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Ropaj E, Haddock G, Pratt D. Developing a consensus of recovery from suicidal ideations and behaviours: A Delphi study with experts by experience. PLoS One 2023; 18:e0291377. [PMID: 37729121 PMCID: PMC10511083 DOI: 10.1371/journal.pone.0291377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 08/28/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Understanding recovery in mental health has received significant attention and consequently, recovery has been incorporated into health policy across many countries in the Global North. In comparison, the concept of 'recovery' from suicidal thoughts and behaviours has received little attention. However, the few studies in this area appear to suggest that recovery is a complex and an idiosyncratic process with many contributing factors. This can present a challenge for clinicians and services seeking to become more recovery focused. Thus, it seems of importance to develop a consensus on how recovery from suicidal thoughts and behaviours is conceptualised. AIM The study aimed to use the Delphi design to establish a consensus of how recovery is defined by those with lived experience of suicidal thoughts and behaviours. The Delphi method draws on the expertise of a panel, often involving clinicians, researchers and lived experience experts to develop consensus over a topic by inviting them to rate the importance of, often a series of statements to a given topic area. METHOD Lived experience experts were asked to complete two rounds of questionnaires distributed online to capture their views on recovery. RESULTS A total of 196 individuals gave their views on the first round of the study and 97 gave their views on the second round. A final list of 110 statements was developed that 80% or more of participants defined as essential or important. Statements covered items that were important in defining, facilitation and hindering the process of recovery. CONCLUSION Findings are consistent with the wider literature that suggests that recovery is an idiosyncratic process, but with many commonly shared features. Here we also show that a comprehensive definition of recovery must include factors that hinder the process of recovery. Implications and recommendations for practice, policy development and future research are discussed.
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Affiliation(s)
- Esmira Ropaj
- Division of Psychology & Mental Health, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Gillian Haddock
- Division of Psychology & Mental Health, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Daniel Pratt
- Division of Psychology & Mental Health, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
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Kasal A, Táborská R, Juríková L, Grabenhofer-Eggerth A, Pichler M, Gruber B, Tomášková H, Niederkrotenthaler T. Facilitators and barriers to implementation of suicide prevention interventions: Scoping review. Glob Ment Health (Camb) 2023; 10:e15. [PMID: 37854412 PMCID: PMC10579684 DOI: 10.1017/gmh.2023.9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/12/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023] Open
Abstract
We know that suicide is preventable, yet hundreds of thousands of people still die due to suicide every year. Many interventions were proven to be effective, and dozens of others showed promising results. However, translating these interventions into new settings brings several challenges. One of the crucial obstacles to success is not anticipating possible barriers to implementation nor enhancing possible benefits of factors facilitating the implementation. While we witnessed great support for suicide prevention activities globally in the past years, implementation barriers and facilitating factors are yet to be comprehensively mapped to help implementation activities worldwide. This scoping review maps current knowledge on facilitators and barriers to the implementation of suicide prevention interventions while using the Consolidated Framework for Implementation Research (CFIR) for classification. We included 64 studies. Barriers and facilitators were most commonly identified in the outer setting CFIR domain, namely in the sub-domain of patient needs and resources, which refers to the way in which these needs and resources are reflected by the reviewed interventions. The second most saturated CFIR domain for facilitators was intervention characteristics, where relative advantage, adaptability and cost of intervention sub-domains were equally represented. These sub-domains refer mostly to how the intervention is perceived by key stakeholders, to what extent it can be tailored to the implementation context and how much it costs. While intervention characteristics domain was the second most common also for barriers, the complexity sub-domain referring to high perceived difficulty of implementation was the most frequently represented. With reference to the results, we recommend adapting interventions to the needs of the target groups. Furthermore, carefully selecting the intervention to suit the target context concerning their adaptability, costs and complexity is vital for a successful implementation. Further implications for practice and research are discussed.
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Affiliation(s)
- Alexandr Kasal
- Department of Public Mental Health, National Institute of Mental Health, Klecany, Czech Republic
- Faculty of Social Sciences, Charles University, Prague, Czech Republic
| | - Roksana Táborská
- Department of Public Mental Health, National Institute of Mental Health, Klecany, Czech Republic
| | - Laura Juríková
- Department of Public Mental Health, National Institute of Mental Health, Klecany, Czech Republic
- Department of Psychology, Faculty of Arts, Charles University, Prague, Czech Republic
| | | | - Michaela Pichler
- Department of Psychosocial Health, Gesundheit Österreich GmbH, Wien, Austria
| | - Beate Gruber
- Department of Psychosocial Health, Gesundheit Österreich GmbH, Wien, Austria
| | - Hana Tomášková
- Department of Public Mental Health, National Institute of Mental Health, Klecany, Czech Republic
- Department of Psychology, Faculty of Arts, Charles University, Prague, Czech Republic
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3
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Farmani A, Rahimianbougar M, Mohammadi Y, Faramarzi H, Khodarahimi S, Nahaboo S. Psychological, Structural, Social and Economic Determinants of Suicide Attempt: Risk Assessment and Decision Making Strategies. Omega (Westport) 2023; 86:1144-1166. [PMID: 33736538 DOI: 10.1177/00302228211003462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The aim of this research was to conduct a risk assessment and management of psychological, structural, social and economic determinants (PSSED) in a suicide attempt. The sample consisted of 353 individuals who had a recorded history of suicidal attempt; and 20 professional individuals by purposive sampling method within a descriptive cross-sectional design. Worksheets for RAM and AHP were used for data collection in this study. The rate of suicide attempt was 7.21 per 100,000 population in this study. Analysis showed that depression and mental disorders; personality disorders; family problems; socio-cultural and economic problems; lack of awareness; and low level of education have a high level of risk for suicide attempts. Psychiatric and psychological services; awareness and knowledge of life skills; medical services to dysfunctional families; development of community-based planning for PSSED of suicide; and employment and entrepreneurship services may lower suicide attempt risk.
