Good Practices In Suicide Prevention Strategies Towards Suicide Attempters

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Good Practices In Suicide Prevention Strategies
Towards Suicide Attempters
Rita Vanhove, An Lievrouw , Annemie
Durang, Jolien Mertens, Suzy Van der
Meeren, Marijke Vandervoort, Vicky Van Dooren,
Karen De Waele, Karl Andriessen Suicide
Prevention Program Flemish Mental Health
Centres Belgium C. Van Heeringen, Gwendolyn
Portzky, Stephanie De Munck University
Gent rita.vanhove_at_dagg-cgg.be
www.zelfmoordpreventievlaanderen.be www.unitforsu
icideresearch.be www.uhasselt.be www.zorg-en-gezon
dheid.be
Supported by
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Aims Of The Workshop

• Presenting Flemish strategy to optimise the care
  for people who were hospitalised following a
  suicide attempt (DSH)
• Presenting critical success factors and
  limitations
• To exchange experiences regarding
• prevention strategies towards suicide attempters
  and its implementation

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Introduction Context?

• Flemish Ministry Welfare, Public Health and
  Family The number of suicides has to be reduced
  by 8 in ten years (2000-2010)
• Sub-goals suidepreventionplan are
• Reduction in the number of attempted suicides
• Reduction in the level of suicidal ideation
• Reduction in the number of depressions
• Suicide attempters are an important target group
• ? pilotregion pilotstudies (2003-2006)
• ? implementation in Flanders (2007-2010)
• aim implementation in 75 General Hospitals
  in 2010

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Introduction Why Focus On Suicide Attempters?

• Suicide attempt most important clinical
  riskfactor for subsequent suicide
• Repetition in Flanders 44-47
• Risk of repetition highest in the first weeks
  after discharge
• Patients who leave the hospital prematuraly get
  no assessment and are at a higher risk
• Comorbidity psychiatric disorders (90)
  personality problems (40)
• Motivation for treatment is often lacking
• Crucial continuity in care, chain of care

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Introduction current situation in Flanders

• Patients come to attention after presentation to
  a general hospital (GP not involved)
• Hospitals have no standard procedure
• Patients leave the general hospital very quickly
• GP not always informed by the hospital, no
  systematic communication with GP
• after-care low compliance
• No systematic psychiatric assessment of patients
• Not every general hospital has a psychiatric ward
• Mental health professionals not always available
  in the general hospital

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Introduction Basic Assumptions

• Good management starts at the ED
• Negative attitudes and lack of knowledge in
  hospital staff
• A semi-structured assessment procedure (of risks
  and needs) is recommended
• Assessment procedure itself can be highly
  therapeutic and increase motivation for therapy
• Non-medical staff and clinical staff (nurses,
  social workers, psychologists) can be trained to
  assess reliably, make effective aftercare
  arrangements and provide effective therapy
• Outreaching improves compliance (van Heeringen,
  1995)

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Flemish Project Integrated Care for Suicide
Attempters

• Optimise care for suicide attempters
• ? Management of care continuity, chain of care
• ? Integrated tool in clinical practice
• ? Aftercare arrangements communication

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Flemish Project Integrated Care for Suicide
Attempters 2 strategies

• GP crucial in chain of care especially after
  patient discharge flyerstrategy
• Optimising care in General Hospital
• ? making sure that every suicide attempter gets
  the best care available (i.e. risk and needs
  assessment, exploring psychosocial/treatment
  needs and motivation, follow up care after
  discharge)
• ? by using tool IPEO

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Flemish Project Integrated Care for Suicide
Attempters Flyerstrategy

• Goal
• Report GP immediately after discharge
• Patient contacts GP within 1 week
• GP outreaching within 2 weeks
• Flyer motivation, basic guidelines, offering
  support

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Flemish Project Integrated Care for Suicide
Attempters Flyerstrategy

• Research conclusions
• GP involvement in the intervention condition (IC)
  increased to 71.2, compared to 46.2 in the
  control condition (CC)
• Contacts within 2 weeks 83 initiated by
  patient, 17 initiated by GP
• Outreaching of GPs was slightly more prevalent
  in IC compared with CC (11.9 versus 7.7, ns.)
• Favourable effect of referral strategy regarding
  contact with GP and outreaching

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Flemish Project Integrated Care for Suicide
Attempters Tool IPEO 1 and 2

• Goal
• Assessment of risks and needs
• Management of care (including aftercare)
• Communication between services and caretakers

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Flemish Project Integrated Care for Suicide
Attempters Tool IPEO 1 and 2

• Research conclusions
• IPEO is thorough and useful, (generates
  epidemiological data)
• IPEO is time-consuming (1550 min)
• Staff ED is capable of working with IPEO 1 after
  training
• Electronic version available
• Positive response to training
• Significant improvement of knowledge
• Significant change in attitudes
• Significant appraisal of self-efficacy
• Need for service planning

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IPEO 1 ASAP When In Hospital

• How was the patient found? Respons patient and
  significant others
• How was the patient presented to the hospital
  (by ambulance, police, GP, own initiative,..)
• Method and physical consequenses (severity)
• Demographic features (gender, age, marital
  status, domestic situation, occupation)

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IPEO 1

• Assessment feelings of hopelessness, suicidal
  ideation or suicide plans (how do you feel now?)
• Previous suicide attempt(s)
• Psychiatric history
• Use of medication
• Family, social support
• Motivation (patient and significant others) to
  engage in further assessment and treatment,
• if not refer to and inform GP

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IPEO 2

• Life events (includes Problem Checklist)
• Motives (Reasons for Attempting Suicide
  Questionnaire RASQ36)
• Suicidal ideation/plans
• Suicide intent scale (SIS37)
• Alcohol/drugs (CAGE-AID)
• Social and treatment needs
• Diagnosis
• Risk assessment
• Chain of care
• Treatment planning, arrangements for follow-up
  care
• Report to be send to

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Flemish Project Integrated Care for Suicide
Survivors Conditions For Implementation

• Promoting development integrated care pathway
  (hospital, GP, PH, MHC)
• Informing and training hospital staff to use IPEO
• Informing and training GP
• Offering support to GP
• ? Flyer guidelines
• ? Consultation MHC
• ? Electronic helpdesk
• ? E-learning
• ? Live sessions
• Registration University Gent, Unit for Suicide
  Research

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Difficulties And Limitations

• Not an official guideline, not imperative
• No financial compensation for hospital
  (incentive)
• Competence Federal ? Flemish Government
• Low level of staffing of ED
• Lack of on-call psychiatric service 24/7
• Lack of means of monotoring activity of the
  clinical service and audit function
• Very young patients specific provisions
• GP patients do not always have a GP (city) ,
  outreaching new to GP
• Availability of local support services and
  inpatient psychiatric care
• Preventionworkers of MHC not familiar with
  general hospital

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? Discussion

• Introducing good practices in general hospital
  who is responsible?
• Which authorities, organisations, persons need
  to be involved? Who are the partners?
• How to raise awareness prevention repetition/
  integrated care pathway/ communication with GP,
  MHC, PH,...
• How to make implementation sustainable?
• What are critical success factors?
• What are the limitations?
• Training hospital staff what works?
• Training GP what works?