Lessons from a comprehensive clinical audit of users of psychiatric services who committed suicide

Schizophrenia and Emergency Medicine

Schizophrenia is a chronic condition characterized by positive symptoms (auditory hallucinations, delusion), negative symptoms (avolition, social withdrawal), and disorganized thoughts/behaviors. Although the pathophysiology is incompletely understood, several neurobiological mechanisms have been proposed. Treatment usually involves antipsychotic medication as well as psychotherapy and supportive services. When evaluating patients in the emergency department, acute safety considerations are paramount. Patients should be assessed for suicide risk, violence risk, inability to care for self, and the risk of being the victim of a crime. Persons with schizophrenia are at an increased risk of substance use and a variety of medical problems.

Continuity of care in suicide prevention: current status and future directions

Introduction

Continuity of Care (CoC) is central to suicide prevention. The present study aims to review contemporary definitions, operationalization in research, and key components of CoC in the prevention of suicide.

Methods

The present study is a narrative review. A thorough search of available literature on CoC and suicidality was conducted. Studies published between 1995 and 2021 were reviewed and selected based on relevance to CoC and suicidality. Selected research was subsequently summarized to outline definitions of CoC, its operationalization in research, and key components for suicide prevention.

Results

The definition, measurement, and operationalization of CoC in suicide prevention varies tremendously, derailing clinical practice. Key elements of CoC identified across the literature include (1) CoC across multiple levels of care, (2) the role of primary care providers and case managers in CoC of suicidal patients, (3) the importance of follow up contact with suicidal patients post-treatment, and (4) the role of national and institutional guidelines for CoC of suicidal patients. Limitations: There is a dearth of randomized controlled trials and insufficient evidence on specific populations.

Conclusion

CoC refers to a wide, complex concept that must be broken down into specific categories that can provide more nuanced guidance of research and clinical implications.

A comparison of inpatient suicides in Australian psychiatric and non-psychiatric hospital units between 2009 and 2018

Hospitalisation is designed to protect patients from harm; however, patients have been reported to take their own lives during hospital admissions. While a significant healthcare concern, few studies have analysed inpatient suicides in general and psychiatric hospital units. Understanding these deaths is important for informing future prevention initiatives. Here we investigate a national sample (n = 367) of inpatient suicides in general (24%, n = 87) and psychiatric (76%, n = 278) hospital units. Patient characteristics, suicide location, timing, and suicide methods were assessed and compared. Patients who died from suicide were mostly male and admitted into psychiatric units. General hospital patients were less likely to have a known history of mental illness or previous self-harm and were often admitted for mental illness-related presentations. Suicides frequently occurred outside of the hospital by hanging. Patients in psychiatric units were more likely to be on approved leave at their death, and general patients were more likely to have absconded. These results indicate the need to identify risk factors relevant to each setting and address broader system-level factors. Removing obvious ligature points, preventing absconding, and assessing patients before episodes of leave, could contribute to preventing inpatient suicides.

Coexisting service-related factors preceding suicide: a network analysis

OBJECTIVES

The overall objective was to analyse service-related factors involved in the complex processes that precede suicide in order to identify potential targets for intervention.

DESIGN AND SETTING

Explorative network analysis study of post-suicide root cause analysis data from Swedish primary and secondary healthcare.

PARTICIPANTS

217 suicide cases reported to the Swedish national root cause analysis database between 2012 and 2017.

PRIMARY AND SECONDARY OUTCOME MEASURES

A total of 961 reported incidents were included. Demographic data and frequencies of reported deficiencies were registered. Topology, centrality indices and communities were explored for three networks. All networks have been tested for robustness and accuracy.

RESULTS

Lack of follow-up, evaluations and insufficient documentation issues emerged as central in the network of major themes, as did the contributing factors representing organisational problems, failing procedures and miscommunication. When analysing the subthemes of deficiencies more closely, disrupted treatments and staffing issues emerged as prominent features. The network covering the subthemes of contributing factors also highlighted discontinuity, fragile work structures, inadequate routines, and lack of resources and relevant competence as potential triggers. However, as the correlation stability coefficients for this network were low, the results need further investigation. Four communities were detected covering nodes for follow-up, evaluation, cooperation, and procedures; communication, documentation and organisation; assessments of suicide risk and psychiatric status; and staffing, missed appointments and declined treatment.

CONCLUSION

The results of this study suggest that healthcare providers may improve patient safety in suicide preventive pathways by taking active measures to provide regular follow-ups to patients with elevated suicide risk. In some cases, declined or cancelled appointments could be a warning sign. Tentative results show organisational instability, in terms of work structure, resources and staffing, as a potential target for intervention, although this must be more extensively explored in the future.

Psychiatric and psycho-social characteristics of suicide completers: a 13-year comprehensive evaluation of psychiatric case records and post-mortem findings

Currently, there are limited data comparing demographic and clinical characteristics of individuals who died by probable suicide and who did and did not previously attend mental health services (MHSs). This study compared demographic and clinical factors for both groups, in a Western region of Ireland over a 13-year period. Postmortem reports between January 1, 2006 and March 31, 2019 were reviewed for 400 individuals who died by probable suicide. Relevant sociodemographic and clinical data were extracted from individuals’ lifetime case notes. One hundred and fifty nine individuals (40%) had attended MHSs at some stage (“attendee”). Hanging was the most common method of suicide (61%), followed by drowning (18%) for both attendees and nonattendees of MHSs, with more violent methods utilized overall by nonattendees (p = 0.028). Sixty-eight percent of individuals who previously attempted hanging subsequently died utilizing this method. A higher proportion of attendees were female compared to nonattendees of MHSs (28.9 vs. 14.5%, p = 0.001). Recurrent depressive disorder (55%) was the most common diagnosed mental health disorder. For individuals with a diagnosis of schizophrenia, 39% had antipsychotic medications detectable in their toxicology reports. In conclusion, the majority of people who died by probable suicide had never had contact with MHSs, and nonattendees overall were more likely to utilize violent methods of suicide. Nonconcordance with psychotropic medications in psychotic patients and previous hanging attempt were highlighted as potential risk factors for death by probable suicide.

