Guidelines. Suicidal Person. for Working with the. Shared Learning in Clinical Practice

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1 Guidelines for Working with the Suicidal Person Shared Learning in Clinical Practice

2 Acknowledgements Many thanks to all who contributed to the development of this resource, particularly SA Health, University of South Australia and Country Health SA Local Health Network. This resource was developed by the following members of the Shared Learning in Clinical Practice planning team: > Dr Andrew Champion, Clinical Director, Mental Health, Noarlunga Health Service > Philip Galley, Clinical Practice Mental Health Nursing Director, Country Health SA Local Health Network (LHN) > Lynne James, Senior Project Officer, Office of the Chief Psychiatrist > Annette Jones, Clinical Risk Manager, Safety and Quality Unit, Adelaide Metro Mental Health Directorate > Dr Conrad R. Newman, Senior Consultant Psychiatrist, Flinders Medical Centre, Senior Lecturer, Flinders University > Professor Nicholas Procter, Chair: Mental Health Nursing, School of Nursing and Midwifery and Sansom Institute for Health Research, University of South Australia The planning team would also like to acknowledge the contribution of: > Heath Black > Trudi-Ann Brooks, Nurse Practitioner Candidate, Older Persons Mental Health Service, Country Health SA LHN > Chris Dolman, Narrative Therapist, Rural & Remote Mental Health Network, Country Health SA LHN > Kate Deuter, Research Assistant, University of South Australia > Dr Andrea Gordon, Research Fellow, School of Nursing and Midwifery and Sansom Institute for Health Research, University of South Australia > Lee Martinez, Joint Appointment, University of South Australia Centre for Regional Engagement and Country Health SA LHN > Brendan Pawsey, Director, Healthmaps > Aaron Stuart, Centacare Catholic Family Services Special acknowledgement is given to the work of the Department of Health, Victoria in the publication Working with the suicidal person: Clinical practice guidelines for emergency departments and mental health services and the Department of Health New South Wales in the publication Suicide Risk Assessment and Management Protocols, Community Mental Health Service.

3 Contents Foreword Executive summary...4 Shared Learning in Clinical Practice South Australian Suicide Prevention Strategy Outcomes Matrix Clinical Guidelines for Working with a Suicidal Person...7 Identifying those at risk...7 Evidence-based risk factors...7 Psychiatric Assessment...11 Comprehensive Suicide Risk Assessment...11 Risk Management...18 How to use risk factors in the development of risk management plans The 12 Must Dos of Follow Up and Transfer of Care...24 Information sharing and exchange as a protective factor Cultural considerations when engaging with a suicidal person Educational Scenarios and Country Health SA Local Health Network Practice Tools Simulated Learning References, resources and further reading...35 page 2

4 Foreword Suicide can be prevented and we all have a role to play. These guidelines are provided for all health professionals and allied health workers across all levels of health service delivery including, emergency departments, hospitals, community facilities, general practice and the non-government sector. They provide instruction on the mandatory management of the suicidal person. The South Australian Suicide Prevention Strategy implores each one of us to do all that we can to offer compassion and support to the suicidal person. The distress experienced by the suicidal person is very real and accompanied by a sense of isolation, intolerable emotional pain and of being a burden, for them finding a way to hold on to hope and personal value no matter how small is a significant step in the decision to live. Every life is worth living and measures must be taken to ensure this principle is communicated in all our interventions. Suicide has a devastating effect upon families and the community, impacting the health and wellbeing of those left behind. Evidence shows that for every suicide six people are significantly affected causing both physical and psychological morbidity. Our services can effectively reduce this disease burden by positively engaging a person seeking assistance for suicidal behaviour and addressing the needs of their family and community. Literature tells us that outcomes can be significantly improved for the person displaying suicidal behaviour if effective front-end interventions are delivered by compassionate services and assertive follow up is provided with assistance for the person to connect back to their family and community in supportive ways. My thanks and appreciation to the health professionals who have developed these important guidelines to ensure the person seeking help will be understood and experience compassionate and consistent health services. I would also like to thank Country Health SA Local Health Network for their generous sponsorship of this project, which has contributed significantly to evidence-based practice guidelines being made available to a wide audience across the whole of South Australia. Dr Peter Tyllis Chief Psychiatrist and Director Mental Health Policy page 3

5 1. Executive summary These guidelines have been fashioned (with permission) from similar guidelines produced by the Victoria and New South Wales governments, to support and inform clinical assessment, decision-making and transfer of care in relation to people who may be feeling suicidal or experiencing suicidal ideation. The guidelines have also been expanded and contextualised to a South Australian setting as part of Shared Learning in Clinical Practice, a joint venture between SA Health Mental Health Unit Acute Matters capacity-building initiative and the University of South Australia Mental Health and Substance Abuse Research Group. These guidelines are provided for all health professionals and allied support workers across all levels of health service in South Australia including emergency departments, hospitals, community facilities, general practice and the non-government sector. They provide instruction on the mandatory management of the suicidal person. Production of the guidelines has been made possible by funding from the Country Health SA Local Health Network Mental Health Simulated Patient Learning Project, generously supported by ClinEdSA and Health Workforce Australia. Shared Learning in Clinical Practice Almost half of all Australians will experience mental illness in their lifetime. While this presents significant challenges for mental health consumers and their carers, careful consideration must also be given to how best to prepare and support the current mental health workforce. In rising to this challenge a dedicated group of clinicians and academics from across Adelaide and regional South Australia have come together over the past two years to organise symposia and guide best practice in mental health. The group have established themselves through a democracy of ideas openly sharing, discussing and debating information, resources and expertise specific to risk and vulnerability in mental health. Under the banner of Shared Learning in Clinical Practice, the group have brought together more than 500 clinicians, consumers, carers, policy makers and service managers to talk about ways to engage with and improve our service response to people with mental illness and their carers. At a deeper level the Shared Learning in Clinical Practice initiative has provided a forum for fresh leadership and commitment to mental health care based on therapeutic engagement in South Australia. People come together because they find value and meaning in their interactions. More specifically, participants have commented: Today s event has generated reflection and energy to more deeply consider the meaning of risk in my practice, in the context of staff and clients. Today s symposium has made me re-think very differently about how I not only assess, but engage clients in a different manner. I hope that in the future I will do better and be more aware of useful risk assessments. There have been many take home messages from today (and) it has been good to see the support network for mental health get together. These guidelines are a tangible outcome of the Shared Learning in Clinical Practice initiative. Suicide is a major public health problem. At the time of publication, the latest available statistics reveal 2,361 deaths by suicide were registered in Australia between , representing an age-standardised rate of 10.1 per 100,000. Suicide remains the leading cause of death among Australians between 15 and 34 years of age. By combining best evidence in suicide prevention with the opportunity to act quickly following an attempt, suicide can be prevented. These guidelines adopt an all-encompassing approach to engaging with, responding to and supporting people early following a suicide attempt, and/or presenting with thoughts of suicide, drawing from a comprehensive evidence base and mobilising relevant protective factors. Professor Nicholas Procter Chair: Mental Health Nursing University of South Australia Convenor: Mental Health and Substance Abuse Research Group Co-convenor: Shared Learning in Clinical Practice page 4

