63 Treatment of suicide attempts and suicidal patients in psychiatric care

No other known risk factor has such a high suicide prevention potential as a psychiatric disorder. However, to release this potential psychiatric care needs to be made more available to suicidal individuals, and there is a necessity to establish a continuity of care between hospital and outpatient treatment for patients who have been admitted after a suicide attempt. In this chapter important aspects of the psychiatric treatment of suicidal individuals are described. The importance of conducting systematic and repeated clinical risk assessments, providing treatments targeted at the patient's needs and instigating safety measures according to the actual risk level is re-inforced. Treatment standards should be kept high through continuous staff education measures, clinical supervision, adherence to written procedures, and should be improved through suicide review procedures whenever there has been a severe suicidal incident within the context of the clinical unit.

Psychiatric disorders are present in at least 90 per cent of suicides (Cavanagh et al. 2003), and in most cases patients are untreated at the time of death (Lonnqvist et al. 1995). The strong association between suicide, attempted suicide and psychiatric disorders makes effective psychiatric treatment and care central components to suicide prevention (Mann et al. 2005). A major problem is, however, that most of the treatments we currently rely upon in clinical practice have not yet demonstrated their effectiveness in preventing suicide. One reason for this is that suicidal individuals have often been excluded from clinical trials on treatment efficacy due to ethical, legal and practical considerations. Since suicide remains the most serious outcome of mental disease, it is essential that we find ways of overcoming these research obstacles in order to provide a set of evidence-based treatments adapted to the specific needs for different groups of suicidal patients. Data from Danish registers have demonstrated that the population-attributable risk (PAR)—the proportion of suicides in the population that could be removed if the risk factor could be removed—for suicide associated with lifetime psychiatric hospitalization is about 40 per cent (Qin et al. 2003). No other known risk factor has such a strong PAR. Furthermore, as demonstrated in the systematic literature review by Pirkis and Burgess (1998) perhaps as many as 40 per cent of individuals in the general population who died by suicide had undergone inpatient psychiatric care less than one year before their death. Accordingly, this chapter will place its emphasis on the situation of patients in psychiatric hospital care and describing aspects of such care relevant to suicide prevention.

According to estimates by Bertolote et al. (2003) as many as 165 000 lives could possibly be saved worldwide annually if adequate psychiatric treatment for major psychiatric disorders were provided. In large parts of the world, particularly developing countries, there is a profound lack of mental health resources. There is a scarcity of hospital facilities, community mental health centres and adequately trained mental health workers. Even in many so-called developed countries of North America and Europe, not enough psychiatric treatment resources are available to populations that seem to have become increasingly in need of them. The downsizing and closing of psychiatric hospitals in many countries have made things worse since not enough outpatient facilities have been established to compensate for such cutbacks. A study by Hansen and co-workers of downsizing of psychiatric inpatient facilities in Norway suggested an association between the downsizing and a subsequent substantial increase in suicide rates of the patient population in the relevant catchment areas (Hansen et al. 2001).

There is clearly a need to strengthen psychiatric services in most countries. Equally important is to carefully plan services in order to make them more optimally available. Whereas many developed countries are in the process of strengthening community mental health services, some countries—for example many European countries in transition—have retained a nearly totally hospital-based psychiatric care. Yet, in the Baltic States for example, most patients with mental disorders, such as depression, will never encounter hospital psychiatrists. Still, there are general practitioners who have generally not received sufficient training in the treatment of common psychiatric disorders and suicidality. From a suicide preventive perspective, it is of the utmost importance to resolve the problems of access to psychiatric treatments in all regions of the world.

