Journal Article Annotations
2020, 1st Quarter

Suicide

Kemuel Philbrick, MD, FACLP
March 30th, 2020

Development and Implementation of a Suicide Prevention Checklist to Create a Safe Environment.
Recession, recovery and suicide in mental health patients in England: time trend analysis.

PUBLICATION #1 — Suicide

Development and Implementation of a Suicide Prevention Checklist to Create a Safe Environment.

Debra A Frost, Colleen K Snydeman, Martin J Lantieri , Janet Wozniak, Suzanne Bird, Theodore A Stern

Abstract: Psychosomatics , 61 (2), 154-160 Mar-Apr 2020

Background:
An increasing number of patients are admitted to general hospitals for injuries sustained in suicide attempts and for assessment of their ongoing risk for suicide. However, clinical staff may lack knowledge and expertise in the provision of a safe environment for potentially suicidal patients.

Objective:
In an effort to follow the Joint Commission’s recommendations on the care of suicidal patients, a Suicide Prevention Interdisciplinary Task Force was created. The task force sought to design and implement a suicide checklist that would facilitate creation of a safe environment for potentially suicidal inpatients on nonpsychiatric units in a general hospital.

Methods:
We describe the development and implementation of a Care of the Suicide and Self-Injury Patient Checklist and report on data derived from incident reports related to self-harm/suicide attempts over a 4-year period. We also report results of a Research Electronic Data Capture survey of nurses’ feedback on the checklist.

Results:
After implementation of the Care of the Suicide and Self-Injury Patient Checklist, a total of 47 incidents of patient self-injury were reported over 4 years on nonpsychiatric inpatient units at a large general hospital; only three sustained permanent or serious harm. The Research Electronic Data Capture survey revealed that 88% of responding nurses believed that the Care of the Suicide and Self-Injury Patient Checklist guided creation of a safe environment and 90% believed that it supported consistent practice.

Conclusions:
The Care of the Suicide and Self-Injury Patient Checklist contributed to the creation of a safe environment while caring for potentially suicidal patients on nonpsychiatric inpatient units and guided clinicians on the management of potentially self-injurious individuals.

Keywords:
interventions; mental health; prevention; suicide.

Annotation

The Findings:
A concerted effort to develop and implement a suicide checklist tool designed to mitigate environmental risk factors and optimize bedside care of at-risk patients in a general hospital while also improving communication and hand-offs among clinical staff was received enthusiastically by nurses on nonpsychiatric units and was associated with a decrease in safety incidents in the year following its implementation.

Strengths and Weaknesses:
This tool illustrates one means of constructing and applying a standardized checklist to facilitate the systematic reduction of potential hazards in the environment and management of general hospital patients who are assessed to be at heightened risk for self-harm or suicide. Although not every detail of the checklist will translate directly to all other institutions, the full checklist is provided and can serve as a stepping-stone template for other hospitals who share an interest in providing nursing staff with a methodical approach to risk reduction.

Relevance:
Although suicides in the general hospital are uncommon (averaging about 85 annually over the last five years according to the Joint Commission), C/L services regularly encounter at-risk patients for whom psychiatric transfer may not be immediately medically feasible or logistically available. For those patients, interventions that improve their safety while awaiting further definitive psychiatric care are welcome.

Type of study:
Description of a suicide prevention checklist for the care of general hospital patients.

PUBLICATION #2 — Suicide

Recession, recovery and suicide in mental health patients in England: time trend analysis.

Ibrahim S, Hunt IM, Rahman MS, Shaw J, Appleby L, Kapur N.

Abstract: Br J Psychiatry. 2019 Jun 13:1-7.

Background:
The 2008 economicrecession was associated with an increase in suicideinternationally. Studies have focused on the impact in the general population with little consideration of the effect on people with a mental illness.

Aims:
To investigate suicidetrends related to the recession in mental health patients in England.

Method:
Using regression models, we studied suicidetrends in mental health patients in England before, during and after the recession and examined the demographic and clinical characteristics of the patients. We used data from the National Confidential Inquiry into Suicideand Safety in Mental Health, a national data-set of all suicidedeaths in the UK that includes detailed clinical information on those seen by services in the last 12 months before death.

Results:
Between 2000 and 2016, there were 21 224 suicidedeaths by patients aged 16 or over. For male patients, following a steady fall of 0.5% per quarter before the recession (quarterly percent change (QPC) 2000-2009 -0.46%, 95% CI -0.66 to -0.27), suiciderates showed an upward trend during the recession (QPC 2009-2011 2.37%, 95% CI -0.22 to 5.04). Recession-related rises in suicidewere found in men aged 45-54 years, those who were unemployed or had a diagnosis of substance dependence/misuse. Between 2012 and 2016 there was a decrease in suicidein male patients despite an increasing number of patients treated. No significant recession-related trends were found in women.

Conclusions:
Recession-associated increases in suicidewere seen in male mental health patients as well as the male general population, with those in mid-life at particular risk. Support and targeted interventions for patients with financial difficulties may help reduce the risk at times of economic hardship. Factors such as drug and alcohol misuse also need to be considered. Recent decreases in suicidemay be related to an improved economiccontext or better mental healthcare.

Declaration of interest:
N.K. is supported by Greater Manchester Mental Health NHS Foundation Trust. L.A. chairs the National SuicidePrevention Strategy Advisory Group at the Department of Health (of which N.K. is also a member) and is a non-executive Director for the Care Quality Commission. N.K. chairs the National Institute for Health and Care Excellence (NICE) depression in adults guideline and was a topic expert member for the NICE suicideprevention guideline.

Keywords:
Suicide; economiccrisis; mental health patients; mental illness; recession

Annotation

The Findings:
Although there had been a slight downward trend in suicide amongst men in the pre-recession period (2004-2008), this was followed by a rise in each quarter during the recession (2009-2011), and then a slight downward trend once again in the recession recovery period (2012-2016). The increased incidence of suicide during the recession was most prominent in men aged 45-54 and those who were unemployed. There were no clear suicide trends in terms of overall incidence related to the recession in women, either in those who had a history of mental health difficulties, or those in the general population. However, women who died by suicide during the recession were more likely to be unemployed and have a comorbid diagnosis of drug misuse/dependence.

Strengths and Weaknesses:
This was an ambitious attempt to appreciate recession-related trends and characteristics of patients who elected suicide before, during, and after a season of particular economic difficulty. The selected time periods do not reflect the evolution of economic phenomena and the adverse economic consequences of the recession were aggregate findings that would not necessarily apply to all individuals in equal fashion. As a study in the United Kingdom, some of the findings may be less applicable to countries with different social supports and health systems.

Relevance:
The economic consequences of the SARS-CoV-2 virus are many. Job restriction or loss, debt, medical expense, educational disruption, diminished personal agency and self-esteem, amongst a multitude of other individual hardships will likely threaten the capacity of many individuals to cope effectively. As consult psychiatrists encountering diverse patients in the months ahead, we will serve them better by remaining vigilant and sensitive to the gang of adversities they may experience in the wake of a looming recession.

Type of study:
Retrospective observational review.