• Alcohol: Current intoxication, dependence, recent changes
• Drugs: Type, frequency, recent use
• Prescription medication misuse

Social History

• Living situation and social supports
• Employment/financial status
• Relationships and recent losses
• Access to lethal means (firearms, medications)
• Children or dependents

Mental State Examination

Systematic mental state examination is essential:

Critical Alert: COMMAND HALLUCINATIONS: Always specifically ask about voices commanding self-harm or suicide. Patients may not volunteer this information. Command hallucinations with perceived malevolent identity and history of acting on commands confer highest risk.

Physical Examination

General assessment:

• Vital signs (tachycardia, hypotension, fever may indicate toxicity)
• Level of consciousness (GCS)
• Pupil size and reactivity
• Signs of intoxication
• Evidence of trauma

Wound assessment for cutting/self-injury:

Signs suggestive of significant overdose:

• Altered mental status
• Respiratory depression
• Tachycardia or bradycardia
• Hypotension or hypertension
• Seizures
• Hepatic tenderness (acetaminophen)
• Nystagmus, ataxia (anticonvulsants)

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Red Flags

Features Indicating High Suicide Risk

Critical Alert: The following features indicate HIGH or IMMINENT suicide risk and typically warrant psychiatric admission:

Protective Factors

Protective factors may mitigate risk but should never lead to dismissal of concerning features:

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Differential Diagnosis

Primary Considerations

Other Considerations

Clinical Pearl: Patients with personality disorders who present repeatedly with self-harm are sometimes dismissed as "not really suicidal." This is dangerous—the suicide rate in borderline personality disorder is 8-10%, and repeated NSSI is a strong risk factor for eventual completed suicide.

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Investigations

Medical Assessment

All patients presenting with self-harm require medical evaluation to exclude toxicity or injury requiring treatment.

Mandatory for All Overdoses

Additional Investigations Based on Presentation

Psychiatric Assessment Tools

Columbia Suicide Severity Rating Scale (C-SSRS)

The C-SSRS is a validated, structured interview tool for assessing suicide risk. It assesses: [1]

• Severity of ideation (5 levels from passive to active with intent and plan)
• Intensity of ideation (frequency, duration, controllability)
• Suicidal behavior (actual attempts, interrupted/aborted attempts, preparatory behaviors)

Clinical Pearl: The C-SSRS provides standardized language and structure for suicide risk assessment. It is freely available and widely recommended in emergency settings.

Other Validated Tools

Critical Alert: LIMITATIONS OF TOOLS: No risk assessment tool can accurately predict suicide at an individual level. Scales should inform—not replace—comprehensive clinical assessment. Over-reliance on tools may lead to false reassurance or false alarm.

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Psychosocial Assessment

NICE Guidance

NICE Clinical Guideline 16 recommends that all individuals presenting with self-harm receive a comprehensive psychosocial assessment, ideally within 48 hours and certainly before discharge. [8]

This assessment should include:

1. Circumstances of the self-harm
2. Current suicidal intent and mental state
3. Hopelessness
4. Psychiatric history and diagnosis
5. Social circumstances and supports
6. Personal resources and coping strategies
7. Risk of further self-harm or suicide
8. Need for ongoing treatment and appropriate setting

Structured Approach

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Risk Assessment and Formulation

Principles of Risk Assessment

Risk assessment is a clinical process, not a bureaucratic checkbox exercise. The goal is to understand the individual's current state and develop a management plan that addresses modifiable risk factors.

Key principles:

1. Risk is dynamic: Risk changes over time and with circumstances
2. Risk is contextual: Environmental factors (means access, supports) are crucial
3. Prediction is limited: Focus on reducing modifiable factors, not predicting the unpredictable
4. Documentation is essential: Record reasoning, not just risk level label

Risk Stratification

Clinical Pearl: Risk stratification is a communication tool and guide to intensity of intervention—not a prediction of outcome. A patient rated "low risk" may still complete suicide; a "high risk" patient may not. Document the reasoning behind your formulation.

Risk Formulation

A risk formulation synthesizes the assessment into a coherent narrative that explains the individual's current state and guides management.

