Public Awareness

Public awareness of suicide as a leading cause of death is growing. It is often the case that people suffering from serious suicidal thoughts will not reach out for help because they are worried that acknowledging their suicidality will lead to being invalidated or even being hospitalised (which can be a significant life disruption). While hospitalisation may be necessary in extreme cases, our goal should be to keep the service user out of the hospital for the benefit of the service user and the system of care as a whole. The goal of any system of care should be to provide resources to a large percentage of the population as effectively as possible. Growing numbers of celebrities have come forward with their mental health struggles and suicidal thoughts which may encourage more people who struggle to ask for help. We need to ensure that the right resources are available to effectively treat those who seek help.

Community Awareness

There are a number of training tools for communities and systems of care that educate everyone involved how to talk to people with serious suicidal thoughts. ‘Gatekeepers’ include essential workers and NHS staff, school counsellors, teachers, families and friends, first responders, mental health workers, volunteers and stakeholder organisation colleagues.

A person with serious suicidal thoughts will often express his or her pain in ways that invite others to reach out and help. Gatekeeper training helps someone to recognise these signs and provide help to the person who is suffering, ideally so that such people receive evidence-based care.

Anyone, regardless of background or experience, can learn skills to help keep someone safe and alive. Well known tools in this domain include:

• • Zero Suicide Alliance training
  • ASIST
  • Suicide First A
  • safeTALK

Suicide Risk Assessment

Suicide risk assessment is a process for gauging the severity of suicide risk, although this must never be used to predict the possibility of future suicide. The goal of a thorough suicide risk assessment is to learn about the circumstances for an individual person that have led to them deciding suicide is an option, including warning signs, risk factors, and protective factors. Severity of suicide risk should be regularly re-evaluated throughout the course of care to assess the service user’s response to treatment and care, but also personal situational changes and response to clinical interventions. Valid and reliable risk assessment requires a clinician to integrate their clinical judgement with the latest evidence-based literature so that an individualised and bespoke understanding of each individual’s thinking about suicide is clearly documented.

Suicide-Focused Treatments

Studies show that clinicians who use ‘Treatment as Usual’ are generally providing a lower standard of care for their service users than clinicians who use evidence-based, suicide-focused, clinical treatments. There are four major evidence-based treatments, namely DBT for self harm, CT-SP, BCBT, and CAMS. The vast majority of clinicians are not taught about suicide-focused treatment in professional training programs. CAMS-care UK hopes to change this reality and we thus encourage all clinicians to train in one or more of these evidence-based treatments for suicidal risk.

Non-Demand Caring Contacts

The goal of these interventions is to reduce the risk of suicide by sending various forms of caring communication (e.g. using letters, postcards, texts, emails, and phone calls). These one-directional communications of caring require no response and have been shown to decrease suicide attempts and completions in various large-scale intervention trials.

Social Care Support

Finally, depending upon the resources available in an area, certain systems of care or social services work with the discharged service user to help them with factors that might have caused them to want to end their life, such as housing or healthcare. We know from suicide prevention research that case management can play a key role in supporting people who are struggling. Indeed, organisations specialising in these areas can help support people who are dealing with suicidal thoughts to find jobs, housing, and transportation, which can make a life saving difference.

Around-the-clock Support

People with suicidal thoughts will frequently have feelings of despair outside regular office hours. Services like Samaritans provide an ecosystem of support available around the clock to help people find the support they need in their time of crisis.

NAViGO Case Study

An example of an effective system of care is the NAViGO Suicide Triage Model (NSTM). This ensures local clinicians and stakeholders are working in partnership to ensure those who require mental health service support during crisis receive it, in a timely fashion, whilst those whose risk can be managed through supportive inputs also access the care they need.

Suicide prevention remains an ongoing public health concern around the world. In the United Kingdom, figures from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), the body that has collated suicide data since 1996, indicate that approximately 4,683 suicides were registered annually in England between 2008 and 2018, with little changes in national rates (and in fact, a rise in rates in the general population) during the data collection period (NCISH, 2021). Despite this, there are few efficacious treatments with robust support for reducing suicidal thoughts and behaviours (Fox et al., 2020). Amongst the effective treatments that do exist, there appears to be replicated support for psychological interventions such as Dialectical Behaviour Therapy (DBT), Cognitive Behaviour Therapy (CBT) and the Collaborative Assessment and Management of Suicidality (CAMS; Jobes et al., 2015), yet the evidence base within the National Health Service (NHS) remains sparse. As such, the evaluation of the CAMS intervention within an NHS mental health setting was most opportune.