Suicidal ideation or behaviour is frequently seen in patients seeking emergency psychiatric care. Such care is differently organized across the world. Frequently, however, the suicide attempter will require crisis intervention at a general hospital or in an emergency room. Working with patients in suicidal crises, clinicians are faced with three important challenges: (a) to protect the patient against the danger of suicide or irreversible injury; (b) to reduce the patient's profound feeling of hopelessness and despair; and (c) to elevate the patient's subjective experience of quality of life. Essential to the first challenge is to conduct a systematic clinical assessment of suicide risk. Specific questionnaires and interviews have been developed for the purpose of evaluating suicide intent and suicide risk (Beck et al. 1974; Mieczkowski et al. 1993), but since they have so far not been able to predict suicide more effectively than clinical evaluations, the clinical interview remains the gold standard in suicide risk assessment. This includes a psychiatric examination, in which adequate history is taken, psychiatric symptoms are recorded and the patient's current suicidal ideation and intent is evaluated. For a detailed description of the assessment interview see Chapter 43 and 44 in this volume. The psychiatric consultation should provide information necessary for treatment planning and it should also serve as a clinical intervention focusing on the patient's most critical problems and psychological needs. To establish a therapeutic alliance is of the utmost importance for successful treatment of patients in suicidal crises. While patients must get the opportunity to recover from their medical condition, e.g. the intoxication, and to rest in an atmosphere of kindness and reassurance, most patients will also need to express, with the therapists help, their problems and emotions verbally. Emotions such as hopelessness, feelings of guilt, shame, rage, abandonment and self-hatred are commonly seen in suicidal patients (Hendin et al. 2004) and may evoke countertransference reactions in the therapist (the arousal of the therapist's own repressed feelings through identification with the patient's experiences and problems, or through responding to the patient's expressions of love or hostility toward the therapist). In case of countertransference this must be dealt with properly through professional supervision. The therapists need to demonstrate that they accept and validate the patient but not necessarily the suicidal behaviour, and discuss problem-solving strategies other than suicide. Most patients will initially be in a state of emotional turmoil and chaos, and need help to get a better understanding of what has happened and why. Patients who have attempted suicide will often require treatment in an emergency room, and then be observed for the next 1–3 days in an acute medical ward according to their medical condition. After this, some patients will need further hospitalization, as discussed below. However, effective treatment of the majority of patients will, under most circumstances, be possible in an outpatient setting. Depending on the clinical picture there may be a need for follow-up of medication, referral for alcohol or drug rehabilitation and individual or family therapy. Some patients can rely on their family doctor as a coordinator of the different treatment components, but treatment delivered by the family doctor alone is seldom enough. To ask the patient whether they have easy access to potentially toxic medication, other substances or guns that can be easily used for suicide, and to consequently have these removed from the patient's home before they are discharged from the hospital is an advisable and effective precaution (Kruesi et al. 1999). The patient and their family should furthermore be provided with written information about available crisis resources in case of rapid re-emergence of suicidal impulses; this has been demonstrated to reduce the risk of repetitive suicidal behaviour (Cotgrove et al. 1995).

It is recommended that treatment contact is continued in some form with most of these patients for the first year after the suicide attempt. Longitudinal studies have shown that patients treated for suicide attempts run a particularly high risk of completed suicide during the first year after their discharge (Hawton et al. 2003). Since many patients have a strong tendency to drop out of follow-up care, any measures that can motivate the patient and improve adherence to treatment will be important, and good results have been attained with several treatment compliance-oriented programmes for suicide attempters in emergency care (Rotheram-Borus et al. 1996; Koons et al. 2001; Guthrie et al. 2001; Spirito et al. 2002). A special chain of care programme for suicide attempters has been implemented as part of the Norwegian national strategy for suicide prevention (Norwegian Board of Health 1994), establishing a structured collaboration between general hospitals, emergency facilities and after-care providers (Mehlum 2000) resulting in a substantially improved level in the quality of care (Mork et al. 2001) and a decreased prevalence of rapid repetition of the suicide attempt (Dieserud et al. 1992).

Patients who have one or more of the following characteristics will usually need a prolonged psychiatric inpatient treatment: having made suicide attempts with a high degree of suicidal intent; having a continued wish/plan for suicide; having symptoms of a severe mental disorder such as severe major depression or psychosis and/or alcohol or other substance use disorder; having poor impulse control or weak barriers against suicide; having poor social support; having experienced recent severe social stressors, loss or emotional trauma. The exception is patients with a pattern of repetitive episodes of suicide attempts and suicidal gestures and signs and symptoms of borderline personality disorder, for which extended hospitalization is not necessarily beneficial (Paris 2002). These patients' suicidality may actually intensify through what has been labelled as ‘malignant regression’ (Balint 1968). This may lead to escalating suicide threats, self-mutilating or suicidal behaviour and, as a consequence, extended admissions or, even worse, precipitating premature discharge or other angry rejection from the hospital staff. Except in cases of severe suicide risk and/or psychotic symptoms, these often chronically suicidal patients should preferably be treated in an outpatient setting where increased therapeutic support will often be necessary in situations of increased suicidal feelings and tendencies. Therapeutic support means both specific psychiatric interventions and psychosocial support from the clinician. Such support is essential to counteract the often profound feeling of hopelessness, abandonment and shame experienced by the suicidal patient. While providing such support, it is important to actively avoid teaching borderline patients that appropriate attention to their needs will only be provided when they show signs of suicidality; sadly, this is often the case in many busy clinical outpatient units. Hence, there is a strong need for carefully planned long-term outpatient treatment programmes for borderline patients with suicidal behaviour.

