Asking about self-harm and suicide in primary care: Moral and practical dimensions

Hybrid simulation and immersive, lived-experience perspectives to shape medical student attitudes towards patients experiencing emotional distress, suicidality, and self-harm

BACKGROUND

When medical students enter their first psychiatry rotation, they often feel under-prepared for the complex milieu of psychopathology, emotional distress, and complex psychosocial issues. Simulation is valued for its ability to orient learners to new environments. In this project, a hybrid simulation workshop was designed and delivered for fourth-year medical students. This study aimed to examine students' experience of this workshop and to explore participant attitudes towards people who experience mental distress.

METHODS

Fourth-year undergraduate medical students were invited to complete pre- and post-workshop questionnaires that contained a series of previously developed scales, including the Stigma of Suicide Scale, the Literacy of Suicide Scale, the General Help-Seeking Behaviour Scale, the Attitudes and Confidence in the Integration of Psychiatry Scale, and the Satisfaction with Simulation Experience Scale.

RESULTS

From a cohort of 172, 118 students participated (68.8%). The mean percentage of suicide literacy rose from 65.8 to 70.1%, with the highest literacy in the "treatment and management" domain (pre-workshop mean 92.9%, post-mean 95.0%) and lowest in the "signs and symptoms" domain (pre-workshop mean 38.0%; post-mean 44.5%). Suicide stigma was low both pre- and post-workshop. In both pre- and post-workshop, participants identified feeling most confident about screening for depression and least confident about managing symptoms of anxiety for patients and their relatives. Concerningly, 11% of the cohort stated they would not seek help themselves if they experienced thoughts of self-harm or suicide.

CONCLUSION

Using a combination of simulation modalities, students were oriented to their psychiatry placements. Importantly, this orientation focused on the experiences of people with lived experience of mental illness and how health professionals impact patient journeys through health and mental health services. Findings suggest this type of simulation workshop can support students in their dispositional readiness for placement in psychiatry units.

Attitudes, experiences, and implications of asking about suicide during the perinatal period: A qualitative study with maternity healthcare practitioners

BACKGROUND

Suicide is a leading cause of maternal death. Maternity healthcare practitioners (HCPs) are uniquely positioned to identify perinatal mental health (PMH) problems and/or suicidality. Research exploring HCPs attitudes towards suicide-related screening items and their experiences of asking about perinatal suicidality is limited.

OBJECTIVES

(i) to explore HCPs attitudes towards 16 suicide-related screening items; and (ii) to explore HCPs broader views, experiences and implications of discussing suicide with perinatal women in maternity care settings.

METHODS

Fifteen semi-structured interviews were conducted with maternity HCPs. The sample included midwives, health visitors, general practitioners, and specialist PMH practitioners working in the United Kingdom (UK). Inductive thematic analysis was used to explore the data and identify themes.

RESULTS

Most HCPs felt uncomfortable with, disliked, or found half of the suicide-related items unhelpful. Reasons included use of ambiguous or emotive terms. HCPs preferred not to use the word 'suicide' with pregnant or postnatal women. In the thematic analysis, four themes were identified: (i) Approaches for discussing and identifying PMH problems and suicidality; (ii) Competing demands and continuity of carer; (iii) PMH and suicidality training and support; and (iv) Availability of PMH services and referral pathways. These factors affected HCPs capacity, willingness, and confidence to ask women suicide-related questions.

CONCLUSIONS

HCPs need targeted PMH and suicidality training and support in maternity care contexts to enable them to feel more equipped, comfortable, and available to have conversations with women about PMH and suicide. Timely detection and intervention may help to improve care for women experiencing perinatal suicidality.

Perinatal women's views and experiences of discussing suicide in maternity care settings: A qualitative study

BACKGROUND

Suicide is a leading global cause of maternal death in the first year after birth. Limited research has explored which factors may support or prevent women from disclosing suicidality. This is important for informing appropriate approaches to identifying perinatal women who may require support.