Components:

1. Predisposing factors: What made this person vulnerable? (e.g., childhood trauma, family history, personality traits)
2. Precipitating factors: What triggered this episode? (e.g., relationship breakdown, job loss)
3. Perpetuating factors: What is keeping them at risk? (e.g., ongoing depression, hopelessness, social isolation)
4. Protective factors: What may prevent further self-harm? (e.g., children, engaged in treatment, future plans)
5. Risk level and rationale: Synthesis of above; explicit statement of reasoning
6. Management plan: What will be done to address modifiable factors

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Management

Principles

1. Medical stabilization first: Treat overdose, wounds, poisoning before psychiatric assessment
2. Compassionate, non-judgmental care: Stigmatizing attitudes worsen outcomes and reduce help-seeking
3. Comprehensive assessment: Every patient deserves thorough evaluation
4. Least restrictive intervention: Balance safety with autonomy
5. Address underlying causes: Treat psychiatric illness, address psychosocial stressors
6. Means restriction: Reduce access to lethal methods
7. Continuity of care: Seamless transition from emergency to ongoing care

Acute Medical Management

Self-Poisoning/Overdose

Refer to specific toxicology protocols. Key principles:

Wound Management

Emergency Department Safety

Psychiatric Management

For High-Risk Patients

• Inpatient psychiatric admission: Voluntary or involuntary under mental health legislation
• Continuous 1:1 observation until admission
• Psychiatry consultation for admission planning
• Medication review: Address undertreated psychiatric illness

For Moderate-Risk Patients

Careful clinical judgment required. May consider discharge with:

• Comprehensive safety plan
• Strong social support engaged
• Means restriction implemented
• Outpatient follow-up within 24-72 hours
• Clear crisis pathway identified
• Underlying condition addressed (medication started/adjusted)

For Lower-Risk Patients

• Safety planning intervention
• Outpatient mental health referral
• Means restriction counseling
• Crisis resources provided
• Follow-up within 72 hours

Safety Planning Intervention

The Safety Planning Intervention (SPI) is an evidence-based, brief intervention that reduces suicidal behavior. [18] It differs from "no-suicide contracts," which lack evidence of effectiveness.

Stanley-Brown Safety Planning Intervention Components:

Clinical Pearl: Safety planning is collaborative—developed WITH the patient, not given TO them. The process of creating the plan is therapeutic. Provide a written copy and photograph for their phone.

Means Restriction

Means restriction is one of the most effective suicide prevention interventions. [2] Counsel all patients and their families on:

Medications:

• Lock up all medications, including over-the-counter
• Dispose of unneeded medications safely
• Prescribe limited quantities (e.g., 1 week supply)
• Consider blister packs rather than bottles

Firearms:

• Most lethal method; firearm access dramatically increases suicide risk
• Counsel on temporary removal or secure storage
• Unloaded, locked, ammunition stored separately
• Ideally removed from the home entirely during crisis

Other means:

• Secure ligature points
• Limit access to heights
• Remove/secure sharp objects

Clinical Pearl: Means restriction works because many suicidal crises are time-limited. Introducing a barrier buys time for the crisis to pass. Substitution to other methods is less common than expected.

Pharmacotherapy

There is no medication specifically approved for acute suicidality, but treatment of underlying psychiatric conditions is essential.

Exam Detail: Lithium's Anti-Suicidal Effect

Lithium has a specific anti-suicidal effect independent of its mood-stabilizing properties. Meta-analyses demonstrate approximately 80% reduction in suicide risk in patients with mood disorders. The mechanism may relate to serotonergic effects and reduction in impulsivity and aggression. [19]

Psychotherapy

Dialectical Behavior Therapy (DBT)

DBT is the most extensively studied treatment for individuals with borderline personality disorder and chronic self-harm. [20] It is considered the gold standard for NSSI.

Components:

• Individual therapy
• Skills training group (core skills: mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness)
• Phone coaching for crisis skills application
• Therapist consultation team

Evidence: Multiple RCTs demonstrate reduced self-harm, reduced suicide attempts, and reduced hospitalization.

Other Evidence-Based Therapies

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Disposition

Criteria for Psychiatric Admission

Critical Alert: The following features typically indicate need for inpatient psychiatric care:

Involuntary Admission

When a patient refuses voluntary admission and meets criteria for danger to self, involuntary admission under mental health legislation may be necessary.

UK (Mental Health Act 1983):

• Section 2: Assessment (up to 28 days)
• Section 3: Treatment (up to 6 months)
• Section 5(2): Doctor's holding power (up to 72 hours)

Documentation requirements:

• Evidence of mental disorder
• Nature and degree warranting detention
• Necessity for health, safety, or protection of others
• Least restrictive option considered

Criteria for Discharge

Patients may be considered for discharge with community follow-up if:

Follow-Up

Clinical Pearl: The first 1-2 weeks after discharge from psychiatric inpatient care is the highest-risk period for suicide. Intensive follow-up during this transition is critical.

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Special Populations

Older Adults

• Higher lethality: More lethal methods, less likely to survive attempts
• Less warning: May give fewer verbal warnings of intent
• Physical illness: Chronic disease, disability, pain are risk factors
• Social isolation: Widowhood, decreased mobility, loneliness
• Depression often unrecognized: May present as somatic complaints

Assessment considerations: Screen for depression, assess functional status, social network, and physical health comorbidities.

