2017 has already been a busy year for mental health policy announcements. On 9th January the Prime Minister announced a package of measures to transform mental health support, highlighting the “shocking reality” of 13 deaths by suicide a day in England. On the same day the Department of Health published a progress update on the suicide prevention strategy, setting out an intention to improve responses to people bereaved by suicide. This had been one of the two overarching objectives of the revised 2012 suicide prevention strategy, but three years on the progress report acknowledged that “delivery in this area has not progressed enough to ensure that there are good quality and consistent suicide bereavement services in every area across the country”.

These pronouncements on service provision after suicide bereavement have direct relevance to NHS mental health trusts. The recent 20 year review of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness reported that 18,172 psychiatric patients in the UK had died by suicide over the period 2004 to 2014, representing 28% of general population suicides. The MRC-funded systematic review we conducted in the UCL Division of Psychiatry has described the effects of suicide bereavement on mental health and suicide risk, and there is a growing awareness that each suicide has an impact on relatives, partners, friends, and mental health professionals. Guidelines set down in 2009 by the National Patient Safety Agency indicate that after the suicide of a psychiatric patient, mental health teams should offer families and carers “prompt and open information” and “appropriate and effective support” as well as involving them in a routine post-suicide review. Until now it has not been clear how often this happens in practice.

This month our analysis of National Confidential Inquiry data, in collaboration with the NCISH team at the University of Manchester, was published in the US journal Psychiatric Services. This found that relatives of psychiatric patients who died by suicide from 2003 to 2012 were not contacted after the death by members of the mental health team in 33% of cases. In our analysis we had hypothesised that specific, potentially stigmatizing, patient characteristics would influence whether the family was contacted after a psychiatric patient’s suicide. We found that a patient’s forensic history, unemployment, and primary diagnosis of alcohol or drug dependence or misuse were independently associated with a reduced likelihood of staff contacting the relatives in the event of their suicide. We noted that these were markers for suicide risk in themselves. However, minority ethnic group, and recent alcohol or drug misuse were not associated with staff contacting relatives. Violent method of suicide was associated with an increased likelihood of being contacted.

We felt these findings suggested that relatives experience inequities in access to support after a potentially traumatic bereavement. This was a concern given the recognised association of suicide bereavement with suicide attempt, and the possibility that patients’ relatives share risk factors for suicide. Mental health trusts should use these findings to revise their policies on serious and untoward incidents; incorporating protocols for the provision of support to relatives and to trust employees after a patient’s suicide. Considering the impact on fellow patients, whether on wards or in social networks, is also important. Resources such as Help is at Hand, published by Public Health England in 2015, list organisations providing support and information and should be disseminated where indicated. Recent commissioning guidance published by Public Health England makes recommendations, informed by our research, on delivering support after a suicide as part of a wider suicide prevention strategy.

I am grateful to Isabelle Hunt, Sharon McDonnell, Louis Appleby and Nav Kapur at NCISH for agreeing to this collaboration. We presented the findings at the RCPsych General Adult Psychiatry and Child and Adolescent Psychiatry joint faculties’ annual conference in Birmingham in October 2016, which was an opportunity to disseminate the findings to clinicians. Onwards dissemination to mental health staff and clinical leaders has the potential to improve the support offered to people bereaved by suicide, in keeping with national suicide prevention strategy.

Click this link to access the article.

Citation

• Pitman A, Hunt I, McDonnell S, Appleby L, Kapur N.  (2017) Support for Relatives Bereaved by Psychiatric Patient Suicide: National Confidential Inquiry Into Suicide and Homicide Findings Psychiatric Services 68(4); 337-344 doi: http://dx.doi.org/10.1176/appi.ps.201600004

