INTERNATIONAL HOSPITALS, PROGRAMS AND GUIDANCE
Self-Harm
Just as the United States has developed guidelines and conducted research surrounding specific policies and practices for suicide and self-harm prevention, international entities have done the same. These guidelines are especially important because self-harm behaviors are often not a singular event but will recur over time (Townsend et al., 2016).
For example, the National Institute for Health and Care Excellence guidelines from the United Kingdom include recommendations for care and psychosocial assessment, as well as guidance to establish care plans and overcome barriers associated with individuals who have experienced self-harm (Kendall, Taylor, Bhatti, Chan, & Kapur, 2011). This guidance provides eight quality statements and ways to measure each regarding the treatment of those who have previously self-harmed: compassionate treatment, initial assessment, comprehensive psychosocial assessment, monitoring, physical environment, risk management plan, psychological interventions, and moving between services (National Institute for Health and Care Excellence, 2013). These quality standards outline how providers, healthcare professionals, and patients themselves can expect these guidelines to work in practice (National Institute for Health and Care Excellence, 2013).
Additionally, the National Institute for Health and Care Excellence outlines guidance that should be followed by all areas of hospitals. For example, emergency departments should follow the guidelines when treating patients after any self-harm attempt and should require a mental health evaluation of all patients before they are released (Olfson et al., 2012). This assessment will help ensure a better understanding of the patient’s current mental state and indicate the best treatment to prevent future incidents (Olfson et al., 2012).
Other researchers also recommend an assessment to understand the mental state of the patients. For example, self-harm patients should complete an assessment to help determine motives, suicide intent, and lifetime problems experienced to provide further insight into treatment and future risk (de Beurs et al., 2018). Differing motives for self-harm may require differing treatment and more personalized care to prevent recurrence or suicide attempts (de Beurs et al., 2018).
Specific treatments for self-harm have shown promising outcomes to reduce death following a self-harm episode. In an outpatient clinical setting, psychosocial therapy helped significantly reduce death caused by suicide related to alcohol and mental health disorders in the year following a self-harm attempt (Birkbak et al., 2016). While the original study was conducted in an outpatient environment, psychosocial therapy may also be effective in a hospital to prevent further self-harm or suicide during an inpatient stay (Birkbak et al., 2016). Nonetheless, since self-harm is generally caused by a wide array of stressful life events and factors, prevention of self-harm will require a multi-faceted to address the various needs of the patients (Townsend et al., 2016).
Suicide
In 2014, the World Health Organization acknowledged the importance of suicide prevention efforts worldwide and provided information about risk factors and treatment measures that should be considered by all governments (2014). These recommendations include screening for suicidal and self-harm thoughts for anyone presenting with these thoughts or those above age ten who have chronic pain, acute emotional distress, or another concerning diagnosis (World Health Organization, 2014). However, the majority of the WHO guidelines do not specifically address suicide in inpatient settings, rather, they focus on the community-level prevention.
The National Institute for Health and Care Excellence has also provided guidance for communities and hospitals to help reduce inpatient suicide risk with five quality statements including prevention partnerships, reduction of access, reporting in media, involving supporters during care, and providing for those affected by suicide (National Institute for Health and Care Excellence, 2019). While most of the recommendations include a multi-agency program to reduce suicide risk, there are a few guidelines for care of suicidal patients in the hospital. First, in the hospital setting specifically, these guidelines call for accurate reporting of self-harm and suicide-related incidents as well as ensuring patient family and/or friends are included (or not), according to the patient’s wishes (National Institute for Health and Care Excellence, 2019). If a patient dies by suicide in the hospital, the staff should be prepared to provide support and help to the family and loved ones as needed to reduce their risk of suicide after the loss (National Institute for Health and Care Excellence, 2019). Similarly, Australian healthcare officials stresses the importance of identifying patients at risk for suicide and conducting proper follow-up with them to prevent suicide (Australian Commission on Safety and Quality in Health Care, 2017).
The Mental Health Act 1983 in the United Kingdom requires hospitalization of those with certain psychiatric disorders and has been used frequently to detain individuals as a way to prevent self-harm and suicide (Wang & Colucci, 2017). While there are many positive effects of hospitalization for care of those admitted after a suicide attempt, the time spent in the hospital can cause adverse response for some (Bantjes et al., 2017) and creates a concern for human rights (Wang & Colucci, 2017). When in an emergency psychiatric unit, a lack of coordination of care received, services available not matching needs, and concern over losing identity all can contribute to a negative inpatient experience and can lead to increased suicide ideation (Bantjes et al., 2017). These concerns regarding hospitalization should be considered when determining the best care for patients who have experienced suicidality.
Clinical practice guidelines exist for suicide prevention but they often lack specific guidance and can be difficult to apply in particular contexts (Wilhelm et al., 2017). However, researchers have identified several procedures to reduce risk of inpatient suicide. First, environmental modifications can address environment or patient-specific concerns. These may include installing a bar in any windows to reduce the risk of jumping or observing patients with more or less frequency based on predicted risk (Navin et al., 2019). Specific medications including antipsychotics, antidepressants, ketamine, and lithium have all helped reduce risk of suicide in inpatient settings (Navin et al., 2019). Cognitive Behavior Therapy and Collaborative Assessment and Management of Suicidality are two therapeutic intervention techniques that have been found to reduce suicide risk in inpatient settings (Navin et al., 2019). Finally, repetitive transcranial magnetic stimulation for three days helped significantly reduce suicidal intent among inpatients (Navin et al., 2019).
Another important aspect of reducing suicide risk is improving staff treatment of patients through staff education. Staff can potentially have negative relationships with patients and may lack the necessary skills to properly take care of suicidal patients (Navin et al., 2019). Therefore, improving staff knowledge and understanding of proper patient care is imperative to reducing suicide risk. One such training is the Skills Training on Risk Management project, which provides various modules to improve problem solving and crisis management. This training program has shown positive results on staff attitudes and knowledge regarding care for patients who may be suicidal (Navin et al., 2019). Gatekeeper training for hospital staff and community members has been shown to increase attitudes, knowledge, and confidence toward suicidal individuals and prevent suicide attempts around the world (Sanne et al., 2018). Training on Additionally, all staff including non-clinical members can benefit from short suicide prevention training to better understand the basis of suicide and how to handle patients who are experiencing suicidal thoughts or behaviors (Berlim, Perizzolo, Lejderman, Fleck, & Joiner, 2007) and should be required at the organizational level to better care for suicidal patients (Donald, Dower, & Bush, 2013). Staff attitudes and behavior can have an effect on patient’s well-being throughout a hospital stay.
The Verbal Suicide Scale was developed to be a short yet effective diagnostic tool to determine suicide risk among psychiatric patients (Koweszko et al., 2016). The scale measures avoidance, internalized aggression, and hopelessness (Koweszko et al., 2016). Use of the Verbal Suicide Scale may allow physicians and hospital staff to quickly and accurately understand the suicide risk of individual patients and help determine the best course of care (Koweszko et al., 2016).
A more recent concern for inpatient suicide relates to assisted suicide. The legality of assisted suicide in some countries can create conflict among providers aiming to prevent suicide attempts while honoring right-to-die desires (Reiter-Theil, Wetterauer, & Frei, 2018). While both suicide prevention and assisted suicide may coexist, it can be difficult to perfectly balance the differing objectives when trying to honor patient wishes and provide quality preventative care. Clearer guidance is needed, especially in countries where assisted suicide is legal, to help alleviate these contradictory situations (Reiter-Theil et al., 2018).