Patients' Experiences of Engagement with Healthcare Services Following a High-Risk Self-Harm Presentation to a Hospital Emergency Department: A Mixed Methods Study

Experiences of engaging with healthcare services following a self-harm presentation to hospital of high lethality or high suicidal intent have not been examined previously, despite this subgroup of self-harm patients being at high risk of suicide. Therefore, this study addressed this issue by documenting patients' experiences of engaging with healthcare services after a high-risk self-harm (HRSH) presentation to hospital. Demographic, psychiatric and psychosocial factors associated with variations in perceptions of care received were also examined. Quantitative information was obtained by interview administered questionnaires 0-3 months following a HRSH presentation to hospital. Semi-structured follow-up interviews, conducted, 6-9 months later, provided qualitative data (n = 32). Satisfaction with aftercare varied. Positive experiences of care included "supportive and compassionate relationships" and "timely and comprehensive follow-up care." The establishment of trust in the services encouraged help-seeking and psychotropic treatment adherence. Conversely, "superficial and unsupportive relationships" and "care lacking continuity and comprehensiveness" left some participants feeling isolated, contributing to inhibited help-seeking and resistance to psychotropic treatment. Participants with a history of self-harm and mental health service engagement were more likely to report dissatisfaction with care provided. Those who described unsupportive relationships more frequently reported repeated self-harm, alcohol misuse, and hopelessness at follow-up. Our findings show that satisfaction with services, help-seeking and treatment adherence may be improved by ensuring the consistent provision of timely, comprehensive and supportive aftercare following a HRSH presentation. Absence of these aspects of care may contribute to ongoing distress and further suicidal behavior.

Adversity Over the Life Course: A Comparison Between Women and Men Who Died by Suicide

Purpose: This study sets out to compare the presence of life events across different domains throughout the life course which may contribute to the burden of adversity experienced differently among men and women who died by suicide. Method: In a sample of 303 individuals (213 men and 90 women), data was derived from extensive clinical interviews conducted with informants. Models allowed the identification of patterns of life trajectories. Results: Overall, the burden of adversity was similar across the life course except for the 5-9, 25-29, and 30-34 age ranges, where a significant difference appeared between genders [t-test = 2.13 (p < 0.05), 2.16 (p < 0.05) and 3.08 (p < 0.005), respectively] that seems to disadvantage women. The early adversities of violence and neglect, between 0 and 19 years old, are important for both groups. During the life course, women were more exposed to interpersonal adverse events such as being victims of negligence and violence, relational difficulties or abuse from their spouse, as well as tension with their own children. Men encountered more academic difficulties, legal entanglements and financial difficulties, and were more than three times more likely to develop an alcohol/drug abuse problem than women. Conclusions: The data suggests some gender differences in exposure to longstanding and severe life problems contributing to suicide vulnerability. For women, the continuing burden emerges from chronic interpersonal adversities, whereas, for men, the adverse events are to a larger degree socially exposed, compounded with alcohol misuse. The adversities, especially those of a public or social nature, may be witnessed by others, which should favor the detection of vulnerability over the life course, and psychosocial or mental health services should be offered and provided earlier during the life course. Yet more men die by suicide than women. Resiliency and protective factors may benefit women to a greater degree. Future research should tackle the challenge of investigating these important elements. Meanwhile, from a public health perspective, access to psychosocial and mental health services and social acceptability of seeking services should be part of an ongoing effort in all institutional structures as a way of decreasing downstream mental health problems and vulnerability to suicide.

Predicting Depressive Symptom Severity Through Individuals' Nearby Bluetooth Device Count Data Collected by Mobile Phones: Preliminary Longitudinal Study

BACKGROUND

Research in mental health has found associations between depression and individuals' behaviors and statuses, such as social connections and interactions, working status, mobility, and social isolation and loneliness. These behaviors and statuses can be approximated by the nearby Bluetooth device count (NBDC) detected by Bluetooth sensors in mobile phones.

OBJECTIVE

This study aimed to explore the value of the NBDC data in predicting depressive symptom severity as measured via the 8-item Patient Health Questionnaire (PHQ-8).

METHODS

The data used in this paper included 2886 biweekly PHQ-8 records collected from 316 participants recruited from three study sites in the Netherlands, Spain, and the United Kingdom as part of the EU Remote Assessment of Disease and Relapse-Central Nervous System (RADAR-CNS) study. From the NBDC data 2 weeks prior to each PHQ-8 score, we extracted 49 Bluetooth features, including statistical features and nonlinear features for measuring the periodicity and regularity of individuals' life rhythms. Linear mixed-effect models were used to explore associations between Bluetooth features and the PHQ-8 score. We then applied hierarchical Bayesian linear regression models to predict the PHQ-8 score from the extracted Bluetooth features.

RESULTS

A number of significant associations were found between Bluetooth features and depressive symptom severity. Generally speaking, along with depressive symptom worsening, one or more of the following changes were found in the preceding 2 weeks of the NBDC data: (1) the amount decreased, (2) the variance decreased, (3) the periodicity (especially the circadian rhythm) decreased, and (4) the NBDC sequence became more irregular. Compared with commonly used machine learning models, the proposed hierarchical Bayesian linear regression model achieved the best prediction metrics (R2=0.526) and a root mean squared error (RMSE) of 3.891. Bluetooth features can explain an extra 18.8% of the variance in the PHQ-8 score relative to the baseline model without Bluetooth features (R2=0.338, RMSE=4.547).

CONCLUSIONS

Our statistical results indicate that the NBDC data have the potential to reflect changes in individuals' behaviors and statuses concurrent with the changes in the depressive state. The prediction results demonstrate that the NBDC data have a significant value in predicting depressive symptom severity. These findings may have utility for the mental health monitoring practice in real-world settings.

How health care systems let our patients down: a systematic review into suicide deaths

PURPOSE

To synthesize the literature in relation to findings of system errors through reviews of suicide deaths in the public mental health system.

DATA SOURCES

A systematic narrative meta-synthesis using the PRISMA methodology was conducted.

STUDY SELECTION

All English language articles published between 2000 and 2017 that reported on system errors identified through reviews of suicide deaths were included. Articles that reported on patient factors, contact with General Practitioners or individual cases were excluded.

DATA EXTRACTION

Results were extracted and summarized. An overarching coding framework was developed inductively. This coding framework was reapplied to the full data set.

RESULTS OF DATA SYNTHESIS

Fourteen peer reviewed publications were identified. Nine focussed on suicide deaths that occurred in hospital or psychiatric inpatient units. Five studies focussed on suicide deaths while being treated in the community. Vulnerabilities were identified throughout the patient's journey (i.e. point of entry, transitioning between teams, and point of exit with the service) and centred on information gathering (i.e. inadequate and incomplete risk assessments or lack of family involvement) and information flow (i.e. transitions between different teams). Beyond enhancing policy, guidelines, documentation and regular training for frontline staff there were very limited suggestions as to how systems can make it easier for staff to support their patients.

CONCLUSIONS

There are currently limited studies that have investigated learnings and recommendations. Identifying critical vulnerabilities in systems and to be proactive about these could be one way to develop a highly reliable mental health care system.

Suicidal Ideations and Attempts in Patients With Isolated Dystonia

OBJECTIVE

To evaluate the hypothesis that individuals with isolated dystonia are at an increased risk for suicidal behavior, we administered an anonymous electronic survey to patients with dystonia, asking them about their history of suicidal ideations and suicide attempt.