AIMS

(i) explore perinatal women's views and experiences regarding the barriers, facilitators, and implications of identifying and disclosing suicidality in maternity care settings; and (ii) explore their perspectives on appropriate approaches for healthcare practitioners (HCPs) to take when asking about suicide during pregnancy or after birth.

METHODS

Twenty-one semi-structured interviews with perinatal women in the UK. Of these women, 17 had experienced self-reported perinatal mental health (PMH) problems and/or suicidality. Inductive thematic analysis was used to explore the data and identify themes.

RESULTS

Four themes, comprising 11 subthemes were identified. Barriers that affected women's willingness and capacity to disclose suicidality included: stigma, social expectations of motherhood, not recognising symptoms, not being asked about PMH and/or rushed appointments, lack of care continuity, and HCPs interpersonal skills. Important facilitators were the provision of PMH information and peer support. Women also suggested providing more choice in how PMH and suicide-related questions are administered (e.g., via a form and in-person) and for HCPs to frame these discussions sensitively.

CONCLUSIONS

Significant barriers impact perinatal women's disclosure of suicidality. Appropriate approaches for identifying suicidality in maternity contexts need to be developed that take account of these barriers and support women to feel safe, comfortable, and able to answer suicide-related questions honestly.

Acceptability and content validity of suicidality screening items: a qualitative study with perinatal women

Background

Suicide is a leading cause of death for perinatal women. It is estimated that up to 50% of women with mental health issues during pregnancy and/or after birth are not identified, despite regular contact with healthcare services. Screening items are one way in which perinatal women needing support could be identified. However, research examining the content validity and acceptability of suicide-related screening items with perinatal women is limited.

Aims

This study sought to: (i) assess the acceptability and content validity of 16 suicide-related items that have been administered and/or validated in perinatal populations; and (ii) explore the potential barriers and facilitators that may affect how women respond to these items when administered during pregnancy and after birth.

Methods

Twenty-one cognitive and semi-structured interviews were conducted with pregnant and postnatal women in the UK. The sample included women who had experienced self-reported mental health problems and/or suicidality during the perinatal period, and those who had not. Interviews were transcribed verbatim, and a coding framework based on the Theoretical Framework of Acceptability was applied to explore the data using deductive and inductive approaches.

Results

Findings indicated that the acceptability and content validity of suicide-related items were largely unacceptable to perinatal women in their current form. Women found terms such as 'better off dead' or 'killing myself' uncomfortable. Most women preferred the phrase 'ending your life' as this felt less confronting. Comprehensibility was also problematic. Many women did not interpret 'harming myself' to include suicidality, nor did they feel that abstract language such as 'leave this world' was direct enough in relation to suicide. Stigma, fear, and shame was central to non-disclosure. Response options and recall periods further affected the content validity of items, which created additional barriers for identifying those needing support.

Conclusions

Existing suicide-related screening items may not be acceptable to perinatal women. Maternity practitioners and researchers should consider the phrasing, clarity, context, and framing of screening items when discussing suicidality with perinatal women to ensure potential barriers are not being reinforced. The development of specific suicidality screening measures that are acceptable, appropriate, and relevant to perinatal women are warranted.

Communication in Primary Healthcare: A State-of-the-Art Literature Review of Conversation-Analytic Research

We report the first state-of-the-art review of conversation-analytic (CA) research on communication in primary healthcare. We conducted a systematic search across multiple bibliographic databases and specialist sources and employed backward and forward citation tracking. We included 177 empirical studies spanning four decades of research and 16 different countries/health systems, with data in 17 languages. The majority of studies originated in United States and United Kingdom and focused on medical visits between physicians and adult patients. We generated three broad research themes in order to synthesize the study findings: managing agendas, managing participation, and managing authority. We characterize the state-of-the-art for each theme, illustrating the progression of the work and making comparisons across different languages and health systems, where possible. We consider practical applications of the findings, reflect on the state of current knowledge, and suggest some directions for future research. Data reported are in multiple languages.

