Dealing with suicide on a psychiatric inpatient unit

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.

The Impact of Suicide on Co-patients

While there is a large literature on the impact of patient suicide on care providers and on family members, and a small literature on the impact of hospital suicide on inpatients and on surviving members of a therapy group, nothing has been written about the effect of a suicide on patients in a community mental health facility. This paper discusses the potential for ripple effects and the need for extra care and surveillance when a patient commits suicide in an outpatient program for the seriously mentally ill. The paper draws on related literature (suicide in groups, hospitals, schools, and college campuses) and, using examples from a clinic for women with psychosis, makes recommendations for psychiatric intervention post suicide. After the trauma of suicide, staff needs protected time to inform and support survivors, taking special care with those seen as most vulnerable. Following a trauma such as suicide, patients tend to stay near a source of comfort, and may require extra staff time. Survivors need to make sense of what happened and to honor the dead. This brings privacy concerns to the fore, as well as staff ambivalence about the respect due to a person who should be remembered, but should not serve as a role model to fellow patients who are susceptible to contagion effects. The review that follows a suicide can lead to closure for staff and patients and to the development of a protocol to follow should similar incidents recur.

L’impact du suicide d’un patient chez des professionnels en santé mentale

Cet article rapporte les résultats d’une recherche réalisée auprès de 141 professionnels en santé mentale pratiquant au Québec et ayant vécu le suicide d’un patient. Les professionnels ont réagi à cet événement différemment en fonction de leur sexe. Les femmes y ont répondu par un niveau de stress élevé au cours du premier mois, alors que les hommes ont dévoilé un niveau de stress faible. Le niveau élevé de stress relevé chez les femmes était accompagné de répercussions initialement plus intenses sur leur pratique professionnelle : tendance accrue à hospitaliser des patients suicidaires ou précautions accrues dans leur traitement, évaluation d’un plus grand nombre de patients comme présentant un risque de suicide, sentiment accru d’impuissance lors de l’évaluation ou du traitement de patients suicidaires, consultation plus fréquente de collègues et de superviseurs, attention accrue aux aspects légaux dans la pratique. L’article tente de mieux comprendre les différences entre les réactions des professionnels observées selon leur sexe, à la lumière des théories de la socialisation et du développement professionnel.

Effects of Suicidal Behavior on a Psychiatric Unit Nursing Team

1. Suicide of a psychiatric inpatient can have significant, although diverse, effects on the emotions and behavior of both individual nurses and team functioning. 2. The majority of participants in this study felt there was a need for formal debriefing or counseling for themselves and their colleagues after a critical incident, although there was less consensus about the timing and structure of such an intervention. 3. This research highlights the need for advanced training of critical incident stress management team members and for flexibility in the application of critical incident stress management techniques.

Patient Suicide and Assault: Their Impact on Psychiatric Hospital Staff

Psychiatric nursing entails its own particular hazards, specifically patient suicide and patient assault on staff. The reactions to these occurrences are manifested in the symptoms of PTSD and grief, which often are exacerbated by administrative reactions and the staff's own countertransference issues.

Psychiatric Stress Debriefing: Alleviating the Impact of Patient Suicide and Assault

Psychiatrists and psychologists have developed the psychological autopsy into a debriefing tool, as well as a learning tool. Use of the CISD has been an effective protocol to help police, fire, ambulance, emergency room, and ICU personnel cope with the effects of violence and trauma. Psychiatric nurses and ancillary personnel also face frequent exposure to violence and trauma. The psychiatric debriefing protocol offers a practical intervention.

The Healing Process for the Multidisciplinary Team: Recovering Post-Inpatient Suicide

1. With an inpatient suicide, the staff may experience grief for a variety of reasons. The staff member's perception of self as a competent mental health care provider may be destroyed. The caregiver may grieve the loss of an ideal. Some inpatient staff members mistakenly believe that suicide can always be prevented and that the multidisciplinary team can accurately assess all patients. 2. To successfully mourn a loss, Worden (1982) identified four tasks of grieving that must be completed: accept the reality of the loss; experience the pain of grief; adjust to an environment in which the deceased or lost object is missing; and withdraw emotional energy and reinvest it in another relationship. 3. Interventions to promote healing post-inpatient suicide must be aimed at individual caregivers and the multidisciplinary team. Individual caregivers will differ in their responses based on experiences, beliefs, values, and culture.