METHODS

A total of 542 patients with dystonia completed an online 97-question survey, which captured the demographics of suicidal behavior and major psychiatric disorders. Statistical analyses examined the prevalence of suicidal behavior in patients with dystonia compared to the prevalence of suicidal ideations and attempt in the general global population and assessed the significance of risk associations between suicidality and psychiatric history in these patients.

RESULTS

Overall, 32.3% of patients with isolated dystonia reported a lifetime history of suicidal behavior, which was significantly different from the reported rates of suicidal ideation (9.2%) and attempt (2.7%) in the general global population. The prevalence of suicidality was higher in patients with multifocal/segmental and generalized forms of dystonia (range of 46%-50%) compared to patients with focal dystonias (range of 26.1%-33.3%). The highest suicidal ideation-to-attempt ratio of 4:1 was found in patients with generalized dystonia. Suicidality in patients with focal dystonia was significantly associated with history of depression and anxiety disorders.

CONCLUSION

Patients with isolated dystonia have an increased, albeit unrecognized, prevalence of suicidal behavior compared to the general global population. Screening for suicidal risk should be incorporated as part of the clinical evaluation of patients with dystonia to prevent their suicide-induced injury and death.

Suicides in Psychiatric Patients: Identifying Health Care-Related Factors through Clinical Practice Reviews

The objective of this study was to identify health care-related factors associated with death by suicide in psychiatric patients and to gain insight into clinician views on how to deal with suicidality. The study material derived from a clinician committee in a psychiatric department reviewing every outpatient and inpatient suicide in a standardized way. Reports' conclusions and corresponding plenary discussion minutes regarding 94 suicides were analyzed using inductive thematic content analysis. Health care-related factors were categorized into 4 themes: patient evaluation, patient management, clinician training, and involvement of relevant non-clinical partners. Clinician views on the themes were expressed through statements (i) promoting or restricting an aspect of care (here called recommendations), which mainly followed existing guidelines and were consensual and (ii) without precise indication (here called comments), which departed from mainstream opinions or addressed topics not covered by existing policy. Involvement of non-clinical partners emerged as a new key issue for suicide prevention in psychiatric departments and should be openly discussed with patients. Clinicians preferred balanced conclusions when they reviewed suicide cases.

Psychological autopsy review on mental health crises and suicide among youth in Pakistan

INTRODUCTION

Ascertaining putative sociodemographic and clinical causes for death by probable suicide can potentially help implement region-specific strategies to reduce suicide rates. In this study, we wanted to investigate methods utilized and the psychosocial and mental health characteristics of youths (aged 12-26 y) who died by probable suicide.

METHOD

We examined data from mental health clinical files and forensic reports and performed qualitative psychological autopsy interview from more than multiple sources for each youth who died by probable suicide between 1 May and 31 December 2015 in the Khyber Pakhtunkhwa Province of Pakistan.

RESULTS

The two most common methods of probable suicide were by firearm use and self-poisoning utilizing pesticides that were significantly associated with male and female gender, respectively. The most common mental health difficulties were major depressive disorder and harmful use of psychoactive substances. Other clinical features particularly evident included thoughts of self-harm, irritability and aggression, low self-esteem, treatment nonadherence, family dispute, and financial distress.

CONCLUSION

Efforts to reduce the ease of access to firearms and pesticides may potentially have a beneficial effect in reducing the suicide rate in this region of Pakistan.

Is It Rational to Pursue Zero Suicides Among Patients in Health Care?

Suicide prevention is a major health care responsibility in need of new perspectives. This study reviews Zero Suicide, an emerging approach to suicide prevention that embraces the aspirational goal of zero suicides among patients treated in health care systems or organizations. Zero Suicide is gaining international momentum while at the same time evoking objections and concerns. Fundamental to Zero Suicide is a multilevel system view on suicide prevention, with three core elements: a direct approach to suicidal behaviors; continual improvement of the quality and safety of care processes; and an organizational commitment to the aspirational goal of zero suicides. The rationale and evidence for these components are clarified and discussed against the backdrop of concerns and objections that focus on possible undesired consequences of the pursuit of zero suicide, in particular for clinicians and for those who are bereaved by suicide. It is concluded that it is rational to pursue zero suicides as an aspirational goal, provided the journey toward zero suicides is undertaken in a systemic and sustained manner, in a way that professionals feel supported, empowered, and protected against blame and inappropriate guilt.

Smartphone app to investigate the relationship between social connectivity and mental health

Interpersonal relationships are necessary for successful daily functioning and wellbeing. Numerous studies have demonstrated the importance of social connectivity for mental health, both through direct peer-to-peer influence and by the location of individuals within their social network. Passive monitoring using smartphones provides an advanced tool to map social networks based on the proximity between individuals. This study investigates the feasibility of using a smartphone app to measure and assess the relationship between social network metrics and mental health. The app collected Bluetooth and mental health data in 63 participants. Social networks of proximity were estimated from Bluetooth data and 95% of the edges were scanned at least every 30 minutes. The majority of participants found this method of data collection acceptable and reported that they would be likely to participate in future studies using this app. These findings demonstrate the feasibility of using a smartphone app that participants can install on their own phone to investigate the relationship between social connectivity and mental health.

OPUS study: Suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis

Background

Patients with first-episode psychosis comprise a high-risk group in terms of suicide.

Aims

To identify predictive factors for suicidal behaviour and to examine the effect of integrated treatment on suicidal behaviour and hopelessness.

Method

A total of 341 patients with a first-episode schizophrenia-spectrum disorder were randomised to integrated treatment or treatment as usual.

Results

During the 1-year follow-up period, 11% attempted suicide. This was associated with female gender, hopelessness, hallucinations and suicide attempt reported at baseline, with the two latter variables being the only significant ones in the final multivariate model. The integrated treatment reduced hopelessness.

Conclusions

Hallucinations and suicide attempt before inclusion in the study were the most significant predictors of suicide attempt in the follow-up period.

A Linguistic Analysis of Suicide-Related Twitter Posts

Abstract. Background: Suicide is a leading cause of death worldwide. Identifying those at risk and delivering timely interventions is challenging. Social media site Twitter is used to express suicidality. Automated linguistic analysis of suicide-related posts may help to differentiate those who require support or intervention from those who do not. Aims: This study aims to characterize the linguistic profiles of suicide-related Twitter posts. Method: Using a dataset of suicide-related Twitter posts previously coded for suicide risk by experts, Linguistic Inquiry and Word Count (LIWC) and regression analyses were conducted to determine differences in linguistic profiles. Results: When compared with matched non-suicide-related Twitter posts, strongly concerning suicide-related posts were characterized by a higher word count, increased use of first-person pronouns, and more references to death. When compared with safe-to-ignore suicide-related posts, strongly concerning suicide-related posts were characterized by increased use of first-person pronouns, greater anger, and increased focus on the present. Other differences were found. Limitations: The predictive validity of the identified features needs further testing before these results can be used for interventional purposes. Conclusion: This study demonstrates that strongly concerning suicide-related Twitter posts have unique linguistic profiles. The examination of Twitter data for the presence of such features may help to validate online risk assessments and determine those in need of further support or intervention.