6 Philip Galley Clinical MH Nursing Director Country Health SA Mental Health Services Co-convenor: Shared Learning in Clinical Practice page 5

7 2. South Australian Suicide Prevention Strategy Outcomes Matrix These guidelines are designed to support the principles, goals and implementation plan of the South Australian Suicide Prevention (SASP) Strategy The development of the strategy brought together people from all walks of life and forums were held in a dozen key centres across South Australia. Over 750 people participated and shared their journey, to progress the Strategy. The table below illustrates key outcomes from the Strategy which the Shared Learning in Clinical Practice initiative and CHSALHN Mental Health Simulated Patient Learning project aim to progress via the Guidelines for Working with the Suicidal Person : Guiding principles Do no harm. It is imperative that initiatives are carefully developed, informed by best practice, assessed to be safe, are comprehensively evaluated to ensure they are effective and most importantly, do not place vulnerable people at an increased risk of suicide. The first door is the right door. Services need to be widely promoted and easily accessible through a wide range of entry points with the first service responsible for finding the best fit that meets the vulnerable person s needs. People need compassion and understanding when experiencing psychological or physical distress. Demonstrate sustainability and long-term commitment. Suicide prevention is a complex issue and requires sustained action at a range of levels, supported by a commitment to long-term investment. Goals SASP outcomes served by the guidelines 1. To provide a socially inclusive community of resilient individuals and supportive environments 1.4 Improved education and training across the community 2. To provide a sustainable, coordinated approach to service delivery and resources and information within communities to prevent suicide 3. To provide targeted suicide prevention initiatives, activities and programs 4. To address, as a priority, the issues that affect regional South Australians 5. To provide targeted postvention activities and programs 6. To improve the evidence base and understanding of suicide and suicide prevention 7. To implement standards and continuous practice improvement in suicide prevention 2.3 Joint ownership of suicide prevention enabling partnerships between governments, industry, professional bodies and non-government organisations 2.4 Agencies and departments linking effectively so that people experience a seamless service 3.1 Provision of selective and indicated programs and interventions available for all high risk groups 3.2 Reduced access to means 4.4 Provision of support during times of physical and emotional crisis in a community 5.1 Provision of effective support to those who are affected by suicidal behaviour or a suicide 5.2 Appropriate care for those people who present with behaviour identified as suicidal 5.3 Increased understanding of factors that facilitate recovery after a suicide attempt 6.4 The application of evidence into practice across all areas of suicide prevention 7.3 Continuous evaluation of strategies, therapies and programs to enhance their value and effectiveness over time page 6

8 3. Clinical Guidelines for Working with a Suicidal Person The following clinical guidelines for working with a suicidal person have been adapted and expanded from guidelines developed by the Department of Health, Victoria, and the Department of Health, New South Wales (now known as the NSW Ministry of Health). We gratefully acknowledge their contribution to this publication. Identifying those at risk It has been estimated that up to ninety percent (90%) of people who die by suicide, suffer from a diagnosable mental disorder. It is vital that a preliminary suicide risk assessment is conducted periodically on all people known to have a mental illness. Irrespective of the point of access to mental health services, there are several main principles for staff to consider in the assessment and management of people at risk of suicide. Good communication is vital Communicating with people who are emotionally distraught or behaviourally disturbed can be challenging but the key to engagement is listening; validate the person s feelings and persevere with questioning in an empathetic way. Walk along side to know their distress. Information gathering is crucial Ascertain the person s level of distress, their feelings about, and reasons for, living and dying, and whether they have a sense of hope. Certain mental states, for example despair, guilt, anger, abandonment, are indicative of a higher likelihood of suicide, as is the presence of mental illness. Ascertain if the person has made any preparations in anticipation of death, such as giving possessions away or saying goodbye to loved ones. Have they talked to others about wanting to die? Do they have a plan to commit suicide? What is the lethality of the plan? Find out if there is a history of mental illness. If a suicide attempt has been made, ask about any precipitating event, whether it was impulsive or premeditated, if the person understood the potential lethality of their actions, whether they tried to avoid discovery during the attempt, whether they sought help beforehand and so on. Find out if there is a history of mental illness, any previous suicide attempts and recent medication history. Is the person a client of a mental health service? Use an interpreter where needed the use of family or friends for this purpose is contraindicated. It is very important to gain information, not only from presenting individuals, but also from other informants such as friends or family, case notes and other professionals. The perceived level of risk should guide the breadth of this information gathering. A person cannot be held against their will where, following a detailed psychiatric assessment, the clinician determines that, although they are at risk of suicide, they are not mentally ill within the meaning of the Mental Health Act (2009). In cases of this type, however, the clinician should document the clinical basis for this diagnosis together with the nature of the treatment and care offered to the person, including the strategies used to stabilise the person. The clinician should contact family and friends so that they can provide informed ongoing support. Wherever possible, discussion with a Senior Clinician is also imperative. The collection, use and disclosure of consumer information are subject to health privacy principles information sharing is vital where the clinician and/or team believe; it is necessary to prevent or lessen the threat to the consumer s life, health, safety or welfare. Investment in a thorough assessment based on respectful engagement with the individual is essential Use the information gathered to inform the decisionmaking process regarding the person s management. Assess current level of risk on the basis of the available information to ensure that acute risk has been alleviated. Intoxication should not preclude early assessment of a person s suicide risk, particularly as it can increase impulsiveness and the risk of self-injury in the short term. Although risk factor checklists do not substitute for an assessment, they are useful when formulating a management plan. Particular attention should be given to the needs of identified at risk groups. Evidence-based risk factors In the realm of suicide research and clinical practice, there has been an increasing recognition of the factors that elevate suicide risk. Intoxication should not preclude initial assessment of a person s suicide risk, particularly as it can increase impulsiveness and the risk of self-injury in the short term. page 7

