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Interventions to prevent suicide - Secondary care hospitals, clinics and community health Services

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In this section:

• Key Messages |
• Interventions |
• References |
• Contributors |

Key Messages

• Good clinical care for all mental health patients is fundamental
• Some medicines may affect suicidality, either positively or negatively, independently of their impact on the underlying mental illness
• Inpatient units provide a controlled environment where it is possible to reduce access to the means of suicide
• Staff should be trained in risk assessment and in resuscitation
• While a number of interventions are promising, more evidence is needed on the best way to follow up and treat people who have self-harmed
• Risk may be reduced by education of parents or other carers about limiting access to means.

Population Interventions

Population interventions that work

Optimal clinical care for mental illness

More than 90% of people who take their own lives have depression or another diagnosable mental or substance misuse disorder. We know this either because they are already known to services, or from research studies which have used the technique known as “psychological autopsy”. ¹ Secondary care services should offer the best possible mental health care in line with the latest clinical evidence (www.clinicalevidence.com) and guidelines published from time to time by the National Institute for Health and Clinical Excellence (NICE) (www.nice.org.uk/guidance/topic/behavioural). There is evidence for the impact of certain treatments on suicidality, which may be at least partially independent of their impact on the symptoms of the disorder concerned.

Clozapine

In 980 patients with schizophrenia or schizoaffective disorder aged 16 to 25 judged to be at high risk for suicide and treated with clozapine, there appeared to be a 26% reduced risk for suicide attempts or hospitalisations to prevent suicide compared with controls treated with olanzapine. ²

Lithium

Lithium seems to have an effect on reducing suicidal behaviour and suicide in people with bipolar affective disorder which has not been demonstrated for other mood stabilisers (but it should be noted that there is a high risk of suicidal acts, especially in the first year, if lithium is discontinued). ²

Depot flupenthixol

Depot flupenthixol appeared to be significantly better than placebo in reducing further self-harm in multiple repeaters. ^{1 3 4}

Follow-up letter after discharge from hospital

A single RCT found that simple contact by letter was sufficient to reduce the risk of suicide after discharge. 843 patients who had been hospitalised for depression or suicidality but had refused ongoing care were randomised to receive either contact by letter at least four times a year for five years, or no further contact. The suicide rate in the contact group was lower in all five years of the intervention, significantly so in the first two years (p=0.04). Differences in the rates gradually diminished until there was no difference at 14 years. ⁵ In each of the first two years, the cumulative percentage of suicides in the contact group was less than half that in the no-contact group, but the percentages began to converge by the fifth year.

Population interventions that may work

Reducing access to means

Reducing access to means of self-harm on inpatient wards seems intuitively an obvious precaution. Hanging accounts for 75% of inpatient deaths, with nearly one third of these taking place in toilets or bathrooms. ²

A national programme to remove all non-collapsible bed, shower and curtain rails from inpatient psychiatric units has coincided with a reduction in the number of inpatient suicides. ⁶

Inspection of wards for potential ligature points should be undertaken, bearing in mind that fatal hangings often occur from ligature points below head height. ^{2 7}

Provision of clothing without belts/cords and shoelaces may also be helpful, though clearly it is also important to maintain patients’ dignity so this requires sensitive discussion. ⁷

Training in resuscitation and emergency management

Hospital staff should be trained in the resuscitation and emergency management of attempted suicide by hanging. ⁷

“Chain of care”

After a suicide attempt, structured collaboration between hospitals and teams providing follow-up via a multi-disciplinary network (known as a “chain of care”) reduced treatment drop-out and repeat attempts in Norway compared with regions with no chain of care, but much is not known about the optimal post-attempt interventions. ⁸

Community Mental Health Teams

Team management of people with severe mental illness and disordered personality may be superior to non-team “standard care” as it was in the UK in the late 1990s in avoiding death by suicide, but the results are not clear. ⁹

“Green card”

Provision of cards (often known as “green cards”) to people who have self-harmed, giving details of how to obtain help in an emergency, appears promising. Those who received such cards in addition to standard care showed a trend towards reduced repetition of self-harm compared with those offered standard care alone, but this difference did not reach statistical significance. Only a minority of patients actually used the card, so further research is needed both to the confirm the effectiveness (or even possible risk in some sub-groups) and to explore what role the card might play. ^{1 3 4} (One study found that provision of an emergency contact card actually increased repetition for those with a previous history of deliberate self-harm, but the outcome in terms of subsequent completed suicides was not reported.) ¹⁰

Dialectical Behaviour Therapy

Dialectical behaviour therapy is a form of psychotherapy developed specifically for people with borderline personality disorder. It combines validation (affirming the individual’s feelings as understandable) with skills training in problem-solving to help the individual cope better with their situation.

One study reported that dialectical behaviour therapy (DBT) for women with borderline personality disorder who have attempted suicide appeared to be significantly better than standard care in reducing further self-harm. However, because the sample size was small (five patients actually treated out of 19 allocated to intervention; 12 controls receiving standard care out of 20 allocated to control group), and such results may reflect publication bias ⁴ we have categorised this intervention as promising rather than effective. ^{3 4}

Problem-solving therapy

Problem-solving therapy appears to be promising in reducing rates of repeated self-harm among suicide attempters where this is focused on cognitive deficits disrupting the ability to solve interpersonal problems (in contrast with psychosocial crisis interventions focusing on current problems - see Population interventions that do not work.) ^{1 2 3 4}

Educating parents/carers about limiting access to means

An American study of educating parents of depressed adolescents about limiting access to means showed some effect on parental behaviour (26.9% of those with guns reported removing them). However, 17.1% of parents who had not initially had guns, and therefore did not receive the educational intervention, actually acquired firearms over the next two years. This suggests that education about access to means may need to be given to all families where there is an identified individual at risk. ² However, the impact on subsequent suicidal behaviour was not reported. The relevance of this study to the UK, where guns are much less commonly kept at home, is unclear.

Population interventions that do not work

Guaranteed free readmission

Giving patients who self-harm a guarantee of free readmission to hospital in the event of an emergency did not appear to have any effect on repeated episodes. ^{1 11}

Intensive intervention plus outreach

Intensive intervention plus outreach showed no consistent benefit when compared with standard care for people who had self-harmed. ⁴

Long-term therapy

There is no evidence that for patients with a history of self-harm, long-term therapy (unspecified) is more effective than short-term therapy in preventing repetition. ⁴

Psychosocial crisis intervention

Psychosocial crisis intervention, with a focus on resolution of current problems, did not appear to be effective. ^{1 11}

Antidepressants

There is no evidence that antidepressants were more effective than placebo in preventing repetition of self-harm. ^{1 4} However, several of the drugs used in this trial are no longer available, and there was some indication that the effect might vary according to the frequency of previous self-harm. ⁴

There has been much recent concern about whether certain pharmaceutical interventions (particularly some widely used antidepressants) may increase suicidality, particularly in children and adolescents. New evidence is emerging all the time, and you should liaise closely with your pharmaceutical advisers to ensure best practice in the light of currently available research.

What we don't know

There is still much that is not yet known about the optimal intervention following an episode of self-harm. The current multi-centre monitoring trial covering deliberate self-harm (DSH) presenting in Accident and Emergency Departments in Oxford, Manchester, Bristol and Derby (http://cebmh.warne.ox.ac.uk/csr/resmulticentre.html) may help to illuminate this.

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