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Abstract
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We thank Helen Stallman for her interest in our Article. It is worth highlighting that the high-risk paradigm has proven to be unsuccessful as an approach to mental health care. Our view is that care should be based on the patients' needs. In our Article, we concluded that individual factors have poor utility when evaluating the future risk of suicide at hospital presentation. We did not advocate a risk-based approach to the clinical care of patients who self-harm, but rather an approach whereby mental health practitioners should provide all patients presenting to hospital following self-harm with a thorough (bio)psychosocial assessment. This assessment—which includes enquiring about an individual's problems that contributed to their self-harm, mental health, risks of future self-harm, and the type of aftercare that would be most helpful—should lead to an individually tailored care plan to their specific needs. This is presented in the 2011 National Institute for Health and Care Excellence guidelines.
We also stress that preparations for discharge from the hospital should include safety planning. This has several components including helping patients plan how to manage further crises, especially in the period shortly after discharge (which has been shown to be a time of particularly high suicide risk),1
identifying coping strategies (and sources of help should a further crisis develop), reducing access to means for self-harm, and sharing safety plans with others. Evidence suggests that such an approach can be effective in reducing further self-harm.
Furthermore, we did not refer to specific therapeutic approaches in the Article because our study did not evaluate interventions to reduce self-harm. Clearly, the needs of patients vary; in the Article we recommended an individualised follow-up care plan that follows a thorough assessment immediately after presentation to hospital by a health-care professional.
We agree with Dr Stallman's emphasis on prevention of self-harm and suicide by focusing on contributing factors. However, recognition of the realities of clinical management of the increasing number of patients who present to general hospitals having self-harmed (which is the focus of our study) is important. Furthermore, viewing all suicide deaths as catastrophic failures of the clinical care system is unhelpful and could be dangerous. Such blanket statements suggest an unrealistic view of the effectiveness of clinicians in preventing suicide. It might also perpetuate a blame culture and hinder learning within health systems.
Epidemiological studies—such as ours—are insightful in many ways, but we stress that risk factors need not be taken to mean the presence or absence of immediate danger and therefore should not be used to guide action. As highlighted elsewhere
Language: en |