Self-harm is a major public health problem and it confers a considerable risk of completed suicide. Services for self-harm thus have great potential in suicide prevention.[9] Clinical guidelines and standard operating procedures[10] should specify how best to manage individual patients when they present to health services. There is a pressing need for epidemiological surveillance and appropriate local research for contributing to a better understanding of this major public health problem and improve the possibilities of prevention.[11]

Service provision for self-harm remain extremely variable even in Western countries.[12] The care of patients who attempt suicide needs to include psychiatric and psychosocial assessment and systematic referral to professional services after discharge.[13] There is research evidence that individuals who leave accident and emergency (A and E) settings without psychosocial assessment have higher rates of repetition of self-harm.[14] Several documents published in the West elaborating guidelines to care for those who self-harm emphasize the role of psychosocial assessments, multidisciplinary approaches to working, adequate training and supervision, and the organization of services.[15,16]

It was found in this survey that only 66% of the centers have a system where a mental health professional assesses those who have self-harmed in the casualty department. Deliberate self-harm (DSH) patients who are not assessed and are discharged directly from the A and E may be at greater risk of further DSH and completed suicide as compared to those who are assessed. Further, DSH during the subsequent year occurred in 37.5% of the non-assessed patients as compared to 18.2% of matched assessed patients.[14] Having a clear policy for referral to specialist psychosocial assessment of patients admitted to general medical wards is mandatory.[15] A referral for self-harm assessment should be made when the patient is fully conscious and able to complete a psychosocial assessment.[16] All hospital attendance following self-harm should lead to a specialist psychosocial assessment. This should aim to identify motives for the act and associated problems that might be amenable to intervention, such as psychological or social problems, mental disorder, and alcohol or other substance abuse.[17] Presence of mental illness increases the suicide intent and lethality of the attempt.[18]

Training in assessing suicide risk should be made widely available to staff working in areas where contact with suicidal patients regularly occurs, including accident and emergency departments and general medical wards.[19] Non-specialist staff can be trained to perform assessments following self-harm. Studies have demonstrated that certain key skills in both assessment and management of people at risk of suicide can be taught to non-mental health professionals.[20,21] Given the patchy availability of psychiatric services even in teaching hospitals with psychiatry departments, training emergency physicians to perform psychosocial assessments and referring only those at a higher risk of repetition is more likely to succeed. Patients with a psychiatric diagnosis are at an increased risk of a repeat self-harm and appropriate management of mental illness is the cornerstone of any suicide prevention efforts.[22] Psychological therapies like problem solving therapy[23] and cognitive behavior therapy[23] have been found to be useful in reducing repetition rates of deliberate self-harm. The importance of psychological therapies is obtaining more recognition, but funding and recruitment issues continue to be major hurdles. Professionals should remember the major role relatives can play in providing collateral information and supporting the patients. Successful interventions for suicide prevention in this sociocultural background would include the family as well.[24]

Exposure to psychiatry is essential to attract medical students to become career psychiatrists.[25] It is essential that skills for assessment of suicidal patients are taught during this attachment, as this is one of the essential skills identified by the World Psychiatric Association in its core curriculum in psychiatry for medical students.[26] Only 34% of colleges have any ongoing training programmes in assessing and managing suicide attempters. This roughly corresponds to the number of colleges with postgraduate training courses in psychiatry. Training is essential to refresh and keep oneself abreast with information. The importance of refresher courses cannot be overemphasized in this area of psychiatry.

This study has a few limitations. We assessed the nature of services available only in teaching hospitals, which are generally better resourced than other hospitals where these findings might not be replicated. The next generation of studies should look at mapping services in other settings as well. We also did not try to assess the attitudes and satisfaction of the respondents with the care they provide. We acknowledge that this report suffers from the general limitations of a postal survey and the information provided in the response sheets cannot be verified.