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Affiliation(s)
- Azam Farmani
- Social Emergency Center, Welfare General Bureau of Fars Province, Shiraz, Iran
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4
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Olarte-Godoy J, Jack SM, Campbell K, Halladay J, Cleverley K, McGillion M, Links P. Psychosocial interventions addressing suicidality in inpatient psychiatry: a scoping review protocol. JBI Evid Synth 2023; 21:1034-1042. [PMID: 36598156 DOI: 10.11124/jbies-22-00146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The objective of this review is to provide an overview of the existing literature on psychosocial interventions aimed at addressing suicidality among adults in the context of an inpatient psychiatric admission. INTRODUCTION For individuals admitted to a psychiatric inpatient unit, their risk of suicide in the period following discharge is significantly higher compared to the prevalence of death by suicide in the general population. During an inpatient admission, there is opportunity for supportive interventions that may lead to reduced risks of suicide. Yet, interventions that directly address suicidality have primarily been studied in outpatient settings. A broader understanding of inpatient interventions will assist clinicians in understanding key considerations when implementing suicide-related interventions in this setting. INCLUSION CRITERIA Studies involving adult patients (≥18 y) that describe psychosocial interventions aiming to address suicidality in the context of inpatient psychiatry will be considered. Studies that only describe pharmacological interventions will be excluded, as will studies that describe psychosocial interventions initiated in the context of an outpatient setting. METHODS We will search MEDLINE (Ovid), CINAHL (EBSCO), APA PsycINFO (EBSCOhost), the Cochrane Central Register of Controlled Trials (CENTRAL), Embase (Ovid), and Web of Science for studies in English and Spanish. Gray literature and materials will also be searched for using Google and websites relevant to the review topic. No date limit will be set. Two independent reviewers will screen titles and abstracts from studies that meet the inclusion criteria and review eligible studies at full text. Data will be extracted and synthesized and then presented in tabular and graphical formats accompanied by a narrative summary. REVIEW REGISTRATION NUMBER Open Science Framework (https://osf.io/5cwhx).
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Affiliation(s)
| | - Susan M Jack
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Kaitryn Campbell
- McMaster University, Hamilton, ON, Canada.,St. Joseph's Healthcare Hamilton, ON, Canada
| | - Jillian Halladay
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Kristin Cleverley
- University of Toronto, ON, Canada.,Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Michael McGillion
- School of Nursing, McMaster University, Hamilton, ON, Canada.,The Population Health Research Institute, Hamilton, ON, Canada
| | - Paul Links
- McMaster University, Hamilton, ON, Canada.,St. Joseph's Healthcare Hamilton, ON, Canada
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5
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Huggett C, Gooding P, Haddock G, Quigley J, Pratt D. The relationship between the therapeutic alliance in psychotherapy and suicidal experiences: A systematic review. Clin Psychol Psychother 2022; 29:1203-1235. [PMID: 35168297 PMCID: PMC9546023 DOI: 10.1002/cpp.2726] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 01/10/2022] [Accepted: 02/10/2022] [Indexed: 11/10/2022]
Abstract
It is well established that there is a fundamental need to develop a robust therapeutic alliance to achieve positive outcomes in psychotherapy. However, little is known as to how this applies to psychotherapies which reduce suicidal experiences. The current narrative review summarizes the literature which investigates the relationship between the therapeutic alliance in psychotherapy and a range of suicidal experiences prior to, during and following psychotherapy. Systematic searches of MEDLINE, PsycINFO, Web of Science, EMBASE and British Nursing Index were conducted. The search returned 6472 studies, of which 19 studies were eligible for the present review. Findings failed to demonstrate a clear link between suicidal experiences prior to or during psychotherapy and the subsequent development and maintenance of the therapeutic alliance during psychotherapy. However, a robust therapeutic alliance reported early on in psychotherapy was related to a subsequent reduction in suicidal ideation and attempts. Study heterogeneity, varied sample sizes and inconsistent reporting may limit the generalizability of review findings. Several recommendations are made for future psychotherapy research studies. Training and supervision of therapists should not only highlight the importance of developing and maintaining the therapeutic alliance in psychotherapy when working with people with suicidal experiences but also attune to client perceptions of relationships and concerns about discussing suicidal experiences during therapy.