The Attitude of Psychiatric and Non-psychiatric Health-care Workers Toward Suicide in Malaysian Hospitals and Its Implications for Training

OBJECTIVES

This research is aimed to examine the attitude of health-care workers toward suicidal patients in Malaysian hospitals, comparing responses from psychiatric and non-psychiatric workers, and to identify specific needs in suicide prevention and management training.

METHOD

This is a multi-site cross-sectional study. The authors conducted a survey based on a translated self-administered questionnaire to participants from seven core hospital departments.

RESULTS

While most health-care workers regardless of department and specialty took their duty to prevent suicide seriously, a large majority of them expressed negative attitudes such as finding suicidal behavior irritating, and more than half believed suicidal attempts were a way of making others sorry. However, psychiatric workers were less likely to have judgmental attitudes that included believing suicide attempters as being selfish or trying to get sympathy from others.

CONCLUSIONS

As there were more similarities than differences in health-care workers' attitudes toward suicide, recommendations on basic and continuous suicide prevention and management training among hospital workers were made. The interventions focused on improving knowledge, affective, and skill-based areas that were aimed to correct the wrongful understanding of and to minimize the negative attitudes toward suicidal individuals indicated by the study results.

Cross-Cultural Adaptation and Validation of the Attitudes Toward Suicide Questionnaire Among Healthcare personnel in Malaysia

Understanding attitudes toward suicide, especially among healthcare personnel, is an important step in both suicide prevention and treatment. We document the adaptation process and establish the validity and reliability of the Attitudes Toward Suicide (ATTS) questionnaire among 262 healthcare personnel in 2 major public hospitals in the Klang Valley, Malaysia. The findings indicate that healthcare personnel in Malaysia have unique constructs on suicide attitude, compared with the original study on a Western European sample. The adapted Malay ATTS questionnaire demonstrates adequate reliability and validity for use among healthcare personnel in Malaysia.

Suicidal patients' experiences regarding their safety during psychiatric in-patient care: a systematic review of qualitative studies

Background

In-patient suicide prevention is a high priority in many countries, but its practice remains poorly understood. Patients in a suicidal crisis who receive psychiatric care can provide valuable insight into understanding and improving patient safety. The aim of this paper was therefore to summarize the qualitative literature regarding suicidal patients’ in-patient care experiences. The following question guided the review: How can we describe suicidal patients’ experiences regarding safety during psychiatric in-patient care?

Methods

Systematic searches were conducted in the MEDLINE, Academic Search Premier, CINAHL, SOCINDEX and PsycINFO databases, identifying 20 qualitative studies on suicidal patients and their psychiatric in-patient care experiences. These studies were systematically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, synthesized via thematic analysis and subjected to quality appraisals.

Results

Patients described safety as “feeling safe”, and three components, i.e., connection, protection and control, were vital to their experiences of safety. Fulfilling these needs was essential to patients recovering from suicidal crises, feeling safe during encounters with health care professionals and feeling safe from suicidal impulses. Unmet needs for connection, protection and control left patients feeling unsafe and increased their suicidal behaviour.

Conclusion

Our review addresses the importance of adopting a wider perspective of patient safety than considering safety solely in technical and physical terms. Safety for the suicidal patient is highly dependent on patients’ perceptions of their psychological safety and the fulfilment of their needs. The three patient-identified factors mentioned above – connection, protection and control – should be considered an integral part of patient safety practices and should form the basis of future efforts to understand the safety of suicidal patients during psychiatric in-patient care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2023-8) contains supplementary material, which is available to authorized users.

Root Cause Analyses of Suicides of Mental Health Clients: Identifying Systematic Processes and Service-Level Prevention Strategies

BACKGROUND

The ability to predict imminent risk of suicide is limited, particularly among mental health clients. Root cause analysis (RCA) can be used by health services to identify service-wide approaches to suicide prevention.

AIMS

To (a) develop a standardized taxonomy for RCAs; (b) to quantitate service-related factors associated with suicides; and (c) to identify service-related suicide prevention strategies.

METHOD

The RCAs of all people who died by suicide within 1 week of contact with the mental health service over 5 years were thematically analyzed using a data collection tool.

RESULTS

Data were derived from RCAs of all 64 people who died by suicide between 2008 and 2012. Major themes were categorized as individual, situational, and care-related factors. The most common factor was that clients had recently denied suicidality. Reliance on carers, recent changes in medication, communication problems, and problems in follow-through were also commonly identified.

CONCLUSION

Given the difficulty in predicting suicide in people whose expressions of suicidal ideation change so rapidly, services may consider the use of strategies aimed at improving the individual, stressor, support, and care factors identified in this study.

Psychiatrists' experiences of suicide assessment

BACKGROUND

Clinical guidelines for suicide prevention often stress the identification of risk and protective factors as well as the evaluation of suicidal intent. However, we know very little about what psychiatrists actually do when they make these assessments. The aim was to investigate psychiatrists' own accounts of suicide assessment consultations, with a focus on their behaviors, attitudes and emotions.

METHOD

Semi-structured in depth interviews were carried out with a purposive selection of 15 psychiatrists.

RESULTS

Thematic analysis revealed three main themes: understanding the patient in a precarious situation, understanding one's own reactions, and understanding how the doctor-patient relationship impacted on risk assessment and management decisions. Emotional contact and credibility issues were common subthemes that arose when the respondents talked about trying to understand the patient. The psychiatrists stressed the semi-intuitive nature of their assessments. Problems related to the use of risk factor assessments and rating scales were apparent. Assessment consultations could evoke physical and emotional symptoms of anxiety, and concerns about responsibility could lead to repressive management decisions. In situations of mutual trust, however, the assessment consultation could kick-start a therapeutic process.

CONCLUSION

This study highlights psychiatrists' experiences in clinical suicide assessment situations. Findings have implications for professional development as well as for service delivery.

