Health services, suicide, and self-harm: patient distress and system anxiety

Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management

Suicide prevention in psychiatric practice has been dominated by efforts to predict risk of suicide in individual patients. However, traditional risk prediction measures have been shown repeatedly in studies from high income countries to be ineffective. Several factors might contribute to clinicians' preoccupation with risk prediction, which can have negative effects on patient care and also on clinicians where prediction is seen as failing. The model of therapeutic risk assessment, formulation, and management we outline in this article regards all patients with mental health problems as potentially at increased risk of suicide. It is aimed at reducing risk through use of a person-centred approach. We describe how a move towards therapeutic risk assessment, formulation, and risk management, including collaborative safety planning, could help clinicians develop a more tailored approach to managing risk for all patients, incorporating potentially therapeutic effects as well as helping to identify other risk reduction interventions. Such an approach could lead to enhanced patient safety and quality of care, which is more acceptable to patients.

Coexisting service-related factors preceding suicide: a network analysis

OBJECTIVES

The overall objective was to analyse service-related factors involved in the complex processes that precede suicide in order to identify potential targets for intervention.

DESIGN AND SETTING

Explorative network analysis study of post-suicide root cause analysis data from Swedish primary and secondary healthcare.

PARTICIPANTS

217 suicide cases reported to the Swedish national root cause analysis database between 2012 and 2017.

PRIMARY AND SECONDARY OUTCOME MEASURES

A total of 961 reported incidents were included. Demographic data and frequencies of reported deficiencies were registered. Topology, centrality indices and communities were explored for three networks. All networks have been tested for robustness and accuracy.

RESULTS

Lack of follow-up, evaluations and insufficient documentation issues emerged as central in the network of major themes, as did the contributing factors representing organisational problems, failing procedures and miscommunication. When analysing the subthemes of deficiencies more closely, disrupted treatments and staffing issues emerged as prominent features. The network covering the subthemes of contributing factors also highlighted discontinuity, fragile work structures, inadequate routines, and lack of resources and relevant competence as potential triggers. However, as the correlation stability coefficients for this network were low, the results need further investigation. Four communities were detected covering nodes for follow-up, evaluation, cooperation, and procedures; communication, documentation and organisation; assessments of suicide risk and psychiatric status; and staffing, missed appointments and declined treatment.

CONCLUSION

The results of this study suggest that healthcare providers may improve patient safety in suicide preventive pathways by taking active measures to provide regular follow-ups to patients with elevated suicide risk. In some cases, declined or cancelled appointments could be a warning sign. Tentative results show organisational instability, in terms of work structure, resources and staffing, as a potential target for intervention, although this must be more extensively explored in the future.

Application of an accident approach to the study of acute suicidal episodes through repeated in-depth interviews

We modified an accident analysis model for the study of acute suicidal episodes (ASEs). Our aim was to use this model (SCREAM, Suicidal Cognitions' Reliability and Error Analysis Method) as a lens to understand the worst-ever ASEs of nine patients who took part in repeated in-depth interviews. Guided by the theory of SCREAM including four predetermined categories, nine themes were identified. ASEs were triggered by interactions with the interpersonal and physical environment and spiraled into a state of lost control. Timing and the availability of promoters and barriers in the environment were salient features. Findings may aid person-centered safety planning.

A call for change from impersonal risk assessment to a relational approach: professionals' reflections on the national guidelines for suicide prevention in mental health care in Norway

PURPOSE

The purpose of the study is to explore how professionals working with suicide prevention experience the influence of the national guidelines on mental healthcare, and to gather recommendations for which steps to take next.

METHODS

This is a qualitative study with an explorative design. We interviewed 22 professionals responsible for implementing suicide prevention action plans and guidelines, and/or conducting relevant research. We analysed the data by means of thematic analysis.

RESULTS

We found that the participants had an ambivalent view on risk assessment-it may be a tool, but it may also compromise other important aspects in prevention. Moreover, the possibility of liability has resulted in the need for self-protection. Instead, the participants recommended a relational approach to suicide prevention.

CONCLUSIONS

We found that the emphasis on standardized suicide risk assessment has negatively influenced suicide prevention in mental healthcare, and an approach emphasizing relational aspects is recommended. However, the prevailing objectifying concept of knowledge, the epistemological debate and the emergence of the New Public Management ideology may obstruct a fundamental emphasis on relationships. A paradigm shift in mental healthcare is called for with respect to the concept of knowledge, which forms our understandings and practices.