LGBTQ+ Individuals

• Elevated risk: 2-3x higher rates of suicidal ideation and attempts
• Contributing factors: Minority stress, discrimination, family rejection, identity-related distress
• Protective factors: Affirming environments, community connection, family acceptance

Assessment considerations: Create affirming environment, ask about gender identity and pronouns, assess for discrimination-related distress.

People with Intellectual Disabilities

• Underrecognized: Self-harm may be attributed to challenging behavior
• Communication difficulties: May have difficulty expressing distress
• Increased vulnerability: Trauma, abuse, loss more common

Assessment considerations: Adapted communication, involve caregivers, assess for pain/physical causes of behavioral change.

Perinatal Period

• Perinatal mental illness: Significant risk factor for self-harm and suicide
• Suicide is leading cause of maternal death: In high-income countries
• Specific considerations: Baby's welfare, bonding, support needs

Assessment considerations: Perinatal mental health team involvement, mother-baby unit consideration, safeguarding.

Substance Use Disorders

• High comorbidity: Greatly elevated suicide risk
• Intoxication increases impulsivity: Reassess when sober
• Chronic use increases risk: Even when not acutely intoxicated

Assessment considerations: Assess for withdrawal, integrated mental health and substance treatment, address SUD in care plan.

Chronic Self-Harm

• Pattern of repeated NSSI: Often in context of borderline personality disorder
• Not "just attention seeking": NSSI confers significant suicide risk
• Compassion fatigue in providers: Maintain non-judgmental stance

Assessment considerations: Each presentation deserves thorough assessment; DBT referral; avoid dismissive attitudes.

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Patient and Family Education

For the Patient

Key messages to communicate:

• "What you're going through is serious, and help is available."
• "These thoughts and feelings can change with treatment and support."
• "We've made a safety plan together—please use it when you're struggling."
• "It's important to remove access to things that could hurt you."
• "Please come back to the ED or call the crisis line if things get worse."

For Family/Support Persons

Key messages:

• "Your loved one is going through a very difficult time."
• "You can help by removing access to medications, firearms, and other means."
• "Watch for warning signs: increased talk of death, giving things away, social withdrawal."
• "Encourage use of the safety plan and follow-up appointments."
• "It's OK to ask directly about suicidal thoughts—it doesn't make things worse."
• "If you're concerned, bring them back to the ED or call the crisis line."

Crisis Resources

International:

• International Association for Suicide Prevention: https://www.iasp.info/resources/Crisis_Centres/

United Kingdom:

• Samaritans: 116 123 (24/7, free)
• Crisis Text Line: Text SHOUT to 85258
• Papyrus (under 35s): 0800 068 4141

United States:

• 988 Suicide and Crisis Lifeline: Call or text 988
• Crisis Text Line: Text HOME to 741741
• Veterans Crisis Line: 988, press 1

Australia:

• Lifeline: 13 11 14
• Beyond Blue: 1300 22 4636
• Suicide Call Back Service: 1300 659 467

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Prognosis

Risk of Repetition

Following a self-harm presentation:

Factors Associated with Worse Outcome

Factors Associated with Better Outcome

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Quality Metrics and Documentation

Documentation Requirements

All self-harm assessments should document:

Quality Indicators

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Key Clinical Pearls

Assessment

Clinical Pearl: Ask directly about suicide. Research consistently shows that asking about suicidal thoughts does not increase risk—it often provides relief and facilitates help-seeking. Avoiding the question due to discomfort is a missed opportunity.

Clinical Pearl: Prior suicide attempt is the strongest predictor of future completed suicide. Always ask about previous self-harm in detail: method, lethality, intent, what interrupted the attempt.

Clinical Pearl: Hopelessness is more predictive than depression severity. A patient may score "moderately" depressed but have profound hopelessness—this warrants heightened concern.

Clinical Pearl: Reassess when sober. Intoxication impairs judgment and increases impulsivity. A patient who appears high-risk while intoxicated may be lower risk when sober—but requires reassessment, not assumption.

Clinical Pearl: NSSI is not "just attention seeking". Non-suicidal self-injury confers significant risk for future suicide. Every episode deserves thorough assessment and compassionate care.

Management

Clinical Pearl: Safety planning is evidence-based; "no-suicide contracts" are not. Safety planning is collaborative, specific, and addresses capability. Contracts are passive and lack evidence of effectiveness.

Clinical Pearl: Means restriction saves lives. Counseling on means restriction (especially firearms) is one of the most effective interventions. Most crises are time-limited—barriers buy time.