Development of ACROSSnet: an online support system for rural and remote community suicide prevention workers in Queensland, Australia

Communication and information technologies can reduce the barriers of distance and space that disadvantage communities in Australia's underserved rural areas, where the health status of residents is often worse than that of their urban counterparts. ACROSSnet (Australians Creating Rural Online Support Systems) is a 3 year collaborative action research project that aims to design and develop an online support system that will assist rural communities in accessing information, education and support regarding suicide and its prevention, whilst considering the challenges of Internet speed, cost and availability that can impede the delivery of online services. The site provides three distinct levels of access: one level for community members, and two further levels for appropriately credentialled mental health workers. In creating this environment, the ACROSSnet team hopes that online communities of practice will develop, engaging participants of different ages, income and education levels, location, and socioeconomic backgrounds.

Mental health treatment use and perceived treatment need among suicide planners and attempters in the United States: between and within group differences

Background

Despite many previous studies of suicidal ideation and/or attempts, little research has examined mental health treatment use and perceived treatment need among and within groups of ideators and/or attemptors. We examined mental health treatment use and perceived treatment need in four groups of US adults who had serious suicidal ideation: (1) no suicide plan/no attempt; (2) planned/no attempt; (3) no plan/attempted; and (4) planned/attempted.

Methods

We compared ideators and nonideators using the 154,923 U.S. residents aged 21 and older who participated in the 2008–2012 National Survey on Drug Use and Health (NSDUH). We then employed logistic regression analyses to discern factors associated with treatment use and perceived treatment need among and within the four groups of ideators (N = 7,348).

Results

More than 30% of ideators who made suicide plans and/or attempted suicide received no treatment before or after planning or attempting. Racial/ethnic minorities had lower odds of treatment use in all four groups, but major depression significantly increased the odds in all but the no plan/attempted group. Treatment use and substance use disorder increased the odds of perceived need in all four groups.

Conclusions

The four groups have different rates of treatment access and perceived treatment need that do not appear to be commensurate with their risk level. The findings underscore the importance of treatment access for all those at-risk of suicide, especially racial/ethnic minorities and those of lower SES.

Psychiatric and psycho-social characteristics of suicide completers: a comprehensive evaluation of psychiatric case records and postmortem findings

Objectives

To explore the demographic, psychosocial and clinical characteristics of individuals known to the mental health services, who died by probable suicide in the West of Ireland.

Methods

Postmortem reports between January 2006 and May 2012 detailed 153 individuals who died by probable suicide, 58 of whom attended the mental health services. Relevant socio-demographic and clinical data was extracted from individuals’ lifetime case notes.

Results

Recurrent depressive disorder (44%) was the most common diagnosis and hanging the most common method of death (58%). Of individuals who died by hanging, 79% previously attempted suicide by the same method. For individuals with a documented history of depression, only 32% had antidepressants detected in their toxicology reports. Similarly, only one individual (20%) with schizophrenia had antipsychotics detected in their toxicology report.

Conclusions

Individuals who died by probable suicide, most commonly died by hanging and drowning; with previous attempts of hanging particularly prevalent in the group who subsequently died by hanging. At the time of death, less than one-third of individuals according to toxicology reports were taking the medication that was last prescribed to them by the mental health services suggesting a high rate of treatment non-concordance in individuals who died by probable suicide.

The Isle of Wight Suicide Study: a case study of suicide in a limited geographic area

BACKGROUND

Suicide is a major public health problem, with mental disorders being one of its major risk factors. The high incidence of suicide on the Isle of Wight has motivated this study, the first of its kind on suicide in this small geographic area. Aim The aim of the study was to identify socio-demographic and clinical risk factors for suicide in the population of service users and non-service users, and gender-related characteristics of suicidal behaviour in a limited geographic region.

METHOD

Data were collected on 68 cases of suicide (ICD-10×60-X84) from residents of the Isle of Wight District between January 2006 and December 2009. All data were statistically analysed using Pearson's χ 2 test and Yates' correction for continuity.

RESULTS

The mean annual suicide rates over the period were 5.65 per 100 000 for women and 19.28 for men. Significantly (p=0.0006), more men than women (male/female ratio 3:1) died as a result of suicide. Relatively (p=0.07) more women (56.2%) than men (32.7%), and significantly more (p=0.05) service users (45.3%) than non-service users (13.3%) were unemployed. Significantly, more (p=0.0006) service users (64%) than non-service users (20%) had a history of suicide attempts and relatively (p=0.06) more (50.9%) service users than non-service users (20%) had attended the accident and emergency department before their death; 69% had an adverse life event within a year before their suicide. Depression as the most common Axis-I illness was diagnosed in 36% of all; but significantly (p=0.008) more in women (66.6%) than men (17.3%). Relatively (p=0.07) more women (56.2%) than men (32.7%) have contacted services before their death. Suicide by hanging was the most common cause, accounting for the death of 71% of men and 50% of women.

CONCLUSIONS

The study found that 80% of all suicides occurred in people suffering from mental disorder. Men are at a significant risk of suicide. Depressive disorders in women and stress-related disorders in men were the most common mental disorders. Treating mental disorders and co-morbid conditions seems to be one of the key elements in suicide prevention strategies.

Yearning to Be Heard

Background: Patients with serious mental illness can be at higher risk for suicide. Most research has focused on determining the risk factors for suicide-related events using quantitative methodologies and psychological autopsies. However, fewer studies have examined patients’ perspectives regarding the experience of suicidal events. Aims: To better understand suicide experiences from the perspective of patients diagnosed with serious mental illness. Method: This study purposively sampled and qualitatively interviewed 23 patients within the Veterans Affairs Hospital who were diagnosed with serious mental illness and who had attempted suicide. Using a phenomenological design, hermeneutic interviews included questions about the precursors, characteristics, and treatment of the suicide events, as well as patients’ recommendations for care. Results: Loneliness, isolation, depression, and hopelessness were commonly described as emotional precursors to the suicide events for all patients, while command hallucinations were reported among patients with schizophrenia-spectrum disorders. When evaluating whether treatments were effective, patients focused primarily on the level of empathy and compassion shown by their providers. Conclusion: The most common recommendation for the improvement of care was to increase clinicians’ empathy, compassion, and listening skills. Additionally, efforts to bolster social supports were highlighted as a means to diminish suicide events.

Preventing suicide among inpatients

OBJECTIVE

Inpatient suicide comprises a proportionately small but clinically important fraction of suicide. This study is intended as a qualitative analysis of the comprehensive English literature, highlighting what is known and what can be done to prevent inpatient suicide.

METHOD

A systematic search was conducted on the Cochrane Library, PubMed, Embase, Web of Knowledge, and a personal database for articles on cohort series, preferably controlled, of inpatient suicide (not deliberate self-harm or attempted suicide, unless they also dealt specifically with suicide data).

RESULTS

A qualitative discussion is presented, based on the findings of the literature searched.

CONCLUSIONS

The bulk of inpatient suicides actually occur not on the ward but off premises, when the patient was on leave or had absconded. Peaks occur shortly after admission and discharge. It is possible to reduce suicide risk on the ward by having a safe environment, optimizing patient visibility, supervising patients appropriately, careful assessment, awareness of and respect for suicide risk, good teamwork and communication, and adequate clinical treatment.

