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Abstract
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Several mental health problems are associated with self-harm. These include borderline personality disorder, depression, bipolar disorder, schizophrenia, and drug and alcohol-use disorders (1). The management of these disorders is not the scope of this paper. Rather, we discuss how the risk assessment for future self-harm and/or suicide is carried out in the aeromedical context. One challenge is that many individuals do not receive an adequate and timely psychological assessment at hospitals and in healthcare in general (2). In these cases, it is possible that aeromedical examiners (AME) or aviation psychologists are among the first professionals who carry out the risk assessment of aircrew. This task is specialized and demanding and to date, there is a paucity of specific guidance or articles available on how this should be conducted. The importance of self-harm in safety-critical work settings has not been extensively studied (3). The COVID-19 pandemic has had a significant impact on the aviation industry leading to job loss, furlough, disruption to careers and training trajectories and uncertainties among airline employees. There is also evidence that COVID-19 disease itself can cause neurological and psychiatric morbidity (4).
Examples of presentations of self-harm are self-poisoning with medication or self-injury by cutting (5). Excessive alcohol consumption or accidental harm to oneself are usually not included in self-harm. Self-harm is not a disorder, but it is commonly associated with several definable mental health problems and conditions including personality disorders, depression and bipolar disorder, which may compromise aviation safety (6, 7). Those patients who self-harm have a 50-100-fold higher likelihood of dying by suicide in 1 year follow-up compared to those individuals without any self-harm acts (1). Recent research into the genetic etiology of non-suicidal and suicidal self-harm was published (8). Researchers found seven genes associated with self-harm ideation and four genes with self-harm behavior. Despite preliminary findings clearly more research of genetic etiology of self-harm needs to be carried out. The relationship between self-harm and suicide is complex because people often switch methods of self-harm (9). Several risk-assessment scales have been evaluated to determine whether they may predict suicide risk following self-harm. Recent meta-analysis showed that use of the scales is not practical as predictors (10) and instead comprehensive psychosocial assessment and individualized risk analysis could be useful practices.
Impact of COVID-19
While there are concerns that a pandemic may have an impact on increasing suicide risk (11, 12), the direct impact of a pandemic on self-harm is complex, uncertain and still under investigation (13, 14). It is evident that emotional distress increases during pandemics (15). Furthermore, those being treated for existing mental health disorders may experience a worsening of their condition during pandemics (16). Additionally, undiagnosed mental health conditions could worsen during a pandemic and therefore become clinically relevant. To date, there is no clear indication that self-harm rates have increased during the pandemic, at least in UK. It has been also shown that the impact is dynamic and may change in the course of different phases of the pandemic (17, 18). It is also possible that when the pandemic crisis finally ends, self-harm and suicide rates may increase (19).
From the aviation health and safety point of view, self-harm is a complex issue, and the guidance provided for assessment is limited (20). The term self-harm is referred to as an act of self-poisoning or self-injury carried out by the person itself (21). There are different estimates of the prevalence of self-harm. In larger population-based studies in UK, the self-reported lifetime prevalence of non-suicidal self-harm increased from 2.4% (95% CI 2.0-2.8) in 2000, to 6.4% (5.8-7.2) in 2014. It is estimated, based on literature reviews, that rates of community-based self-harm (300-1,100/100,000/year) are much higher compared to hospital-treated self-harm (2.6-542/100,000/year) (22). The range of self-harm presentations is wide, and many presentations will have a benign outcome...
Language: en |