Clinical Pearl: Follow-up within 72 hours is critical. The period after ED discharge or inpatient care is high-risk. Ensure clear follow-up and that the patient knows how to access help.

Clinical Pearl: Document your reasoning, not just the risk level. A risk level label without explanation is clinically and legally insufficient. Explain why you assessed risk as you did and what your plan addresses.

Disposition

Clinical Pearl: High risk = psychiatric evaluation and usually admission. When risk is high, err on the side of caution. A missed high-risk patient has catastrophic consequences.

Clinical Pearl: Involve family and supports. Engage trusted others in safety planning, means restriction, and monitoring. They are a crucial part of the safety net.

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Exam-Focused Content

Common Viva Questions

1. "A 25-year-old woman presents after cutting her forearms. How would you assess her?"
2. "What are the key risk factors for suicide following self-harm?"
3. "How do you distinguish between NSSI and a suicide attempt?"
4. "What is the evidence for safety planning interventions?"
5. "When would you consider involuntary admission for a patient with self-harm?"
6. "What is the role of means restriction in suicide prevention?"
7. "How do you manage a patient with chronic self-harm and borderline personality disorder?"
8. "What are the principles of psychosocial assessment after self-harm?"

Model Viva Answer

Q: "A 35-year-old man presents to the emergency department after a paracetamol overdose. Describe your approach to assessment and management."

A: "I would approach this systematically, addressing both medical and psychiatric aspects.

Medical management first: I would assess the quantity and timing of ingestion, as this determines management. I would take blood at 4 hours post-ingestion for paracetamol level and plot this on the nomogram. If the level is above the treatment line, or if there's any doubt about timing (staggered overdose), I would commence N-acetylcysteine. I would also check LFTs, renal function, coagulation, and blood glucose. Any patient with rising ALT or coagulopathy needs urgent hepatology input.

Comprehensive psychiatric assessment: Once medically stable, I would conduct a thorough psychosocial assessment including the circumstances of the overdose, current suicidal ideation, mental state examination, psychiatric and personal history, and social circumstances. I would specifically assess intent—did he want to die? Did he expect to die? Is he disappointed to have survived?

Risk assessment: I would formulate risk by considering predisposing factors, precipitants, perpetuating factors, and protective factors. Key high-risk features would include a high-lethality method, planning, precautions against discovery, ongoing hopelessness, and lack of social support.

Management plan: Depending on risk level, I would consider psychiatric admission if risk is high. For moderate or lower risk, I would develop a collaborative safety plan, counsel on means restriction, arrange follow-up within 48-72 hours, and provide crisis contacts. I would involve family in safety planning with the patient's consent.

Documentation: I would document my assessment, risk formulation, reasoning for disposition, and the specific safety plan."

Common Mistakes in Exams

Critical Alert: ❌ Mistakes that fail candidates:

• Assuming NSSI means "not really suicidal"
• Failing to ask directly about suicidal ideation
• Using "no-suicide contracts" as a management strategy
• Discharging high-risk patients without psychiatric assessment
• Not documenting risk assessment reasoning
• Forgetting to counsel on means restriction
• Assuming that intoxicated patients cannot be assessed
• Dismissing chronic self-harmers as "attention-seeking"
• Not arranging follow-up after ED assessment

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References

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11. Carroll R, Metcalfe C, Gunnell D. Hospital presenting self-harm and risk of fatal and non-fatal repetition: Systematic review and meta-analysis. PLoS One. 2014;9(2):e89944. doi:10.1371/journal.pone.0089944

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13. McManus S, Gunnell D, Cooper C, et al. Prevalence of non-suicidal self-harm and service contact in England, 2000-14: Repeated cross-sectional surveys of the general population. Lancet Psychiatry. 2019;6(7):573-581. doi:10.1016/S2215-0366(19)30188-9

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16. O'Connor RC, Kirtley OJ. The integrated motivational-volitional model of suicidal behaviour. Philos Trans R Soc Lond B Biol Sci. 2018;373(1754):20170268. doi:10.1098/rstb.2017.0268

17. Daigle MS. Suicide prevention through means restriction: Assessing the risk of substitution. A critical review and synthesis. Accid Anal Prev. 2005;37(4):625-632. doi:10.1016/j.aap.2005.03.004

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19. Cipriani A, Hawton K, Stockton S, et al. Lithium in the prevention of suicide in mood disorders: Updated systematic review and meta-analysis. BMJ. 2013;346:f3646. doi:10.1136/bmj.f3646

20. Linehan MM, Korslund KE, Harned MS, et al. Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: A randomized clinical trial and component analysis. JAMA Psychiatry. 2015;72(5):475-482. doi:10.1001/jamapsychiatry.2014.3039