Effectiveness of online self-help for suicidal thoughts: results of a randomised controlled trial

Background

Many people with suicidal thoughts do not receive treatment. The Internet can be used to reach more people in need of support.

Objective

To test the effectiveness of unguided online self-help to reduce suicidal thoughts.

Method

236 adults with mild to moderate suicidal thoughts were randomised to the intervention (n = 116) or a waitlist control group (n = 120). Assessments took place at baseline, and 2, 4 and 6 weeks later. Primary outcome was suicidal thoughts. Secondary outcomes were depressive symptoms, anxiety, hopelessness, worry, and health status.

Results

The intervention group showed a small significant effect in reducing suicidal thoughts (d = 0.28). Effects were more pronounced for those with a history of repeated suicide attempts. There was also a significant reduction in worry (d = 0.33). All other secondary outcomes showed small but non-significant improvements.

Conclusions

Although effect sizes were small, the reach of the internet could enable this intervention to help many people reduce their suicidal thoughts.

Trial Registration

Netherlands Trial Register NTR1689

Short-term effects of a suicide education intervention for family caregivers of people who are suicidal

AIMS AND OBJECTIVES

To evaluate the short-term effects of a suicide care educational intervention on the family's ability to care, family's caring stress levels and family's attitudes towards attempted suicide.

BACKGROUND

Research has demonstrated that suicide prevention educational programmes are provided mostly for professional staff and not for the family caregivers of people who are suicidal.

DESIGN

A experimental design, using two groups and a pre- and postintervention survey method, was used.

METHODS

A randomised controlled study was conducted with 74 family caregivers of people who are suicidal (37 using suicide education and 37 in the control group). The experimental group was provided with a two-hour suicide care education intervention, and the control group received normal suicide care support. Participants were recruited at a Suicide Prevention Centre and two acute psychiatric hospitals between October 2009-December 2010. Three questionnaires were collected: (1) the Suicidal Caring Ability Scale (2) the Caring Stress Scale and (3) the Suicide Attitudes Scale. Descriptive statistics, independent t-tests or Mann-Whitney U-tests were used to analyse the data.

RESULTS

The results demonstrated that there were statistically significant differences in the Suicidal Caring Ability Scale and the Suicide Attitudes Scale but no statistically significant differences in the Caring Stress Scale. That is, the suicide education programme can promote the ability to care for people who are suicidal and can generate a positive attitude towards people who are suicidal from their caregivers.

CONCLUSIONS

Family caregivers of suicidal individuals who attended the psycho-education programme had an increased caring ability and positive attitudes for their suicidal relatives.

RELEVANCE TO CLINICAL PRACTICE

Nurses could use the two-hour personal suicidal education programme to increase one's ability to care for their relatives who had attempted suicide and promote one's positive attitudes towards attempted suicide.

Evaluation of the Dawson College Shooting Psychological Intervention: Moving Toward a Multimodal Extensive Plan

In 2006, following the shooting at Dawson College, the authorities implemented an intervention plan. This provided an opportunity to analyze the responses to services offered, and afforded a learning opportunity, which led to the proposal of an extensive multimodal short- and long-term psychological plan for future needs. Both quantitative and qualitative data were gathered 18 months after the event, involving the participation of 948 students and staff. Mental health problems and the perception of services offered after the shooting were investigated, using standardized measures. Second, focus groups and individual interviews were conducted among a subgroup of participants (support team members; teachers and employees; students and parents) and permitted to gather data on services received and services required. Individual report of events, the extent of psychological impact and services offered and received were analyzed in terms of the following dimensions: intervention philosophy, training, ongoing offer of services and finally, detection and outreach. A significant incidence of disorders and a high rate of exacerbation of preexisting mental disorders were observed within the 18 months following the shooting. Postimmediate and short-term intervention appeared adequate, but the long-term collective vision toward community support and availability of mental health services were lacking. Lessons learned from this evaluation and other school shootings suggest that preparedness and long-term community responses are often overlooked. A multimodal extensive plan is proposed based on a theoretical model from which interventions strategies could be drawn.

Suicide assessment and prevention during and after emergency commitment

The purpose of this study was to address two primary issues within the context of emergency commitment: (a) the suicide-prevention measures implemented at receiving facilities where emergency commitments occur and (b) the perceptions of key stakeholders about access to community services post-discharge. One hundred seventy-eight respondents who worked in receiving facilities, where emergency commitments occur, responded to an online survey or were interviewed. Respondents indicated the use of suicide-prevention measures such as suicide assessment tools used at intake and discharge and strategies utilized to maintain client safety when the issue of suicidality had been determined at intake. Almost half of respondents (46.6%) described the availability of community mental health treatment at discharge from emergency commitment as being "less than adequate." Emerging themes about community service availability are discussed and include long waiting periods and funding issues.

The association between anomalous self-experience and suicidality in first-episode schizophrenia seems mediated by depression

BACKGROUND

A recent hypothesis is that suicidality in schizophrenia may be linked to the patients' altered basic self-awareness or sense of self, termed self-disorders (SDs).

AIM

The aim of the study was to investigate whether SDs in first-episode schizophrenia spectrum disorders are related to suicidality and whether this relationship is independent of or mediated by depression or other standard clinical measures.

METHOD

Self-disorders were assessed in 49 patients with first-episode schizophrenia by means of the Examination of Anomalous Self-Experience (EASE) instrument. Symptoms severity and functioning were assessed using the Structured Clinical Interview for the Positive and Negative Syndrome Scale, Calgary Depression Scale for Schizophrenia, and Global Assessment of Functioning-Split Version. Suicidality was measured by the Calgary Depression Scale for Schizophrenia item 8.

RESULTS

Analyses detected a significant association between current suicidality, current depression, and SDs as measured by the EASE. The effect of SDs on suicidal ideation appeared to be mediated by depression.

CONCLUSION

The interaction between anomalous self-experiences and depression could be a rational clinical target for the prevention of suicidality in the early phases of schizophrenia and supports the rationale for including assessment of SDs in early intervention efforts.

Acute Cognitive Therapy in Reducing Suicide Risk Following a Presentation to an Emergency Department

The ACT (Acute Cognitive Therapy) Program was implemented as a patient follow-up initiative to respond to people presenting to emergency departments with suicidal behaviour or ideation, in a psychosocial crisis. Over 12 months 188 patients were referred to the program of which 160 attended at least one appointment and 109 completed the program. Pre- and postmeasures indicated that significant improvement occurred in those who completed the program, that improvements were maintained at 6 months and representation rates were reduced. Immediate short-term directed treatment appears beneficial in the short and medium term, and the rapidity and location of follow-up appears to promote compliance.