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Affiliation(s)
- Charlotte Huggett
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science CentreManchesterUK
| | - Patricia Gooding
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science CentreManchesterUK
| | - Gillian Haddock
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science CentreManchesterUK
| | - Jody Quigley
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Pennine Care NHS Foundation TrustAshton‐under‐LyneUK
| | - Daniel Pratt
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Science CentreUniversity of ManchesterManchesterUK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science CentreManchesterUK
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Benjenk I, Saliba Z, Duggal N, Albaroudi A, Posada J, Chen J. Impact of COVID-19 Mitigation Efforts on Adults With Serious Mental Illness: A Patient-Centered Perspective. J Nerv Ment Dis 2021; 209:892-898. [PMID: 34846356 PMCID: PMC8614196 DOI: 10.1097/nmd.0000000000001389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
ABSTRACT In response to COVID-19 mitigation policies, mental health and social service agencies have had to rapidly change their operations, creating challenges for patients with serious mental illness (SMI). This study aimed to explore the experiences of adults with SMI navigating these altered systems during the pandemic. In-depth interviews were conducted with 20 hospitalized adults with SMI in the fall of 2020; they were coded using thematic analysis. Most participants found the new systems effective at meeting their essential needs. However, several reported significant unmet needs, including inability to access mental health care and public benefits. These participants lacked identification documents, housing, and/or a personal device. Although none of the participants used telemedicine before COVID-19, most reported no or minimal problems with telemental health. Those reporting difficulties did not have personal devices, were receiving audio-only services, or viewed telemedicine as less personal or too distracting.
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Affiliation(s)
| | | | - Neel Duggal
- School of Medicine, George Washington University, Washington, DC
| | - Asmaa Albaroudi
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, Maryland
| | | | - Jie Chen
- Department of Health Policy and Management, School of Public Health, University of Maryland, College Park, Maryland
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7
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Huggett C, Gooding P, Haddock G, Pratt D. The Relationship between the Therapeutic Alliance and Suicidal Experiences in People with Psychosis Receiving Therapy. Int J Environ Res Public Health 2021; 18:ijerph182010706. [PMID: 34682451 PMCID: PMC8535896 DOI: 10.3390/ijerph182010706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 01/25/2023]
Abstract
Few studies have examined the relationship between the therapeutic alliance in therapy and suicidal experiences. No studies have examined this relationship with people with non-affective psychosis. The present study sought to redress this gap in the literature. Sixty-four participants with non-affective psychosis and suicidal experiences who were receiving a suicide-focused cognitive therapy were recruited. Self-reported suicidal ideation, suicide plans, suicide attempts, depression, and hopelessness were collected from participants prior to starting therapy. Suicidal experience measures were collected again post-therapy at 6 months. Therapeutic alliance ratings were completed by clients and therapists at session 4 of therapy. Dose of therapy was documented in number of minutes of therapy. Data were analyzed using correlation coefficients, independent samples t-tests, a multiple hierarchical regression, and a moderated linear regression. There was no significant relationship found between suicidal ideation prior to therapy and the therapeutic alliance at session 4, rated by both client and therapist. However, there was a significant negative relationship between the client-rated therapeutic alliance at session 4 and suicidal ideation at 6 months, after controlling for pre-therapy suicidal ideation, depression, and hopelessness. Furthermore, the negative relationship between the client-rated alliance and suicidal ideation was the strongest when number of minutes of therapy was 15 h or below. A stronger therapeutic alliance developed in the first few sessions of therapy is important in ameliorating suicidal thoughts in people with psychosis. Nevertheless, it is not necessarily the case that more hours in therapy equates to a cumulative decrease in suicidal ideation of which therapists could be mindful. A limitation of the current study was that the alliance was analyzed only at session 4 of therapy, which future studies could seek to redress.
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Affiliation(s)
- Charlotte Huggett
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Zochonis Building, Brunswick Street, Manchester M13 9PL, UK; (P.G.); (G.H.); (D.P.)
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, 3rd Floor, Rawnsley Building, Manchester Royal Infirmary, Hathersage Road, Manchester M13 9WL, UK
- Correspondence:
| | - Patricia Gooding
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Zochonis Building, Brunswick Street, Manchester M13 9PL, UK; (P.G.); (G.H.); (D.P.)
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, 3rd Floor, Rawnsley Building, Manchester Royal Infirmary, Hathersage Road, Manchester M13 9WL, UK
| | - Gillian Haddock
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Zochonis Building, Brunswick Street, Manchester M13 9PL, UK; (P.G.); (G.H.); (D.P.)
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, 3rd Floor, Rawnsley Building, Manchester Royal Infirmary, Hathersage Road, Manchester M13 9WL, UK
| | - Daniel Pratt
- Division of Psychology and Mental Health, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Zochonis Building, Brunswick Street, Manchester M13 9PL, UK; (P.G.); (G.H.); (D.P.)
