64 A specialized inpatient unit for suicidal patients: Advantages and disadvantages

In 1986, the Suicide Research Unit (SRU) in Lund, Sweden was established. The unit included a psychiatric inpatient facility specializing in suicidal behaviour until it closed down in 2001. Structured management based on research, scientific evidence and confidence-building measures was offered. The SRU also had a consultation liaison with somatic clinics, an outpatient facility, as well as a unit for the aftermaths of suicide. At SRU, a structured psychiatric diagnostics as well as an organized nursing concept with different levels of supervision and treatment planning were in use. Care included contacts with families and significant others. SRU also collaborated with child and adolescent psychiatry staff. In order to prevent further suicidal acts, a confidence-inspiring relationship with the patients was created at SRU. Strong empathy for suicidal patients, non-judgemental attitudes as well as acceptance of the various feelings of the patients were cornerstones of the care. Warning signs of suicidal behaviour were discovered and discerned.

A structured management is essential when taking care of patients after a suicide attempt. In order to prevent further suicidal acts, one important strategy is to create and maintain a confidence-inspiring relationship with the patient. During 1986–2001, the clinical organization of the Suicide Research Unit (SRU) in Lund, Sweden, included a consultation liaison with somatic clinics, an inpatient and outpatient facility, as well as a unit for the aftermaths of suicide. Continuous contact was kept with the department of forensic medicine. Research and development were integral to all the services offered. Professional structure, confidence-building measures and knowledge were the cornerstones of the organiztion. This structure had several advantages. In the year 2001, the SRU was closed, primarily due to economic cutbacks. The ward became a conventional general psychiatric facility. The university-affiliated part of the SRU is still active as is the philosophy concerning the care of suicidal patients.

A psychiatrist specializing in suicidology, and in many instances a social worker, were in charge of the consultation liaison with somatic clinics. Most psychiatric assessments of suicide attempters were performed in the medical intensive care unit as soon as the patient was able to communicate after a suicide attempt—usually within 12 hours. A structured assessment after a suicide attempt formed the basis for further investigations, assessments and care of the patient (Niméus et al. 2000; Holmstrand et al. 2006; Niméus et al. 2006). Apart from the diagnostic procedure and ratings, the assessment was based on a checklist of items, including information on previous suicidality, psychiatric and somatic diseases, substance use and social status. Suicide risk was estimated with help of the SAD PERSONS scale ([male] sex, [high] age, depression, previous suicide attempt, ethanol abuse, [ir]rational thinking, social support lacking, organized plan [to commit suicide], no spouse, [somatic] sickness) (Patterson et al. 1983) and suicidal intent with the Beck Suicide Intent Scale (SIS) (Beck et al. 1974a). The Diagnostic and statistical manual of mental disorders (American Psychiatric Association 1987) axis I for psychiatric diagnostics was used. In most cases, significant others were contacted and interviewed. After this evaluation, about 50 per cent of all suicide attempters were referred to an inpatient unit, which specialized in suicide attempters (Niméus et al. 2000). Acute suicidality combined with severe psychiatric morbidity, and/or a weak social network was often behind the decision for referral. A member of the nursing staff usually brought the patient to the ward. Admissions could sometimes be compulsory.

The psychiatric inpatient investigation of the suicidal patient and their family started immediately after arrival on the ward. A life history, including the family history of somatic and psychiatric conditions and suicidality, was collected. Comprehensive DSM III diagnostics were often performed by more than one psychiatrist. The psychosocial situation was evaluated by a psychologist (Fribergh et al. 1992) and a social worker. The latter investigated the patient's social network (Magne-Ingvar et al. 1992). In the evaluation process, different kinds of rating scales were also used, such as the Suicide Assessment Scale (SUAS) (Stanley et al. 1986; Niméus et al. 2000, 2006), the Scale for Suicide Ideation (SSI) (Beck et al. 1988), the Hopelessness Scale (HS) (Beck et al. 1974b), the Comprehensive Psychopathological Rating Scale (CPRS), from which the Montgomery–Åsberg Depression Rating Scale (MADRS) was extracted (Montgomery and Asberg 1979). Temperament was also assessed by use of various questionnaires (Engstrom et al. 1996). From a biological point of view, the patient could be assessed concerning the regulation of stress-hormones and peptides, e.g. by use of the Dexamethasone suppression test (DST) (Westrin et al. 1997). Lumbar cerebrospinal fluid (CSF) offered information on, for example, monoamine metabolites (Träskman-Bendz et al. 1981).

The patient always received an intensive and continuous nursing supervision at the medical intensive care unit, and this continued until the point of evaluation by a psychiatrist belonging to the SRU. On arrival in the ward, the staff always searched for and secured the patient's belongings for their own safety (Neilson and Brennan 2001). Professional supervision is a complex nursing procedure, involving both life-preserving actions and a good opportunity for building a nursing alliance (Duffy 1995; Cleary et al. 1999; Neilson et al. 2001; Sullivan et al. 2005; Vråle and Steen 2005). The main aim of surveillance is to reduce suicidal behaviour, to increase trust, to create hope, and to find alternative non-suicidal behaviour. Therefore, a vigilant inpatient nursing staff and good communication between the staff members were important requirements of nursing at the ward.

