Preventing Suicide among Psychiatric Inpatients with Psychotic Depression

Adverse mental health inpatient experiences: Qualitative systematic review of international literature

BACKGROUND

Trauma has a well-established link with poor health outcomes. Adverse experiences in mental health inpatient settings contribute to such outcomes and should impact service design and delivery. However, there is often a failure to fully address these experiences.

OBJECTIVE

To describe the spectrum of negative experiences that people identify while they are inpatients in adult mental health services.

DESIGN

Qualitative systematic review of the international literature.

SETTING(S)

Inpatient mental health settings globally.

PARTICIPANTS

Analysis includes findings from 111 studies across 25 countries.

METHODS

CINAHL, MEDLINE and PsycINFO were searched from 2000 onwards, supplemented by Google Scholar. Studies were appraised using the Critical Appraisal Skills Programme qualitative checklist. Data were synthesised using the 'best-fit' framework synthesis approach, enriched by patient and public involvement.

RESULTS

Adverse mental health inpatient experiences can be conceptualised under three headings: the ecosystem (the physical environment and the resources available, and other people within or influential to that environment); systems (processes and transitions); and the individual (encroachments on autonomy and traumatisation).

CONCLUSIONS

This paper highlights the interplay between systemic, environmental and individual factors contributing to adverse experiences in mental health inpatient settings. By recognising and addressing these factors, we can significantly enhance patient outcomes. Application of adversity to Bronfenbrenner's ecological systems theory provides a strategic approach to improving service design and delivery, advocating for environments that prioritise patient safety, dignity and respect. However, further research is needed to validate the framework and effectively integrate these insights into practice, ultimately transforming the inpatient care experience for all stakeholders.

REGISTRATION

The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022323237).

TWEETABLE ABSTRACT

Review suggests traumatic experiences in mental health inpatient settings can worsen outcomes. Urges redesign of environment, processes and autonomy to improve care @dr_nutmeg @EmxEn @RAVresearchUoB @IMH_UoB.

Association between cytokines and suicidality in patients with psychosis: A multicentre longitudinal analysis

Suicide is a common cause of death in all phases of schizophrenia spectrum disorder, particularly in the youngest patients. Clinical measures have demonstrated limited value in suicide prediction, spurring the search for potential biomarkers. The causes of suicidal behaviour are complex, but the immune system seems to be involved as it reflects or even causes mental suffering. We aimed to identify cytokines with associations to suicidality in a sample of patients with symptoms of active psychosis. Patients with schizophrenia spectrum disorder (N = 144) participating in a semi-randomized antipsychotic drug trial (the BeSt InTro study) were assessed with the Positive and Negative Syndrome Scale (PANSS) and the Calgary Depression Scale for Schizophrenia (CDSS) at eight visits across 12 months. The Clinical Global Impression for Severity of Suicidality scale (CGI-SS) was used for assessing suicidality. Serum concentrations of tumour necrosis factor (TNF)-alpha, interferon (IFN)-gamma, interleukin (IL)-1beta, IL-2, IL-4, IL-6, and IL-10 were measured using immunoassays. A logistic regression model was used to investigate the association between cytokine levels and suicidality. To enhance clinical significance, the CGI-SS scores were dichotomized into two groups before analyses: low (=1) and high (≥2) risk for suicidality. Both uni- and multi-variate analyses revealed an inverse correlation between IL-2 and IL-10 serum levels and suicidality, where lower cytokine concentrations of IL-2 and IL-10 were associated with higher suicidality scores. The results were consistent when adjusted for depression and substance use. These results indicate that inflammatory processes are linked to the risk of suicidality in patients with schizophrenia spectrum disorders.

Suicidal behavior among inpatients with severe mental conditions in a public mental health hospital in Uganda

BACKGROUND

Suicidal behaviors are prevalent among inpatients with severe mental conditions and may result in many dying by suicide. Few studies have focused on the burden of suicidal behaviors among these inpatients in low-income settings, despite suicide being consistently higher in lower-income countries such as Uganda. This study, therefore, provides the prevalence and associated factors of suicidal behaviors and suicide attempts among inpatients with severe mental conditions in Uganda.