Implementation of national guidance for self-harm among general practice nurses: a qualitative exploration using the capabilities, opportunities, and motivations model of behaviour change (COM-B) and the theoretical domains framework

BACKGROUND

Patients who self-harm may consult with primary care nurses, who have a safeguarding responsibility to recognise and respond to self-harm. However, the responses of nursing staff to self-harm are poorly understood, and opportunities to identify self-harm and signpost towards treatment may be missed. It is unclear how to support nursing staff to implement national guidelines.

AIMS

Among primary care nursing staff to: [1] Examine reported barriers and enablers to nurses' use of, and adherence to, national guidance for self-harm; and [2] Recommend potential intervention strategies to improve implementation of the NICE guidelines.

METHODS

Twelve telephone interviews partly structured around the capabilities, opportunities and motivations model of behaviour change (COM-B) were conducted with primary care nurses in the United Kingdom. The Theoretical Domains Framework was used as an analytical framework, while the Behaviour Change Wheel was used to identify exemplar behaviour change techniques and intervention functions.

RESULTS

Nursing staff identified a need to learn more about risk factors (knowledge), and strategies to initiate sensitive conversations about self-harm (cognitive and interpersonal skills) to support their professional competencies (professional role and identity). Prompts may support recall of the guidance and support a patient centred approach to self-harm within practices (memory, attention, and decision making). GPs, and other practice nurses offer guidance and support (social influences), which helps nurses to navigate referrals and restricted appointment lengths (environmental context and influences).

CONCLUSIONS

Two converging sets of themes relating to information delivery and resource availability need to be targeted. Nine groups of behaviour change techniques, and five intervention functions offer candidate solutions for future intervention design. Key targets for change include practical training to redress conversational skill gaps about self-harm, the integration of national guidance with local resources and practice-level protocols to support decision-making, and creating opportunities for team-based mentoring.

Implying implausibility and undermining versus accepting peoples' experiences of suicidal ideation and self-harm in Emergency Department psychosocial assessments

Background

Patients seeking emergency care for self-harm and suicidality report varying experiences from being believed and taken seriously to not being believed and taken seriously. Epistemic injustice provides a conceptual framework to explore how peoples' experiences of self-harm and suicidality are believed or not. We use an empirical method -conversation analysis - to analyze epistemics in clinical communication, focusing on how knowledge is claimed, contested and negotiated. In courtroom, police and political interaction, conversation analysis has identified communication practices implying implausibility in a person's story to contest and recharacterize their accounts.

Aims

To investigate communication practices in Emergency Department (ED) biopsychosocial assessments that may (1) undermine, imply implausibility and recharacterize or (2) accept peoples' experiences of suicidal ideation and self-harm.

Methods

Using conversation analysis, we micro-analyzed verbal and non-verbal communication in five video-recorded biopsychosocial assessments with people presenting to the ED with self-harm or suicidal ideation, and conducted supplementary analysis of participants' medical records and post-visit interviews. We present three cases where experiences were not accepted and undermined/recharacterized and two cases where experiences were accepted and validated.

Results

When peoples' experiences of suicidality and self-harm were not accepted or were undermined, questioners: did not acknowledge or accept the person's account; asked questions that implied inconsistency or implausibility ("Didn't you tell your GP that you were coping okay?"); juxtaposed contrasting information to undermine the person's account ("You said you were coping okay before, and now you're saying you feel suicidal"); asked questions asserting that, e.g., asking for help implied they were not intending to end their life ("So when you called 111 what were you expecting them to do"); and resistinged or directly questioned the person's account. Multiple practices across the assessment built on each other to assert that the person was not suicidal, did not look or act like they were suicidal; that the person's decision to attend the ED was not justified; that an overdose was impulsive and not intended to end life; asking why the person didn't take a more harmful medication to overdose; that self-harming behaviors were not that serious and should be in the person's control. Alternative characterizations were used to justify decisions not to provide further support or referrals to specialist services. At times, these practices were also delivered when speaking over the patient. When peoples' experiences were accepted, practitioners acknowledged, accepted, validated suicidality/self-harm and introduced a shared understanding of experiences that patients found helpful. Non-verbal feedback such as nodding and eye contact was central in acceptance of patients' accounts.