- Greater Manchester Mental Health NHS Foundation Trust, Manchester Academic Health Science Centre, 3rd Floor, Rawnsley Building, Manchester Royal Infirmary, Hathersage Road, Manchester M13 9WL, UK
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Abstract
BACKGROUND Self-harm (SH; intentional self-poisoning or self-injury regardless of degree of suicidal intent or other types of motivation) is a growing problem in most counties, often repeated, and associated with suicide. There has been a substantial increase in both the number of trials and therapeutic approaches of psychosocial interventions for SH in adults. This review therefore updates a previous Cochrane Review (last published in 2016) on the role of psychosocial interventions in the treatment of SH in adults. OBJECTIVES To assess the effects of psychosocial interventions for self-harm (SH) compared to comparison types of care (e.g. treatment-as-usual, routine psychiatric care, enhanced usual care, active comparator) for adults (aged 18 years or older) who engage in SH. SEARCH METHODS We searched the Cochrane Common Mental Disorders Specialised Register, the Cochrane Library (Central Register of Controlled Trials [CENTRAL] and Cochrane Database of Systematic reviews [CDSR]), together with MEDLINE, Ovid Embase, and PsycINFO (to 4 July 2020). SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing interventions of specific psychosocial treatments versus treatment-as-usual (TAU), routine psychiatric care, enhanced usual care (EUC), active comparator, or a combination of these, in the treatment of adults with a recent (within six months of trial entry) episode of SH resulting in presentation to hospital or clinical services. The primary outcome was the occurrence of a repeated episode of SH over a maximum follow-up period of two years. Secondary outcomes included treatment adherence, depression, hopelessness, general functioning, social functioning, suicidal ideation, and suicide. DATA COLLECTION AND ANALYSIS We independently selected trials, extracted data, and appraised trial quality. For binary outcomes, we calculated odds ratio (ORs) and their 95% confidence intervals (CIs). For continuous outcomes, we calculated mean differences (MDs) or standardised mean differences (SMDs) and 95% CIs. The overall quality of evidence for the primary outcome (i.e. repetition of SH at post-intervention) was appraised for each intervention using the GRADE approach. MAIN RESULTS We included data from 76 trials with a total of 21,414 participants. Participants in these trials were predominately female (61.9%) with a mean age of 31.8 years (standard deviation [SD] 11.7 years). On the basis of data from four trials, individual cognitive behavioural therapy (CBT)-based psychotherapy may reduce repetition of SH as compared to TAU or another comparator by the end of the intervention (OR 0.35, 95% CI 0.12 to 1.02; N = 238; k = 4; GRADE: low certainty evidence), although there was imprecision in the effect estimate. At longer follow-up time points (e.g., 6- and 12-months) there was some evidence that individual CBT-based psychotherapy may reduce SH repetition. Whilst there may be a slightly lower rate of SH repetition for dialectical behaviour therapy (DBT) (66.0%) as compared to TAU or alternative psychotherapy (68.2%), the evidence remains uncertain as to whether DBT reduces absolute repetition of SH by the post-intervention assessment. On the basis of data from a single trial, mentalisation-based therapy (MBT) reduces repetition of SH and frequency of SH by the post-intervention assessment (OR 0.35, 95% CI 0.17 to 0.73; N = 134; k = 1; GRADE: high-certainty evidence). A group-based emotion-regulation psychotherapy may also reduce repetition of SH by the post-intervention assessment based on evidence from two trials by the same author group (OR 0.34, 95% CI 0.13 to 0.88; N = 83; k = 2; moderate-certainty evidence). There is probably little to no effect for different variants of DBT on absolute repetition of SH, including DBT group-based skills training, DBT individual skills training, or an experimental form of DBT in which participants were given significantly longer cognitive exposure to stressful events. The evidence remains uncertain as to whether provision of information and support, based on the Suicide Trends in At-Risk Territories (START) and the SUicide-PREvention Multisite Intervention Study on Suicidal behaviors (SUPRE-MISS) models, have any effect on repetition of SH by the post-intervention assessment. There was no evidence of a difference for psychodynamic psychotherapy, case management, general practitioner (GP) management, remote contact interventions, and other multimodal interventions, or a variety of brief emergency department-based interventions. AUTHORS' CONCLUSIONS Overall, there were significant methodological limitations across the trials included in this review. Given the moderate or very low quality of the available evidence, there is only uncertain evidence regarding a number of psychosocial interventions for adults who engage in SH. Psychosocial therapy based on CBT approaches may result in fewer individuals repeating SH at longer follow-up time points, although no such effect was found at the post-intervention assessment and the quality of evidence, according to the GRADE criteria, was low. Given findings in single trials, or trials by the same author group, both MBT and group-based emotion regulation therapy should be further developed and evaluated in adults. DBT may also lead to a reduction in frequency of SH. Other interventions were mostly evaluated in single trials of moderate to very low quality such that the evidence relating to the use of these interventions is inconclusive at present.
