"This is a question we have to ask everyone": asking young people about self-harm and suicide

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.

Self-harm and suicidal behaviors in children: perspectives of mental health clinicians

OBJECTIVE

Presentations for self-harm and suicidal behaviors are increasing in children and young people, although less is known about these presentations in children aged 12 years and under. This study aims to understand how mental health clinicians in public health services conceptualize, identify and respond to self-harm and suicidal behaviors in children.

METHODS

26 mental health clinicians provided their perspectives through interviews or focus groups. Participant responses were analyzed using reflexive thematic analysis.

RESULTS

Mental health clinicians described how self-harm and suicidal behaviors may present differently in children compared with adolescents, particularly with the methods used. Using developmentally appropriate language and including parents or carers when screening for self-harm and suicidal behaviors was recommended by clinicians. The inclusion of parents or carers throughout the treatment process was important for clinicians, including helping parents understand their child's behavior and manage their own distress. Clinicians also highlighted the benefit of collaborating with schools to support children, yet noted primary school staff require training in responding to child self-harm and suicidal behavior. The limited services available for children 12 years and under including emergency care services, was identified as a problem.

CONCLUSIONS

Findings highlight the importance of timely assessment and interventions which include mental health and medical clinicians, parents, carers, and school staff to support children with self-harm and suicidal behaviors.

Towards a suicide-responsive police culture: police experiences of working with suicide

Across the globe suicide rates are creating concern, and the World Health Organisation (WHO) argues that suicide is the responsibility of everyone. The WHO recognises that police have an important role in suicide prevention and the management of mental health crises. We suggest that police officers and staff are inevitably impacted by the emotional labour of meeting the demands of this aspect of the role. We argue for more research attention on the experiences and views of police who work with suicide. This study comprised qualitative reflective interviews with police in the UK, Guyana and New Zealand, with the focus on identifying commonalities in experience across the three locations. Four themes were generated through reflective thematic analysis: (1) the context; (2) the traumatic impact; (3) the difficult aspects of this work and (4) organisational opportunities for supporting police officers and staff. Our data illustrated that suicide is qualitatively different from other forms of death, and the nature of the work did have considerable emotional and traumatic impact on police. We conclude our paper with several recommendations for police forces to build their welfare support for staff. These recommendations could help promote a healthier workforce and recognise the specific issues associated with this part of the role.

Observed behaviours and suicide assessment language post-Mental Health First Aid training in Australia and the United States: a mixed methods study using discourse analysis

BACKGROUND

Mental Health First Aid (MHFA) training teaches participants how to respond to mental health crises, including suicide. Little is known about the impact of training on participants' observed MHFA behaviours. This exploratory study aimed to compare MHFA-trained Australian and US student pharmacists' performance and suicide assessment language during simulated patient role-play (SPRP) assessments.

METHODS

Student pharmacists (n = 265) completed MHFA training and participated (n = 81) in SPRPs with simulated patients (SP) who were people with lived experience of mental illness. Each SPRP was marked by three raters (student, tutor and SP). One-way ANOVA, chi-squared tests and independent samples t-tests were used to compare scores and pass/fail rates, where appropriate. Transcribed audio-recordings of suicide assessments underwent discourse analysis. A chi-squared test was conducted to investigate the differences in how suicide assessment language was coded across six discursive frames ('confident'/'timid', 'empathetic'/'apathetic', and 'direct'/'indirect').

RESULTS

Three raters assessed 81 SPRPs, resulting in quantitative analysis of 243 rubrics. There were no significant differences between student pharmacists' mean scores and pass/fail rates across countries. Overall, both cohorts across Australia and the US performed better during the mania scenario, with a low failure rate of 13.9 and 19.0%, respectively. Most students in both countries passed their SPRP assessment; however, 27.8% did not assess for suicide or used indirect language during suicide assessment, despite completing MHFA training. Australian student pharmacists demonstrated, more direct language (76.9% versus 67.9%) and empathy (42.3% versus 32.1%) but less confidence (57.7% versus 60.7%) compared to US student pharmacists, during their suicide assessment; however, these differences were not statistically significant.