References

• Department of Health. (2012) Preventing suicide in England: A cross-government outcomes strategy to save lives. 17680.
• The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Making Mental Health Care Safer. Annual Report and 20-year Review, October 2016.  University of Manchester. http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/reports/2016-report.pdf
• National Patient Safety Agency. (2009) Preventing suicide: a toolkit for mental health services. National Patient Safety Agency.  Contract No.: 1133.
• Pitman A. Osborn D. King M. Erlangsen A. (2014) Effects of suicide bereavement on mental health and suicide risk The Lancet Psychiatry, 1(1): 86-94 doi:10.1016/S2215-0366(14)70224-X http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(14)70224-X/fulltext
• Pitman A, Hunt I, McDonnell S, Appleby L, Kapur N.  (2017) Support for Relatives Bereaved by Psychiatric Patient Suicide: National Confidential Inquiry Into Suicide and Homicide Findings  Psychiatric Services 68(4); 337-344 doi: http://dx.doi.org/10.1176/appi.ps.201600004 http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201600004  
• Public Health England, National Suicide Prevention Alliance. (2015) Help is at Hand: Support after someone may have died by suicide.  London, HMSO.
• Public Health England (2017) Support after a suicide: a guide to providing local services. https://www.gov.uk/government/publications/support-after-a-suicide-a-guide-to-providing-local-services PHE publications gateway number: 2016392

Research from the UCL Psychiatry Marie Curie Palliative Care Research Department has been reported on the front page of The Times, as well as by The Daily Telegraph and The Sun.

The study reveals that clinicians’ estimates are frequently inaccurate with a tendency to over-estimate rather than under-estimate survival.

A study by Dr Alexandra Pitman, Prof David Osborn and Prof Michael King (UCL Psychiatry), funded by the Medical Research Council, has found that people bereaved by the suicide of a friend or relative have a greater probability of suicide attempt than those bereaved by the sudden natural death of a close contact.

Read the January 2016 paper in BMJ Open here: http://bmjopen.bmj.com/content/6/1/e009948.full

They also found that the probability of dropping out of a job or an educational course was higher in people bereaved by suicide, suggesting that employers and teaching staff should consider how to support people after a suicide (you can read more about this in the following Times Higher Education piece:  www.timeshighereducation.com/news/dropout-rates-soar-those-affected-suicide ).

The team analysed data from a national sample of over 3,400 adults aged 18-40 who had experienced the sudden death of a close contact. Of this sample, 31% had experienced a depressive episode since the bereavement, and 6% reporting having had to drop out from a course or job.  Almost half (45%) the sample reported suicidal thoughts since the bereavement, and 6% had made a suicide attempt since the loss. To give a rough comparison with the general population in England, the 2007 Adult Psychiatric Morbidity Survey had shown that up to 21% of people in the equivalent age group had ever had suicidal thoughts in their life, and 7% had ever attempted suicide in their life. The UCL study figures of 45% and 6%, respectively, only related to the period since the bereavement – an average of only 4 years.

The study authors had input from voluntary sector organisations providing bereavement support when piloting the questionnaire, including Cruse Bereavement Care, Samaritans, Widowed by Suicide, and Survivors of Bereavement by Suicide. Samaritans also advised on the wording of the press release accompanying the publication of this article, being mindful of the language used and avoiding any implication that suicide attempt might be inevitable after suicide bereavement. Read the Samaritans media guidelines on reporting suicide here:  www.samaritans.org/media-centre/media-guidelines-reporting-suicide

– Click the following link for the press release for this study: www.ucl.ac.uk/news/news-articles/0116/270116-bereavement-suicide-attempt-risk/

– A statement from Samaritans about the study findings: www.samaritans.org/news/comment-study-bereavement-suicide-risk-factor-suicide-attempt-published-bmj-open

– A statement from Cruse about the study findings: www.cruse.org.uk/news/BMJsuicide

– If you have been affected by suicide, you can find a Public Health England resource called ‘Help is at Hand‘ at this link: www.gov.uk/government/news/you-are-not-alone-help-is-at-hand-for-anyone-bereaved-by-suicide

A study led by Dr Rory Sheehan, a psychiatrist and academic research fellow, has found a significant number of people with intellectual disabilities might be inappropriately prescribed psychotropic drugs. In particular, the number of people prescribed antipsychotics substantiallyoutweighs the number of diagnoses of severe mental illness in this population. Use of antipsychotics for other presentations, such as challenging behaviour, may be a factor, but the authors suggest that further work is needed to establish why this is the case and to optimise psychotropic prescribing. Dr Sheehan’s article in the BMJ (http://www.bmj.com/content/351/bmj.h4326) has received a lot of media coverage and has drawn attention to the disparity between rates of psychotropic prescription and recorded mental illness in people with intellectual disability. You can read a summary of the research on NHS Choices:http://www.nhs.uk/news/2015/09September/Pages/scale-of-antipsychotic-chemical-cosh-use-explored.aspx

UCL Psychiatry’s Dr Naaheed Mukadam recently wrote an article for The Independent that analyses a recent study suggesting that dementia levels may be stabilising. Read it here.