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Affiliation(s)
- Katrina G Witt
- Orygen, Parkville, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Sarah E Hetrick
- Department of Psychological Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Gowri Rajaram
- Orygen, Parkville, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Philip Hazell
- Speciality of Psychiatry, University of Sydney School of Medicine, Sydney, Australia
| | - Tatiana L Taylor Salisbury
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ellen Townsend
- Self-Harm Research Group, School of Psychology, University of Nottingham, Nottingham, UK
| | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
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Evlat G, Wood L, Glover N. A systematic review of the implementation of psychological therapies in acute mental health inpatient settings. Clin Psychol Psychother 2021; 28:1574-1586. [PMID: 33870590 DOI: 10.1002/cpp.2600] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/27/2021] [Accepted: 03/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Research has demonstrated that psychological therapies are not routinely delivered in acute mental health inpatient settings despite being recommended by the National Institute for Health and Care Excellence (NICE) guidelines. This study aimed to identify the barriers and facilitators to implementing psychological therapies in acute mental health inpatient settings. METHODS A systematic review and narrative synthesis was undertaken. Primary studies were included if they examined the implementation of a NICE recommended psychological therapy in acute psychiatric inpatient settings and were of any study design. Four databases were searched for eligible studies (MEDLINE, CINAHL Plus, PsycINFO and Embase) and Google Scholar. RESULTS A total of 16 studies (a mixture of both qualitative and quantitative methodologies) were included in the review, and the majority evaluated the implementation of Cognitive Behaviour Therapy. Overall, the literature was deemed to be of poor to moderate quality. The main barriers to the implementation of psychological therapy were the busy nature of the ward, multi-disciplinary professionals not being suitability trained and the acute nature of service users mental health difficulties. Facilitators to implementation included the adaptation of interventions to be specifically delivered in the acute inpatient setting, training of multi-disciplinary professionals, leadership support with the delivery of psychological therapies and prioritising the therapeutic relationship. CONCLUSIONS There is a requirement for senior management to prioritise the implementation of psychological therapies and update clinical guidelines to describe modifications necessary to implement psychological therapies in acute inpatient settings. Future research should improve their methodological quality and continue to develop the evidence base of brief psychological therapies in acute inpatient settings.
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Affiliation(s)
- Gamze Evlat
- Division of Psychiatry, University College London, London, UK
| | - Lisa Wood
- Division of Psychiatry, University College London, London, UK.,North East London NHS Foundation Trust, Acute and Rehabilitation Directorate, Goodmayes Hospital, Ilford, UK
| | - Naomi Glover
- Division of Psychiatry, University College London, London, UK
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10
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Raphael J, Price O, Hartley S, Haddock G, Bucci S, Berry K. Overcoming barriers to implementing ward-based psychosocial interventions in acute inpatient mental health settings: A meta-synthesis. Int J Nurs Stud 2021; 115:103870. [PMID: 33486388 DOI: 10.1016/j.ijnurstu.2021.103870] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/23/2020] [Accepted: 01/02/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The culture of acute mental health wards is often dominated by medical models of care despite some patient dissatisfaction with care in these settings and a demand for increased access to psychosocial interventions. Research has found that psychosocial interventions can improve a number of patient and staff outcomes, however, implementation within these settings is often challenging. OBJECTIVES The aim of this review was to provide a comprehensive synthesis of the barriers and facilitators to implementing psychosocial interventions on acute wards, in order to develop a list of recommendations for embedding psychosocial interventions within the ward culture in acute settings. METHODS Databases were systematically searched using search terms related to acute mental health wards and psychosocial intervention implementation from inception to December 2019. Thirty-nine studies (forty-three papers) that explored the implementation of psychosocial interventions on adult acute mental health wards using qualitative methods met inclusion criteria. Data relating to barriers and facilitators to implementing psychosocial interventions extracted from the results sections of the papers were synthesised using the COM-B model. RESULTS AND CONCLUSIONS We conclude that to address barriers to the implementation of psychosocial interventions, services should provide clear information to patients regarding the benefits of engagement, and additional training for staff. A shift in ward culture is required and can be achieved through the recruitment of empathic implementers, together with providing staff with protected time for delivery of psychosocial interventions with clear accountability for intervention delivery through the provision of clearly defined roles.
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Affiliation(s)
- Jessica Raphael
- Greater Manchester Mental Health NHS Foundation Trust and Manchester Academic Health Science Centre, Manchester, UK; Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.
| | - Owen Price
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.
| | - Samantha Hartley
- Pennine Care NHS Foundation Trust, Oldham, UK; Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.
| | - Gillian Haddock
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.
| | - Sandra Bucci
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.
| | - Katherine Berry
- Greater Manchester Mental Health NHS Foundation Trust and Manchester Academic Health Science Centre, Manchester, UK; Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.