At the ward, the doctor usually prescribed the level of surveillance. In an emergency situation, however, a nurse could do so. A written record was always made in the patient's chart, and the patient was always verbally informed about the concerns, safety and rules of the ward. If a high level of surveillance (i.e. constraint) was prescribed, the patient was restricted to the ward environment, and thus not allowed to leave the ward as a safety precaution. After a new assessment of suicidality and an oral agreement with the patient, the surveillance was always terminated by a psychiatrist.

The nursing staff created this observation method in order to solve the problem of long-term continuous observation of patients showing signs of repeated self-injuries. This type of observation included a daily and well-structured schedule from 7 a.m. until 9.30 p.m. together with other patients and nursing staff (Table 64.1. The goal was to reduce anxiety and to divert thoughts of self-injury. Each day, the staff and the patient discussed the patient's behaviour, in order to help the patient find new skills to prevent self-harm. This special observation was prescribed by the psychiatrist and lasted for at least one week, or until the patient was able to make a ‘no self-harm agreement’ with the staff. Since the introduction of this concept of fighting self-harm, the number of days on continuous observation decreased by roughly 50 per cent as compared to the year before (Sunnqvist et al. 1996).

No suicides occurred inside the SRU. The unit rules concerning special observation were written very clearly and were agreed upon and understood by the staff. The rules were not flexible. This might be in contrast with policies of other units as described by Duffy (1995) and Vråle and Steen (2005). Our understanding is that the work by all staff members of the ward aimed at promoting the patients' responsibility for their own situation. The staff aimed at supporting and helping the patient before a self-injury, instead of afterwards, and wanted the patient to contact the staff when they felt suicidal or had suicidal thoughts. In the preventive work, the nursing staff used its knowledge about the suicidal process and was vigilant to signs, symptoms and feelings shown by the patients. The staff confronted and helped the patients each time they mentioned anything about suicide thoughts. If the staff intuitively felt that something was wrong, or if they didn't get eye contact with the patient, they again confronted the patient concerning their thoughts and feelings. The atmosphere at the ward was warm, gentle and supportive. Evaluations showed that the patients found it meaningful to make an agreement concerning their suicidality (Sunnqvist et al. 1996).

It is a true challenge to help a person who does not want to live any more. The patient was always offered two contact persons, usually one nurse and one assistant nurse. The nursing staff used a humanistic view and a holistic existential psychiatric nursing model described by Hummelvoll and Bunch (1994). The humanistic view of a person means that the person is seen as a unique individual, i.e. an autonomous, rational, social and spiritual being with responsibilities for their choices and actions. The staff tried to understand, support, inform, guide and create a good, warm and kind atmosphere for all patients. The patients' coping strategies were assessed in different situations. In order to establish a good nursing relationship, the nursing staff used specialized care planning (Persson and Stenquist 1990; Sunnqvist 1990; Träskman-Bendz et al. 1991), which included elements like trusting, listening and focusing on the patient (Cleary et al. 1999; Langley and Klopper 2005).

Based on the care plan, the contact person(s) had at least two 45-minute conversations a week with the patients. Psychiatric nursing is a planned activity, and the work has a clear purpose, which in the case of nursing suicide-prone patients is to give hope for the future. The care plan supported and helped the nursing staff and the patient to get a structure, and also to make a tailor-made nursing plan for each patient (Samuelsson et al. 2000). It also offered opportunities to talk about the suicide attempt, formulate the patients' problems, and to work for a better situation by use of goals and preventive measures (McLaughlin 1999). The care plan dealt with the patient's qualities, strengths and patterns of coping.

In our view, we dealt with two extremes of patients, according to their psychiatric diagnoses: patients with major depressive disorder, melancholia, and those with a cluster B personality disorder. Patients with melancholia needed rest and no nursing demands until their antidepressive treatment showed effect. Then we tried to stimulate them to again become interested in their environment, e.g. family, work, and their own health. Patients with a personality disorder needed structured nursing from the very beginning. Usually, we made an every day schedule, including chores at the ward, but also outside. The aim was, in this case, to keep busy in order to reduce anxiety and self-destructive thoughts.

Twice a week, the nursing staff had a psychological tutorial, aimed at penetrating their own feelings and attitudes towards the suicidal patients. This proved extremely important for the nursing relationship (Hawton et al. 1981; Wolk-Wasserman 1987; Samuelsson et al. 1997, 2000). Negative or hopeless emotions among the nursing staff can be dangerous for a suicidal person (Rayner et al. 2004). If a contact person felt helpless in respect to a patient, the rules were to receive an immediate tutorial because of psychological transference reactions. The tutorial session also helped the nursing staff to perceive and follow the care plan and offered support concerning different cognitive techniques. The nursing staff was also educated in basic conversational and cognitive therapy, as well as continuous training education for suicide prevention (Samuelsson and Åsberg 2002; Ramberg and Wasserman 2004).

