SUICIDE PREVENTION

IN HOSPITAL AND

COMMUNITY HEALTHCARE SETTINGS

DR JUSTIN BROPHY

FCPSYCHI FRCPSYCH

VISION: An Ireland

where fewer lives are lost through suicide,

and where communities and individualsare empowered to improve their mental health and wellbeing.

Can suicide be prevented?UK NATIONAL DATA UK MH SERVICES DATA

Relevant CFL Strategic GoalsTo target approaches in priority groups.

To enhance accessibility, consistency and care◦ Assessment : Clear pathways : Programmes

To ensure safe and high-quality services◦ Learning from Incidents ◦ Effective interventions : Standards

To restrict access to means ◦ Environment : Drugs

Suicide in Healthcare settings

Key: Recognise the clinical value of empathy and how to challenge stigma and its role in suicide prevention.

What are the rates in healthcare?•Substantially lower than community-based suicide rates.1,6,7

•do occur and pose profound challenges –for patients and their families, health care workers, and

hospital administrators.8,9

•Can have substantial effect on the hospital environment, –especially for a staff that lacks specific training in the

assessment and management of suicide.

So why suicide prevention in healthcare?Suicide risk increased in many illnesses

Contacts with healthcare occurs before suicide

Staff have an opportunity to screen & intervene

Not doing it is not justified

Equipped and trained staff are effective

It is not burdensome when this is in place

once pathways and processes are clear

Shifting Attitudes

Outline of today- Suicide prevention

In settings where risk is identified

In Primary Care ◦ Screening, identification, management, referral

In General Hospital ◦ Screening, identification, management, referral

◦ Eg ED, In-patient settings

In Residential care / Chronic care

Screening

recommended that primary, emergency, and mental health clinicians

look for suicidal ideation in all patients in both acute and nonacute healthcare settings.

Screen questions all patients for suicide risk factors using a brief, standardized, evidence-based screening tool;

◦ Ask Suicide-Screening Questions (ASQ), a four-question tool useful in identifying youth aged 10-21 years at risk for suicide;

◦ Suicide Assessment Five-Step Evaluation and Triage (SAFE-T);

Screening should be repeated periodically and checked before the patient leaves

Screen all patients for depression, ◦ Patient Health Questionnaire-9 (PHQ-9), the most commonly used screening tool for depression;

If a patient screens positive, Review each patient's personal and family history for suicide risk factors; Obtain past medical records and gather information

& use "safety planning."

Safety planning often includes

speaking with family & removal of lethal means in the home.

Communication, referral to mental health specialist and treatment should be commensurate with the severity of symptoms and risk for future harm.

Have an alternative provider accessible to the individual if and when the primary clinician is unavailable.

Have the means to admit the person to inpatient care, if necessary.

Make follow-up contact with the at-risk person in the next 48 hours.

Engage the individual in writing up an agreement that states goals of treatment,

such as reducing stressors; developing coping strategies; sources of support,

Provide the number for the National Suicide Prevention Hotline (116123)

https://stayingsafe.net/ST/

Awareness of higher risk

Identify mental illnesses that carries risk

– bipolar disorder,

– major depressive disorder,

– schizophrenia, schizoaffective disorder,

– anxiety disorders

– panic disorder and PTSD,

– substance use disorders (especially alcohol use disorder),

– borderline personality disorder,

– antisocial personality disorder,

– eating disorders,

– and adjustment disorders• (American Psychiatric Association, 2013).

Medical Conditions and suicide riskIn patients with arthritis,

◦ suicide risk may be confounded by comorbid psychiatric disorders and is possibly modified by the level of pain and ensuing disability.

Asthma is associated with psychiatric comorbidity and suicidal ideations. ◦ However, available evidence is unclear as to whether this association is a result of common risk factors or

a similar underlying disease process, apart from evidence that medications used to treat asthma, such as synthetic glucocorticoids and leukotriene inhibitors, can be associated with adverse neuropsychiatric sequelae.

Suicide risk is likewise increased in patients diagnosed with cancer. ◦ The authors underscore the increased risk in the first 5 years following the diagnosis. They identify

common fears of pain, adverse effects of medication, the unknown, uncertain prognosis, loneliness, and disability as precipitants of crisis situations.

Patients chronic pain highlights the increased suicide risk ◦ and reports that prescription drug overdose is the most common method of suicide in these patients.

The Evidence in epilepsy ◦ includes the hypothesis that impulsivity, drug abuse, and chronic disability are the prominent risk factors for suicide.

Medical Conditions and suicide riskIn patients diagnosed with human immunodeficiency virus,

◦ factors such as physical symptoms, adverse effects of treatment, fear of pain, and anxiety can be prognostic of suicidal ideations and suicide attempts, with most attempts occurring within a month of diagnosis.

Among patients with headache disorders, ◦ those who have migraine with aura are described as having a higher risk of suicidal ideations and attempts.

In patients with Parkinson disease, ◦ depression seems to confound the relationship with increased suicidal ideations.

In the setting of hemodialysis for chronic kidney disease,◦ an ethical dilemma can arise from patient requests to withdraw treatment, and the authors encourage readers to identify underlying

dynamics and to refrain from classifying all such requests as suicidal in nature.

The risk of suicide is noted to be less common in patients with Alzheimer disease

◦ than in the general population; however, risk is increased in patients with mild dementia.

