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Trigger-warning.

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.

Acute mental health wards need to be better equipped to deal with suicidal patients.

Methods

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.

Results

• 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).

This pilot RCT found that cognitive-behavioural suicide prevention (CBSP) therapy was safe and feasible, but no significant differences were found when treatment as usual (TAU) plus CBSP were compared to TAU alone.

Conclusions

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.”

We can deliver cognitive-behavioural suicide prevention therapy to mental health inpatients, but we won’t know if it works until a bigger study is 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.

Studies that try to deliver therapy on mental health wards are always challenging. The environments can be chaotic, and lengths of stays are not predetermined.

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.

Do we need cognitive behavioural suicide prevention or better community care?

Conflicts of interest

None of note.

Links

Primary paper

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

Other references

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

Photo credits

John Baker was appointed to Chair of Mental Health Nursing in 2015. John’s research focuses on developing complex clinical and psychological interventions in mental health settings. He is particularly interested in i) acute/inpatient mental health services and clinical interventions; ii) medicines management in mental health care; iii) the attitudes and clinical skills of mental health workers, iv) the mental health workforce. The good practice manuals which he developed have been evaluated, cited as examples of good practice, and influenced clinical practice in the UK and abroad. The training package for patients, service users and carers to promote research awareness and understanding has been cited by the MHRN and NICE as an exemplar of good practice.

John is a member of the NIHR post-doctoral panel, sits on the Editorial boards for Journal of Psychiatric and Mental Health Nursing & International Journal of Mental Health Nursing. He is a Registered Nurse Teacher with the Nursing, Midwifery Council (NMC) and is active within Mental Health Nursing Academics (UK).