The influence of religious/spiritual beliefs on Malaysian hospital healthcare workers’ attitudes towards suicide and suicidal patients: a qualitative study

Background

There has been mixed findings on whether a healthcare workers’ religious beliefs contribute positively or negatively to their attitudes towards suicidal patients.

Aims

This study aims to explore qualitatively the influence of religious/spiritual beliefs on healthcare workers’ attitudes towards suicide and suicidal patients in the culturally heterogeneous Malaysian population.

Methods

Thirty-one healthcare workers from diverse religious backgrounds, professions and medical disciplines were interviewed. Thematic analysis revealed the centrality of religion in determining healthcare workers’ acceptability of suicide, specific religious beliefs that influenced their views on the right-to-die issue, perceptions of the suicidal patient’s religiousness/spirituality, and the aspects and extent of religious relevance in professional philosophy and practice.

Results

Healthcare workers who could perceive the multifactorial nature of suicide causation had a more empathetic response. There were high levels of paternalism in the care of suicidal patients, involving unsolicited religious/spiritual advice practised as a form of suicide deterrent and social support.

Conclusions

The formal integration of religious/spiritual practices into the professional care of suicidal patients was indicated.

Depression and Anxiety Predict Healthcare Workers' Understanding of and Willingness to Help Suicide Attempt Patients

We examined whether burnout, depression, anxiety, stress, lifetime suicidal ideation, self-efficacy in preventing suicide and demographic factors predicted the understanding of and willingness to help suicidal patients among hospital healthcare workers. A total of 368 healthcare workers from the major surgical and medical departments in a general hospital setting were recruited. Participants responded to the Depression Anxiety and Stress Scale-21, Self-efficacy in Suicide Prevention, and Understanding Suicide Attempt Patient Scale. Those from the psychiatric department, with higher suicide prevention self-efficacy, and lower personal accomplishment indicated more understanding and helpful attitudes; doctors, depressed and anxious healthcare workers reported less understanding and helpful attitudes. Suicide prevention efforts must be conducted in tandem with equipping and supporting the healthcare workers who manage suicidal patients.

Responding to a Tragedy: Evaluation of a Postvention Protocol Among Adult Psychiatry Residents

OBJECTIVE

In a time of "zero suicide" initiatives and rising suicide rates, resident physicians are particularly susceptible to the psychological and professional ramifications of patient suicide. An adult psychiatry residency program developed and implemented a postvention protocol to address the impact of patient suicide among resident physicians. The current study is a formal evaluation of a training program's postvention protocol from June 2018 to April 2020.

METHODS

Process and outcome indicators were identified to assess protocol implementation and effectiveness. Process indicators included were postvention protocol adherence. Outcome indicators were perceived helpfulness of postvention protocol-related supports, occupational and general health measures, posttraumatic growth, and posttraumatic stress symptoms following resident participation in the postvention protocol.

RESULTS

Study response rate was 97% (n = 57/59) and 81% completed the entire survey (n = 48/59). Twenty percent of residents (n = 10/48) experienced patient suicide during residency. Postvention protocol adherence was between 57 and 100%. Protocol-related supports, such as speaking with attendings who had previously experienced an adverse event, were more helpful than other supports (p < 0.01). Compared to residents who had not experienced patient suicide, mean work empowerment, burnout, mental health, and quality of life scores were not significantly different from residents who participated in the postvention protocol (p > 0.05). Posttraumatic growth was positively correlated with self-determination at work (p = 0.01).

CONCLUSIONS

The postvention protocol was helpful to residents and potentially effective at mitigating the psychological and professional consequences of patient suicide. Study findings may inform standardization of postvention protocols among psychiatry training programs.

Implementing a systems approach to suicide prevention in a mental health service using the Zero Suicide Framework

OBJECTIVE

The Zero Suicide Framework, a systems approach to suicide prevention within a health service, is being implemented across a number of states in Australia, and internationally, although there is limited published evidence for its effectiveness. This paper aims to provide a description of the implementation process within a large health service in Australia and describes some of the outcomes to date and learnings from this process.

