Self-Harm or Suicide

Field test version-1.
00 May 2012
DO NOT UPLOAD ON THE INTERNET
Base Course
Self-harm/Suicide
mhGAP-IG base course - field test version 1.00 – May 2012 1

Contents (Self-harm/suicide)
A. Introduction
B. Learning objectives
C. Emergency medical treatment for act of self-harm
D. Key actions
1. Establish communication and build trust
2. Conduct assessment
3. Plan and start management
4. Link with other services and supports
5. Follow up

True or False
• Asking people about suicide gives them the idea to commit

suicide
FALSE
• Asking about self-harm does NOT provoke acts of self-harm.

Asking often reduces anxiety associated with thoughts or acts
of self-harm and helps the person feel understood
3
Self-harm/suicide associated stigma
• A single act of self-harm can have long-term effects on a

person's family, social and working life
• The person and the family can both experience stigma and
discrimination
• The person may have difficulty finding work and making
friends
• Have you seen examples of stigma and discrimination against

someone who has attempted self-harm/suicide?

Terminology
• Suicide is the act of deliberately killing oneself
• Suicidal intent means an intention of killing oneself, to end

one's life, to die
• Suicidal thoughts or ideation means having thoughts of killing

oneself. They can be vague and non-persistent
• Suicide plan means that someone has made a concrete plan

to kill oneself, e.g. I will take my dad’s entire medication this
weekend when my family goes to visit my grandparents
5
Terminology
• An act of self-harm without suicidal intent is deliberately

harming oneself, e.g. cutting oneself
• A suicide attempt is an act of self-harm with suicidal intent

but not resulting in death
• Both are to be taken very seriously because they are

important risk factors for completed suicide in the future
6
Why is it important for you to learn about
self-harm/suicide?
• Suicide can be prevented

• Almost 1 million persons die from suicide every year
• Suicide is among the three leading causes of death in the 15-
24 years old group in many countries
• More common in adolescents to young adults
• Self-harm/suicide has entered mainstream media
• About one third of all suicides in the world are committed by
self-poisoning with pesticides.
• Suicide leaves a devastating legacy for those who have
survived a loved one’s suicide
• Suicide attempt is to be taken very seriously by health
professionals
7
A. Introduction
D. Key actions
5. Follow up
8
Learning Objectives
• To be able to conduct emergency assessment and

management after a medically serious act of self-harm
• To be able to assess people with thoughts, plans, or acts of
self-harm/suicide
• To know that it is necessary to assess for other mhGAP
conditions, chronic pain and acute emotional distress
• To be able to manage people with thoughts, plans, or acts of
self-harm/suicide
• To be able to activate psychosocial support
• To be able to keep contact and follow up
9
A. Introduction
D. Key actions
5. Follow up

Emergency medical treatment: general principles
• Treat medical injury or

poisoning immediately
• If there is acute pesticide

intoxication, follow the WHO
pesticide intoxication
management document
11
Emergency assessment of suicide attempt
Assess if there is evidence of self-injury and/or

signs/symptoms requiring urgent medical treatment:
• Signs of poisoning or intoxication

• Bleeding from self-inflicted wound
• Loss of consciousness
• Extreme lethargy
12
Recognizing a pesticide poisoned person
• Be aware of the possible smell of a pesticide
• The person may be unconscious, with slow breathing and low

blood pressure.
• People who are initially well need to be watched carefully for

new signs (sweating, pinpoint pupils, slow pulse, and slow
breathing).

Treating pesticide poisoning
• A person with possible pesticide poisoning must be treated

immediately
• For a pesticide poisoned person to be safe in a health care

facility, a minimum set of skills and resources must be
available. If they are not available, TRANSFER the person
immediately to a facility that has the minimum set of skills and
resources
• We will discuss the minimum requirements on the next slide
14
Treating pesticide poisoning
Minimum set of skills and resources:

• skills and knowledge about how to resuscitate people and
assess for clinical features of pesticide poisoning
• skills and knowledge to manage the airway, in particular to
intubate and support breathing until a ventilator can be
attached
• atropine and means for its intravenous (IV) administration if
signs of cholinergic poisoning develop;
• diazepam and means for its IV administration if the person
develops seizures

Treating pesticide poisoning: What not to do
• DO NOT force the person to vomit
• DO NOT give oral fluids
• DO NOT leave the person alone
• You may give activated charcoal if

– The person is conscious
– The person gives informed consent
– The person presents within 1 hour of the poisoning
16
When medically stable
• Assessment and management happen simultaneously in an

emergency situation
• Once the initial emergency situation has been resolved,

before the person goes home you must return to do a full
self-harm/suicide assessment and then manage according to
the mhGAP-IG

A. Introduction
D. Key actions
5. Follow up

Establish communication and build trust
• Establish a relationship before asking self-harm questions
• Ask openly about self-harm
• When asking the person about suicide, the question should

be asked with an appropriate transition from a previous point
leading into this issue

Establish communication and build trust
• Treat the person with respect and privacy
• Be sensitive to emotional distress
• Make sure to see the person alone if culturally possible
• Include the carers in assessment and treatment if the person

gives consent
• Do not try to use moral or cultural values to make the person

feel guilty about his or her suicidal thoughts, plans or acts

A. Introduction
D. Key actions
5. Follow up
21
Process of assessment
Does the presentation

suggest a priority condition
NO
according to the master chart?
End
Go to relevant module(s)
assessment
Conduct assessment according to the module
Identify the condition and treatment
If the person is presenting

with multiple possible
Develop a management plan conditions, all must be
assessed.