9 Risk factors are not only important for identifying a person s immediate risk of suicide, but are particularly important consideration in any management decision. At the same time, clinicians should remember that people thinking about suicide or who may have made a recent attempt are under significant psychological and often situational distress, necessitating thoughtful and sensitive engagement through the assessment process. It is not simply risk factors that count a collaborative, therapeutic alliance with a respectful clinician can in itself provide a strong protective factor in assisting a person to contemplate reasons to live. Table 1: Major risk factors for suicidal behaviour (listed in alphabetical order) Individual risk factors for suicide Co-morbidity People with mental illness often present with more than one psychiatric disorder [2 3]. For example, a person with bipolar disorder may have borderline personality disorder or may have a substance use problem [2]. Co morbid substance use disorders are common in persons with schizophrenia and increase suicidality in this cohort [5]. A diagnoses of mental illness and alcohol related problems remain significant clinical correlates of suicidal ideation, plans, and attempts (Nock et al., 2008) [63]. Moreover, there is also a strong association between substance abuse disorders and suicide. Measurable levels of alcohol and other drugs have been found in 30-50% of people who died by suicide in Australia (Hamilton, 2009) [64]. Deliberate self-harm Hopelessness Mental illness Deliberate self-harm includes intentional self-poisoning or self-injury, irrespective of the apparent purpose of the act. While it is accurate to say that not all persons who are hospitalised due to self-harm have attempted suicide, the risk of the person committing suicide in the first year after an episode of self-harm is up to 100 times greater than the general population risk [6 8]. Moreover, within 5 to 10 years, up to 7 per cent of self-harmers will die by suicide [9, 10]. The more serious the level of suicidal intent at the time of self-harm, the greater the risk of subsequent suicide [11]. A sense of hopelessness, desperation, demoralisation or emotional pain has been identified as a strong precipitant of eventual suicide [8, 12]. The main factors to be taken into account when assessing risk of suicide in p with schizophrenia are affective symptoms or syndromes, suicidal thoughts, threats or behaviour, poor adherence to treatment, fears of the impact of the illness on mental functioning, and drug misuse. Prevention of suicide is likely to result from active treatment of affective symptoms and syndromes, improving adherence to treatment, use of medication that may have special anti-suicidal effects (clozapine and lithium, where appropriate), and maintaining vigilance in patients with risk factors, especially when faced with significant loss events [70]. Establishing whether command hallucinations to harm self or others is an important part of assessment. Pain and physical illness Pain associated with physical illness, especially in the elderly, is associated with increased suicide risk [22 24]. Helplessness and hopelessness about pain, the desire for escape from pain and problem-solving deficits are psychological processes that contribute to suicidality in people with chronic pain [24]. A diagnosis of a somatic illness, especially cancer, coronary heart disease, chronic pulmonary disease, neurological diseases (including epilepsy and multiple sclerosis), and HIV/AIDS is a risk factor for suicide. Also, chronic physical pain is a risk factor for suicidal ideation and behaviour [65]. People recently discharged from acute psychiatric care Postpartum suicide risk Where people have been discharged from a psychiatric facility, the suicide risk discharged in the first 4 weeks after discharge increases to 100 to 200 times greater from acute than normal [25, 26], and the risk remains for at least 5 to 10 years after last psychiatric discharge [27]. Those with a history of suicide attempts and those with mood disorders are at particular risk of post-hospitalisation suicidal behaviour [28]. Particular care is advisable with persons admitted for self-harm, as this group has been shown to be a high risk of suicide both within hospital and within one year of discharge [29]. Women with a psychiatric disorder, substance use disorder or both, have a significantly increased risk of a postpartum suicide attempt, particularly in the first year after giving birth [30 32]. page 8