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Gooding PA, Pratt D, Awenat Y, Drake R, Elliott R, Emsley R, Huggett C, Jones S, Kapur N, Lobban F, Peters S, Haddock G. A psychological intervention for suicide applied to non-affective psychosis: the CARMS (Cognitive AppRoaches to coMbatting Suicidality) randomised controlled trial protocol. BMC Psychiatry 2020; 20:306. [PMID: 32546129 PMCID: PMC7298803 DOI: 10.1186/s12888-020-02697-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/27/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Suicide is a leading cause of death globally. Suicide deaths are elevated in those experiencing severe mental health problems, including schizophrenia. Psychological talking therapies are a potentially effective means of alleviating suicidal thoughts, plans, and attempts. However, talking therapies need to i) focus on suicidal experiences directly and explicitly, and ii) be based on testable psychological mechanisms. The Cognitive AppRoaches to coMbatting Suicidality (CARMS) project is a Randomised Controlled Trial (RCT) which aims to investigate both the efficacy and the underlying mechanisms of a psychological talking therapy for people who have been recently suicidal and have non-affective psychosis. METHODS The CARMS trial is a two-armed single-blind RCT comparing a psychological talking therapy (Cognitive Behavioural Suicide Prevention for psychosis [CBSPp]) plus Treatment As Usual (TAU) with TAU alone. There are primary and secondary suicidality outcome variables, plus mechanistic, clinical, and health economic outcomes measured over time. The primary outcome is a measure of suicidal ideation at 6 months after baseline. The target sample size is 250, with approximately 125 randomised to each arm of the trial, and an assumption of up to 25% attrition. Hence, the overall recruitment target is up to 333. An intention to treat analysis will be used with primary stratification based on National Health Service (NHS) recruitment site and antidepressant prescription medication. Recruitment will be from NHS mental health services in the North West of England, UK. Participants must be 18 or over; be under the care of mental health services; have mental health problems which meet ICD-10 non-affective psychosis criteria; and have experienced self-reported suicidal thoughts, plans, and/or attempts in the 3 months prior to recruitment. Nested qualitative work will investigate the pathways to suicidality, experiences of the therapy, and identify potential implementation challenges beyond a trial setting as perceived by numerous stake-holders. DISCUSSION This trial has important implications for countering suicidal experiences for people with psychosis. It will provide definitive evidence about the efficacy of the CBSPp therapy; the psychological mechanisms which lead to suicidal experiences; and provide an understanding of what is required to implement the intervention into services should it be efficacious. TRIAL REGISTRATION ClinicalTrials.gov (NCT03114917), 14th April 2017. ISRCTN (reference ISRCTN17776666 https://doi.org/10.1186/ISRCTN17776666); 5th June 2017). Registration was recorded prior to participant recruitment commencing.
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Affiliation(s)
- Patricia A Gooding
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK.
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK.
| | - Daniel Pratt
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK
| | - Yvonne Awenat
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK
| | - Richard Drake
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK
| | - Rachel Elliott
- Manchester Centre for Health Economics, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Richard Emsley
- Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK
| | - Charlotte Huggett
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK
| | - Steven Jones
- Lancashire Care NHS Foundation Trust, Lancashire, UK
- University of Lancaster, Lancaster, UK
| | - Navneet Kapur
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK
| | - Fiona Lobban
- Lancashire Care NHS Foundation Trust, Lancashire, UK
- University of Lancaster, Lancaster, UK
| | - Sarah Peters
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
| | - Gillian Haddock
- Division of Psychology and Mental Health, School of Health Sciences, Manchester Academic Health Sciences Centre, University of Manchester, Coupland Building 1, Oxford Road, Manchester, M13 9PL, UK
- Greater Manchester Mental Health NHS Trust (formerly Manchester Mental Health and Social Care Trust), Manchester, UK
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Abstract
OBJECTIVES Patients in inpatient mental health settings face similar risks (eg, medication errors) to those in other areas of healthcare. In addition, some unsafe behaviours associated with serious mental health problems (eg, self-harm), and the measures taken to address these (eg, restraint), may result in further risks to patient safety. The objective of this review is to identify and synthesise the literature on patient safety within inpatient mental health settings using robust systematic methodology. DESIGN Systematic review and meta-synthesis. Embase, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium, MEDLINE, PsycINFO and Web of Science were systematically searched from 1999 to 2019. Search terms were related to 'mental health', 'patient safety', 'inpatient setting' and 'research'. Study quality was assessed using the Hawker checklist. Data were extracted and grouped based on study focus and outcome. Safety incidents were meta-analysed where possible using a random-effects model. RESULTS Of the 57 637 article titles and abstracts, 364 met inclusion criteria. Included publications came from 31 countries and included data from over 150 000 participants. Study quality varied and statistical heterogeneity was high. Ten research categories were identified: interpersonal violence, coercive interventions, safety culture, harm to self, safety of the physical environment, medication safety, unauthorised leave, clinical decision making, falls and infection prevention and control. CONCLUSIONS Patient safety in inpatient mental health settings is under-researched in comparison to other non-mental health inpatient settings. Findings demonstrate that inpatient mental health settings pose unique challenges for patient safety, which require investment in research, policy development, and translation into clinical practice. PROSPERO REGISTRATION NUMBER CRD42016034057.
