Self-harm in young people: the exceptional potential of the general practice consultation

A NATIONAL PRIORITY

The mental health of young people is a leading national priority. Several recent policy documents highlight this, with the government’s 2017 green paper leading the way.¹ Mental illness is associated with significant costs to individuals and society. We know that 75% of mental ill- health begins before the age of 24 years so early interventions are key in preventing debilitating mental illness into and throughout adulthood.¹ The government has allocated £1.4 billion to children and young people’s mental health care over the next few years, and local transformation plans include the mental health of children and young people.¹

The green paper aims to increase the number of senior leads for mental health in schools and colleges where close access to Children and Adolescent Mental Health services (CAMHS) is planned and supported by community Mental Health Support Teams (MHSTs). A 4-week waiting time following referral to CAMHS is also intended.¹ What is important, however, and somewhat overlooked in the green paper, is that general practices should be in liaison with the MHSTs; and GPs must be incorporated into the mental health care that young people receive in the education setting for continuity of care and a joined-up, holistic approach.

WHERE IS ACTION NEEDED IN SELF-HARM?

Self-harm not only affects the individual, but also impacts on families, friends, and those around the person who self-harms.⁶ Integrated care involving families, schools and colleges, third-sector organisations, and NHS healthcare services are crucial to enhance safety among distressed young people in the short term, and to help secure their future mental health and wellbeing in the long term. GPs should involve families and/or caregivers in the management of self-harm in young people where the young person has given consent.

The role of third-sector organisations should not be overlooked. Charities such as ECHO (www.brighter-futures.org.uk/echo/) and Harmless (www.harmless.org.uk/) are vital community services that provide young people with a supportive, informal, and non-judgemental environment to openly discuss self-harm. However, it is vital that such services are evidence based in their approach to supporting those who self-harm and follow existing National Institute for Health and Care Excellence (NICE) guidance.⁷

It is troubling that young people find the internet helpful in normalising self-harm, with images of self-harm providing inspiration for self-harm acts.⁸ Online resources also offer an avenue for young people seeking mental health support and in reducing social isolation.⁸ A recent Public Health England report identified that a focus on the protective factors of family, school environment, and wider community should inform public mental health strategies in preventing self-harm in young people.⁹ Public mental health measures should improve the digital literacy of parents and teachers, and target prevention and early detection of adverse childhood experiences.

The NICE self-harm clinical guideline (CG16) states that ‘primary care has an important role in the assessment and treatment of people who self-harm’ and provides guidance on when to refer young people who may self-harm to secondary care.⁷

PRIMARY CARE AND GENERAL PRACTICE

General practice remains a pillar of primary care, with the consultation the cornerstone of general practice.

Morgan et al highlight the important role of primary care in early intervention and inquiry, monitoring, and targeting of young people who may not openly engage with healthcare services for current self-harming behaviour.² Self-harm incidence in young people in primary care is rising and GPs are seeing more self-harm than previously.²

A youth-friendly general practice can make young people feel welcomed, accepted, supported, and more likely to disclose information such as self-harm thoughts or acts. General practices should at minimum attempt to make their practice youth-friendly for young people who are known to be regular attendees.¹⁰ Offering online appointment booking and a text messaging service will improve young people’s engagement and facilitate the opportunity of support and intervention in the consultation.¹¹ Box 1 suggests ways of adopting a youth-friendly practice approach (for further details refer to the Royal College of Nursing/Royal College of General Practitioners (RCGP) leaflet Getting it Right for Young People in Your Practice).¹²

GPs are uniquely placed to provide comprehensive holistic care and should be central to the health journey of a young person and their family. Young people may see their GP before and after an episode of self-harm, so play a key role in assessing, managing, and preventing self-harm, repeat self-harm, and suicide.¹³w The challenge of providing such care and support in a time-limited consultation, however, should not be underestimated. It is important that digital resources, such as the app Calm Harm (https://calmharm.co.uk/), are developed with young people as these can help GPs in supporting young people in the community. Kooth.com (https://www.kooth.com/) is a free and anonymous online service to which young people can be signposted.

GPs can refer to tailored Charlie Waller Memorial Trust GP training,¹⁴ RCGP self-harm in children and young people guidance,¹⁵ and MindEd’s self-harm in young people e-learning¹⁶ for educational resources.

It is important that GPs take the disclosure of self-harm thoughts and episodes seriously, and are vigilant in responding empathetically and with consideration and compassion towards the young people. This will facilitate rapport building and make young people feel listened to in the consultation. Self-harm behaviour evolves over time and suicidal intent is fluid, thus all self-harm, irrespective of suicidal intent, should be taken seriously.¹⁷

To date, only mentalisation-based therapy has shown a modest reduction in frequency of repeat self-harm in young people aged ≤18 years.¹⁸ In those aged ≥18 years, cognitive behavioural therapy-based psychological therapy can reduce repeat self- harm.¹⁹ The development of acceptable and effective self-harm interventions are needed to ensure a consistent clinical management approach for self-harm among children and young people in primary care, specifically in the general practice setting.

CONCLUSION

Realising the full potential of a consultation with young people with self-harm depends on the GP’s ability to listen non-judgementally and communicate effectively, and on the organisation of primary care services. Deficiencies in either of these, according to Stott and Davis, will harm the potential of the consultation.⁴ In the context of self-harm in young people, both factors are equally and crucially as important.

Given the strong association of self-harm, regardless of suicidal intent, with death by suicide, it is vital to view providing adequate support to young people who self-harm as a key element in suicide prevention.⁵ It is an opportunity not to be missed.