Royal Australian and New Zealand College of Psychiatrists clinical practice guideline for the management of deliberate self-harm Gregory Carter1,2,3, Andrew Page1,4, Matthew Large1,5, Sarah Hetrick1,6, Allison Joy Milner1,7,8, Nick Bendit1,9,10, Carla Walton1,11, Brian Draper1,12,13, Philip Hazell1,14, Sarah Fortune1,15,16,17, Jane Burns1,18,19,20, George Patton1,21,22,23,24, Mark Lawrence1,25, Lawrence Dadd1,26,27,28,29, Michael Dudley12, Jo Robinson1,6 and Helen Christensen1,30 Abstract Objective: To provide guidance for the organisation and delivery of clinical services and the clinical management of patients who deliberately self-harm, based on scientific evidence supplemented by expert clinical consensus and expressed as recommendations. Method: Articles and information were sourced from search engines including PubMed, EMBASE, MEDLINE and PsycINFO for several systematic reviews, which were supplemented by literature known to the deliberate self-harm working group, and from published systematic reviews and guidelines for deliberate self-harm. Information was reviewed by members of the deliberate self-harm working group, and findings were then 1Clinical Practice Guideline for Deliberate Self-harm Working Group, RANZCP, Melbourne, Victoria, Australia 2Centre for Translational Neuroscience and Mental Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia 3Department of Consultation Liaison Psychiatry, Calvary Mater Newcastle Hospital, Waratah, NSW, Australia 4Centre for Health Research, Western Sydney University, Richmond, NSW, Australia 5School of Psychiatry, The University of New South Wales, Sydney, NSW, Australia 6Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC, Australia 7Centre for Population Health Research, School of Health and Social Development, Deakin University, Burwood VIC, Australia 8Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia 9School of Medicine and Public Health, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW, Australia 10School of Psychology, Faculty of Science and Information Technology, The University of Newcastle, Callaghan, NSW, Australia 11 Centre for Psychotherapy, Hunter New England Mental Health Service and Centre for Translational Neuroscience and Mental Health, The University of Newcastle, Callaghan, NSW, Australia 12School of Psychiatry, The University of New South Wales, Sydney, NSW, Australia 13Academic Department for Old Age Psychiatry, Prince of Wales Hospital, Sydney, NSW, Australia 14Discipline of Psychiatry, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia 15The University of Auckland, Auckland, New Zealand 16University of Leeds, Leeds, UK First published in Australian and New Zealand Journal of Psychiatry 2016, Vol. 50(10) 939-1000 2 17Kidz First, Middlemore Hospital, Auckland, New Zealand 18Young and Well Cooperative Research Centre, The University of Melbourne, Melbourne, VIC, Australia 19Brain & Mind Research Institute, The University of Sydney, Sydney, NSW, Australia 20Orygen Youth Health Research Centre, Melbourne, VIC, Australia 21Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia 22National Health and Medical Research Council, Canberra, ACT, Australia 23Centre for Adolescent Health, The Royal Children’s Hospital, Melbourne, VIC, Australia 24Murdoch Children’s Research Institute, Melbourne, VIC, Australia 25Tauranga Hospital, Bay of Plenty, New Zealand 26Mental Health & Substance Use Service, Hunter New England, NSW Health, Waratah, NSW, Australia 27Awabakal Aboriginal Medical Service, Hamilton, NSW, Australia 28Pital Tarkin, Aboriginal Medical Student Mentoring Program, The Wollotuka Institute, The University of Newcastle, Callaghan, NSW, Australia 29Specialist Outreach NT, Darwin, Northern Territory, Australia 30Black Dog Institute, The University of New South Wales, Sydney, NSW, Australia Corresponding author: Gregory Carter, Centre for Translational Neuroscience and Mental Health, Faculty of Health and Medicine, The University of Newcastle, Locked Bag #7, Hunter Region Mail Centre, Callaghan, NSW 2310, Australia. Email: [email protected] formulated into consensus-based recommendations and clinical guidance. The guidelines were subjected to successive consultation and external review involving expert and clinical advisors, the public, key stakeholders, professional bodies and specialist groups with interest and expertise in deliberate self-harm. Results: The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for deliberate self-harm provide up-to-date guidance and advice regarding the management of deliberate self-harm patients, which is informed by evidence and clinical experience. The clinical practice guideline