Conclusion

These findings advance our understanding of how peoples' experiences of suicidality or self-harm are undermined or accepted in mental health encounters in the ED. They have important clinical implications: patients report that when their experiences are not accepted or undermined, this makes them more distressed, less hopeful about the future and discourages future help-seeking when in crisis. Conversely, acknowledging, accepting and validating suicidality/self-harm and introducing a new ways of understanding peoples' experiences may make people less suicidal and more hopeful, generates shared understanding and encourages future help-seeking.

Hidradenitis Suppurativa Burdens on Mental Health: A Literature Review of Associated Psychiatric Disorders and Their Pathogenesis

Skin, mental health and the central nervous system (CNS) are connected by a deep link. It is not only the aesthetic and sometimes the disfiguring aspects of dermatological conditions that can cause a severe psychological burden; also, different studies have shown how chronic skin-inflammatory diseases may influence the activity of the CNS and vice versa. Moreover, the skin and brain share a common embryogenic origin. Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease affecting the hair follicles of the apocrine regions. The main clinical features are nodules, abscesses, cysts, fistulae and disfiguring scars. Pain and stinking discharge from fistulae are often present. It is not surprising that the psychological burden associated with HS is frequently a challenge in dermatologists' daily routines. Patients often suffer from depression and anxiety, but also from substance abuse, psychotic and bipolar disorders and an increased suicide risk. The aim of this article is to review the main psychiatric disorders associated with HS and their pathophysiology. Research on Pubmed was conducted with the key words Hidradenitis suppurativa, psychiatric, depression, anxiety, bipolar, schizophrenia, abuse, suicidal. A high incidence of psychiatric disorders has been described in HS compared to controls. Hidradenitis suppurativa is not a rare disease, and acknowledging the HS psychological burden, psychiatric-associated diseases and associated biomolecular pathways will help dermatologists to better care for their patients.

Raising Suicide in Medical Appointments-Barriers and Facilitators Experienced by Young Adults and GPs: A Mixed-Methods Systematic Review

The aim of this review was to understand the barriers and facilitators facing GPs and young adults in raising and addressing suicide in medical appointments. A mixed-methods systematic review was conducted of qualitative and quantitative studies. The focus was papers that explored barriers and facilitators experienced by young adults aged 18 to 26, and GPs working in primary care environments. Nine studies met the inclusion criteria. Four studies provided information on young adults' views, four on GPs, and one considered both GP and young adults' viewpoints. Nine barrier and seven facilitator themes were identified. Unique to this review was the recognition that young adults want GPs to initiate the conversation about suicide. They see this as a GP's responsibility. This review further confirmed that GPs lack the confidence and skills to assess suicide risk in young adults. Both findings combined could explain previous results for reduced identification of suicide risk in this cohort. GP training needs considerable focus on addressing skill deficiencies and improving GP confidence to assess suicide risk. However, introducing suicide risk screening in primary care for young adults should be a priority as this will overcome the need for young adults to voluntarily disclose thoughts of suicide.

Shame anxiety, stigma and clinical encounters

Stigma has been associated with delays in seeking treatment, avoiding clinical encounters, prolonged risk of transmission, poor adherence to treatment, mental distress, mental ill health and an increased risk of the recurrence of health problems, among many other factors that negatively impact on health outcomes. While the burdens and consequences of stigma have long been recognized in the health literature, there remains some ambiguity about how stigma is experienced by individuals who live with it. The aim of this paper is to elucidate the phenomenology of stigma, or to describe how it is that stigma shows up in the first-person experience of individuals who live with stigma and its burdens. Exploring the relationship between shame and stigma, I argue that shame anxiety, or the chronic anticipation of shame, best characterises the experience of living with a health-related, or health-relevant, stigma. Understanding the experiential features, or phenomenology, of shame anxiety will give healthcare professionals a greater sensitivity to stigma and its impacts in clinical settings and encounters. I will conclude by suggesting that 'shame-sensitive' practice would be beneficial in healthcare.