METHOD

Gold Coast Mental Health and Specialist Services has undertaken an implementation of the Zero Suicide Framework commencing in late 2015, aiming for high fidelity to the seven key elements. This paper describes the practical steps undertaken by the service, the new practices embedded, emphasis on supporting staff following the principles of restorative just culture and the development of an evaluation framework to support a continuous quality improvement approach.

RESULTS

Improvements have been demonstrated in terms of processes implementation, enhanced staff skills and confidence, positive cultural change and innovations in areas such as the use of machine learning for identification of suicide presentations. A change to 'business as usual' has benefited thousands of consumers since the implementation of a Suicide Prevention Pathway in late 2016 and achieved reductions in rates of repeated suicide attempts and deaths by suicide in Gold Coast Mental Health and Specialist Services consumers.

CONCLUSION

An all-of-service, systems approach to suicide prevention with a strong focus on cultural shifts and aspirational goals can be successfully implemented within a mental health service with only modest additional resources when supported by engaged leadership across the organisation. A continuous quality improvement approach is vital in the relentless pursuit of zero suicides in healthcare.

Suicide in psychiatry and medical liability: A case series

The suicide of a patient is a serious event that may constitute a therapeutic failure. To prevent these situations, national and international guidelines exist. When a suicide occurs in a psychiatric hospital or immediately after release, legal action may follow, most frequently for malpractice claims related to the failure to provide reasonable management of the suicide risk. In an attempt to respond to the increased anxiety in the health care system and among practitioners, we used case reports to determine the minimum medico-legal standards that the physician must follow in the context of suicide. From February 1st to May 30th, 2019, we gathered all available expert psychiatric reports following criminal prosecutions from the University Center of Legal Medicine of Geneva. We restricted the extraction of cases to those from January 1st, 2007, to May 30th, 2019. We identified 7 cases. The psychiatrist expert provided a care setting assessment, clinical/survey assessment, and suicidal risk assessment. Improper care setting assessment was the most commonly found conclusion, but the two other categories were as detrimental concerning suicidal risk. Only one psychiatrist was condemned, but the decision was revoked on appeal. The combination of our cases and a scoping review on the subject leads to the recommendation of minimum medico-legal standards to complete individualized suicide risk reduction plans. Minimal medico-legal standards should be applied and documented to optimize care practice for the reduction of suicidal risk at three different levels: the initial evaluation, the treatment, and the surveillance.

Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework

OBJECTIVE

The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians' experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations.

METHOD

We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases.

RESULTS

An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed.

CONCLUSIONS

The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare settings and can have devastating effects on staff and the broader healthcare community. These issues represent 'inconvenient truths' that must be identified, reconciled and integrated into our future pathways towards reducing suicides in health care. The introduction of Zero Suicide Framework can support the much-needed transition from relying on a retrospective focus on errors (Safety I) to a more prospective focus which acknowledges the complexities of healthcare (Safety II), when based on the Restorative Just Culture principles. Restorative Just Culture replaces backward-looking accountability with a focus on the hurts, needs and obligations of all who are affected by the event. In this paper, we argue that the implementation of Zero Suicide Framework may be compromised if not supported by a substantial workplace cultural change. The process of responding to critical incidents implemented at the Gold Coast Mental Health and Specialist Services is provided as an example of a successful implementation of Restorative Just Culture-based principles that has achieved a culture change required to support learning, improving and healing for our consumers, their families, our staff and broader communities.

Texting for Help: Processes and Impact of Text Counseling with Children and Youth with Suicide Ideation

OBJECTIVE

To explore: (1) how children contacting a child helpline with suicide ideation differ from children discussing other topics, (2) whether text messaging effectively helps, and (3) which counselor behaviors are most effective.

METHOD

Of 6,060 text sessions at the Danish national child helpline, 444 concerned suicidality, of which the 102 sessions that included self-rated, end Session ratings were selected for content analysis.

RESULTS

Twenty-six percentage of suicidal children had severe suicidality. The suicide sample had significantly more girls, was older than the nonsuicide sample, and more often recontacted the helpline in the 2 weeks prior to follow-up. 35.9% of suicidal children felt better immediately and over half ended the session with a plan of action. At follow-up, 23.9% of suicidal children reported feeling better; however, 37.0% reported feeling worse. Talking about emotions, expressing empathy, and encouraging the child to talk to someone were associated with positive impacts. Setting boundaries was associated with negative impacts.