10 3. Clinical Guidelines for Working with a Suicidal Person Isolation / remoteness Previous suicide attempts Stressful life events Marital status and sexual orientation Rurality, isolation and remoteness, and their associated factors such as socioeconomic decline, health service availability and accessibility, culture, community attitudes to mental health and help seeking, and access to firearms, have also been identified as contributing to higher rates of suicide [33, 34 37]. Suicide rates of 15 to 24-year-old males living in remote Australia are close to twice those of males living in capital cities. People who have made previous suicide attempts are significantly more at risk of further suicidal behaviour [8, 12, 15, 38, 39]. However, the absence of a history of suicide attempts should not be taken as diminishing risk. An estimated 60 to 70 percent of those who complete suicide, do so on the first known attempt [40]. Certain recent life events can precipitate suicidal behaviour, especially in combination with existing vulnerabilities. Stressful life events could include conflict in, or the loss of, a close relationship, job termination, rejection, failure, humiliation, poor health, retirement and financial stressors [14, 6, 16, 41]. In retrospective review of completed suicides, often more than one of these stressful life events is present. stressful life events is present. Marital status is associated with the level of suicide risk. Studies show that persons who are divorced, widowed or separated have the highest rates of suicide, and married people have lower suicide rates than individuals who were never married. Homosexual orientation seems to be a risk factor for nonfatal suicidal behaviour and ideation, especially among homosexual adolescents and young adults. However, based upon results of (scarce) studies conducted to date, completed suicide rates do not appear to be increased among the gay and lesbian populations [65]. Family risk factors for suicide Childhood Adolescents and young adults with a history of childhood physical/sexual abuse are 3 times more likely to become depressed or suicidal than those without such a history of abuse [42, 43]. Family factors Older people Relatives and peers of people who have died by suicide Family factors, including high levels of conflict, parental mental illness and a family history of suicidal behaviour can elevate the risk for suicide [14]. When compared with other population groups, suicide in older people is often characterised by less warning or explicit cues, less history of previous attempts, greater prevalence of depression and physical illness, high levels of hopelessness, poor approaches to problem solving, inability to open up to others including initiating contact with GPs although some studies show increased contact with GPs prior to suicide [61]. A recent suicide or suicide attempt by a relative or peer is also associated with a higher suicide risk (up to 5-fold) [14]. Demographic factors for suicide Men and women There were 2,361 deaths from suicide registered in 2010, resulting in a ranking as the 15th leading cause of all deaths. Over three-quarters (76.9%) of suicides were males, making suicide the 10th leading cause of death for males. Men who are the most at risk are: > > young or in their middle years (20 to 44 years old). Suicide accounts for around a quarter of all deaths among men in their middle years > > older men (over 75) > > men living in rural or remote areas > > men from Aboriginal communities. Suicide was the leading external cause of death for Aboriginal males in Highest age specific suicide rate in 2010 for females was in year age group with 7.6 deaths per 100,000 [68]. page 9

11 Socio-economic and culture Social networks Sociological studies consistently find a correlation between high suicide rates and low socioeconomic status, although there are few high-status occupations at increased risk of suicide, for example dentists, physicians and veterinarians. In addition, being unemployed elevates the risk of suicide, but the nature of the relationship between unemployment and suicide is not clear. Other socio-cultural factors, including religion and migration, also seem to impact levels of suicide risk. Lower suicide rates are reported in countries with religious sanctions against suicide, mostly countries which are predominantly Muslim or Roman Catholic. In regards to migration, rates of suicide among diverse migrant groups tend to reflect suicide rates of countries of origin with a convergence trend toward the rates of the host country observed in some studies. A migrant status could increase the risk of suicide in vulnerable individuals (for example people forced to leave their country and/or individuals with pre-existing psychopathology) due to a language barrier, stress of acculturation, and social isolation [65]. Lack of social support, isolation and loneliness has been related to many aspects of psychopathology, ineffective coping with stress and life crises, and suicidality. People at risk of suicide are frequently described as alienated from their families and having insufficient social support, and other resources necessary to cope with life stressors. Such isolation may results from adverse life circumstances and/or inability to maintain good interpersonal networks. In addition, isolated and lonely people are at higher risk of death when they engage in suicidal behaviours: their chances of being found and rescued by others are severely reduced or non-existent [65]. A comprehensive suicide risk assessment should be made for the following presentations: > > People who present following a suicide attempt or an episode of self-harm. > > Those who report or are reported to be preparing for suicide or have definite plans. > > People with probable mental illness or disorder. > > Those who are depressed or have schizophrenia or other psychotic illness. > > Those who report accidental overdoses or unexplained somatic complaints. > > Those who present following repeated accidents, increased risk-taking behaviours (eg. superficial wristcutting), co-morbidity (eg. with alcohol and other drugs, intellectual disability, organic brain damage). > > People recently discharged from an acute psychiatric in-patient unit, especially within the previous month. People recently discharged from an emergency department following presentation of psychiatric symptoms or repeat presentations for somatic symptoms. A broad view of all of the risk factors associated with suicidal behaviour is important for the clinician to consider during the assessment. However, the most important risk factors for estimating the current and immediate risk are the personal risk factors, including the current mental state, that are impacting on the individual s life at the present time (see Table 1: Major risk factors for suicidal behaviour). Examples include: > > at risk mental status, eg depression, hopelessness, despair, agitation, shame, guilt, anger, psychosis, psychotic thought processes > > recent interpersonal crisis, especially rejection or humiliation > > recent suicide attempt > > recent major loss, trauma or anniversary > > alcohol intoxication > > drug withdrawal state > > financial difficulties or unemployment > > impending legal prosecution or child custody issues > > cultural or religious conflicts > > lack of a social support network Aboriginal Australians die by suicide at a rate twice higher than the non- Aboriginal population, yet they are significantly less likely to seek professional help for mental health concerns. Help seeking behaviour among Aboriginal Australians at risk of suicide should be promoted through provision of culturally appropriate services. Sveticic, J, Milner A, De Leo D (2012) General Hospital Psychiatry 34, page 10