CONCLUSIONS

Findings indicate most MHFA-trained student pharmacists from Australia and the US can provide MHFA during SPRPs, as well as assess for suicide directly, empathetically and confidently. This exploratory study demonstrates the importance of practicing skills post-training and the need for further research exploring participants' hesitance to assess for suicide, despite training completion.

What's the harm in asking? A systematic review and meta-analysis on the risks of asking about suicide-related behaviors and self-harm with quality appraisal

Research emphasizes the importance of asking about suicidality. Unfortunately, misperceptions of harm remain which can compromise clinical care, research, and public health surveillance efforts. Our objective was to evaluate the empirical evidence on whether and how asking about suicide related behaviors (SRB), such as suicidal ideation and suicide attempts, and non-suicidal self-injury (NSSI) results in harmful outcomes. We reviewed and rated seventeen studies and conducted a systematic review and random-effects meta-analysis on eight studies comparing those asked vs. not asked on immediate and later SRB, NSSI, and psychological distress (PD). Forest plots demonstrated no statistically significant effects of asking on SRB, NSSI, or PD. Eight RCTs provided the strongest evidence and demonstrated either low or unclear risk of bias, and the remaining cohort studies were of low to moderate quality. With the current available evidence, we found no harmful outcomes of asking, however more RCTs with a low risk of bias are required to firmly conclude that asking through self-report and interview methods does not further exacerbate distress, SRB and NSSI compared to those not asked.

Hospitalisation in Child Neuropsychiatry: A Case Study Along a Five-Year Epidemiological-Clinical Trend

OBJECTIVE

In Italy, the number of patients admitted to child and adolescent neuropsychiatry services has almost doubled in the last 10 years. Despite this significant increase in demand, there is still a paucity of literature on mental disorders in the paediatric population. Therefore, we investigated and described the clinical and socio-demographic characteristics of a sample of young Italian inpatients with psychiatric disorders. The aim was to contribute to the jet scarce literature on this topic, while also providing useful information for the clinical-care organisation of mental health services dedicated to children and adolescents.

METHOD

In this retrospective cohort study, data were collected from 361 hospitalised patients aged̀ 1 to 18 who had been admitted to a Child Neuropsychiatry Unit in Northern Italy, from January 2016 to December 2020. Descriptive analyses, Univariate Analysis of Variance (ANOVA), and Chi-square tests were applied.

RESULTS

During a five-year timeline, a higher admission rate for females was recorded, and the average age of inpatients was 13.4 years (SD = 3.01). Most of the admissions occurred through the Paediatric Emergency Department, and suicidal behaviour was the most frequent reason for admission. At discharge, affective disorders were the main diagnoses, which were also found to be the most frequent in patients with self-injurious behaviours. Non-suicidal self-injury, which was mainly reported as occurring in order to obtain relief from suffering, regarded 40.8% of the total sample. Almost half of the subjects reported suicidal ideation, and 21.1% attempted suicide. The mean hospitalisation length significantly decreased from 2016-2018 to 2019-2020. In general, patients with psychotic disorders had the longest stays.

CONCLUSIONS

Ad hoc diagnostic-therapeutic protocols should be developed for psychiatric emergencies, and health personnel should be adequately trained to manage acute psychiatric conditions in developmental age. Primary and secondary prevention programs should be implemented to promptly recognise and treat mental health issues in this age group.

Non-disclosing youth: a cross sectional study to understand why young people do not disclose suicidal thoughts to their mental health professional

BACKGROUND

Prevalence of suicidal ideation increases rapidly in adolescence, and many choose not to seek help and disclose their ideation. Young people who do disclose suicidal ideation, prefer to do so with peers and family compared to mental health professionals, who are best placed to provide evidence-based treatment. This study aimed to identify key factors associated with young people's decision to, or not to disclose suicidal thoughts to their mental health practitioner.

METHODS

A community-based sample of young Australians (16 - 25 years), who had experienced suicidal ideation and engaged with a mental health professional, completed an online questionnaire (N=513) which assessed demographic characteristics, severity of depression, anxiety, psychological distress, and suicidal ideation, lifetime suicide attempts, exposure to suicide loss, personal suicide stigma, prioritisation of mental health issues, and therapeutic alliance. Logistic regression analyses were used to identify factors associated with disclosure.