for deliberate self-harm is intended for clinical use and service development by psychiatrists, psychologists, physicians and others with an interest in mental health care. Conclusion: The clinical practice guidelines for deliberate self-harm address self-harm within specific population sub-groups and provide up-to-date recommendations and guidance within an evidence-based framework, supplemented by expert clinical consensus. Keywords Guidelines, deliberate self-harm, management, treatment Executive summary Introduction This clinical practice guideline (CPG) is for psychiatrists and other health professionals who assess and treat people after deliberate self-harm (DSH) in Australia and New Zealand. People who present to acute care services after DSH (‘hospital-treated’ DSH) probably represent a minority of all those who self-harm in the community. The most common form of hospital-treated DSH is self-poisoning, followed by self-cutting and other methods such as hanging, jumping and burning. In Australia, rates of hospital-treated DSH are higher for women than men and higher for Aboriginal and Torres Strait Islander people than for the First published in Australian and New Zealand Journal of Psychiatry 2016, Vol. 50(10) 939-1000 3 general population. In New Zealand, rates of hospital-treated DSH are higher among Māori and lower among Pacific Islander people, compared with the general population. Up to one in five people repeat DSH within the first year after an episode of hospital-treated DSH, but most people never repeat DSH at all. The most common forms of DSH in the community are cutting, burning and biting, while self- poisoning is also common. Such self-injury is almost equally common among males and females, less likely to be suicidal in intention and more likely to be motivated by the need to regulate distressing psychological experiences. Repetition rates are high, although precise estimates are not available. Published DSH rates are likely to be underestimates. Systems should be developed to effectively monitor the prevalence, incidence and trends of community and hospital-treated DSH in Australia and New Zealand. Monitoring should include specific sentinel surveillance units established in general hospitals, improved state and national hospital (institutional) data collection systems and inclusion of questions about DSH in national health and mental health surveys. Organisation of healthcare services Waiting times should be minimised for people who present to emergency departments (EDs) after DSH. Psychosocial assessment should be performed by a trained mental health professional. Services that provide care for people with DSH should improve staff knowledge about DSH and improve communication and collaboration between patients and clinical staff during assessment and treatment. Clinical staff should show empathy and respect for patients who self-harm and should provide high-quality medical and mental health care. A thorough clinical assessment of the patient’s situation and treatment needs should include an assessment of modifiable risk factors for self-harm, such as substance use, psychosis, mood disorder, anxiety disorder, eating disorder, personality disorder, medical conditions, relationship difficulties and social problems. Treatment decisions about patients who present with DSH should be made following a thorough personalised assessment and on the basis of a discussion with the patient and their family, friends or carers, where appropriate. The use of risk assessments scales or tools does not reduce repetition of DSH and should not be used as the basis to allocate treatment or aftercare. Specialist multidisciplinary teams should be established, if possible. Patients who leave before completion of assessment or treatment should be actively followed up and offered aftercare. For patients who frequently present with DSH, primary and specialist care providers should be identified and should collaborate with hospital staff to develop a management plan. Access to effective aftercare and information about DSH should be improved for patients, carers and the public. Which treatments are effective to reduce repetition of DSH? Unselected hospital-treated DSH populations. Overall, the limited evidence available from a small number of randomised controlled trials (RCTs) shows that pharmacological treatment does not reduce the risk of repetition of DSH or has an unfavourable risk–benefit ratio. In general, psychotropic agents should not be initiated to manage DSH, unless they would otherwise be indicated. First published in Australian and New Zealand Journal of Psychiatry 2016, Vol. 50(10) 939-1000 4