NAViGO Community Interest Company (CiC) have utilised the CAMS intervention as part of the introduction of the NAViGO Suicide Triage Model (NSTM), an organisation-wide, systems-level approach to assessing and managing suicide risk which has recently won 2 national awards. As described in the original case study, NSTM is a hierarchically supervised, individual-specific real-time suicide risk assessment and care planning process that seeks to assess suicide risk and intervene accordingly, including rapid access to evidence-based treatments for individuals presenting with life-threatening behaviours.

Unlike most NHS mental health providers, NAViGO operates a 24/7 open-access Crisis Resolution Home Treatment (CRHT) service, without need for a referral, that is the gatekeeper of acute admissions. In addition, the Liaison Psychiatry service ensures that all individuals presenting with self-harm and/or life-threatening behaviours to Accident and Emergency within the local general hospital are offered further assessment and treatment. This health and social care model has been an integral part of local service provision since NAViGO’s inception in 2011, allowing all individuals residing in the locality to access these services regardless of the presence of mental health symptomology. As a result, many individuals that help-seek with risk of suicide triggered by negative life events such as relationship problems, bereavement, unemployment and more recently, the COVID-19 pandemic, have received input from NAViGO despite no evidence of a diagnosable mental health condition that would require treatment through mental health services. The research to date suggests that these cases equate to approximately 50% of all suicide risk presentations to the organisation. Due to the unique nature of these services, we would argue that our dataset is far broader in terms of its responsivity to suicide risk “drivers” and associated help-seeking than those seen by other NHS mental health services.

NAViGO’s suicidality cohort therefore, extends beyond just those who have a diagnosed mental health condition or are already receiving treatment within mental health services. The national data for death by suicide numbers for each mental health NHS trust, against which NAViGO is compared, does not account for our inclusivity of social care needs. We estimate that at least double the number of help-seeking presentations engage with our services than would be the case if we restricted our suicide prevention provision to those with mental health conditions alone. The recognition within CAMS-Care that the treatment of mental health conditions per se, is only part of the challenge of suicide prevention work, is borne out by our findings.

Since the implementation of NSTM in April 2018, over 8,000 suicide risk triages have been undertaken within NAViGO, with over 100 individuals (around 1%) requiring the CAMS intervention due to life-threatening behaviours. To date, none of these individuals within the CAMS cohort have died by suicide. The suicide rate for North East Lincolnshire during the project period (2018-2020) has averaged at 8.4 per 100,000 individuals, which was lower than the national average of 10.4 and the lowest of all 15 regions in the Yorkshire and Humber area.

Within the dataset of over 8,000 suicide risk triages, it is estimated that at least three-quarters of individuals did not have a mental health diagnosis at the time of their suicide risk triage. From this cohort, who help-seek through NAViGO services and are identified due to suicidal risk/ideation, there are around 3 confirmed or “suspected” suicides for every 2,000 triages equating to a suicide rate to date of 0.2%. This includes both coroner-confirmed and “suspected” suicides, the latter identified through real-time surveillance to provide appropriate support to bereaved families. Our triage cohort is comprised primarily of cases where an individual’s suicidality is such that that they are actively help-seeking through our services, or who are made known to Liaison Psychiatry due to suicidal behaviours and/or self-harm. Sadly, there is no comparative dataset we are aware of in the UK where the outcomes for those help-seeking for suicidality are followed up in this extensive way.

References

Fox, K. R., Huang, X., Guzmán, E. M., Funsch, K. M., Cha, C. B., Ribeiro, J. D., & Franklin, J. C. (2020). Interventions for suicide and self-injury: A meta-analysis of randomized controlled trials across nearly 50 years of research. Psychological Bulletin, 146(12), 1117-1145. https://doi.org/10.1037/bul0000305

Jobes, D. A., Au, J. S., & Siegelman, A. (2015). Psychological approaches to suicide prevention and treatment. Current Treatment Options in Psychiatry, 2, 363-370. https://doi.org/10.1007/s40501-015-0064-3

National Confidential Inquiry into Suicide and Safety in Mental Health. (2021). Annual Report: England, Northern Ireland, Scotland and Wales 2021. University of Manchester. Retrieved from https://documents.manchester.ac.uk/display.aspx?DocID=55332

Public Health England. Suicide Prevention Profile. https://fingertips.phe.org.uk/profile-group/mental-health/profile/suicide