 Extreme hopelessness and despair
 Current thoughts, plan or act of self-harm/suicide,
or history thereof
 Any of the other priority conditions, chronic pain,
or extreme emotional distress
mhGAP-IG level 1 course - PHL adaptation ver.1c– 23

Is there an imminent risk of self-
harm/suicide?
Does the person have concurrent MNS

conditions?
Does the person have chronic pain?
Does the person have emotional

symptoms severe enough to warrant
clinical management?

Self-harm/Suicide - Assessment
Is there an imminent risk of self-

harm/suicide?
• Ask the person and carers if there are ANY of the ff:
– Current thoughts or plan of self-harm/suicide
– History of thoughts or plan of self-harm in the past month
or act of self-harm in the past year in a person who is now
extremely agitated, violent, distressed or lacks
communication
Make sure you never leave a
person alone until you have
finished your assessment and
started your management plan
IF NO
• Ask the person and carers if there are ANY of the ff:
– Current thoughts or plan of self-harm/suicide
– History of thoughts or plan of self-harm in the past month
or act of self-harm in the past year in a person who is now
extremely agitated, violent, distressed or lacks
communication
Make sure you never leave a
person alone until you have
finished your assessment and
started your management plan
How do you ask these questions?
• Have you thought about hurting yourself?

• Have you made any plans to end your life?
• How are you planning to do it?
• Do you have pesticides / a gun or other means readily
available to you?
• Have you considered when to do it?

Does the person have concurrent MNS

conditions?
• Depression
• Disorders due to substance use
• Child & adolescent mental and
behavioral disorders
• Psychoses
• Epilepsy
28
Does the person have chronic pain?
•All people with chronic pain should be asked about

self-harm/suicide
29
Does the person have emotional

symptoms severe enough to warrant
clinical management?
Ask about:
• Difficulty carrying out usual work, school, domestic
or social activities
• Repeated self-medication for emotional distress, or
unexplained physical symptoms
• Marked distress or repeated help-seeking

Video
Video

A. Introduction
D. Key actions
5. Follow up
34
Management: Imminent risk of
self-harm/suicide attempt
• Place the person in a secure and supportive environment at

the health facility, if possible, offer separate, quiet room
while waiting
• Do not leave the person alone
• Remove the means of self-harm
• If prescribing medication:
– use medicines that are the least dangerous in case of
overdose
– give prescriptions for short periods of time (e.g. one week
at a time)
• Hospitalization in non-psychiatric services of general hospitals
with the goal of preventing acts of self-harm is not
recommended
35
Management: Co-occurring conditions
• If there is a concurrent mhGAP condition, e.g. depression,

alcohol use disorder, manage according to the mhGAP-IG for
the self-harm/suicide and also for the mhGAP condition
• If there is chronic pain, you need to manage the pain. Consult

a pain specialist if necessary
• If the person has no mhGAP condition but has nonetheless

severe emotional symptoms, then manage as explained in the
module on other significant mental health complaints (OTH)

Management: All cases of thoughts, plans or acts of
self-harm/suicide
• Consult a mental health specialist, if available
• Offer and activate psychosocial support
• Maintain regular contact and follow-up
37
Management: Consult a mental health specialist
• Find out whether a mental health specialist is available and

make an appointment for the person
• The specialist and the carers should both know when the
appointment is and why the person needs the appointment
• If a mental health specialist is not available, mobilize family,

friends and other concerned individuals or available
community resources to monitor and support the individual
during the imminent risk period
38
Offer psychosocial support
• Offer support to the person

– Explore reasons and ways to stay alive
– Focus on the person’s strengths by encouraging them to

talk of how earlier problems have been resolved
– Consider problem-solving therapy to help people with acts
of self-harm within the last year, if sufficient human
resources are available. Go to Essential care and practice
(ECP)
39
How do you address psychosocial stressors
• Offer the person an opportunity to talk, preferably in a

private space.
• Ask about current psychosocial stressors
• Assess any situation of maltreatment, abuse (e.g. domestic
violence) and neglect or bullying
• Brain storm together for solutions or for ways of coping
• Identify supportive family members and involve them as
much as possible and appropriate.
• Encourage involvement in self-help and family support
groups, where available.