METHOD

This was a retrospective chart review of all individuals admitted with severe mental conditions to a large psychiatry inpatient unit in Uganda for four years (2018-2021). Two separate logistic regressions were conducted to determine the factors associated with suicidal behaviors or suicidal attempts among the admitted individuals.

RESULTS

The prevalence of suicidal behavior and suicidal attempts among 3104 (mean age = 33, Standard deviation [SD] = 14.0; 56% were males) were 6.12% and 3.45%, respectively. Having a diagnosis of depression increased the likelihood of both suicidal behaviors (adjusted odds ratio [aOR]: 5.36; 95% confidence interval [CI]: 2.14-13.37; p =0.001) and attempts (aOR: 10.73; 95% CI: 3.44-33.50; p < 0.001). However, a diagnosis of substance-related disorder increased the likelihood of having attempted suicide (aOR: 4.14; 95% CI: 1.21-14.15; p = 0.023). The likelihood of having suicidal behavior decreased as one increased in age (aOR: 0.97; 95% CI: 0.94-0.99; p = 0.006) and increased among individuals reporting stress from financial constraints (aOR: 2.26; 95% CI: 1.05-4.86; p = 0.036).

CONCLUSION

Suicidal behaviors are common among inpatients managed for severe mental health conditions in Uganda, especially those with substance use and depressive disorders. In addition, financial stressors are a main predictor in this low-income country. Therefore, regular screening for suicide behaviors is warranted, especially among individuals with depression, and substance use, among those who are young, and among those reporting financial constraints/stress.

Self-harm During Visits to the Emergency Department: A Qualitative Content Analysis

BACKGROUND

Some patients engage in self-harm behaviors while in the emergency department, both suicidal and nonsuicidal self-harm. Little is known about what motivates these behaviors. This gap in the empirical literature limits efforts to develop early identification and risk mitigation strategies.

OBJECTIVE

To describe methods and motivations when patients self-harm in the emergency department.

METHOD

Authors reviewed self-harm incident reports and medical records from two academic urban emergency departments. Event timing and self-harm methods were extracted. Authors performed a qualitative content analysis of self-harm narratives to examine the question, "Which factors motivate patients to engage in deliberate (nonaccidental) self-harm in the emergency department?"

RESULTS

The sample included 184 self-harm incidents involving 118 unique patients. A wide variety of self-harm methods were present in the data. Suicidal intent was present in a minority of incidents. Other motives included psychosis, intoxication, aggression, managing distress, communication, and manipulation.

CONCLUSIONS

Self-harm behaviors in the emergency department encompassed a variety of methods and motivations. These findings suggest risk mitigation strategies that emphasize suicide screening, reducing environmental hazards, and increasing observation are unlikely to achieve the goal of zero harm. Strategies focusing on engagement may create more fruitful opportunities to improve patient safety.

Safe clinical practice for patients hospitalised in mental health wards during a suicidal crisis: qualitative study of patient experiences

AIM

The aim of this study was to explore suicidal patients' experiences of safe clinical practice during hospitalisation in mental health wards. The study was guided by the following research question: How do suicidal patients experience safe clinical practice during hospitalisation in mental health wards?

DESIGN, SETTING AND PARTICIPANTS

A qualitative design with semistructured individual interviews was applied. Eighteen patients hospitalised with suicidal behaviour in specialised mental health wards for adults at a Norwegian hospital participated in the study. Data were analysed thematically and inductively using qualitative content analysis.

RESULTS

Patients in a suicidal crisis experienced safe clinical care in mental health wards characterised by the following three themes: (1) being recognised as suicidal, (2) receiving tailor-made treatment and (3) being protected by adaptive practice.

CONCLUSION

This study illuminates the experiences of safe clinical practice for patients in a suicidal crisis. The patient group was multifaceted, with variable experiences of how safe clinical practice affected their subjective experience of safety and suicidal behaviour. The finding highlights the importance of embracing personalised activities in all parts of safe clinical practice and to recognise rather than efface patients' variability in patient safety efforts.