Professor Helen Killaspy from the Division of Psychiatry has just published a new edition of her Rehab Psychiatry textbook called – “Enabling Recovery”.

How can people with severe mental health problems be supported in their personal recovery?  This question lies at the heart of rehabilitation psychiatry, and perhaps of mental healthcare as a whole. This brand new edition of one of RCPsych Publications’ bestselling titles aims to answer that question:
‘Enabling Recovery: The Principles and Practice of Rehabilitation Psychiatry (2nd edn)’ – edited by Frank Holloway, Sridevi Kalidindi, Helen Killaspy and Glenn Roberts

A Christian group has reported the Royal College of Psychiatrists to the General Medical Council – for saying homosexuality isn’t an illness. The group also named three psychiatrists in its complaint: Professor Sue Bailey, former college president, college registrar Dr Laurence Mynors-Wallis and Professor Michael King, who previously chaired the college’s LGBT special interest group. 

Read the full article from the Independent

http://i100.independent.co.uk/article/christian-group-reports-psychiatrists-to-gmc-for-saying-homosexuality-isnt-a-choice–lygmdskZY1b

23rd Sociology of Health & Illness Monograph

Editors: Paul Higgs and Chris Gilleard

The sociology of dementia is a relatively neglected but increasingly important topic in studies of health and illness. The 23rd Sociology of Health & Illness Monograph will bring together theoretical and empirical contributions to progress a distinctive sociological understanding of this rapidly developing and globally significant field. The Monograph will be published in 2017. It will address the following cross-cutting themes:

Dementia and the construction of personhood. Topics coming under this theme might include the social construction of dementia, the idea of dementia as the social death of the person and the usefulness of Tom Kitwood’s location of the ‘problem’ of dementia within a ‘malignant’ social psychology. Contributions are welcome that draw parallels and contrasts between dementia and other health care conditions where agency and personhood are called into question.

The social representation of dementia. As dementia rises up the agenda of ‘globalisation’, contributions are solicited on the wider range of representations of this condition that go beyond the ‘conventional’ bifurcation between dementia as normal ageing and the ‘medical model’ as a neurological disorder. This could include issues concerning professional-patient interaction, the diagnostic process and the treatment of dementia. We particularly seek perspectives from the global south that situate dementia as a major challenge facing the global community.

The social framing of care. Contributions are invited on formal (paid) and informal (unpaid) care and on the role of professional discourses in ordering relationships between different groups engaged with the provision of care. We would also welcome contributions examining the social categorisation both of people with dementia and of those paid to look after them. We welcome contributions investigating the intersectional links between the care of people with dementia and issues of ethnicity, gender and power.

The social imaginary of a fourth age. We invite contributions examining dementia as an unsuccessful, failed and ‘frailed’ old age contrasted with successful, productive and active later life. Issues that we would expect to be addressed include the moral conflict between a ‘positive’ view of later life and those wary that such advocacy risks further marginalising those disadvantaged by dementia and disablement.

The monograph will appear both as a regular issue of the journal and in book form in February 2017. Potential contributors should send an abstract of up to 600 words to p.higgs@ucl.ac.uk by 30th January 2015. Abstracts should clearly indicate the proposed paper’s sociological importance. Informal email enquiries prior to submission are welcome. Name and institutional affiliation of author(s) should also be supplied, including full contact details. Proposals will be reviewed and potential authors notified by 31 March 2015. Short-listed authors will be invited to submit their work by 31 July 2015. Submissions will be refereed in the usual way and should follow the journal’s style guidelines<http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1467-9566/homepage/ForAuthors.html>

Website Link: http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1467-9566/homepage/call_for_proposals__23rd_monograph.htm

A team led by UCL Psychiatry researchers has recently published the main findings from the NIHR-supported TAS 2 study, a mixed methods investigation of therapeutic relationships in crisis houses and on acute wards. Crisis houses are 24 hour staffed residential services in the community that aim to support people who would otherwise be at high risk of hospital admission through a crisis. A recent national survey of crisis care suggests about 35% of English catchment areas offer some access to a crisis house. Study findings included that therapeutic relationships are substantially stronger in crisis houses than in acute wards. This difference, together with greater support from peers and fewer negative events, may explain the recurrent finding of greater service user satisfaction in crisis houses than in acute wards.

