Systems of Care
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:
Suicide Risk Assessment
Non-Demand Caring Contacts
Social Care Support
NAViGO Case Study
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.
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