Suicide on the Isle of Wight: A Case-study of 35 Suicides among Mental Health Service Users Between 2006 and 2008

AIMS

To identify the sociodemographic, clinical and service delivery risk factors for suicide in psychiatric patients in a limited geographic area.

METHOD

A retrospective case study of 35 patients who died as a result of suicide between January 2006 and December 2008.

RESULTS

Male gender, unemployment, living alone, basic education and significant life events were identified as sociodemographic factors. A history of previous psychiatric admission, previous suicide attempt, suffering from depression, co-morbidity of another psychiatric disorder (mainly stress-related symptoms and alcoholism), and contacting the services prior to suicide were found as typical clinical factors. Hanging was the most common method of suicide in both men and women. Most men died in spring and summer, while the majority of females died in autumn.

CLINICAL IMPLICATIONS

As in similar studies, mental disorders could be identified as the strongest risk factor for suicide. Almost 70% of suicides were conducted by people suffering from a mental disorder. Treating mental disorders and identifying certain sociodemographic and clinical characteristics of people suffering from mental disorders and addressing them is the key in suicide prevention strategies.

Characteristics of suicide attempts in young people undergoing treatment for first episode psychosis

OBJECTIVES

Understanding the characteristics of suicide attempts in people undergoing treatment for first episode psychosis (FEP) may have implications for risk management at a service level and local suicide prevention strategies. Although studies have focused on identifying individual-level risk factors for suicide attempts in this patient group, none have yet conducted an in-depth profile of suicide attempts. The aim of the present study was to examine the characteristics of suicide attempts in young people during the initial 18 months of treatment for FEP.

METHOD

A retrospective medical record audit study of a cohort of patients accepted for treatment at a specialist FEP service between 1/12/2002 and 30/11/2005.

RESULTS

Of 607 patients, 73 (12%) attempted suicide during treatment. Of these 73, most (72.6%) attempted suicide on one occasion. The majority of attempts (85.3%) occurred when patients were treated as outpatients and were in regular contact with the service. Suicide attempts tended to be impulsive (77.6%), triggered by interpersonal conflict or distress due to psychotic symptoms. Two thirds involved self-poisoning, usually by overdose of prescribed medications. All inpatient suicide attempts were by hanging or strangulation. Individuals infrequently sought help immediately before or after the attempt; if help-seeking occurred, informal sources of support were contacted.

CONCLUSIONS

To reduce the number of suicide attempts among individuals treated for FEP, psychiatric services could consider: restricting the amount of medication prescribed per purchase; individualised suicide risk management plans for all newly admitted patients, including those who do not appear to be at risk; stringent reviews of inpatient psychiatric units for potential ligature points; providing information and psycho-education for significant others in recognition and response to suicide risk; fostering patients' problem solving and conflict resolution skills; and regular risk assessment and close monitoring of patients, particularly during the high risk period of 3 months after a suicide attempt.

Youth and young adult suicide: a study of life trajectory

OBJECTIVES

Explore the unique developmental challenges and early adversity faced by youth and young adult who died of suicide.

METHOD

Sixty-seven suicide victims (SG) were compared with 56 living control with no suicidal ideations in the last year, matched for age, gender, and geographical region. Mixed methods were used: consensus DSM-IV diagnoses were formulated based on Structured Clinical Interview for DSM-IV (SCID)-I and -II interviews complemented by medical charts. Life calendar method was conducted with closest third party informant. Life-history calendar served to measure life events and adversity throughout the life course and were analyzed by attributing burden of adversity score per five-year segment, which was then cluster-analyzed to define suicide victim profiles.

RESULTS

During the last year, mood disorders, abuse and dependence disorders, and anxiety disorder were between 8 and 63 times more likely to be present in the suicide group. Between 0 and 4 years old, 50% of children in the SG were exposed to abuse, physical and/or sexual violence; 60% between 5 and 9 years old; and by the time they were 10-14 years old, 77% were exposed to these forms of violence. In the control group, the respective figures were 14%, 18% and 34%. In the suicide group, the trajectories leading to suicide are different as we observe two different subgroups, one with early-onset and one with later-onset of adversity. To a large extent, people in the suicide group were exposed to major adversity and they were more likely to present cumulative comorbid disorders.

Suicides in psychiatric in-patients: what are we doing wrong?

Given the uncontested role of psychiatric illnesses in both fatal and non-fatal suicidal behaviours, efforts are continuously made in improving mental health care provision. In cases of severe mental disorder, when intensified treatment protocols and continuous supervision are required due to individual's impaired emotional, cognitive and social functioning (including danger to self and others), psychiatric hospitalisation is warranted. However, to date there is no convincing evidence that in-patient care prevents suicide. In fact, quite paradoxically, both admissions to a psychiatric ward and recent discharge from it have been found to increase risk for suicidal behaviours. What elements in the chain of well-intentioned approaches to treating psychiatric illness and suicidality fail to protect this vulnerable population is still unclear. The same holds true for the identifications of factors that may increase the risk for suicide. This editorial discusses current knowledge on this subject, proposing strategies that might improve prevention.

Suicides in users of mental health care services: treatment characteristics and hindsight reflections

The current study aims to describe the patient and treatment characteristics of a sample of 505 suicides by mental health care patients, and to determine how clinicians view the care provided and what they learned. The results indicate that the quality of mental health care for suicidal patients could be improved by focusing on communication among clinicians, continuity of care, suicide risk assessment procedures, and the involvement of relatives.

Rural-urban differences in suicide rates for current patients of a public mental health service in Australia

Rural versus urban rates of suicide in current patients of a large area mental health service in Australia were compared. Suicide deaths were identified from compulsory root cause analyses of deaths, 2003-2007. Age-standardized rates of suicide were calculated for rural versus urban mental health service and compared using variance of age-standardized rates with 95% confidence intervals. There were 44 suicides and the majority (62%) were rural. Only urban patients used jumping from heights as a method of suicide (4/17; p = 0.02). Rural patients had 2.7 times higher rates of suicide, similar to findings for rural versus urban community suicides and may reflect the underlying community rates, differences in mental health service delivery, or socioeconomic disadvantage.

Self-disorder and subjective dimensions of suicidality in schizophrenia

We studied 25 schizophrenia patients using the Examination of Anomalous Self-Experience phenomenological interview framework. In a previous study, this sample was qualitatively interviewed concerning subjective reasons for suicidal ideation. We hypothesized that 2 main identified reasons for suicidality, that is, sense of solitude and inferiority feelings, would be associated with disturbances measured by the Examination of Anomalous Self-Experience scale, that is, disorders of self-awareness and self-presence. The hypothesis was empirically supported. The results shed some additional light on suicidality in schizophrenia: it appears to be partly motivated by a disordered sense of self. These findings, if replicated, may have considerable therapeutic and preventive implications.

