SUICIDE RISK MANAGEMENT IN EARLY INTERVENTION

1. SUICIDE RISK MANAGEMENT IN EARLY INTERVENTION Moggie McGowan 16/09/11

2. First episode psychosis and suicide: • Who? • Why? • When? • What?

3. Psychosis and suicide • Lifetime risk up to 1:10 • Highest risk in first 3-5 years • Very high levels of suicidality for up to 18 months after initial presentation. • PTSD like symptoms heighten the risk of suicide • Most suicides occur in the post psychotic recovery phase after the psychosis has remitted • Often within months of discharge from hospital

4. Timing of last contact: patient suicides

5. Anger Self loathing Shame Revenge Anxiety Fear Panic Reckless abandon Emptiness, Loneliness, Resignation, Depression, Hopelessness, A wish to escape what can seem like an impossible situation Emotional reactions and suicideEmotions that can precipitate a suicidal state:

6. Distress, loss, hopelessness and despair…. • An intensely lonely time for some people • Long periods of social isolation and inactivity. • Rejection, alienation and stigma • Profound sense of personal loss as a reaction to the perceived impact of their illness • Identification with the chronically mental ill • People may be expected to return to the very situation that precipitated their psychosis • Support being withdrawn (in the belief that the risks has abated).

7. High risk times • At-risk mental states/Prodrome • Untreated Psychosis Phase (DUP) • The transition from ARMS/prodrome to psychosis • Relapse of psychosis • Implications for earlier detection and access to services • Unresponsive services may contribute to suicide

8. Preventing Suicide • Suicide is a relatively rare event • It is extremely difficult to predict or prevent • Identifying those at greatest risk remains problematic • It is unrealistic to expect services to prevent all suicides BUT…

9. There is a danger in generalising and accepting the inevitability of individual deaths. • Suicide is preventable and there is encouraging evidence that early intervention reduces the risk of suicide in psychosis.

10. Suicide Risk • Most service users will experience some degree of suicidal ideation • Only a minority with act upon this and a very small fraction end up with a lethal outcome • Suicide risk should be ascertained as early as possible in the assessment process • The Suicide Risk Factor Check-list enables a systematic consideration of known risk factors • It is intended to complement clinical risk assessment

11. RISK STATUS Red: Assertive action to reduce immediate suicide risks and MDT review of care plan Amber: Care plan for current risk factors and remain vigilant for future risk factors Green: Remain vigilant for future risk factors

12. Suicide Risk Tools • SIS: Suicidal Intent Scale • BHS: Beck Hopelessness Scale • SSI: Scale for Suicide Ideation • ASIST: Applied Suicide Intervention Skills Training • STORM: Skills-based Training on Risk Management • A tool can only contribute one part of an overall view of a particular individual at a particular time • Therefore, tools should only ever be used as part of a general clinical assessment

13. Assessing Suicide Risk • Suicide risk should be ascertained as early as possible • Responsibility for suicide risk assessment rests with senior, experienced MH professionals • All members of the MDT are expected to contribute to suicide risk assessment • A systematic consideration of known risk factors supports formulation, care planning and risk management • Best practice relies on a consistent approach • Holistic assessment will include many aspects of an individual’s life and current situation

14. At the point of referral: • Ascertain as much information as possible about historical and current suicide risk factors • Agreement should be reached with the referrer regarding the urgency of the referral in relation to suicide risk • With first episodes there is often very little history upon which to rely • Therefore, accumulation of information about current risk factors must be a priority for initial assessment. • Information may be sought from the client, their family or significant others as well as the referrer

15. Engagement • The mainstay of suicide prevention in psychosis is successful engagement. • Engagement is a vital precursor to assessment • Failure to engage the client is in itself a significant risk factor • There must be multidisciplinary agreement with any plan to tolerate unknown suicide risk during a prolonged/difficult engagement. • Information from third parties (families and friends etc.) can be invaluable prior to engagement

16. Investigating suicide risk • Assessors should ideally work in pairs • Timing is important - give enough time first to develop rapport • Explore feelings/emotions before direct questions • Have they been thinking of, researching or have actually attempted suicide? • Where is the person is situated along the continuum of suicidality?

17. Continuum of Suicidality IDEATION INTENT PLANS ACTIONS Actions’ include procuring the means and making an attempt.

18. Try to identify: What has made them feel this way What emotions they are experiencing Whether it is driven by psychotic features What their rationale for suicide is What plans they have made What is stopping them from doing it. You should leave enough time to: Explore the risk further if service users reveal they are suicidal as you may have to revise your plans and put in place preventative measures ‘Debrief’ service users after any discussion about suicide, as such inquiries may prompt service users to re-evaluate their future and potentially trigger feelings of hopelessness.

19. It is helpful to determine whether the service user’s suicidality is driven by: • The acute symptoms/experience of psychosis • Complicating mood disturbance • Pre-existing co-morbid conditions, e.g. depression, personality disorder, substance misuse/dependence • The individual’s psychological reaction to the impact of their illness • External factors such as reactions of significant others and losses • PTSD features related to a previous trauma, secondary trauma, suicide attempt or death of a significant other • Suicide pacts with others Establishing this will help to tailor individual packages of interventions and identify the goals to be achieved

20. Probing • Some people will be very guarded at the initial assessment • Some will be ashamed of their suicidal thoughts • Some will be fearful that if they mention feeling suicidal then they will be immediately hospitalised. • It is helpful to normalise the experience: - fleeting thoughts of suicide are a common reaction to their circumstances - these feelings will tend to subside once they get help and treatment.

