The Suicidal Patient Principles of Management. Dr T L Lo FRCPsych FHKAM(Psychiatry) Chief of Service Kwai Chung Hospital 10 Sept 2011

Transcription

1 The Suicidal Patient Principles of Management Dr T L Lo FRCPsych FHKAM(Psychiatry) Chief of Service Kwai Chung Hospital 10 Sept

2 Suicide is an individual action and a deliberate act of self destruction Psychological processes Social circumstances Cultural influence Acutely suicidal and self-harming patients are a heterogeneous group, but Treatment approach are common to all at large Adolescent self-harming patients who repeat their act may require a different approach 2

3 Clinical Approach to Suicide Patient Assessing suicidal risk Assessing treatment needs Psychological therapies Pharmacological treatments Social and service level interventions 3

4 Principles of Management Rapid assessment of physical and psychological needs at the point of triage Effective engagement of service user/carers Timely initiation of treatment Rapid and supportive psychosocial assessment Prompt referral for further psychological, social and psychiatric assessment/treatment Prompt and effective psychological and psychiatric treatment when necessary NICE Guidelines

5 User/Carer s Experience in Service Contact Poor staff attitudes Vs Positive staff attitudes Being listened to and given time Providing a safe environment Be treated with dignity and respect as injuries that are not self-inflicted Being involved in treatment decisions NICE Guidelines

6 Suicidal Patients Assessment / Treatment Mental Health Services Assessment / Referral / Treatment Hospital Medical / Surgical Care Accident & Emergency Dept Detection / Assessment / Referral / Treatment Primary Health Care Social Workers, Counsellors, Teachers, Police, Prison, NGOs User/Carers experience in service Contact Family, Friends & Acquaintance 6

7 Assessment of Suicide Risk Para-suicide Young female History of self-harm Psychiatry history Current unemployment Lower social class Alcohol / drug problem Criminal record Antisocial personality Hopelessness High suicidal intent Suicide Old Age Male Previous attempt* Psychiatric history* Unemployment* Poor physical health Living alone Medical severity of the act Hopelessness High suicide intent Owens 1994 Hawton & Van Heeringen

8 Assessment of Needs Social debt*, work, social isolation*, legal problems Personal relationship breakdown Life events recent / current Psychiatric contact with psychiatric services, alcohol / drug problem Psychological Hopelessness, impulsivity Motivation desire to die, to communicate distress, to obtain temporary escape, to effect change in behaviour of others, 8 to express another emotion such as anger

9 Who should undertake assessment? Psychiatrist * Social Workers * Psychiatric Nurses * Both initial assessment of suicidal risk and further follow up can be satisfactorily done by non-medical staff with suitable training and supervision * Non-medical staff take longer assessments and recommend psychiatric follow up more often (Newson-Smith 1980) 9

10 Management of Suicidal Patient Where to treat Suicide intent Severity of symptoms + Social support Outpatient Treatment Full assessment of patient and proposed carer Organisation of adequate social support Regular review of suicidal risk Safe psychiatric treatment using drugs with less toxicity Small prescriptions Involve relative in safe keeping of tablets Immediate access to extra help 10

11 Management of Suicidal Patient Where to treat Suicide intent + Severity of symptoms + Social support Inpatient Treatment Assessment of mental capacity Safe ward environment Adequate number of well-trained nursing staff Good working relationship between staff and between staff / patients Agreed policies for suicidal observation 11

12 * The appropriate treatment of suicidal patients involves usually a combination of emotional support, problem solving advice and regular follow up * Evidence base for treatment of suicidal behaviour is weak and most of the studies are small and works for specific subgroups Psychological Therapies Problem oriented therapy Dialectical behaviour therapy (borderline personality) Inpatient behaviour therapy Home-based family therapy Group therapy (multiple attempters) (Adolescent) 12

13 Pharmacological Treatments Use of antipsychotics Use of antidepressants Service Level Intervention Intensive intervention plus outreach Emergency Card Same therapist / different therapist General hospital admission / discharge Nurse led case management Specialised services NICE Guidelines

14 Suicide Prevention Better and more available psychiatric services Restricting the means of suicide Encouraging responsible reporting Educational programmes Improved care for high risk groups Crisis Centres and Hotlines 14

15 Overview of Suicide in Hong Kong - A clinician perspective Suicide in Hong Kong Intervention programmes / projects Ways forward 15

16 Suicide in Hong Kong 1981 WH Lo & TM Leung (1985) N =

17 Suicide in Hong Kong 1981 WH Lo & TM Leung (1985) N =

18 Suicide in Hong Kong 1981 WH Lo & TM Leung (1985) N =

19 Suicide in Hong Kong 1981 WH Lo & TM Leung (1985) N =

20 Suicide in Hong Kong PS Yip, CK Law & YW Law (2003) 20

21 Suicide in Hong Kong PS Yip, CK Law & YW Law (2003) 21

22 Suicide in Hong Kong PS Yip, CK Law & YW Law (2003) 22

23 Suicide in Hong Kong PS Yip, CK Law & YW Law (2003) 23

24 Suicide in Hong Kong PS Yip, CK Law & YW Law (2003) 24

25 Suicide in Hong Kong PS Yip, CK Law & YW Law (2003) 25

26 Suicide in Hong Kong A case control psychological autopsy study EY Chen etal (2006) N = 150 Aged

27 Suicide in Hong Kong A case control psychological autopsy study EY Chen etal (2006) N = 150 Aged

28 Suicide in Hong Kong A case control psychological autopsy study PW Wong etal (2008) N = 85 Aged

29 Suicide after discharge from psychiatric inpatient care A case control study in Hong Kong PH Yim etal (2003) N = 73 Discharged

