Letters to the Editor
Self-Inflicted Harm Is Not an Indication of Suicidal Behavior
TO THE EDITOR: I reviewed with interest the article on screening for suicide risk1 from the U.S. Preventive Services Task Force department in American Family Physician, especially the association with deliberate self-inflicted harm. I have been confronted with this phenomenon repeatedly through my work in college health and in my supervisory role in our Family Medicine Teen Clinic. There appears to be a lack of information in the medical literature on deliberate self-inflicted harm and some misunderstanding about this disorder in the medical community. It is receiving more attention in the popular media and literature, however, with television shows and movies addressing this topic and Web sites devoted to self-inflicted harm.
I am concerned by one of the Clinical Quiz questions related to this department: "Which of the following is/are risk factors for attempted suicide?" Answer B, "cutting oneself," might support the mistaken belief that cutting is a suicide attempt or the first step on a continuum toward suicidal behavior. However, self-inflicted injury is a coping mechanism, albeit not a particularly healthy one, used by those who want to live and are struggling to control their emotions. This behavior was documented previously in persons with comorbid depression, obsessive-compulsive disorder, borderline personality disorder, substance abuse, or pervasive developmental disorders. Designations have now been proposed to classify the increases we are seeing in adolescent populations not associated with these disorders. In 1983, Pattison and Kahan2 proposed a diagnostic entity, "the deliberate self-harm syndrome," as a distinct category that excluded suicidal behavior. In 1993, Favazza and Rosenthal3 proposed the diagnosis of "repetitive self-harm syndrome," in which patients repeatedly harm themselves without intent to kill but with the purpose of relieving mental and emotional pain. I believe we will see a greater push in the psychiatric and medical literature toward developing a separate diagnostic entity to address self-injury in adolescents who are using this method to regulate emotional distress and who do not have suicidal intent or an associated personality disorder.
Reactions by parents, health care professionals, friends, or teachers to episodes of self-inflicted injury can be highly variable, ranging from dismissal of the behavior as simply a phase to disgust, anger, and fear, or to misinterpretation as suicidal behavior with subsequent inappropriate admission to a psychiatric facility. I am concerned that this latter option will be overutilized if those reading the article or quiz were to presume cutting was equated with suicidal behavior. If the patient does not exhibit suicidal intent or more severe psychopathology, and the method is of low lethality, they would likely be much better served by being linked with a therapist who is experienced in treating this disorder and trained to help them develop more healthy and effective methods of coping with their emotions.
REFERENCES
1. Calonge N. Screening for suicide risk: recommendation and rationale [USPSTF]. Am Fam Physician 2004;70:2187-90.
2. Pattison EM, Kahan J. The deliberate self-harm syndrome. Am J Psychiatry 1983;140:867-72.
3. Favazza AR, Rosenthal RJ. Diagnostic issues in self-mutilation. Hosp Community Psychiatry 1993;44:134-40.
Update on Outpatient Treatment of Systolic Heart Failure
TO THE EDITOR: I read with interest the article1 by McConaghy and Smith in American Family Physician, on the outpatient treatment of systolic heart failure. I want to clarify two points. First, the authors correctly note that the Randomized Aldactone Evaluation Study (RALES) showed reductions in mortality and hospitalization in patients with congestive heart failure who received spironolactone (Aldactone). However, publication of these findings was associated with an abrupt increase in the rate of prescriptions for spironolactone and in hyperkalemia-associated morbidity and mortality.2 Other studies3,4 have reported much higher rates of drug discontinuation because of hyperkalemia than those reported in RALES, particularly in the presence of angiotensin-converting enzyme inhibitors. These differences highlight the challenge of translating findings from controlled trials into practice, and suggest the need for intensive monitoring of serum potassium levels in patients receiving spironolactone for this purpose.
Second, the authors correctly note that the first Vasodilator-Heart Failure Trial (V-HeFT I) showed no improvement in overall mortality in patients given a combination of hydralazine (Sorbitrate) plus isosorbide (Apresoline) dinitrate compared with those treated with enalapril (Vasotec). However, a subanalysis5 showed benefit for blacks, and the recent African-American Heart Failure Trial (A-HeFT),6 involving only blacks, showed a 43 percent reduction in all-cause mortality among patients receiving hydralazine plus isosorbide dinitrate in addition to standard therapy. Both drugs are available generically at modest cost.
REFERENCES
1. McConaghy JR, Smith SR. Outpatient treatment of systolic heart failure. Am Fam Physician 2004;70:2157-64.
2. Juurlink DN, Mamdani MM, Lee DS, Kopp A,
Austin PC, Laupacis A, et al. Rates of hyperkalemia after publication of the
Randomized Aldactone Evaluation Study.
N Engl J Med 2004;351:543-51.
3. Cruz CS, Cruz AA, Marcilio de Souza CA. Hyperkalaemia in congestive heart failure patients using ACE inhibitors and spironolactone. Nephrol Dial Transplant 2003;18:1814-9.
4. Witham MD, Gillespie ND, Struthers AD. Tolerability of spironolactone in patients with chronic heart failure-a cautionary message. Br J Clin Pharmacol 2004;58:554-7.
5. Carson P, Ziesche S, Johnson G, Cohn JN. Racial differences in response to therapy for heart failure: analysis of the vasodilator-heart failure trials. J Card Fail 1999;5:178-87.
6. Taylor AL, Ziesche S, Yancy C, Carson P, D'Agostino R Jr, Ferdinand K, et al. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med 2004;351:2049-57.
editor's note: This letter was sent to the authors of "Outpatient Treatment of Systolic Heart Failure," who declined to reply.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org.
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