CONCLUSIONS

Texting with suicidal children can be helpful, but should be considered a first step toward obtaining more sustainable help. Research is needed to determine how to better help children who felt worse or did not improve in the 2 weeks after contacting the helpline. Suggestions to further training of counselors are discussed.

Is It Rational to Pursue Zero Suicides Among Patients in Health Care?

Suicide prevention is a major health care responsibility in need of new perspectives. This study reviews Zero Suicide, an emerging approach to suicide prevention that embraces the aspirational goal of zero suicides among patients treated in health care systems or organizations. Zero Suicide is gaining international momentum while at the same time evoking objections and concerns. Fundamental to Zero Suicide is a multilevel system view on suicide prevention, with three core elements: a direct approach to suicidal behaviors; continual improvement of the quality and safety of care processes; and an organizational commitment to the aspirational goal of zero suicides. The rationale and evidence for these components are clarified and discussed against the backdrop of concerns and objections that focus on possible undesired consequences of the pursuit of zero suicide, in particular for clinicians and for those who are bereaved by suicide. It is concluded that it is rational to pursue zero suicides as an aspirational goal, provided the journey toward zero suicides is undertaken in a systemic and sustained manner, in a way that professionals feel supported, empowered, and protected against blame and inappropriate guilt.

Gatekeeper Suicide Training's Effectiveness Among Malaysian Hospital Health Professionals: A Control Group Study With a Three-Month Follow-Up

INTRODUCTION

There is a lack of suicide-related training in the nonpsychiatric health professional's basic education. We suggest that a continuing education through a brief gatekeeper suicide training program could be a suitable platform to improve suicide-related knowledge, self-efficacy, and attitudes. This study aimed at examining the effectiveness of the Question, Persuade, Refer gatekeeper program on improving the knowledge, self-efficacy in suicide prevention, and understanding of/willingness to help suicidal patients of Malaysian hospital health professionals.

METHODS

The Question, Persuade, Refer program materials were translated and adapted for implementation in the hospital setting for nonpsychiatric health professionals. There were 159 (mean age = 35.75 years; SD = 12.26) participants in this study. Most participants were female (84.9%), staff/community nurses (52.2%), who worked in the general medical department (30.2%) and had no experience managing suicidal patients (64.2%). Intervention participants (n = 53) completed a survey questionnaire at pretraining, immediately after training, and after three months. Control participants (n = 106) were not exposed to the training program and completed the same questionnaire at baseline and three months later.

RESULTS

Significant improvement occurred among intervention participants in terms of perceived knowledge, self-efficacy, and understanding of/willingness to help suicidal patients immediately after training and when compared with the control participants 3 months later. Improvements in declarative knowledge were not maintained at the 3-month follow-up.

DISCUSSION

This study confirmed the short-term effectiveness of the gatekeeper training program. Gatekeeper suicide training is recommended for implementation for nonpsychiatric health professionals nationwide.

The association between attempted suicide and stock price movements: Evidence from Taiwan

This study is the first comprehensive analysis to investigate the potential association between stock market fluctuations and attempted suicide events as measured by self-inflicted injuries treated in hospitalization. Using nationwide, 15-year population-based data from 1998 through 2012, we observe that the occurrences for the hospitalizations of attempted suicides are apparently predicted by stock price movements. A low stock price index, a daily fall in the stock index, and consecutive daily falls in the stock index have been shown to be associated with increased risk of hospitalization in patients with attempted suicide. More specifically, stock price index is found to be significant impact on attempted suicide in the 45-54 age groups of both genders, whilst daily change is significant for both genders in the 25-34 and 55-64 age groups and accumulated change is only significant in female aged 25-44 and above 65. On the basis of the results, relevant organizations should consider the suicidal factors that relate prime-working-age and near-retirement-age people to better carry out specific suicide prevention measures, and, meanwhile, encourage those people to pay less attention towards daily stock price movements.