12 3. Clinical Guidelines for Working with a Suicidal Person > > unwillingness to accept help > > difficulty accessing help due to language barriers, lack of information, lack of support or negative experience with mental health services prior to and following settlement. > > rejection of refugee claims by asylum seekers living in the community [62]. Hopelessness is one of the main factors mediating the relationship between depression and suicidal intent [33]. Some people experiencing hopelessness may conclude that death is a better alternative than living a life in which they believe there is no hope for a positive future. Hopelessness can be determined by exploring how a person feels about his/her future. Lack of positive expectancies and a negative view on life are important factors in suicidal behaviour. Psychiatric Assessment Most frequently, suicidal behaviours are symptoms of underlying mental health problems or disorders. Therefore, a suicide risk assessment cannot be undertaken in isolation from an overall mental health assessment. The clinician needs to assess for depression, schizophrenia, other psychosis, bipolar disorder, anxiety, the patient s personality style, command hallucinations and current and previous drug and alcohol use. Exploration of these areas will provide further important information on the changeability of risk status. For example, a person with a history of impulsivity under stress would be assessed as having a high level of changeability. How plausible is the denial of suicidal ideation in the context of a consumer s recent psychotic experiences (including any command hallucinations) or with the current severity of their depression? Assess whether the person is psychologically competent to enter into a therapeutic alliance. For example, a person who is distressed and deluded that they are responsible for the AIDS epidemic cannot give a meaningful reassurance they have no intention of harming themselves. A complete psychiatric assessment requires a medical assessment and physical examination and may require investigations to detect or rule out organic illness. People from Aboriginal or CALD communities and older persons require additional considerations specific to their needs. For example, when assessing the suicide risk for an Aboriginal person, local Aboriginal resources should be included in the assessment process. Comprehensive Suicide Risk Assessment Engagement is critical to the risk assessment. It provides an empathetic opportunity to restore hope in the individual through care and active listening. A comprehensive suicide risk assessment should explore the following elements: Distress / Psychic pain > > What is the nature and level of the person s inner distress and pain? > > What are the main sources of the person s distress? Meaning / Motivation > > What is the person s understanding of their predicament? What is the meaning of recent events for them? > > What is motivating the person to harm himself or herself? Has the person lost his/her main reason for living? > > Does the person believe that it might be possible for their predicament to change and that they might be able to bring this about? > > Explore cultural aspects of meaning and motivation with persons from culturally and linguistically diverse backgrounds. At-risk mental states > > The presence of certain at-risk mental states escalates the level of suicide risk. These include hopelessness, despair, agitation, shame, anger, guilt and psychosis. These emotions may be associated with specific body language and specific cues exhibited in the assessment interaction. Clinicians should look for and directly inquire about such feelings. History of suicidal behaviour > > Has the person felt like this before? > > Has the person harmed himself or herself before? > > What were the details and circumstances of the previous attempt/s? > > Are there similarities in the current circumstances? > > Is there a history of suicide of a family member or friend? History of suicide attempt/s or self-harm greatly elevates a person s risk of suicide. The elevated risk is independent of the apparent level of intent of previous attempts. Suicide often follows an initial suicidal gesture. page 11

13 Current suicidal thoughts > > Are suicidal thoughts and feelings present? > > What are these thoughts? (Determine the content for example, guilt, delusions or thoughts of reunion.) > > When did these thoughts begin? > > How frequent are they (how many times per day, week or month)? > > How persistent are they (seconds, minutes, hours)? > > What has happened since these thoughts commenced? > > Can the person control them? > > What has stopped the person from acting on their thoughts so far? Lethality / Intent > > What is the person s degree of suicidal intent? > > How determined were/are they? > > Was their attempt carefully planned or impulsive? > > Was rescue anticipated or likely? > > Were there elaborate preparations and measures taken to ensure death was likely? > > Did the person believe they would die? (Objectively question the person s perception of lethality.) > > Has the person finalised personal business, for example, made a will, made arrangements for pets, debts, goodbyes and giving away possessions? Intent and lethality are very important to explore with the person. Sometimes they may be obvious from his or her account. However, they might be more complex; for example, it is possible that a person who attempts to overdose using paracetamol may assume it is a safe drug on the basis that it can be purchased without prescription. Such an attempt would be assessed as low intent, but high lethality. Intent and lethality may also be more complex with people from culturally and linguistically diverse backgrounds. For example, planning may not be part of a culture s scripts, or culturally influenced methods which are of lower lethality in an extended family (due to likelihood f discovery). Asylum seekers released from held immigration detention and experiencing settlement difficulties are vulnerable during this period [67]. Presence of a suicide plan > > How far has the suicide planning process proceeded? > > Has the person made any plans? > > Is there a specific method, place, time? > > How long has the person had the plans? > > How often does the person think about them? > > How realistic are the plans? A suicide plan or preparation for death, such as saying goodbyes, making arrangements for pets, giving away possessions, settling debts or writing a suicide note, indicates serious suicidal intent. Access to means and knowledge > > Does the person have access to lethal means? Is there a firearm available? Has a firearms notification to South Australian Police (SAPOL) been completed? Are there poisons in the house or shed? Are there lethal medications such as insulin, cardiovascular medications or tricyclic antidepressants available to the person? Ensure these questions are also asked of a reliable corroborative source [44]. > > Is the method chosen irreversible, for example, shooting or jumping? > > Has the person made a special effort to find out information about methods of suicide or do they have particular knowledge about using lethal means? > > What is the person s type of occupation? For example, police officer, farmer (access to guns, poisons and pesticides), health worker (access to drugs). > > Have they made any preparations such as stockpiling medication or procuring a rope, hose or tubing? In most cases, if a person has developed a potentially fatal or effective plan and has the means and knowledge to carry it out, the chances of dying from a suicide attempt are much higher [45]. It is important to assess the level of intention and the person s understanding of the level of lethality of their suicide attempts or plan. Efforts should be made to remove access to lethal means. The suicidal person should not be tasked with removing the means as this places them in direct contact with a lethal method and could trigger them to act. They should be accompanied by a support person (friend, relative or clinician) and the means taken out of their environment. If there is a risk of overdose, medication should always be prescribed in small amounts. If possible there should be communication between the prescriber and dispensing pharmacist [69]. page 12