RECALL:
How do you help someone problem-solve
1. Identify the problems

2. Prioritize the problems
3. Select the problem to be addressed
4. Think about all possible solutions to the problem
5. Select the most appropriate solution
6. Implement the solution
41
A. Introduction
D. Key actions
5. Follow up
42
Link with other services and supports
•Identify and mobilize possible sources of social and community

support in the local area, including educational, housing and
vocational supports
•For children and adolescents, coordinate with schools to

mobilize educational and social support
• Encourage involvement in self-help and family support groups

Activate psychosocial support
• Mobilize family, friends, to monitor the person and to restrict

access to means of self-harm
• Inform carers that asking about suicide will often reduce the
anxiety surrounding the feeling; the person may feel relieved
and better understood
• Carers often experience severe stress. Provide emotional

support to carers as needed
44
• Optimize social support from available community resources

– Religious leaders
– Formal community resources
– Crisis centers and local mental health centers
45
Reactivate
Reactivatesocial networks
social networks
• Identify prior social activities that, if reinitiated, may provide

psychosocial support
• family gatherings,
• outings with friends,
• visiting neighbors,
• sports,
• community activities
• Encourage the person to resume these social activities

• Advise the family members that these activities can help with
recovery

A. Introduction
D. Key actions
5. Follow up
47
Follow up
• You will need frequent contact initially (e.g. weekly for the
first 2 months) and less frequent contact as the person
improves (e.g. once every 2–4 weeks).
• But you will need to follow up for as long as suicide risk

persists
• At every contact, routinely assess thoughts, plans and acts of

self-harm/suicide

Follow up
Follow up
• How do you usually follow up people with self-harm/suicide

attempt?
• Can you think of any other follow up methods that would be

culturally acceptable?
• Any follow up MUST include another full assessment of self-

harm/suicide

KeyKeymessages
messages
• Everyone with thoughts, plans, or acts of self-harm/suicide

must be assessed for mhGAP conditions
• Anyone with a mhGAP condition must be assessed for self-
harm/suicide
• The means of suicide must be removed from the individual
• Psychosocial support should be offered to the person and
family
• Follow up is essential
• If your facility does not have the skills and resources to
manage pesticide poisoning, transfer a person with pesticide
poisoning immediately

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Field test version-1.

mhGAP-IG base course - field test version 1.00 – May 2012 1

mhGAP-IG base course - field test version 1.00 – May 2012 2

• Asking people about suicide gives them the idea to commit

• Asking about self-harm does NOT provoke acts of self-harm.

• A single act of self-harm can have long-term effects on a

• Have you seen examples of stigma and discrimination against

mhGAP-IG base course - field test version 1.00 – May 2012 4

• Suicide is the act of deliberately killing oneself

• Suicidal intent means an intention of killing oneself, to end

• Suicidal thoughts or ideation means having thoughts of killing

• Suicide plan means that someone has made a concrete plan

• An act of self-harm without suicidal intent is deliberately

• A suicide attempt is an act of self-harm with suicidal intent

• Both are to be taken very seriously because they are

• Suicide can be prevented

• To be able to conduct emergency assessment and

mhGAP-IG base course - field test version 1.00 – May 2012 10

• Treat medical injury or

• If there is acute pesticide

Assess if there is evidence of self-injury and/or

• Signs of poisoning or intoxication

• Be aware of the possible smell of a pesticide

• The person may be unconscious, with slow breathing and low

• People who are initially well need to be watched carefully for

mhGAP-IG base course - field test version 1.00 – May 2012 13

• A person with possible pesticide poisoning must be treated

• For a pesticide poisoned person to be safe in a health care

• We will discuss the minimum requirements on the next slide

Minimum set of skills and resources:

mhGAP-IG base course - field test version 1.00 – May 2012 15

• DO NOT force the person to vomit

• DO NOT give oral fluids

• DO NOT leave the person alone

• You may give activated charcoal if

• Assessment and management happen simultaneously in an

• Once the initial emergency situation has been resolved,

mhGAP-IG base course - field test version 1.00 – May 2012 17

mhGAP-IG base course - field test version 1.00 – May 2012 18

• Establish a relationship before asking self-harm questions

• Ask openly about self-harm

• When asking the person about suicide, the question should

mhGAP-IG base course - field test version 1.00 – May 2012 19

• Treat the person with respect and privacy

• Be sensitive to emotional distress

• Make sure to see the person alone if culturally possible

• Include the carers in assessment and treatment if the person

• Do not try to use moral or cultural values to make the person

mhGAP-IG base course - field test version 1.00 – May 2012 20

Does the presentation

Conduct assessment according to the module

Identify the condition and treatment

If the person is presenting

mhGAP-IG base course - field test version 1.00 – May 2012 22

mhGAP-IG level 1 course - PHL adaptation ver.1c– 23

Does the person have concurrent MNS

Does the person have chronic pain?