Dr Angela Sweeney was employed as lead research worker on this study. She is a survivor researcher who has now moved to St George’s, University of London, where she is undertaking a five year NIHR Post-Doctoral Fellowship focused on understanding and improving assessment processes for talking therapies. The following is her personal view, drawing on her experiences of conducting the study, of the current state of therapeutic relationships in acute care, and of the fundamental changes she hopes can occur in future.

Are therapeutic relationships between staff and service users on psychiatric wards possible? My hope for engagement on equal terms

         Dr Angela Sweeney, UCL and SGUL

I was sitting in the nurses’ station of a psychiatric ward waiting to talk to a nurse about our ongoing research into therapeutic relationships. “I haven’t had my medication yet” a man said to staff at the nurses’ station. “You have”. No eye contact, curt response, minimal engagement. “I haven’t”. Pause. “I haven’t, can you check”. No response. Increasing frustration, rising anger. “Ask that nurse, she knows”. No response, no engagement. The man began shouting. ‘Don’t talk to me like that. Keep shouting and we’ll call the police’. More shouting, increasing anger. A nurse moved out of the nurses’ station and stood in front of the man. “Calm down or we’ll call the police”. The man drew back his fist, verbally and physically threatening to punch her. Eventually he backed down, walked off, still visibly angry. His medication was still not checked.

It would be easy to dismiss this scene as atypical or unrepresentative. But in interviews with staff and service users as part of our research into therapeutic relationships in psychiatric wards and crisis houses, we found that the basic building blocks of therapeutic relationships between staff and service users on psychiatric wards were often absent. Service users on wards felt that some staff didn’t demonstrate human qualities like warmth and kindness, appeared to be going through the motions of their job to receive a wage, often ignored them, and at worst, baited them to react before forcibly injecting them. Service users often learnt which staff would engage with them and which would ignore or provoke them. In interviews, some nurses, generally early in their careers, described the same situation. One particularly compassionate nurse felt exhausted by being the only staff member that service users made requests to knowing that she wouldn’t ignore them. She felt burnt out, had taken sick time, and was considering leaving to work in the community.

Should we blame staff for the opening scene above? If some staff members can retain their compassion, why not others? Staff typically enter the mental health system because they are compassionate and want to make a positive difference to people’s lives. Scenes like that above are a product of a psychiatric system which reduces people to symptoms of a biological illness, and that believes people need treatment and control, including sectioning, psychopharmacology, seclusion, restraint and forcible injection. One young black man in our study had been pinned down by numerous staff, had his trousers pulled down and been forcibly injected. He described this experience as “simulated rape”. How do service users engage with staff when they have the power to mimic abusers? How do staff truly engage with service users when they are seen as objects of treatment and control?

The answer is not to see staff as the problem (nor indeed service users). Instead, there are calls for psychiatric systems to become trauma-informed. This means assuming that people in the system have experienced trauma (such as poverty, childhood abuse, marginalisation, racism) and that this impacts on how they engage with others and their environment. For an individual staff member, this means considering, ‘how do I create a sense of safety, collaboration and choice for this person in this moment?’ Crucially, the system must support its employees through training, supervision and ongoing support – otherwise, just like the compassionate staff member mentioned above, burn out and high staff turnover will dominate.

My hope? That our research will join the growing clamour calling for an overhaul of psychiatric wards, and that this will eventually lead to staff and service users being free to engage in therapeutic relationships. For me, this can only happen when mechanisms of control – seclusion, restraint and forcible injection – are minimised and eventually abolished. When people are seen in their full contexts, rather than having their distress reduced to symptoms of an illness. And when our experiences of trauma are acknowledged and respected. This will enable staff and service users to engage with one another meaningfully, respectfully and on equal terms, meaning that scenes like the one I opened with become the exception rather than the norm.

For more information on trauma-informed approaches please visit:
The National Centre for Trauma-Informed Care
The Anna Institute

Angela would like to thank Beth Filson, Jasna Russo and Sarah Clement for helpful conversations and comments regarding this blog.

“The importance of music for people with dementia: the perspectives of people with dementia, family carers, staff and music therapists” by Dr Orii McDermott is now available in Aging & Mental Health, Volume 18, Issue 6, 2014 at http://www.tandfonline.com/doi/pdf/10.1080/13607863.2013.875124 and is rated as one of the most viewed this year!