RESULTS

Though the full sample had engaged in therapy, 39% had never disclosed suicidal ideation to their clinician. Those who had disclosed were more likely to report greater therapeutic alliance (OR=1.04, 95% CI=1.02-1.06), personal suicide stigma (OR=1.04, 95% CI=1.01-1.06), prioritisation of suicidal ideation (OR=.24, 95% CI=0.14-0.42), and lifetime history of suicide attempt (OR=.32, 95% CI=0.18-0.57). The most common reason for not disclosing was concern that it would not remain confidential.

CONCLUSION

These findings provide new insights into why young people may not seek help by disclosing suicidal ideation, despite having access to a mental health professional, and establish evidence to inform practice decisions and the development of prevention strategies to support young people for suicide.

GPs may help people at risk of self-harm by asking open questions and acknowledging distress

The studyFord J, Thomas F, Byng R, McCabe R. Asking about self-harm and suicide in primary care: moral and practical dimensions. Patient Educ Couns 2020;104:4.To read the full NIHR Alert go to: https://evidence.nihr.ac.uk/alert/open-questions-improve-gp-conversations-self-harm/.

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

OBJECTIVE

Self-harm and suicide are important topics to discuss with people experiencing mental health conditions. This study explores how such discussions unfold in practice, and how their moral and practical repercussions manifest for patients and doctors.

METHODS

Conversation analysis (CA) was used to examine 20 recorded examples of doctors' questions about self-harm and suicide and their ensuing discussions with patients.

RESULTS

A tendency to frame questions about self-harm towards a 'no' response, to amalgamate questions around self-harm and suicide, and to limit dialogue around the protective factors offered by family and friends restricted discussion of patients' experiences and concerns. Closed questions about thoughts and actions in the context of risk assessment resulted in missed opportunities to validate distressing thoughts. Patients responding affirmatively often did so in a way that distanced themselves from the negative stigma associated with suicide.

CONCLUSION

The wording of questions, along with negative stigma, can make it difficult for patients to talk about self-harm.

PRACTICE IMPLICATIONS

Discussions could be improved by asking about self-harm and suicide separately, encouraging discussion when responses are ambiguous and validating distressing thoughts. Negative stigma could be countered by exploring patients' positive reasons for wanting to stay alive.

Core components and strategies for suicide and risk management protocols in mental health research: a scoping review

BACKGROUND

Suicide and risk management protocols in mental health research aim to ensure patient safety, provide vital information on how to assess suicidal ideation, manage risk, and respond to unexpected and expected situations. However, there is a lack of literature that identifies specific components and strategies to include in suicide and risk management protocols (SRMPs) for mental health research. The goal of this scoping review was to review academic and grey literature to determine core components and associated strategies, which can be used to inform SRMPs in mental health research.

METHODS AND ANALYSIS

The methodological framework outlined by Arksey and O'Malley was used for this scoping review. The search strategy, conducted by a medical librarian, was multidisciplinary and included seven databases. Two reviewers independently assessed eligibility criteria in each document and used a standardized charting form to extract relevant data. The extracted data were then examined using qualitative content analysis. Specifically, summative content analysis was used to identify the core components and strategies used in SRMPs. The data synthesis process was iterative.

RESULTS

This review included 36 documents, specifically 22 peer-reviewed articles and 14 documents from the grey literature. Five core components of SRMPs emerged from the reviewed literature including: training; educational resources for research staff; educational resources for research participants; risk assessment and management strategies; and clinical and research oversight. Potentials strategies for risk mitigation within each of the core components are outlined.

CONCLUSIONS

The five core components and associated strategies for inclusion in SRMPs will assist mental health researchers in conducting research safely and rigorously. Findings can inform the development of SRMPs and how to tailor them across various research contexts.