Predictive accuracy of risk scales following self-harm: multicentre, prospective cohort study

BackgroundScales are widely used in psychiatric assessments following self-harm. Robust evidence for their diagnostic use is lacking.AimsTo evaluate the performance of risk scales (Manchester Self-Harm Rule, ReACT Self-Harm Rule, SAD PERSONS scale, Modified SAD PERSONS scale, Barratt Impulsiveness Scale); and patient and clinician estimates of risk in identifying patients who repeat self-harm within 6 months.MethodA multisite prospective cohort study was conducted of adults aged 18 years and over referred to liaison psychiatry services following self-harm. Scale a priori cut-offs were evaluated using diagnostic accuracy statistics. The area under the curve (AUC) was used to determine optimal cut-offs and compare global accuracy.ResultsIn total, 483 episodes of self-harm were included in the study. The episode-based 6-month repetition rate was 30% (n = 145). Sensitivity ranged from 1% (95% CI 0-5) for the SAD PERSONS scale, to 97% (95% CI 93-99) for the Manchester Self-Harm Rule. Positive predictive values ranged from 13% (95% CI 2-47) for the Modified SAD PERSONS Scale to 47% (95% CI 41-53) for the clinician assessment of risk. The AUC ranged from 0.55 (95% CI 0.50-0.61) for the SAD PERSONS scale to 0.74 (95% CI 0.69-0.79) for the clinician global scale. The remaining scales performed significantly worse than clinician and patient estimates of risk (P<0.001).ConclusionsRisk scales following self-harm have limited clinical utility and may waste valuable resources. Most scales performed no better than clinician or patient ratings of risk. Some performed considerably worse. Positive predictive values were modest. In line with national guidelines, risk scales should not be used to determine patient management or predict self-harm.

Psychiatrists' experiences of suicide assessment

BACKGROUND

Clinical guidelines for suicide prevention often stress the identification of risk and protective factors as well as the evaluation of suicidal intent. However, we know very little about what psychiatrists actually do when they make these assessments. The aim was to investigate psychiatrists' own accounts of suicide assessment consultations, with a focus on their behaviors, attitudes and emotions.

METHOD

Semi-structured in depth interviews were carried out with a purposive selection of 15 psychiatrists.

RESULTS

Thematic analysis revealed three main themes: understanding the patient in a precarious situation, understanding one's own reactions, and understanding how the doctor-patient relationship impacted on risk assessment and management decisions. Emotional contact and credibility issues were common subthemes that arose when the respondents talked about trying to understand the patient. The psychiatrists stressed the semi-intuitive nature of their assessments. Problems related to the use of risk factor assessments and rating scales were apparent. Assessment consultations could evoke physical and emotional symptoms of anxiety, and concerns about responsibility could lead to repressive management decisions. In situations of mutual trust, however, the assessment consultation could kick-start a therapeutic process.

CONCLUSION

This study highlights psychiatrists' experiences in clinical suicide assessment situations. Findings have implications for professional development as well as for service delivery.

Which are the most useful scales for predicting repeat self-harm? A systematic review evaluating risk scales using measures of diagnostic accuracy

OBJECTIVES

The aims of this review were to calculate the diagnostic accuracy statistics of risk scales following self-harm and consider which might be the most useful scales in clinical practice.

DESIGN

Systematic review.

METHODS

We based our search terms on those used in the systematic reviews carried out for the National Institute for Health and Care Excellence self-harm guidelines (2012) and evidence update (2013), and updated the searches through to February 2015 (CINAHL, EMBASE, MEDLINE, and PsychINFO). Methodological quality was assessed and three reviewers extracted data independently. We limited our analysis to cohort studies in adults using the outcome of repeat self-harm or attempted suicide. We calculated diagnostic accuracy statistics including measures of global accuracy. Statistical pooling was not possible due to heterogeneity.

RESULTS

The eight papers included in the final analysis varied widely according to methodological quality and the content of scales employed. Overall, sensitivity of scales ranged from 6% (95% CI 5% to 6%) to 97% (CI 95% 94% to 98%). The positive predictive value (PPV) ranged from 5% (95% CI 3% to 9%) to 84% (95% CI 80% to 87%). The diagnostic OR ranged from 1.01 (95% CI 0.434 to 2.5) to 16.3 (95%CI 12.5 to 21.4). Scales with high sensitivity tended to have low PPVs.

CONCLUSIONS

It is difficult to be certain which, if any, are the most useful scales for self-harm risk assessment. No scales perform sufficiently well so as to be recommended for routine clinical use. Further robust prospective studies are warranted to evaluate risk scales following an episode of self-harm. Diagnostic accuracy statistics should be considered in relation to the specific service needs, and scales should only be used as an adjunct to assessment.