30 Suicide after discharge from psychiatric inpatient care A case control study in Hong Kong PH Yim etal (2003) N = 73 Discharged

31 The Suicide Risk of Discharged Psychiatric Patients TP Ho (2003) N = Discharged

32 The Suicide Risk of Discharged Psychiatric Patients TP Ho (2003) N = Discharged

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34 Three Year Outcome of Phase-specific Early Intervention for First-episode Psychosis A Cohort Study in Hong Kong EY Chen etal (2011) N = 700/839 Aged ( ) ( ) 34

35 Three Year Outcome of Phase-specific Early Intervention for First-episode Psychosis A Cohort Study in Hong Kong EY Chen etal (2011) N = 700/839 Aged Patients in the early intervention group Long full-time employment (P < 0.001) Fewer days of hospitalization (P < 0.001) Less severe positive symptom (P < 0.006) Less severe negative symptom (P < 0.001) Fewer suicide (P = 0.009) Fewer disengagements (P = 0.002) More recovery (P = 0.001) Rates of relapse (P = 0.08) Duration of untreated psychosis (P = 0.72) 35

36 Two Year Outcome of a Two-tiered Multifaceted Elderly Suicide Prevention Program in a Hong Kong Chinese Community (Population 852,796) SS Chan etal (2011) N = 351/2290 aged >65 Pre-intervention Group N = 66 Two year suicide rate was 7.58% in the pre-intervention group and 1.99% in the ESPP group (P = 0.028) Two year re-attempt rates were not significantly different between groups 36

37 Intensive Case Management Projects for Discharged Mentally Ills Home-based Treatment Team (HBTT) Recovery Support Outreach Team (RSOT) Personalised Care Programme (PCP) Integrated Community Centre for Mental Wellness (ICCMW) 37

38 Hospital Authority Mental Health Service Plan for Adults Hong Kong 38

39 Operational Priorities (How we get there) Objective 4 To develop and expand community mental health teams Recruit case managers in all HA clusters for all patients with severe mental illness (SMI) considered suitable for treatment in community settings Develop case management approach to allow better integration of care between inpatient and community, supported by electronic health records under personal data privacy guidelines Establish incentive mechanisms to attract and retain professionals in community settings Pilot community-based multidisciplinary specialist care teams, which provide links with Integrated Community Centres for Mental Wellness (ICCMW) of the Social Welfare Department (SWD) Conduct an external review of psychiatric day hospitals 39

40 Operational Priorities (How we get there) Objective 2 To work for the early identification and management, including self-management, of mental illness Extend the age range of the successful Early Assessment Service for Young Persons with Psychosis (EASY) program for the early assessment of psychosis in young people and adults Resource the expansion and strengthening of the psychiatric consultation liaison services to Accident & Emergency Departments of major hospitals to identify, support and manage people presenting with mental disorders Reduce waiting times for specialist outpatient appointments Work with primary care clinicians on agreed management protocols to facilitate the early identification and treatment of people with common mental disorders Develop new resources for mental illness prevention, education and management to strengthen support for patients and carers Work with SWD and NGOs on agreed management protocols, training programs to support non-health care professionals in community settings 40

41 Suicide with Psychiatric Diagnosis and without Utilization of Psychiatric Services Y W Law, PW Wong & PS Yip (2010) N = 150 Aged Contact group N = 52 Non-contact group N = 67 41

42 Suicide with Psychiatric Diagnosis and without Utilization of Psychiatric Services Y W Law, PW Wong & PS Yip (2010) N = 150 Aged Contact group N = 52 Non-contact group N = 67 42

43 Suicide with Psychiatric Diagnosis and without Utilization of Psychiatric Services Y W Law, PW Wong & PS Yip (2010) N = 150 Aged Contact group N = 52 Non-contact group N = 67 43

44 Way Forward Improving access of mental health services Restricting access to suicide means Innovations of approaches for engaging people at risk for suicide in non-medical settings More research studies on effectiveness of innovative communication means for suicide prevention 44

45 Improving access MHS Hospital AED Better engagement of suicidal patients Primary Care Non-medical Setting Friends 45

46 Means of Suicide and Locality of Completed Suicide 2007 Figure 1: Means of suicide and locality of completed suicide 2007 Sample GIS Output-1 46

47 Way Forward Spatial and Temporal Monitoring of Suicide and Self-harm in Hong Kong More research studies on the clinical profile of suicide attempters in Hong Kong Community based response to suicide clusters Building of community based mutual connections, trust, shared values among people Encourage community based participation, cooperation, networking hence a positive social integration 47

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