Child safety, protection, and safeguarding in the time of COVID-19 in Great Britain: Proposing a conceptual framework

BACKGROUND

Great Britain has the highest coronavirus death rate in Europe. While the pandemic clearly poses a risk to the lives and wellbeing of vulnerable groups, necessary public health measures taken to delay or limit the spread of the virus have led to distinctive challenges for prevention, family support, court processes, placement and alternative care. The pandemic has also come about at a time when statutory changes to partnerships have led to a reduction in the importance of educational professional representation in the new formulation in England and Wales.

OBJECTIVES

In this discussion paper, we propose a novel and pragmatic conceptual framework during this challenging time.

PARTICIPANTS

We consulted with 8 education professionals and 4 field-based student social workers.

SETTING

Bodies responsible for safeguarding have been working quickly to develop new approaches to fulfilling their responsibilities, for example through online home visits and case conferences. However, some communities have been highlighted as experiencing particular challenges because of the pandemic and its impacts. Protection of vulnerable children is increasingly dependent on individualised - and often pathologising - practice with a lack of emphasis on the importance of the social. Holistic consideration of the child is side-lined.

RESULTS

Our framework comprises two phases: pandemic and aspirational.

CONCLUSION

The framework illuminates the importance of interconnected sectors and multi-agency working, the need for resilient and adaptable support systems, and the need to promote the importance of children's rights and voices to be heard above the noise of the pandemic.

Social media and adolescent mental health: the good, the bad and the ugly

Background: Social media are integral in the lives of adolescents. Practitioners need to be able to assess risk, and social media are potentially a new dimension to consider. Adolescent voices and practitioner perspectives are central to understanding the relationship between social media and mental health, yet there is limited work that highlights their views.Aims: This paper aims to illuminate the perspectives of adolescents and practitioners about social media and mental health.Method: Eight focus groups, six with adolescents aged 11-18 years and two with mental health practitioners, were conducted. Ethical approval was provided. Discussions allowed for expression of experiences, views and opinions of the relationship between social media and mental health.Results: Participants discussed what might be thought of as the "good", the "bad" and the "ugly" side of social media, navigating the benefits of social media to well-being against possible negative impacts on adolescents. They differentiated personal use from third party attributions whereby they extolled the risk to adolescents outside of their personal group. Much of the negative rhetoric of social media was repeated by mental health practitioners, although there was some acknowledgement of potential benefit.Conclusions: Practitioners need to consider social media and its role in practice. When risk-assessing adolescents, it is arguably useful to include a social media dimension, without presuming the relationship will be negative.

Suicide in DSM-5: Current Evidence for the Proposed Suicide Behavior Disorder and Other Possible Improvements

Suicide continues to be one of the greatest challenges faced by mental health clinicians and researchers, an issue made worse by increasing trends in the global suicide rate. Suicide behavior disorder (SBD) was introduced in DSM-5 as a disorder for further consideration and potential acceptance into the diagnostic system. There are numerous positive developments that would arise from the addition of a suicide-related diagnosis. Utilizing the 2009 guidelines established by Kendler and colleagues, the present review examines the evidence for SBD's validity and discusses the diagnosis' potential clinical benefits and limitations. Altogether, growing evidence indicates that SBD has preliminary validity and benefit. SBD presents with several significant limitations, however, and possible alternative additions to future DSMs are highlighted.

"It is never okay to talk about suicide": Patients' reasons for concealing suicidal ideation in psychotherapy

Objective: To identify psychotherapy clients' motives for concealing suicidal ideation from their therapist, and their perceptions of how their therapists could better elicit honest disclosure. Method: A sample of 66 psychotherapy clients who reported concealing suicidal ideation from their therapist provided short essay responses explaining their motives for doing so and what their therapist could do to help them be more honest. Content analysis was used to identify major motives and themes in these responses. Results: Seventy percent of suicidal ideation concealers cited fear of unwanted practical impacts outside therapy as the reason they did not disclose. Chief among these unwanted impacts was involuntary hospitalization, a perceived outcome of disclosing even mild suicidal thoughts. Less concrete motives for concealment, such as shame or embarrassment, were significant but secondary concerns. Nearly half of suicide-concealing clients said they would be more honest only if the threat of hospitalization was somehow reduced or controlled. Conclusion: Fostering disclosure of suicidal ideation in therapy may require renewed attention to providing transparent, comprehensive, and easy-to-understand psychoeducation about the triggers for hospitalization and other interventions. Clients make risk-benefit calculations about whether to disclose suicidal ideation, but may operate with exaggerated or inaccurate ideas about the consequences of disclosure.