Beyond a trauma-informed approach and towards shame-sensitive practice

In this article, we outline and define for the first time the concept of shame-sensitivity and principles for shame-sensitive practice. We argue that shame-sensitive practice is essential for the trauma-informed approach. Experiences of trauma are widespread, and there exists a wealth of evidence directly correlating trauma to a range of poor social and health outcomes which incur substantial costs to individuals and to society. As such, trauma has been positioned as a significant public health issue which many argue necessitates a trauma-informed approach to health, care and social services along with public health. Shame is key emotional after effect of experiences of trauma, and an emerging literature argues that we may 'have failed to see the obvious' by neglecting to acknowledge the influence of shame on posttrauma states. We argue that the trauma-informed approach fails to adequately theorise and address shame, and that many of the aims of the trauma-informed are more effectively addressed through the concept and practice of shame-sensitivity. We begin by giving an overview of the trauma-informed paradigm, then consider shame as part of trauma, looking particularly at how shame manifests in post-trauma states in a chronic form. We explore how shame becomes a barrier to successful engagement with services, and finally conclude with a definition of the shame-sensitive concept and the principles for its practice.

‘Wasn’t offered one, too poorly to ask for one’ – Reasons why some patients do not receive a psychosocial assessment following self-harm: Qualitative patient and carer survey

OBJECTIVE

Psychosocial assessment following self-harm presentations to hospital is an important aspect of care. However, many people attending hospital following self-harm do not receive an assessment. We sought to explore reasons why some patients do not receive a psychosocial assessment following self-harm from the perspective of patients and carers.

METHODS

Between March and November 2019, we recruited 88 patients and 14 carers aged ⩾18 years from 16 mental health trusts and community organisations in the United Kingdom, via social media, to a co-designed qualitative survey. Thematic analyses were used to interpret the data.

RESULTS

Patients' reasons for refusing an assessment included long waiting times, previous problematic interactions with staff and feeling unsafe when in the emergency department. Two people refused an assessment because they wanted to harm themselves again. Participants reported organisational reasons for non-assessment, including clinicians not offering assessments and exclusion due to alcohol intoxication. Other patients felt they did not reach clinically determined thresholds because of misconceptions over perceived heightened fatality risk with certain self-harm methods (e.g. self-poisoning vs self-cutting).

CONCLUSION

Our results provide important insights into some of the reasons why some people may not receive a psychosocial assessment following self-harm. Parallel assessments, compassionate care and specialist alcohol services in acute hospitals may help reduce the number of people who leave before an assessment. Education may help address erroneous beliefs that self-injury and self-harm repetition are not associated with greatly raised suicide risk.

Talking About Things: A Patient Cue for Sensitive Healthcare Problems and Effective Physician Responses

In routine healthcare consultations, patients often use prefaces containing the word "thing", including "the thing is", "there's this thing" or "one more thing". Although "thing" is an all-encompassing term that is used in myriad ways, in this article we show that thing-prefaces perform a specific job. This study uses Conversation Analysis to analyze 90 video-recorded primary care consultations with 14 primary care physicians in the United States. Patients' thing-prefaces mark the upcoming talk as a disclosure of sensitive information that may reflect negatively on the patient, physician or service (e.g., medication nonadherence, refill was not sent to pharmacy). Patients pursue explicit resolution of these problems (e.g., personalized recommendation, lab work, referral) despite these problems being downplayed and treated as delicate. Because patients may "talk around" these sensitive issues, thing-prefaces can be an important cue for physicians that patients are seeking resolution for a sensitive healthcare problem.