Suicide risk factors and suicide vulnerability in various major psychiatric disorders

PRIMARY OBJECTIVES

There are many known suicide risk factors (SRF) common to major psychiatric disorders, but their impact on suicide vulnerability remains unclear. We used FALCON (Fuzzy Adaptive Learning Control Network) to evaluate those impacts.

METHODS

Staff psychiatrists completed computerized suicide risk scales (CSRS-III) including 21 SRF for 612 patients. Diagnoses were: schizophrenia, schizoaffective, major depression, anxiety disorder, bipolar affective disorder, personality disorder, organic brain syndromes, delusional disorder and other diagnoses. An optimal trained FALCON was obtained by running the network 10 times with 552 CSRS-III, validating with the balance. Medically serious suicide attempts (the vulnerability factor) served as the target variable. The significance of each variable in the trained network was determined by the magnitude of the change in output as affected by the consecutive change in all points of the variable input, then calculating the mean variance of all cases. The direction of influence was determined by the input on the entire scale of each variable, point by point, across all cases, then calculating the mean of all outputs.

RESULTS

The impact and direction of influence of the various SRF differed for each diagnosis.

CONCLUSION

Evaluation of the individual patient with his/her specific impact profile, determination of direction of influence of the corresponding SRF's may assist in increasing the accuracy of individual suicide risk assessment.

A collaborative therapeutic relationship and risk of suicidal ideation in patients with bipolar disorder

BACKGROUND

A diagnosis of Bipolar Disorder (BD) is among the strongest known risk factors for suicide. The present study examines the relative impact of current mood state (depressed, manic or mixed) and patient perceptions of the therapeutic relationship on suicidal ideation in veterans with BD.

METHODS

We conducted analyses of the baseline data from a naturalistic cohort study of veterans receiving care for BD (N=432) at a large urban VA mental health clinic. Logistic regression was used to examine the relative impact of patient- and treatment-related factors on suicidal ideation within the two weeks prior to recruitment.

RESULTS

Over 49% (213/432) of veterans receiving current outpatient treatment for BD reported at least some suicidal ideation within the two weeks prior to recruitment. After accounting for current mood state and other identified risk factors, even minimal increases (i.e., per point increase on a 0-60 rating scale) in the extent to which the therapeutic relationship is perceived as collaborative (OR=0.97; p<.01) were associated with a reduction in risk of suicidal ideation.

LIMITATIONS

This study is cross sectional and relies exclusively on patient self-report.

CONCLUSIONS

Mental health treatment providers should be aware of the high rate of suicidal ideation in patients with BD. Successful management of suicidal ideation likely involves a focus on improving symptoms as well as establishing a collaborative therapeutic relationship.

Prevalence and predictors of suicide attempt in an incidence cohort of 661 young people with first-episode psychosis

OBJECTIVES

Studies investigating suicidal behaviour in psychosis rarely focus on incidence cohorts of first-episode patients. This is important, because patients who refuse study participation have higher rates of comorbid substance use disorders and longer duration of untreated psychosis as well as worse course illness, variables potentially linked to higher prevalence of suicidal behaviour. The aims of the present study were therefore to examine the prevalence and predictors of suicide and suicide attempt before and during the first 18-24 months of treatment.

METHOD

A retrospective file audit of 661 patients was carried out.

RESULTS

Six patients (0.9%) died by suicide, 93 (14.3%) attempted suicide prior to entry, and 57 (8.7%) did so during treatment. Predictors of suicide attempt were: previous attempt (odds ratio (OR)=45.54, 95% confidence interval (CI)=9.46-219.15), sexual abuse (OR=8.46, 95%CI=1.88-38.03), comorbid polysubstance (OR=13.63, 95%CI=2.58-71.99), greater insight (OR=0.17, 95%CI=0.06-0.49), lower baseline Global Assessment of Functioning Scale and Scale of Occupational and Functional Assessment score (OR=0.96, 95%CI=0.62-0.91; OR=0.98, 95%CI=0.95-0.99), and longer time in treatment (OR=1.05, 95%CI=1.03-1.08).

CONCLUSIONS

The prevalence of suicidal behaviour was high, indicating that suicidal behaviour in incidence populations is higher than in non-epidemiological cohorts of first-episode patients. The rate of repetition of suicide attempt among the sample, however, was lower than expected, suggesting that specialist services can play a role in reducing suicide risk.

Systematic services audit of consecutive suicides in New Brunswick: the case for coordinating specialist mental health and addiction services

OBJECTIVE

To weight the potential of promotion, prevention, and treatment programs to help establish priorities in multipronged suicide prevention strategies.

METHODS

Psychological autopsy methods served to collect information on consecutive suicides over 14 months in New Brunswick (n = 102). A panel of researchers, clinicians, provincial planners, and consumers reviewed the cases and applied a systematic needs assessment procedure to establish interventions and services received, unmet needs at the individual level, and programmatic and systemic shortcomings.

RESULTS

More than two-thirds of the individuals suffered from a depressive disorder and a similar proportion from substance (essentially alcohol) abuse or dependence; one-half also presented a personality disorder. In the last year, more than one-half had been in contact with a mental health services specialist, but less than 5% had contact with addiction services, though one-third had previous contact in their lifetime. In one-third of the cases, service gaps called for greater coordination and integration of mental health specialists and addiction services within the health care system. In one-half of the cases, system needs were found to be unmet for public awareness efforts aimed at encouraging individuals to consult health and social services professionals, and in terms of training efforts geared to improving detection, treatment, and referral for mental illness, substance-related problems, and suicidal behaviour by primary medical, social, and specialist services.

CONCLUSION

This study supports multipronged suicide prevention strategies that should include integrated public promotion, professional development campaigns, and better program coordination. Authorities in New Brunswick have opted to favour the latter strategy component, whose development and application must be evaluated to determine its impact on suicide rates.

Promoting positive risk management: evaluation of a risk management panel

The purpose of this study was to evaluate whether a National Health Service Trust risk management panel (RMP) service was effective in promoting positive risk management by supporting mental health clinicians/teams in their management of people with mental health problems who presented with high risk of harm to themselves or to others. Fifteen mental health workers completed a questionnaire regarding their experience of the RMP. Content analysis revealed several themes. The majority of participants found the RMP helpful because of the support provided by shared case discussion and collective responsibility for risk management offered by the RMP. Medical records of the 23 individuals referred into the RMP were also examined. Trends in diagnoses, risks and RMP recommendations were identified. This study points to the importance of the organization's role alongside the individual clinician's in positive risk management and in supporting people with mental health problems using the recovery model. Improvements in developing a RMP are suggested.