21. Resilience factors It is important that resilience factors are also taken into consideration when assessing suicide risk. These include: • At least one close relationship/confidante • Family support • Things to live for, e.g. plans for the future, children, pets etc. • Strong positive cultural/religious/personal values and anti-suicide attitudes • Social stability • Good service engagement and optimism about recovery

22. Preventative Measures • Least restrictive environment principle. • If you believe that they can be managed at home, it is essential to negotiate an agreement that they will inform carers or staff as soon as it becomes unbearable so more help can be provided. • Those who are mute, partly catatonic, or extremely guarded should be managed with great caution • If they manifest high levels of anxiety, agitation, perplexity, and unpredictability their confused and distressed behaviour may result in self-injurious actions, e.g. wandering in front of traffic or fire-setting. • The person’s treating team should be involved as soon as circumstances change so that they can decide on which interventions might be most appropriate and arrange for prompt admission/re-admission to hospital should this become unavoidable.

23. If a person is clearly intent on suicide or has command hallucinations telling them to kill him/herself (or others) then immediate hospitalisation is generally the safest option. • Positive risk management is necessary and the improper use of disproportionately assertive interventions must be avoided. • The disempowering and potentially traumatic impact of forced treatment and interventions must be recognised • The involvement of police, use of MHA and forced admission, treatment by compulsion and physical restraint can all increase suicide risk. • All staff, carers and agencies should be aware of the risk, the supervision required and any restrictions imposed to prevent access to means of self-harm.

24. The risk factor check-list should be reviewed regularly, given the transient nature of suicidality An awareness of potential risk-factors for the future is important. Suicide risk must be reassessed in the event of the following: Service disengagement and refusing help Relapse of psychosis, especially a first relapse Admission to hospital Discharge from hospital New psychosocial threats to the individual Social rejection/loss of relationship Review and Re-assessment

25. Comprehensive re-assessments of suicide risk should be made after any behaviour suggestive of a suicide attempt. • This should trigger a re-appraisal of the care plan and a formal review with the service user, carer, treating team and any other agencies involved. • The increased risk should also trigger more frequent contact with the service until the risk has subsided. • The full risk assessment should be reviewed again whenever a transfer occurs from one team to another and especially on discharge from hospital.

26. Initial Care Plan • The initial formulation and provisional risk management plan should be developed rapidly and collaboratively with all involved. • Summarise concerns and work out sensible ways of managing the risks over the subsequent few days. • Services must ensure that first episode service users receive ‘enhanced’ care plans (new CPA) • Contingencies should also be planned and 24-hour emergency contact details provided. • Potential means (e.g. ropes, stockpiles of tablets, weapons) should be made inaccessible • Carers/partner agencies should always be involved in the risk management plan.

27. Suicide risk monitoring • Routine risk assessment and management systems should be an integral part of any early intervention service. • Effective communication is vital: An alert should be triggered within the service for any service user assessed to be a suicide risk and the service should remain on high alert until a formal review has determined that the risk has subsided. • Where electronic information systems (e.g. RIO) allow alerts to be posted it is vital that this is fully utilised and that information regarding suicide risk is added and updated in a timely manner.

28. Assertive Outreach approach: Early intervention teams are required to adhere to a model of care based on a team approach, risk tolerance and a high standard of communication • Suicide risk can be reviewed daily • Use of white/smart boards means that essential client information, including suicide risk status, can be displayed prominently • Zoning System: Service users are categorised at team meetings and this assessment is guided by the risk factor check-list.

29. Interventions The suicide risk assessment and formulation should determine: • The immediacy of the risk • What is driving that risk • Which specific interventions are likely to be most effective. • What resources are available to minimise the risk.

30. The immediate priorities are to ensure: - Safety - Supervision - The removal of potential methods of self- harm - If necessary, safe access to a hospital bed • Dual diagnosis and substance use/misuse expertise is required • Self harm expertise is required • Family therapy expertise is required • Staff training programmes in suicide prevention have been shown to provide a significant reduction in suicide rates • Basic ‘first aid’ training for all staff, families and service users themselves

31. Preventable issues • Obstructive pathways to care that can lead to secondary trauma • Inadequate systems for the management of high risk clients • Unchecked dispensing practices • Unsafe medication storage • Record keeping/communication problems • Inadequate staff support and supervision • Inadequate cover for staff on leave • Inadequate incident reporting, SUI investigations, audits and feedback

32. Early Intervention • Simply engaging service users better in care and treatment will reduce the risk of suicide • Psychosocial interventions that protect the person’s developmental trajectory, sense of ‘self’ and instil a sense of hope and optimism are crucial • Managing distressing symptoms/experience through medical and psychological treatment and self help/user groups • Support for social integration, strengthening social networks and the recovery of social confidence are likely to minimise the potentially disruptive impact of an episode of psychosis • Social interventions; Practical support for housing and benefits; employment/training schemes and parenting support can all help to reduce stress and social exclusion • Psychological family interventions and psycho-education may reduce tensions, ‘expressed emotion’ and the burden of care at home; thereby protecting the family against disintegration and reducing the risk of suicide.

33. First Episode Suicide Risk Management Top 10: • Responsive, accessible services with low threshold for assessment • Assume high risk and engage, engage, engage • Thorough assessment (inc. first episode risk factors) • Initial MDT Formulation ASAP • Assertively manage high risks • Positive risk management: Acknowledge resilience factors and use least restrictive environment • Address preventable issues, especially secondary trauma • Provide Early Intervention • Monitor the risk • Suicide can be prevented

34. Suicide Risk Management in EI

35. www.iris-initiative.org.uk www.eiyh.org.uk www.nmhdu.org.uk