Suicide-preventive activities in psychiatric care: evaluation of an educational programme in suicide prevention

Facilitators and barriers to implementation of suicide prevention interventions: Scoping review

We know that suicide is preventable, yet hundreds of thousands of people still die due to suicide every year. Many interventions were proven to be effective, and dozens of others showed promising results. However, translating these interventions into new settings brings several challenges. One of the crucial obstacles to success is not anticipating possible barriers to implementation nor enhancing possible benefits of factors facilitating the implementation. While we witnessed great support for suicide prevention activities globally in the past years, implementation barriers and facilitating factors are yet to be comprehensively mapped to help implementation activities worldwide. This scoping review maps current knowledge on facilitators and barriers to the implementation of suicide prevention interventions while using the Consolidated Framework for Implementation Research (CFIR) for classification. We included 64 studies. Barriers and facilitators were most commonly identified in the outer setting CFIR domain, namely in the sub-domain of patient needs and resources, which refers to the way in which these needs and resources are reflected by the reviewed interventions. The second most saturated CFIR domain for facilitators was intervention characteristics, where relative advantage, adaptability and cost of intervention sub-domains were equally represented. These sub-domains refer mostly to how the intervention is perceived by key stakeholders, to what extent it can be tailored to the implementation context and how much it costs. While intervention characteristics domain was the second most common also for barriers, the complexity sub-domain referring to high perceived difficulty of implementation was the most frequently represented. With reference to the results, we recommend adapting interventions to the needs of the target groups. Furthermore, carefully selecting the intervention to suit the target context concerning their adaptability, costs and complexity is vital for a successful implementation. Further implications for practice and research are discussed.

Suicide Prevention Strategies for General Hospital and Psychiatric Inpatients: A Narrative Review

BACKGROUND

In-patient (IP) suicides contribute a small but significant proportion of overall suicides. Despite this, suicide prevention strategies focusing on the general hospital IP population remain relatively underresearched. This paper is intended to provide an overview of various proposed suicide prevention approaches in the general hospital, including psychiatric IP, settings, and their evidence base.

METHODOLOGY

Electronic searches of MEDLINE through PubMed, ScienceDirect, and Google Scholar databases were performed to identify potentially relevant articles from inception till January 2019. The generated abstracts were systematically screened for their eligibility to be included in the review. Included articles were grouped under five broad themes: environmental modification, staff education, pharmacotherapy, psychotherapy, and brain stimulation. Data extraction was done using a structured proforma.

RESULTS

Environmental modifications and educating the health care professionals appear to be the most promising strategies to reduce suicide-related mortality among IPs. Among pharmacological methods, ketamine has shown initial promise in reducing suicidal ideations. Follow-up data are lacking for most of the described methods. Limited but positive evidence exists for cognitive therapies focusing on the immediate postadmission period and brain stimulation techniques, and it warrants further replication.

CONCLUSION

There is a striking paucity of original research on IP suicide prevention. Given the ethical and methodological issues in carrying out studies with IP suicide as the primary outcome, there is a need to focus on intermediate suicide outcome measures, such as knowledge, attitude, and skills among staff handlers of suicidal patients.

Evaluation of a suicide prevention training program for mental health services staff

Training for health services staff often focuses on improving individual practitioner's knowledge and skills, with less emphasis given to the broader organizational context, in particular those elements that support successful implementation of changes post-training. This paper compares the effectiveness of a standard training model for suicide prevention to an enhanced training model. The training involved the public mental health workforce throughout the State of Queensland, Australia and was developed in collaboration with the State health department and as such took place within a policy and practice context. The standard training involved participation in a one-day training workshop, which provided information on evidence-based suicide prevention strategies. The enhanced model took an organizational development approach and incorporated a focus on creating and strengthening networks to enhance the capacity of mental health service staff to undertake preventive strategies. Findings suggest that multi-component organizational approaches for suicide prevention produces benefits that should now be trialled through experimental approaches.

Dissemination and implementation of suicide prevention training in one Scottish region

BACKGROUND

As part of a national co-ordinated and multifaceted response to the excess suicide rate, the Choose Life initiative, the Highland Choose Life Group launched an ambitious programme of training for National Health Service (NHS), Council and voluntary organisation staff. In this study of the dissemination and implementation of STORM (Skills-based Training On Risk Management), we set out to explore not only the outcomes of training, but key factors involved in the processes of diffusion, dissemination and implementation of the educational intervention.