Also lyme disease, back pain, sleep disorders, traumatic brain injury, congestive heart failure,

chronic obstructive pulmonary disorder, diabetes, stroke, multiple physical health conditions

Major Physical Health Conditions and Risk of Suicide. American Journal of Preventive Medicine, 2017; DOI:

Primary Care

Primary Care: A Crucial Setting for Suicide PreventionJerry Reed, PhD, MSW, Director, Suicide Prevention Resource Center

Up to 45% of individuals who die by suicide have visited their primary care physician within a month of their death;

Given these statistics, primary care has enormous potential to prevent suicides and connect people to needed specialty care — especially when they collaborate or formally partner with behavioural healthcare providers.

Primary care opportunity•In total, GP’s write more prescriptions for antidepressants than psychiatrists

•and see patients more often in the month before their death by suicide.

•Collaborative care models for treating depression • have the potential both to improve depression outcomes and decrease suicide risk.

• nurse practitioners or other health professionals can take on the task

ICGP initiativeConnecting With People (delivered by 4 Mental Health Ltd) was contracted as the training partner for a training initiative

To be implemented over a three year period through a train-the-trainer model.

Already delivered training to a total of 500+ GPs. The initiative will be evaluated in 2019 and 2020.

NOSP also has a partnership with 4 Mental Health and the College of Psychiatrists of Ireland to train trainee psychiatrists in suicide assessment and mitigation.

Primary care opportunityTreatment of depression by primary care physicians is improving,

Alcohol use disorders and anxiety symptoms are important co-morbid conditions to identify and treat.

Emergency Departments

Care Pathway • ED triage staff responsible for triage must consider mental as well as physical health issues when planning treatment. • All patients who present to ED following self-harm should have a skilled semi-structured biopsychosocial assessment of the need and risk by a suitably trained Mental Health Practitioner prior to discharge from Emergency Department. • A named consultant psychiatrist should be identified for all stages of the patient’s care until discharge from secondary care service. • An Emergency Care Plan should be developed with the patient and family/carer members (with consent). • Patients should be actively supported to nominate a family member/carer who can be advised on suicide prevention care before the patient is discharged. • Information (various media) should be available for patients and family/carers appropriate to age and needs. • A discharge summary sheet including the assessment should be sent to the GP and other relevant agencies within 24 hours. A copy must be retained with patient’s medical notes. • Policies and procedures to manage vulnerable groups should be developed. • Language translator services should be available where needed for those who are not fluent in the English language. • A system for accrediting any voluntary counselling agency which provides services for patients experiencing suicidal crisis and / or self-harm should be established nationally.

1. 95% patients admitted or discharged with a care plan < 6 hours

2. <5% leave before completion of treatment

3. 95% GPs receive summary <24 hours

4. 90% of those presenting now receive a biopsychosocial assessment.

5. Surveys show a high level of satisfaction.

Means Restriction

CFL Goal 6: To reduce and restrict access to meansMeans restriction◦ in particular physical barriers reduces the incidence of

suicide

◦ Access to drugs or poisons

◦ in particular benzodiazepines & opiates

Means Restriction

Safer Environments

Provide treatment in environments that are safe and appropriately therapeutic.

monitored room, under one-to-one observation. Do not leave patients alone

Room which all potentially harmful items / anchor points have been removed,

Exit alarm must be engaged at all times while the patient is in bed / locked unit

Patient clothing and belongings are examined / removed for potential harm

Gown of special design or colour used to identify the patient as high risk

Personal items are sent home with a family member or stored in a secure locker.

Advice to the patient and/or family regarding the safety measures being taken.

Meals - disposable trays with plastic utensils; no cans or glass Plastic sheeting

Nurse and unit staff awareness of suicide risk,

Design care plan appropriately

Obtain a psychiatric evaluation - Follow orders regarding observation

http://tspn.org/wp-content/uploads/COMPASS-12-3.pdf

Safe, functional

environment

Safe environment ….A hospital policy on suicide prevention should include direction to staff about screening tools, protocols for one-to-one observation, and environmental rounds.

Guidance on conducting environmental rounds, visit the Joint Commission report Suicide Prevention in Health Care Settings Environmental

Screening tools commonly cited for use in hospital include the

PSS-3, C-SSRS, and ASQ.

Also : Learning from Incidents

Safe Movement•Equally important is safe passage

•from the ED to the intensive care/inpatient unit

•on to the psychiatric unit

•and back to the community.

Long term care settings

Long term care settings•completed suicide is rare,

• 11% to 43% of LTC residents have thoughts of suicide1-3,

• with higher rates in larger facilities and in those with more staff turnover4.

•The main correlates of suicidal behaviour :• depression, social isolation, loneliness, health problems and functional decline.

•Shortly after admission is a risk period

Should have a protocol in place for managing suicide risk

Helps reduce anxiety among staff members,

Identification should not result in transfer

◦ http://www.managedhealthcareconnect.com/article/challenges-associated-managing-suicide-risk-long-term-care-facilities

What about ourselves?

Healthcare is a hazardous occupation. ‘Recent Suicides Highlight Need To Address Depression In Medical Students And Residents’. JAMA 312.17 (2014): 1725. Web. 29 Apr. 2015.

Suicide among health-care workers: time to act 07 January 2017

The rate of depressive disorders among health-care workers compared with the general population is alarming and is an issue that spans the medical profession.

This crisis is not confined to the UK.

However, in response to a suicide rate of 400 physicians per year in the USA—more than double that of the general population

A collaborative platform, due to begin work this month,

aims to assess and understand the underlying causes of clinician burnout and suicide

Healthcare workersAccessing help presents specific challenges.

Employee Assistance programme HSE

Practitioner Health Programme

Thank you