Sometimes the patient refuses to be hospitalized. If in such cases there is imminent danger to the patient's life, involuntary commitment will often be necessary. When the patient is transferred to a psychiatric hospital there is a need to promote the establishment of a new therapeutic alliance through measures mentioned above. A clinical re-evaluation should be conducted immediately and according to this, all necessary safety measures should be undertaken. Necessary precautions such as placing the patient in a special observation unit, removing belts, razors and other dangerous objects among the patient's belongings should be undertaken. Control measures such as these have the potential of threatening the patient's personal integrity and should therefore be implemented with care and respect. In order to reduce the need of control measures over prolonged periods of time the staff may ask the patient to sign or to verbally agree to a ‘no suicide’ contract, in which the patient agrees not to harm himself for a specific limited time period and that they will contact the staff if their feelings or the situation changes.

Special observation units must be carefully designed to remove opportunities for hanging, jumping out of windows or other means that could be used for self-harm. Wards providing treatment for suicidal patients should be audited at least annually to ensure they comply with these requirements (Duffy et al. 2003). Equally important is that staff are adequately trained for the treatment and protection of these critically ill patients. In many hospitals there is, however, an unacceptable and potentially dangerous variation and confusion in terminology and practice regarding procedures for special observation and protection against suicide. For example, a psychiatrist in charge of the treatment may find it necessary to prescribe ‘continuous observation’ as a protective measure against suicide for a given patient and by this he expects the nursing staff to be close to the patient and not to lose sight of them even for a moment. The member of the nursing staff who receives the doctor's orders may, however, have been trained to use the term ‘continuous observation’ in a slightly different and less restrictive manner and this could imply a hazard to the patient's safety. Every treatment facility must therefore have a crystal clear observation policy in which newcomers are to be educated and to which all staff must adhere.

Some phases and situations during the clinical course in suicidal patients are generally regarded as particularly dangerous with respect to completed suicide. One of these phases takes place within the first few days after admission when the patient's condition is often unstable, and should be met with increased levels of observation and protection. Some patients, e.g. young people with a diagnosis of schizophrenia, may become increasingly depressed after acknowledging the severity of the handicaps of their mental disorder (Bourgeois et al. 2004), or because of the seemingly irreversible consequences of the actions they may have undertaken during phases of psychosis or confusion.

Clinical experiences indicate that the risk of suicide could be increased in some patients during early phases of antidepressant medication, when in many instances a normalizing effect upon psychomotor inhibition symptoms precedes a normalizing of the depressed mood. The risk of fatal or non-fatal self-harm associated with the use of selective serotonin reuptake inhibitors (SSRI) seems, however, not to be different than for tricyclic antidepressants (Martinez et al. 2005), with a possible exception for those aged 18 years or younger.

Single case observations, but not clinical and epidemiological studies (Taiminen and Helenius 1994; King et al. 1995), have indicated that there may exist a clustering effect of suicidal behaviour among psychiatric inpatients. In the aftermath of an inpatient suicide, it would therefore be advisable to be alert to the possibility of contagious effects. Particularly important will be to provide adequate information about the incident to the other patients and to help them cope with grief and stress reactions.