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Affiliation(s)
- Bethan Thibaut
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Lindsay Helen Dewa
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sonny Christian Ramtale
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Danielle D'Lima
- Centre for Behaviour Change, Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Sheila Adam
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Hutan Ashrafian
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ara Darzi
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Stephanie Archer
- NIHR Imperial Patient Safety Tranlsational Research Centre, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
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Awenat YF, Peters S, Gooding PA, Pratt D, Huggett C, Harris K, Armitage CJ, Haddock G. Qualitative analysis of ward staff experiences during research of a novel suicide-prevention psychological therapy for psychiatric inpatients: Understanding the barriers and facilitators. PLoS One 2019; 14:e0222482. [PMID: 31550251 PMCID: PMC6759174 DOI: 10.1371/journal.pone.0222482] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/29/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Suicide prevention is a global priority. Psychiatric hospitalization presents an opportunity to intervene positively with, for example, psychological therapies. However, evidenced-based suicide-prevention psychological treatments are rarely available on in-patient wards. Understanding staff engagement with research investigating suicide-prevention psychological treatments is crucial for their effective, efficacious, and pragmatic implementation. A pilot randomised control trial and feasibility study of Cognitive Behavioural Suicide Prevention therapy provided the opportunity for a qualitative investigation of staff experiences and views of a psychological intervention for people with suicidal experiences on psychiatric in-patient wards. AIMS To investigate staff acceptability of Cognitive Behavioural Suicide Prevention therapy for psychiatric inpatients based on their perceptions of their experiences during the conduct of a clinical trial. METHOD Transcribed audio-recordings of qualitative interviews and a focus group (n = 19) of purposively sampled staff from eight psychiatric wards were analysed using inductive Thematic Analysis. RESULTS Facilitators and barriers were identified for: i) the conduct of the research, and, ii) the suicide-prevention intervention (Cognitive Behavioural Suicide Prevention therapy). Research-related barriers comprised communication difficulties between staff and researchers, and increased staff workload. Research-related facilitators included effective staff/researcher relationships, and alignment of the intervention with organisational goals. Suicide-prevention intervention-related barriers comprised staffs' negative beliefs about suicide which impacted on their referral of inpatients to the clinical trial, and staff perceptions of insufficient information and unfulfilled expectations for involvement in the therapy. Facilitators included staff beliefs that the therapy was beneficial for inpatients, the service and their own clinical practice. CONCLUSIONS Staff beliefs that 'suicide-talk' could precipitate suicidal behaviour resulted in covert gatekeeping and restricted referral of only inpatients judged as stable or likely to engage in therapy, which may not be those who could most benefit. Such threats to sample representativeness have implications for future therapy research design. The findings provide novel information for researchers and practitioners regarding the conduct of psychological treatment and research in psychiatric units.
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Affiliation(s)
- Yvonne F. Awenat
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biological, Medical and Health Sciences, Manchester, University of Manchester, United Kingdom
- Manchester Academic Health Science Centre, MAHSC, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Sarah Peters
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biological, Medical and Health Sciences, Manchester, University of Manchester, United Kingdom
- Manchester Academic Health Science Centre, MAHSC, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biological, Medical and Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Patricia A. Gooding
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biological, Medical and Health Sciences, Manchester, University of Manchester, United Kingdom
- Manchester Academic Health Science Centre, MAHSC, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Daniel Pratt
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biological, Medical and Health Sciences, Manchester, University of Manchester, United Kingdom
- Manchester Academic Health Science Centre, MAHSC, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Charlotte Huggett
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biological, Medical and Health Sciences, Manchester, University of Manchester, United Kingdom
- Manchester Academic Health Science Centre, MAHSC, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Kamelia Harris
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biological, Medical and Health Sciences, Manchester, University of Manchester, United Kingdom
- Manchester Academic Health Science Centre, MAHSC, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | - Christopher J. Armitage
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biological, Medical and Health Sciences, Manchester, University of Manchester, United Kingdom
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biological, Medical and Health Sciences, University of Manchester, Manchester, United Kingdom
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Gillian Haddock
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biological, Medical and Health Sciences, Manchester, University of Manchester, United Kingdom
- Manchester Academic Health Science Centre, MAHSC, Manchester, United Kingdom
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