14 3. Clinical Guidelines for Working with a Suicidal Person Safety of others > > Have the person s thoughts ever included harming someone else? > > Has the person harmed anyone else? > > What is the person s rationale for harming another person? > > Have they felt the need to arm themselves in any way (gun, knife, bat)? > > Is there a risk of murder-suicide? Is the person psychotic? > > Are there issues with custody of children and/or financial issues? > > Are the children safe? > > Have they felt it would be better if they and their children and/or partner died together? > > Has the person thought that it would be better for their family/significant others to die rather than be harmed? > > Is there evidence of postnatal depression? Coping potential or capacity > > Does the person have the capacity to enter into a therapeutic alliance/partnership? > > Does the person recognise any personal strengths or effective coping strategies? > > How have they managed previous life events and stressors? What problem-solving strategies are they open to? > > Are the social or community supports (for example, family, friends, church, general practitioner) Can the person use these? > > Is the person willing to comply with the treatment plan? > > Can the person acknowledge self-destructive behaviours? Can the person agree to abstain from or limit alcohol or drug consumption? Can they see how substance abuse can make them more at risk? > > Does the person have a history of aggression or impulsive behaviour? (aggression and impulsivity make risk status less predictable). > > Can the clinician assist the person to manage the risk of impulsive behaviour? Protective factors Consideration of a person s protective factor is as is as important as evaluating risk factors for suicide. Protective factors refer to personal and family supports and experiences that appear to reduce risks for suicide [8, 46]. During an interview with a person, it can be useful for the clinician to investigate some of the personal factors that may serve to protect a person against future suicide attempts [47, 48]. > > Family warmth, support and acceptance. > > Community support and a strong cultural identity. > > Pregnancy (self/partner) or having young children. > > A strong sense of belonging and connection. > > Support from on-going medical and mental health care relationships. > > Skills in coping and problem solving, conflict resolution, and non-violent ways of handling disputes. > > Cultural and religious beliefs that discourage suicide and support instincts for self-preservation. > > Experiences with success and feelings of effectiveness. > > Interpersonal competence. In particular, reasons for living include anything that the person believes prevents them from attempting suicide, such as responsibility toward family, fear of social disapproval, moral objections to suicide, coping and survival skills, fear of suicide and so on [47, 48]. Another factor that might indicate a level of uncertainty in the assessment is conflicting information, or lack of corroborative information. Reflecting on the quality of their engagement and rapport with the person will also assist the clinician in determining their confidence in the assessment. The engagement is an important factor in: > > the quality of assessment > > restoring hope > > engaging a person in subsequent treatment. Care also needs to be taken when a person responds that suicide is not an issue following a limited number of questions asked by the clinician. The clinician must feel confident with the person s response. page 13

15 Premature closure (concluding there is not a suicide risk) should be avoided when the background and facts of the presentation or corroborative history suggest a real suicide risk is probable. When in doubt, the clinician should continue to explore the suicide risk with the person and corroborative sources. Corroborative history > > All means for accessing further information to assist with the risk assessment should be actively sought. The purpose of a corroborative history is to confirm the clinician s assessment, confirm the level of support and promote collaboration with the person and his/her support persons/s. > > Corroboration helps to provide accuracy around the changeability of suicide risk status, enhances assessment confidence, provides opportunities to assess family support and assists with collaboration about management and discharge planning. > > The South Australian Mental Health Act (2009) strengthens consumer and carer involvement to improve outcomes for consumers and families. It allows for disclosing information if the disclosure is reasonably required to lessen or prevent a serious threat to the life, health or safety of a person, or a serious threat to public health or safety. > > If the patient does not give permission for contact with others who could provide corroborative history and there are significant risk concerns, it is suggested contact be made inviting the person to outline any concerns without disclosing information to them. If in doubt it is useful to discuss this issue with a senior colleague. > > In the event no/insufficient corroborative history is obtained this increases the risk due to low assessment confidence [1]. > > The increased level of risk flags to all clinicians who may have further contact with the person; the need to continue to endeavour to gather more information/ history to ensure a thorough assessment and adequate information to accurately assess the risk of harm to self/others. Sources of information > > Communication with other clinicians immediately involved, for example, emergency department staff, ambulance officers. > > Interview of any people accompanying the person at risk. > > Interview/phone contact with other relevant people, general practitioner, primary care team, family members, close friends, significant others, care coordinators, case managers, treating psychiatrist, therapists, school counsellors and other relevant health and welfare service providers who know the person. > > Where possible, access to previous files. > > Suicide note does it present a different sentiment to the comments. There is a need to be aware that due to stigma and shame some families or support persons may not reveal the extent of the person s problems. Some cultures may fear repercussions, for example, an unwell mother may fear having her children taken away. Assess the family/support person s belief about the at risk person s current presentation (distress, attention seeking ) and determine their response to the situation (worried, angry). Assess the family/support person s willingness and capacity to facilitate a protective environment for the person at risk on discharge (monitoring safety, removal of means). Determination of risk level There is no current rating scale or clinical algorithm that has proven predictive value in the clinical assessment of suicide [49, 34, 35]. A thorough assessment of the individual remains the only valid method of determining risk. Assessments are based on a combination of the background conditions and the current factors in a person s life and the way in which they are interacting. Suicide risk assessment generates a clinician rating of the risk of the person attempting suicide in the immediate period. The person s suicide risk in the immediate to shortterm period can be assigned to one of the four broad risk categories: high risk, medium risk, low risk, no (foreseeable) risk. Refer to the Suicide Risk Assessment Guidelines (Table 2), to assist in estimating the current level of suicide risk. It is a guide only, however, and is not intended to replace clinical decision-making and practice. This guide can assist clinicians in assigning a level of suicide risk following comprehensive assessment, and thus influence the management plan for the person. page 14