METHODS

Participants attending STORM training in Highland Region provided by 12 trained facilitators during the period March 2004 to February 2005 were recruited. Quantitative data collection from participants took place at three time points; immediately before training, immediately post-training and six months after training. Semi-structured telephone interviews were carried out with the training facilitators and with a sample of course participants 6 months after they had been trained. We have utilized the conceptual model described by Greenhalgh and colleagues in a Framework analysis of the data, for considering the determinants of diffusion, dissemination and implementation of interventions in health service delivery and organization.

RESULTS

Some 203 individuals completed a series of questionnaire measures immediately pre (time 1) and immediately post (time 2) training and there were significant improvements in attitudes and confidence of participants. Key factors in the diffusion, dissemination and implementation process were the presence of a champion or local opinion leader who supported and directed the intervention, local adaptation of the materials, commissioning of a group of facilitators who were provided with financial and administrative support, dedicated time to provide the training and regular peer-support.

CONCLUSION

Features that contributed to the success of STORM were related to both the context (the multi-dimensional support provided from the host organisation and the favourable policy environment) and the intervention (openness to local adaptation, clinical relevance and utility), and the dynamic interaction between context and the intervention.

Suicide risk in schizophrenia: learning from the past to change the future

Suicide is a major cause of death among patients with schizophrenia. Research indicates that at least 5-13% of schizophrenic patients die by suicide, and it is likely that the higher end of range is the most accurate estimate. There is almost total agreement that the schizophrenic patient who is more likely to commit suicide is young, male, white and never married, with good premorbid function, post-psychotic depression and a history of substance abuse and suicide attempts. Hopelessness, social isolation, hospitalization, deteriorating health after a high level of premorbid functioning, recent loss or rejection, limited external support, and family stress or instability are risk factors for suicide in patients with schizophrenia. Suicidal schizophrenics usually fear further mental deterioration, and they experience either excessive treatment dependence or loss of faith in treatment. Awareness of illness has been reported as a major issue among suicidal schizophrenic patients, yet some researchers argue that insight into the illness does not increase suicide risk. Protective factors play also an important role in assessing suicide risk and should also be carefully evaluated. The neurobiological perspective offers a new approach for understanding self-destructive behavior among patients with schizophrenia and may improve the accuracy of screening schizophrenics for suicide. Although, there is general consensus on the risk factors, accurate knowledge as well as early recognition of patients at risk is still lacking in everyday clinical practice. Better knowledge may help clinicians and caretakers to implement preventive measures. This review paper is the result of a joint effort between researchers in the field of suicide in schizophrenia. Each expert provided a brief essay on one specific aspect of the problem. This is the first attempt to present a consensus report as well as the development of a set of guidelines for reducing suicide risk among schizophrenia patients.

Evaluating STORM skills training for managing people at risk of suicide

AIM

This paper reports a study evaluating the Skills Training On Risk Management (STORM) training initiative in three mental health services in the North-West of England, UK.

BACKGROUND

Training for health workers has been widely advocated as a key route to suicide prevention. However, reports of evaluations are scarce in the literature. In previous research, we have demonstrated that the STORM intervention results in acquisition of new skills and can be disseminated in a community setting.

METHOD

The training was delivered during a 6-month period in 2002 by three mental health nurses who were seconded part-time to the project. The quantitative evaluation, which assessed change in attitudes, confidence, acquisition of skills and satisfaction, used a pretest/post-test design, with participants acting as their own controls. Qualitative interviews were conducted with a purposive sample of 16 participants to explore the impact on clinical practice, and with the three trainers at the end of the study.

FINDINGS

Data from 458 staff members were collected during a 6-month period. Positive changes in attitudes and confidence were shown, but previous evidence of skill acquisition was not replicated. Qualitative interviews revealed important insights into changes in clinical practice, particularly for less experienced or unqualified nursing staff, but also concerns about the lack of an educational culture to foster and support such interventions in practice within the organizations.

CONCLUSION

STORM training for the assessment and management of suicide risk is both feasible and acceptable in mental health trusts. However, we remain uncertain of its longer-term impact, given the lack of engagement of senior staff in the enterprise and the absence of linked supervision and support from the organizational management to reinforce skill acquisition and development. We consider that regular supervision that links STORM training to actual clinical experience would be the ideal.