Caring for people who are suicidal on acute mental health wards is challenging for the person receiving care and those caring for them. Most acute mental health wards are not safe places, despite the investment in removing ligature points from them. Risks can increase with periods of leave away from the ward, and in the first few days of discharge (Sakinofsky et al., 2014). There are few evidence-based interventions for staff working on wards to help people when they are suicidal, and staff are often required to observe people for long periods of time to manage the risk.
This study by Haddock et al., (2019) aimed to determine whether cognitive-behavioural suicide prevention therapy (CBSP) was feasible and acceptable, compared to treatment as usual (TAU) for in-patients who are suicidal.
This study comprised a single-blind pilot randomised controlled trial which compared TAU plus CBSP (cognitive-behavioural suicide prevention therapy) to TAU for people on acute mental health wards who were suicidal. The intervention consisted of up to 20 CBSP sessions delivered by a psychologist over 6 months, which continued in the community following discharge if necessary.
Cognitive-behavioural suicide prevention therapy (CBSP) is a one-to-one psychological therapy that aims to achieve a detailed understanding of an individual’s experiences of suicidality and to change the thinking processes involved in the activation, maintenance and elaboration of suicidal thinking and behaviour.
Participants were assessed at baseline, 6 weeks and 6 months with sixteen secondary outcome measures of psychopathology, suicidal and negative appraisal, and quality of life. Health economic data was collected through the EQ-5D-5L and use of services inventory.
- Of 178 potentially eligible patients only 51 were randomised.
- 27 people received TAU, and 24 CBSP + TAU.
- People received a mean of 11.3 sessions of approximately 52 minutes duration, ten sessions was deemed acceptable although 20 were offered.
- None of the 255 serious adverse events were considered research related, and there were no significant difference between the two groups in the amount of serious adverse events.
- No significant differences were observed between the TAU plus CBSP and the TAU group on any secondary outcome measures, across all assessment time points.
- Overall 57% (29/51) of participants had complete costs and QALY data (CBSP n= 12/24; TAU n = 17/27). The findings were non-significant (no difference in cost or QALYs) although the authors suggest possible savings for TAU+CBSP
- Qualitative interviews of acceptability indicated that both staff and patients viewed the intervention positively, but these findings were reported elsewhere (Awenat et al., 2018; Awenat et al., 2019).
The author’s briefly concluded that:
“Psychological therapy can be delivered safely to patients who are suicidal although modifications are required for this setting. Findings indicate a larger, definitive trial should be conducted.”
Strengths and limitations
- Studies that try to deliver therapy on wards are always challenging. The environments can be chaotic, and lengths of stays are not predetermined.
- As is common with underpowered feasibility studies hampered by missing data, the secondary outcome measures don’t indicate differences when compared to the TAU.
- Clearly it seems feasible to develop and deliver such an intervention, but it was unclear whether the dose of therapy needed to be 10 or 20 sessions and this obviously would impact on the ability of staff to deliver it in future studies.
- Researchers need to continue to develop interventions that are acceptable to patients, in this study only 50% of those approached agreed to take part.
Implications for practice
Periods of leave, and discharge from hospital (first 72 hours) are known risk periods for suicidal patients. The continuity of engaging with patients on wards, and following them into the community whilst trying to help them deal with their suicidal thoughts is therefore important. That this study followed people into the community to continue to deliver the intervention was an important adjunct. However, that only psychologists where chosen to deliver the intervention is frustrating. Whilst wards would benefit from greater availability of psychological interventions, in reality few psychologists work in these environments.
Conflicts of interest
None of note.
Haddock, G., Pratt, D., Gooding, P., Peters, S., Emsley, R., Evans, E., . . . Awenat, Y. (2019). Feasibility and acceptability of suicide prevention therapy on acute psychiatric wards: Randomised controlled trial. BJPsych Open, 5(1), E14. doi:10.1192/bjo.2018.85
Awenat, Y, Peters, S, Gooding, P, Pratt, D, Huggett, C, Harris, K, Armitage, CJ & Haddock, G 2019, ‘Qualitative analysis of ward staff experiences during research of a novel suicide-prevention psychological therapy for psychiatric inpatients: Understanding the barriers and facilitators.‘, PLoS ONE, vol. 14, no. 9, 14(9) e0222482, pp. 1 28.
Awenat, YF, Peters, S, Gooding, PA, Pratt, D, Shaw-núñez, E, Harris, K & Haddock, G 2018, ‘A qualitative analysis of suicidal psychiatric inpatients views and expectations of psychological therapy to counter suicidal thoughts, acts and deaths‘, BMC Psychiatry, vol. 18, no. 1.
Sakinofsky I. Preventing suicide among inpatients. Can J Psychiatry. 2014;59(3):131-140. doi:10.1177/070674371405900304
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Have to wonder if researchers have ever been an inpatient on a MH ward. They are violent threatening settings where nursing staff are there to monitor and watch. Support is an alien concept. Mist staff lock themselves in the office and most pts try avoiding them. Anecdotal accounts of abuse of power and cruelty are widespread. Sexual violence- including from staff- towards women inpts is widely reported in the public domain.
As a pt there is rarely a dedicated person who speaks to you on a shift. Prone restraint remains common, non prone restraint and punitive actions such as refusal of allowing s17 leave granted used frequently
Pts are expected to manage inter pt conflict. Every pt knows the ligature points and best times to try end your life.
What on earth do staff think is being talked about?
There is no trust at all so time with a psychologist who gives a break from what is described above is simply that. You are not going to EVER disclose if you are suicidal with plans because the learnt script is dont tell and deny to get out. Leave or discharged. Which is exactly why the suicide rate when a pt is on leave and just post discharge is so high: so traumatising is a ward getting out at ANY cost with ANY plans becomes a mission.
Most pts will tell you ( if researchers EVER asked) is that the most support received is from the domestic staff or a HCA. Not a professional. And so any positive psychological support is welcome- you font have to be a psychologist who is immediately going to breach therapeutic trust by writing in notes and sharing with an uncaring untrusted MDT.
Give us access to therapy immediately on discharge. Make sure it is trauma based – really so, not just trauma informed, the latest buzz word used. Make sure it addresses the trauma of being in such an abusive setting in the name of health. Better still provide therapy outside of the MH Trust that harmed so we can really get support and safety for the future.
If psychologists want to address suicide it won’t happen on a ward where the majority of pts detest the staff group.