The benefits and risks of asking research participants about suicide: A meta-analysis of the impact of exposure to suicide-related content

One obstacle potentially hindering research on suicide is the assumption that assessing suicide may make individuals more likely to engage in suicidal thoughts or behaviours; a concern expressed by ethics committees, researchers, and clinicians. However, decisions which are overly cautious and restrictive when approving research proposals will hinder important research in this area. The present aim was to conduct a meta-analysis to examine whether asking about suicide or exposure to suicide-related content in research studies led to changes in participants' levels of distress, suicidal ideation, or suicide attempts. A systematic search of peer-reviewed and unpublished literature from 2000 to 2017 identified 18 studies. Exposure to suicide-related content led to significant, albeit small, reductions in suicidal ideation (g = -0.13, p < .001) and a lower likelihood of engaging in suicidal behaviour (OR = 0.714, p < .05). The reduction in suicidal ideation was moderated by age such that adolescents showed nearly twice as large a reduction in suicidal ideation from pre- to post-exposure as adults did. Thus, evidence to date suggests that asking research participants about suicide does not increase risk, and may be associated with small benefits. Ethics review boards should calibrate their consideration of the risks associated with participation based on the available evidence and relative to the cost of depriving potential participants of any benefits that participation may offer.

[Suicide attempts in preadolescents]

Suicide attempts in children and adolescents are a major public health concern. Although the suicide of children remains, fortunately, infrequent, this phenomenon has been constantly increasing since 2009. While many studies have been conducted on adolescent suicidal behaviour, less attention has been paid to suicide attempts in children and preadolescents. Screening for children who are more likely to be suicidal must be performed as early as possible by general practitioners, paediatricians and school doctors.

Motivations for adolescent self-harm and the implications for mental health nurses

WHAT IS KNOWN ON THE SUBJECT?: Self-harm is a relatively common occurrence in adolescents; however, there remains a lack of understanding about the motivations behind adolescent self-harm, and this poor understanding can have a negative impact on how mental health professionals respond to young people who self-harm. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This paper identifies the reasons for self-harm in a community sample of young people and finds that the functions of self-harm differ for different people and that there may be multiple reasons for self-harm. Findings provide support for the affect-regulation model of self-harm which states that young people self-harm to regulate how they are feeling, but provides little support for the interpersonal influence model which proposes that self-harm is an attempt to influence how other people respond to them. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Self-harm for most young people serves at least one specific function and is an indication of distress. There is a requirement for a non-pathologizing response towards young people who self-harm; self-harm should be understood as a meaningful behaviour rather than a symptom of an illness. Mental health nurses need to understand the multiple functions of self-harm. A better understanding of the individualized meaning behind self-harm can positively impact on attitudes towards young people who self-harm and provide for improved mental health service provision.

ABSTRACT

Introduction Although self-harm is a relatively common occurrence in adolescents, there is a lack of understanding about the motivations behind it. A poor understanding of self-harm contributes to negative perceptions about those who self-harm and a poor healthcare experience. Aim & Methods This study identifies motivations behind self-harm in school-based adolescents using a cross-sectional survey. Motivations behind self-harm were elicited using a scale and open-ended responses. Results Of the 856 adolescents who completed the survey across 11 postprimary schools, 103 reported a history of self-harm. The most commonly endorsed reason for self-harm was to 'get relief from a terrible state of mind' (79%). Open-ended responses were consistent with scale responses with most reporting that they self-harmed to relieve distressing emotions. Discussion Findings provide support for the affect-regulation model of self-harm with support also demonstrated for the self-punishment and antidissociation models. There was little support for the interpersonal influence model suggesting that the commonly held belief that self-harm is attention-seeking is one attributed by others to young people, and not widely reported by young people themselves. Implications for practice Mental health services need to be responsive to the needs of young people who self-harm which requires eliciting and understanding the individual and multiple meanings behind self-harm to best inform treatment options.