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Haddock G, Pratt D, Gooding PA, Peters S, Emsley R, Evans E, Kelly J, Huggett C, Munro A, Harris K, Davies L, Awenat Y. Feasibility and acceptability of suicide prevention therapy on acute psychiatric wards: randomised controlled trial. BJPsych Open 2019; 5:e14. [PMID: 30762509 PMCID: PMC6381415 DOI: 10.1192/bjo.2018.85] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Suicidal behaviour is common in acute psychiatric wards resulting in distress, and burden for patients, carers and society. Although psychological therapies for suicidal behaviour are effective in out-patient settings, there is little research on their effectiveness for in-patients who are suicidal.AimsOur primary objective was to determine whether cognitive-behavioural suicide prevention therapy (CBSP) was feasible and acceptable, compared with treatment as usual (TAU) for in-patients who are suicidal. Secondary aims were to assess the impact of CBSP on suicidal thinking, behaviours, functioning, quality of life, service use, cost-effectiveness and psychological factors associated with suicide. METHOD A single-blind pilot randomised controlled trial comparing TAU to TAU plus CBSP in in-patients in acute psychiatric wards who are suicidal (the Inpatient Suicide Intervention and Therapy Evaluation (INSITE) trial, trial registration: ISRCTN17890126). The intervention consisted of TAU plus up to 20 CBSP sessions, over 6 months continuing in the community following discharge. Participants were assessed at baseline and at 6 weeks and 6 months post-baseline. RESULTS A total of 51 individuals were randomised (27 to TAU, 24 to TAU plus CBSP) of whom 37 were followed up at 6 months (19 in TAU, 18 in TAU plus CBSP). Engagement, attendance, safety and user feedback indicated that the addition of CBSP to TAU for in-patients who are acutely suicidal was feasible and acceptable while on in-patient wards and following discharge. Economic analysis suggests the intervention could be cost-effective.DiscussionPsychological therapy can be delivered safely to patients who are suicidal although modifications are required for this setting. Findings indicate a larger, definitive trial should be conducted.Declaration of interestThe trial was hosted by Greater Manchester Mental health NHS Trust (formerly, Manchester Mental Health and Social Care NHS Trust). The authors are affiliated to the University of Manchester, Greater Manchester Mental Health Foundation Trust, Lancashire Care NHS Foundation trust and the Manchester Academic Health Sciences Centre. Y.A. is a trustee for a North-West England branch of the charity Mind.
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Affiliation(s)
- Gillian Haddock
- Professor of Clinical Psychology,Division of Psychology and Mental Health, School of Health Sciences,University of Manchester, Greater Manchester Mental Health NHS Foundation Trust (formerly Manchester Mental Health and Social Care Trust) and Manchester Academic Health Sciences Centre,UK
| | - Daniel Pratt
- Senior Lecturer in Clinical Psychology,Division of Psychology and Mental Health, School of Health Sciences,University of Manchester, Greater Manchester Mental Health NHS Foundation Trust (formerly Manchester Mental Health and Social Care Trust) and Manchester Academic Health Sciences Centre,UK
| | - Patricia A Gooding
- Senior Lecturer in Psychology,Division of Psychology and Mental Health, School of Health Sciences,University of Manchester, Greater Manchester Mental Health NHS Foundation Trust (formerly Manchester Mental Health and Social Care Trust) and Manchester Academic Health Sciences Centre,UK
| | - Sarah Peters
- Senior Lecturer in Psychology,Division of Psychology and Mental Health, School of Health Sciences,University of Manchester and Manchester Academic Health Sciences Centre,UK
| | - Richard Emsley
- Professor of Medical Statistics and Trials Methodology,Division of Population Health,Health Services Research and Primary Care,School of Health Sciences,University of Manchester, Greater Manchester Mental Health NHS Foundation Trust (formerly Manchester Mental Health and Social Care Trust) and Manchester Academic Health Sciences Centre; andBiostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience,Kings College London,UK
| | - Emma Evans
- Trial Therapist, Division of Psychology and Mental Health,School of Health Sciences,University of Manchester, Greater Manchester Mental Health NHS Foundation Trust (formerly Manchester Mental Health and Social Care Trust) and Manchester Academic Health Sciences Centre,UK
| | - James Kelly
- Clinical Psychologist, Division of Psychology and Mental Health,School of Health Sciences,University of Manchester; Manchester Academic Health Sciences Centre; andLancashirecare NHS Foundation Trust,UK
| | - Charlotte Huggett
- Research Assistant,Division of Psychology and Mental Health,School of Health Sciences,University of Manchester, Greater Manchester Mental Health NHS Foundation Trust (formerly Manchester Mental Health and Social Care Trust) and Manchester Academic Health Sciences Centre,UK
| | - Ailsa Munro
- Research Assistant,Division of Psychology and Mental Health,School of Health Sciences,University of Manchester, Greater Manchester Mental Health NHS Foundation Trust (formerly Manchester Mental Health and Social Care Trust) and Manchester Academic Health Sciences Centre,UK
| | - Kamelia Harris
- Research Assistant,Division of Psychology and Mental Health,School of Health Sciences,University of Manchester and Manchester Academic Health Sciences Centre,UK
| | - Linda Davies
- Professor of Health Economics,Division of Population Health,Health Services Research and Primary Care,School of Health Sciences,University of Manchester and Manchester Academic Health Sciences Centre,UK
| | - Yvonne Awenat
- Research Fellow,Division of Psychology and Mental Health,School of Health Sciences,University of Manchester, Greater Manchester Mental Health NHS Foundation Trust (formerly Manchester Mental Health and Social Care Trust) and Manchester Academic Health Sciences Centre,UK
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