When patients are in transition, either between treatment units, therapists, at home leaves or at discharge, there is a danger that they may react with increased suicide risk and that this risk is not detected because of the changes in therapists. To counteract this danger, it is advisable to conduct repeated evaluations of suicide risk before any major changes are made to the patient's treatment setting or to the protection level. Before free exit or home leave is permitted careful evaluation must be performed and the patient's family should be informed. For patients admitted due to suicidality, an evaluation of suicide risk should be conducted no more than 24 hours before discharge to see if the risk signs and symptoms have been adequately ameliorated. A classical type of risk situation may take place when the patient's therapist is unavailable, on leave or quits the job. As a therapist, one should not underestimate the protective effects against suicide that may arise from the patients' attachment; often an indispensable resource in the treatment. This important aspect of our contact with the patient should be addressed in case a temporal or permanent separation is up coming.

A description of specific treatments, both psychological and pharmacological are given in Part 9, Chapters 53–60 of this book.

Many of the treatments described in Part 9 of this book, and procedures reviewed in this chapter have been shown, in randomized controlled studies, to be efficacious in reducing suicidal ideation and/or behaviour. Whether they will prove to be equally effective in daily clinical practice will depend heavily upon our ability to keep up to adequate quality standards over time. Quality work will often require more resources. It is therefore a leadership responsibility to make necessary priorities and resource allocations and, if needed, to protect treatment programmes of good standards against budget cuts and the sometimes detrimental effects of reorganizing processes. It is absolutely necessary that all clinical staff in a wide range of mental health settings are adequately trained in suicide risk assessment, and in the essentials of treatment and protection of patients at risk of suicide during the different critical phases of their illness. This training must be regularly updated. Equally important is that all new staff are educated to comply with the unit's standards and procedures.

Probably only in an ideal world would we be able to prevent every patient suicide. When suicide does occur in the hospital setting, complex reactions arise among the other patients, the patient's family and the staff (Bartels 1987). Unless we respond constructively to the many challenges and needs that arise, there is risk that the suicide will lead to negative processes, both in the group of patients and among the staff (Brown 1987), and we will probably not be able to learn from what has happened. It is therefore essential that early emotional support is given to all those that have been affected by the suicide, especially the patient's family (Wolfersdorf et al. 2001), but also the fellow patients and to those staff members who were responsible for the patient's treatment (Hodgkinson 1987). This supportive work will follow common principles of crisis intervention bearing in mind the special burdens, risks and social stigma suicide survivors often carry over longer periods of time (Brown 1987; Ness and Pfeffer 1990). After necessary emotional support has been provided to those who have been directly affected by the suicide, it is important to review the incident critically in order to identify possible shortcomings or errors that may have been made in the treatment or protection of the patient. For such a purpose, many units find it useful to hold a review meeting in the aftermath of an inpatient suicide. In this meeting, the clinician in charge of the patient's treatment will first present a summary of the case: history, presenting problem, symptoms, diagnostic evaluations, treatments given, and observations made during the hospital stay. It is of particular importance to provide a detailed account of the last days and hours before the suicide. The rest of the involved staff members will then have the opportunity to make their own contribution in order to create a more complete picture of what happened and why. If possible, a review meeting should be chaired by the unit's clinical director and it is their task to clarify the purpose of the meeting and to make sure that painful, but necessary critical questions are raised about shortcomings and errors in the treatment at the same time as he must counteract tendencies of self-blaming or scapegoating (Wasserman 2001, Beskow et al. 1990). Last, but not least, it is important that the suicide review also includes an evaluation of the quality of the emotional and practical support provided by the treatment unit for the bereaved in the aftermath of suicide.

Most clinical units will find it useful to produce written procedures for many of the specific methods, standards, assessments, precautions or protective actions discussed in this chapter. These documents should be made as clear and explicit as possible and should be the basis for staff training and updating. It is necessary that these written procedures be revised at regular intervals. Local health authorities should also consider regularly auditing treatment units for suicidal patients.

Suicide is the most serious outcome of mental disease and no other known risk factor has such a high prevention potential in relation to suicide as psychiatric disorders. While this underlines the important role played by psychiatric care facilities in suicide prevention, there is, however, a need to strengthen several aspects of the care of suicidal individuals. Psychiatric care needs to be made more available to the population in most countries and there is a need to establish a continuity of care between hospital and outpatient treatment for patients who have been admitted after a suicide attempt. Furthermore, the quality of care must be kept to high standards of clinical evaluations, treatments and safety measures through education of staff, clinical supervision and through adherence to written procedures and it should be improved through review procedures whenever there has been a severe suicidal incident during inpatient care by any of the patients.