16 3. Clinical Guidelines for Working with a Suicidal Person Table 2: Risk assessment guidelines (Note: this table is to be used in conjunction with clinical judgement) 1 The risk assessment guidelines are not a questionnaire. They are a guide for clinicians to be completed after comprehensive assessment to help identify gaps and objectively rate risk. In particular, Mild, Moderate and High ought to be seen as a dynamic spectrum of risk ratings, where changeability and fluctuation can occur quickly. Issue Mild Moderate High Ideation Periodic intense thoughts of death or not wanting to live, that last a short while. Frequent, intense thoughts of death and/or wanting to die, which are often difficult to overcome. Intense thoughts of death or wanting to die, which seem impossible to get rid of. Plan No immediate suicide plan. No threats. Does not want to die. Not sure when, but soon. Indirect threats. Ambivalent about dying. Has imminent date/time in mind. Clear threats. Doesn t want to live. Wants to die. Method/ lethality Means available, unrealistic or not thought through. No precautions against discovery. Possibly timed so that intervention is probable. Lethality of method is variable with some likelihood of rescue or intervention. Passive precautions, eg. avoiding others, but doing nothing about preventing intervention (alone in room, door unlocked). Lethal, available method. Active prevention of discovery, such as locking doors. Timed so that intervention is highly unlikely. Emotional state or mood Sad, cries easily, irritable. Mild emotional hurt. Pattern of up-and-down mood swings. Rarely expresses feelings. Moderate anger and hostility. Some symptoms of psychosis. Moderately intense emotional distress. No vitality. May be in emotional turmoil (expressed as angry or hostile). May also present as very calm and reassured, assuring the clinician that all is well and that any recent attempt was a mistake. Unbearable emotional distress or despair. Feels rejected, unconnected and without support. Severe depression or psychosis. Support/ connectedness/ protective factors Person is accepting help. Feels cared for by family, peers and/ or significant others. Support persons are willing/capable of helping. Person is ambivalent about receiving help. Minimal or fragile support. Moderate conflict with family, peers and/or significant others. Supports are unable or unwilling to provide help consistently. Person is socially isolated. Person is refusing help. Intense conflict with family, peers and/or significant others. Supports unable or unwilling to protect or monitor the person. Abuse/violence in the home. Recent breakdown in relationship. Previous attempt(s) None. Previous attempts. Some suicidal behaviour. Previous attempts with lethal intent. Note that any previous attempt in the elderly is significant. Reason to live/hope Feels hopeful about the future. Wants things to change. Person has some future plans. Pessimistic. Vague, negative future plans. Feels hopeless, helpless and powerless. Sees future as meaningless, empty. Recent medical care (eg. serious health problems, recent diagnosis). 1 Adapted from Guidelines for the management of deliberate self-harm in young people. ACEM 2000; Beck Suicide Intent Scale[128]; Working with the client who is suicidal: a tool for adult mental health and addiction services. British Columbia Ministry of Health, 2007; Suicide Risk Assessment and Management: Emergency Department. NSW Health 2004; Suicide Risk Assessment and Management Protocols: Community Mental Health Service, NSW Health 2004; and Patel AS et al.[60] page 15

17 Collateral history Able to access or verify information. Person s account of events is considered plausible. Access to only some information. Some doubts about plausibility of account of events. Unable to access or verify information, particularly where the person refuses that clinician talk to any family, friends or carers. Conflicting account of events to those of the person at risk. Substance use disorder Nil or infrequent use of substances. Risk of intoxication, abuse or dependence. Current substance use, abuse or dependence. Suggested actions > > Gather collateral history. > > During regular hours at an ED, refer for non-urgent contact with a mental health team, ideally within 72 hours of presentation, or when uncertain, escalate to on-call mental health clinician. > > Out-of-hours, ED staff can seek advice from on-call mental health staff. > > Usually won t require admission. > > Family/carer information for post- discharge care, and psycho education. > > Follow-up plan documented and communicated to the person and significant others. > > If the person is not currently linked to an AMHS, ensure they are linked to a GP or psychiatrist prior to discharge. > > Aim for reassessment by mental health clinician within 1 month, or if discharged from an inpatient psychiatric unit, within 7 days. > > Regular review by mental health team. > > Gather collateral history. > > Face-to-face mental health assessment within 24 hours (physical condition permitting). > > Some people (those still intoxicated or with borderline personality disorder) may require short-term admission (24 hours) to suitable shortstay accommodation, awaiting a mental health assessment or until safe discharge can be arranged. > > Family/carer information for post-discharge care, and psycho education > > Follow-up plan documented and communicated to the person and significant others. > > If person is currently known to mental health services, inform the relevant team of their attendance. > > Mental health team follow up all people within 48 hours of discharge, where possible. > > Mental health clinicians to reassess risk within 7 days. > > Regular review by mental health team. > > Gather collateral history. > > Inform security personnel and police if person leaves without assessment. > > Will require one-to-one nursing contact until completion of mental health assessment. Will also benefit from continued service contact in the days following. > > Family/carer information and psycho education. > > Follow-up plan documented and communicated to the person and significant others. > > Utilise on-call psychiatrist to discuss assessment findings and management plan. page 16

18 3. Clinical Guidelines for Working with a Suicidal Person Changeability Changeability of risk status, especially in the immediate period, should be assessed and high changeability should be identified. While risk status is by nature dynamic and requires re-assessment, highly changeable risk status is worth identifying as it will guide clinicians as to the safe interval between risk assessments. High changeability The clinician recognises the need for careful re-assessment and gives consideration as to when the re-assessment should occur, for example, within 24 hours. More vigilant management is adopted with respect to the safety of the person in the light of the identified risk of high changeability. Assessment confidence In some situations, it is reasonable for a clinician to conclude that, on the available evidence, their assessment is tentative and thus of low confidence. Corroboration is important in assessing confidence. Rating assessment confidence is a way for the clinician to reflect on the assessment in order to flag the need for further review and psychiatric consultation. The person s account of the events leading to their contemplation of or attempt to suicide will need to be considered by the clinician in terms of its logic and plausibility. This is best achieved by asking the person for a chronological account of events commencing from before the onset of the suicidal thoughts. It is important that the clinician gently probes apparent gaps in the person s account and listens not only for what is actually said, but what is implied and what is omitted. The clinician needs to feel confident that the person is providing an accurate and plausible account of their suicide-related problems. The clinician should consider the confidence he/she has in the risk assessment. Several factors may indicate low assessment confidence: > > Factors in the person at risk, such as impulsivity, likelihood of drug or alcohol abuse, present intoxication or inability to engage. > > Factors in the social environment, such as impending court case or divorce with child custody dispute. > > Factors in the clinician s assessment, such as incomplete assessment or inability to obtain collateral information. Low assessment confidence The clinician recognises the need for careful re-assessment to occur, for example, within 24 hours. A more vigilant management is adopted with respect to the safety of the person in the light of the gaps in information or rapport. High changeability flag Low assessment confidence flag Consultation with colleagues > > Assessment of people at risk of suicide is a complex and demanding task. It requires involvement of a mature, experienced clinician at some level. > > Wherever possible, all assessments of suicide should be discussed with a colleague or senior clinician at some stage of the assessment process. > > Consideration of the timing of consultation should be based on the degree of concern for the person. The greater the concern, the sooner the consultation should be sought. > > All teams involved in the assessment of people at risk should have access to regular (at least weekly) clinical forums such as clinical reviews. Documentation > > All details of risk assessment, management plans and observations to be clearly documented in the person s medical record using the relevant health record module. > > Document relevant sources of corroborative history and outcome from contact with each source. > > Response to clinical interventions should be noted. > > The rationale and reasons for the decision to manage the person in the community as opposed to hospitalisation and the management plan to support the decision should be documented. > > Contact details for the person, relatives and treating professionals should also be noted. > > If family or other care providers and health professionals contact a clinician in regard to a person at risk, all concerns should be documented. Refer to Suicide Risk Assessment Guide (Table 2) - To be used as a guide only and not to replace clinical decision-making and practice. page 17

