• tachycardia
• postural hypotension (and in overdose they can cause cardiac arrhythmias)
• dysuria
• erectile dysfunction
• blurred vision
Lofepramine is a modified tricyclic antidepressant which mainly affects noradrenaline uptake and it is relatively well tolerated.
The SSRIs block only serotonin reuptake. Common side-effects include:
• nausea
• anxiety
• insomnia
• erectile difficulties
• delayed orgasm.
Although venlafaxine blocks both noradrenaline and serotonin re-uptake, its adverse effect profile is like that of the SSRIs.
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adults. High-risk groups include the economically deprived residents of the inner cities. Single and divorced people are more at risk. Deliberate self-harm is statistically associated with the premature death of a parent and other types of childhood separation. Three-quarters of episodes of self-harm are precipitated by problematic relationships with partners. Those who carry out deliberate self-harm often lack parenting skills and self-harm occurs at least ten times more often among unemployed people than in those who have jobs. Other risk factors include general medical problems and epilepsy. The commonest psychi-atric disorders found in patients who harm themselves are transient
‘adjustment disorders’, followed by depressive illness. Personality disorders and misuse of alcohol are also common.
The vast majority of self-harm is by poisoning, commonly with paracetamol, aspirin or hypnotics. Of other forms of self-harm, wrist-cutting is the commonest.
Many acts of deliberate self-harm are impulsive and patients will often say that they merely wished to go to sleep or to gain respite from distressing thoughts. There is often a mixture of expressive and instrumental motives: that is, patients wish to communicate their distress and also to influence people, such as partners, children or parents and sometimes employers.
Situations which trigger deliberate self-harm include relationship problems and difficulties with employment or studies, and financial worries.
About 15% of patients are involved in a further episode of deliberate self-harm within one year and 1% of patients actually kill themselves during that period.
Factors suggesting serious suicidal intent include:
• planning and preparations (hoarding of tablets and putting financial affairs in order)
• taking precautions to avoid discovery
• leaving a suicide note
• admitting that the aim of the self-harm was to cause death.
The ultimate risk of suicide in those who have harmed themselves is significantly increased in patients who evince a sense of marked hopelessness.
Older women, men, unemployment, people living alone, poor physical health, psychiatric disorder and a history of self-harm, especially if violent methods were used, are all pointers to an increased risk of suicide. A high degree of suicidal intent can be inferred from the use of a dangerous method such as hanging, electrocution, jumping or drowning. Most people who kill themselves have told someone of their intention and repeated attempts often eventually succeed. Multiple methods in the same attempt or violent methods suggest a strong wish to die.
Assessment of risk after deliberate self-harm
• Was the attempt concealed or openly revealed?
• Was it planned or impulsive?
• Was there a note?
• What was the patient’s state of mind at the time of the attempt and leading up to it?
• Does the patient regret the failure of the attempt?
• Is the patient glad to be alive?
• Does the patient intend to try again?
• Is there a history of attempts?
• Is there a family history of suicide?
• Are there delusions of guilt or self-recrimination?
• Are there command hallucinations?
• Is there alcohol or drug misuse?
• Does the patient have any physical illness?
• Does the patient have social supports?
• Is the patient single, widowed, divorced or separated?
• Are there hypochondriacal delusions or delusions of unworthiness?
Caution
The decision to end one’s life or the attempt to do so can have a cathartic effect, so the patient may appear surprisingly cheerful before or after an act of deliberate self-harm and this may give the impression that the depression has lifted or that there is no further risk.
Case 11.5 Suicide
A 50-year-old painter and decorator presented with a painful neck and shoulder following an injury sustained when he was struck by heavy scaffold-ing while workscaffold-ing. Despite orthopaedic and neurological specialist advice and follow-up, he was left with intractable pain and was prevented from resuming his job or any other suitable alternative duties. He could also no longer engage in his hobby of weight-lifting, at which he had reached an international standard. He was given an antidepressant, but in a low dose.
After a year off work he made a serious suicide attempt. The dose of antidepressant was increased and further efforts were made to retrain him as the antidepressants became effective. He was also treated by a clinical psychologist specialising in chronic pain to teach him to cope with daily tasks despite a significant background level of pain. However, there was very little improvement and as he was unable to work he was retired on ill-health grounds. He committed suicide three months later.
Treatment of deliberate self-harm
After an act of deliberate self-harm:
• ensure the person’s physical well-being with appropriate medical treatment
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• evaluate the risk of the act being repeated
• arrange admission to a psychiatric unit for people with serious mental illness or people who still have suicidal intent
• arrange for brief problem-solving counselling sessions relevant to the individual’s current life situation (Lipsedge, 1997).