The team work, composed of professionals from various backgrounds, served as the base of the ward. Everybody aimed at the same goal—the patient's recovery (Bauer and Hill 2000). Different opportunities and means of collaboration were employed, e.g daily reports from nurses to the psychiatrist about the patients' state of health. Twice a week, the psychiatrist held rounds in order to discuss the patients' treatment and/or further medical investigations. Sometimes we also took the opportunity to discuss an individual patient at a grand round. The aim was then to structure and discuss the treatment of the patient, usually together with invited after care personnel. During these different stages of collaboration, the contact person represented the views of the patient. The multilayered structure resulted in effective care and a breeding ground for a protective environment for suicidal patients (Sun et al. 2006).

The time after discharge from an inpatient unit is a critical point for a suicidal person (Jacobs 1999; Sullivan et al. 2005). Therefore, the staff got in touch with the outpatient unit well before the discharge of a patient. If the patient did not have any prior outpatient contact, such contact was established. Nursing and treatment discharge notes were written and sent to the after care facility as a summary of the inpatient process. Usually the patient got a copy of the nursing epicrisis, which contained information such as:

The staff of the ward also offered 24-hour telephone guidance if the patient needed help in a stressful situation, such as in times of suicidal thoughts, anxiety, crisis etc.

The staff members of our specialized unit started collaboration with the patients' family and/or significant others in the psychiatric consultation situation (see above). A social worker or another staff member phoned or met a significant other after acceptance and choice of the patient. The information gathered from a significant other encompassed questions about their view of the patient's situation, the reasons for the suicide attempt, their perception concerning verbal and non-verbal suicidal communication, etc. The social worker also asked about the significant others' own mental and physical health, and if they needed any help (Magne-Ingvar et al. 1999a). Magne-Ingvar et al. (1999b) found that significant others can provide valuable additional information for the global assessment of the patient, and that they also need guidance and support themselves. The family and/or significant others were informed about the patient's treatment, provided that the patient gave permission.

Many of our patients had children, and it was not unusual that children found a parent unconscious after a suicide attempt or lifeless after a suicide. The children might have heard verbal, direct and/or indirect suicidal threats. They had also lived together with a depressed and psychiatrically ill parent for a period of time. Therefore, we collaborated with the department of child and adolescent psychiatry. We could offer all patients with children below the age of 18 years family sessions, together with a child psychiatrist and a social worker of the ward. One aim was to identify risk factors concerning the children's mental health and to offer crisis intervention for the whole family. Many of the children showed one or more anxious and depressive symptoms, which often improved (Fridell-Johnsson et al. 1994).

When a suicide occurred during hospitalization (for example, when on leave), the ward psychiatrist and the head of the clinic were immediately contacted, so that an appraisal of the situation could be organized. The door of the ward was locked immediately, and the staff offered emotional debriefing. The patients were informed by the ward psychiatrist about the suicide as soon as possible. Immediately after this, all patients had a one on one debriefing with the staff, and their reactions were noted. After a few months, upon receiving police and forensic medical reports, the staff had a formal meeting. Then the signs and symptoms preceding the patient's death were analysed. The aim of this meeting was to learn from experience in order to prevent future suicides (Beskow 1979).

The retrospective meeting included the following points:

Significant others usually have more guilt reactions after a suicide than after a regular death. They generally try to find some explanation as to why their relative committed suicide, and they often don't get any support in their grief. The Suicide Research Centre in Lund started a unit to help and support significant others in their grief. Two social workers (psychotherapists) and a medical doctor offered significant others support and crisis intervention (Traskman-Bendz et al. 1999).

In our opinion, SRU offered several advantages. We had the opportunity to develop a structured management of suicidal patients, based on confidence-building measures, knowledge and research. For example, we organized the nursing so that we were able to spend time communicating with the patients. We learned how to become non-judgemental and to accept the feelings of the patients, and also to feel empathy for their situation. These are important attitudes towards suicidal patients (McLaughlin 1999; Talseth et al. 1999; Sun et al. 2004). Our way of nursing also offered the possibility of discerning warning signs of suicidal behaviour (Clearly et al. 1999). The structured management and its cornerstones made the patient and their families believe in the future. Alongside gradually increasing knowledge and experience with suicidal persons as well as the development of new strategies, an alternative scheduled observation could be developed.

The disadvantages were few, but often marked. Preventing suicide and withstanding the patients' physical and emotional state were onerous duties. Suicidal thoughts, behaviour, and self-harm were often transmitted from one patient to another (Taiminen et al. 1998). Negative feelings were aroused both in the staff and in the patient group. The team continuously had to work hard to create a protective environment, and this could sometimes be experienced as very stressful for the staff. However, the grateful attitudes from the patients, when finally recovered, outweighed many disadvantages.

Among other strategies to prevent further suicidal acts, one is to create and keep a confidence-inspiring relationship with the patient. SRU, which was based on research and gained knowledge, taught us to become non-judgemental, to accept feelings of the suicidal patients, to feel empathy for their situation, and to discern warning signs of suicidal behaviour. Structured management is essential when taking care of patients after a suicide attempt, and the ward's cornerstones made the patient and their family believe in the future.