19 Risk Management Maximising a safe environment Evaluation of the person s home and social environment is as important as the evaluation of the person. Enquire about social supports (including individuals, organisations and activities) because they may be necessary in planning a safe clinical intervention. This assessment provides a description of the person s ability to access their support system. It should also reflect whether the person has access to lethal means and, if so, what they are, as well as what efforts have been made to remove them [50]. In most cases, proper management consists of supporting the safety of the person while the underlying mental health problem is treated. Assessing the degree of intervention required is dependent on many factors, some of which include: > > severity of illness > > degree of impulsivity of person > > degree of insight displayed by the person > > safety of current situation > > supports available, for example, family and/or friends > > the person s willingness and ability to engage. These factors need to be considered when determining the level of observation required for the person during the crisis period. The person and their family (if considered appropriate) should always be involved in the discussion of the most appropriate management setting and strategies to minimise the degree of suicide risk. If at any stage of contact a staff member is made aware that the person is in possession of, or can gain easy access to, a firearm and there is concern about the person s mental state, the risk of suicide or threat to public safety, the police should be contacted before the person is discharged to discuss the possibility of removing the firearm [51]. If a person who is considered to be at risk leaves the facility or other community setting, including the person s home, prior to assessment and/or management arrangements being completed, every effort should be made to locate the person. If there is serious concern, the police should be immediately contacted and provided with a description of the person and the likely areas they may be located. High risk or high changeability or low assessment confidence Re-assess within 24 hours The clinician ensures that the person is in an appropriately safe and secure environment. The clinician organises re-assessment within 24 hours. Ongoing management and close monitoring are indicated. Contingency plans are in place for rapid re-assessment if distress or symptoms escalate. Medium risk Re-assess within one week Significant but moderate risk of suicide. The clinician ensures that a person at this level of risk receives re-assessment within one week and contingency plans are in place for rapid re-assessment if distress or symptoms escalate. Low risk Re-assess within one month Definite but low suicide risk. The clinician considers a person at this level or risk requires review at least monthly. The person at risk should be provided with written information on 24-hour access to suitable clinical care. The clinical team may consider community care more appropriate than immediate hospitalisation when: > > suicidal intent is judged to be manageable in that setting > > there is good rapport with the person at risk > > the mental health team has a management plan that is clearly communicated to the person and their support person(s), which includes a rapid response capacity for re-assessment and appropriate escalation of care levels > > there is short to intermediate term stability in social circumstances and accommodation > > the management plan includes specific strategies for the person and their support person(s) to deal with symptoms and distress > > the person has adequate psychosocial supports > > it has been assessed that the family or another carer is willing and has the capacity to take on the responsibility > > there is clear and timely communication between the referring agent and the provider of community care page 18

20 3. Clinical Guidelines for Working with a Suicidal Person > > there is the ability for the person or carer to gain access to appropriate clinical expertise 24 hours a day. This will require the service being able to provide 24 hour access and to inform the person or carer how, when and where help will be available. Reassessment of risk by mental health clinicians entails: > > reviewing current environment, risk and protective factors and how they may have changed > > reviewing treatment effectiveness and engagement with service providers > > re-evaluating previously detected at-risk mental states > > collecting collateral information from family, friends and relevant service providers. > > continuing to build engagement and therapeutic relationship. The use of the Mental Health Act (2009) may be necessary in the following instances to enable the continued observation and safety of the person: > > if suicidal thoughts or verbal intentions are persistent and intense, or > > the self-harming is serious in nature, or > > there is evidence of serious mental disorder or illness. All reasonable efforts to secure the highest level of specialist intervention including review by a consultant on call psychiatrist should be undertaken before resorting to coercive forms of management. Management in the community is not appropriate when suicide risk escalates beyond a critical level and there are significant limits in the levels of support available for the person. Critical level is indicated by an assessment of high lethality and high intent. The rationale and reasons for the decision to manage a person at high risk of suicide in the community as opposed to hospitalisation and the management plan to support the decision should be clearly documented. Management plan The management plan is a record of interventions and contingency plans. The management plan should clearly articulate roles, responsibilities and timeframes for the period between assessments. The management plan should also include explicit plans for responding to noncompliance and missed contact by the client. Suicide risk assessment is not static and the management plan should be updated with the most current information available. Measures which will facilitate risk reduction include: > > support > > instil hope > > increase sense of belonging > > reassure the person that you care > > collaboration with the person and all parties concerned > > regular review, including specialist reviews by a psychiatrist > > problem solving > > supporting and encouraging the person to see a general practitioner. Psycho-education should be provided to the person and, if appropriate, their family, and strategies should be in place targeting the broader psychosocial needs of the person housing, income maintenance, food, employment and social skills development. Psycho-educational themes that might be helpful to explore include relapse prevention, information about the seriousness of persistent suicidal ideation and deliberate self-harm behaviour, education about depression management and treatment, and information about the link between mental illnesses (schizophrenia, depression and bipolar disorder) and suicide. Management plan for a person in the community Before the person leaves the hospital or other facility, he/she should be given a management plan including the level of support to be provided by the service, written information about how to seek further help, including a 24-hour telephone number and the name of a contact person. The management plan should include the date, and in some cases even the time, that a re-engagement with the person (including a re-assessment of risk) will be undertaken. This will depend on the level or risk determined at the previous assessment. The management plan should be negotiated with the person and family/support person. Information concerning the collaborative management of the person s suicidality should also be conveyed to the referrer, treating psychiatrist, general practitioner and other relevant health providers in contact with the person. page 19

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