Family involvement, patient safety and suicide prevention in mental healthcare: ethnographic study.

BACKGROUND: Family involvement has been identified as a key aspect of clinical practice that may help to prevent suicide. AIMS: To investigate how families can be effectively involved in supporting a patient accessing crisis mental health services. METHOD: A multi-site ethnographic investigation was undertaken with two crisis resolution home treatment teams in England. Data included 27 observations of clinical practice and interviews with 6 patients, 4 family members, and 13 healthcare professionals. Data were analysed using framework analysis. RESULTS: Three overarching themes described how families and carers are involved in mental healthcare. Families played a key role in keeping patients safe by reducing access to means of self-harm. They also provided useful contextual information to healthcare professionals delivering the service. However, delivering a home-based service can be challenging in the absence of a supportive family environment or because of practical problems such as the lack of suitable private spaces within the home. At an organisational level, service design and delivery can be adjusted to promote family involvement. CONCLUSIONS: Findings from this study indicate that better communication and dissemination of safety and care plans, shared learning, signposting to carer groups and support for carers may facilitate better family involvement. Organisationally, offering flexible appointment times and alternative spaces for appointments may help improve services for patients.

The temporal relationships between defeat, entrapment and suicidal ideation: ecological momentary assessment study.

BACKGROUND: Psychological models of suicidal experiences are largely based on cross-sectional or long-term prospective data with follow-up intervals typically greater than 1 year. Recent time-series analyses suggest that these models may not account for fluctuations in suicidal thinking that occur within a period of hours and/or days. AIMS: We explored whether previously posited causal relationships between defeat, entrapment and suicidal ideation accounted for temporal associations between these experiences at small time intervals from 3 to 12 h. METHOD: Participants (N = 51) completed an ecological momentary assessment (EMA) study, comprising repeated assessments at semi-random time points up to six times per day for 1 week, resulting in 1852 completed questionnaires. Multilevel vector autoregression was used to calculate temporal associations between variables at different time intervals (i.e. 3 to 12 h between measurements). RESULTS: The results showed that entrapment severity was temporally associated with current and later suicidal ideation, consistently over these time intervals. Furthermore, entrapment had two-way temporal associations with defeat and suicidal ideation at time intervals of approximately 3 h. The residual and contemporaneous network revealed significant associations between all variables, of which the association between entrapment and defeat was the strongest. CONCLUSIONS: Although entrapment is key in the pathways leading to suicidal ideation over time periods of months, our results suggest that entrapment may also account for the emergence of suicidal thoughts across time periods spanning a few hours.

'Wasn't offered one, too poorly to ask for one' - Reasons why some patients do not receive a psychosocial assessment following self-harm: Qualitative patient and carer survey.

OBJECTIVE: Psychosocial assessment following self-harm presentations to hospital is an important aspect of care. However, many people attending hospital following self-harm do not receive an assessment. We sought to explore reasons why some patients do not receive a psychosocial assessment following self-harm from the perspective of patients and carers. METHODS: Between March and November 2019, we recruited 88 patients and 14 carers aged ⩾18 years from 16 mental health trusts and community organisations in the United Kingdom, via social media, to a co-designed qualitative survey. Thematic analyses were used to interpret the data. RESULTS: Patients' reasons for refusing an assessment included long waiting times, previous problematic interactions with staff and feeling unsafe when in the emergency department. Two people refused an assessment because they wanted to harm themselves again. Participants reported organisational reasons for non-assessment, including clinicians not offering assessments and exclusion due to alcohol intoxication. Other patients felt they did not reach clinically determined thresholds because of misconceptions over perceived heightened fatality risk with certain self-harm methods (e.g. self-poisoning vs self-cutting). CONCLUSION: Our results provide important insights into some of the reasons why some people may not receive a psychosocial assessment following self-harm. Parallel assessments, compassionate care and specialist alcohol services in acute hospitals may help reduce the number of people who leave before an assessment. Education may help address erroneous beliefs that self-injury and self-harm repetition are not associated with greatly raised suicide risk.

'Relieved to be seen'-patient and carer experiences of psychosocial assessment in the emergency department following self-harm: qualitative analysis of 102 free-text survey responses.

OBJECTIVES: We sought to explore patient and carer experiences of psychosocial assessments following presentations to hospital after self-harm. DESIGN: Thematic analysis of free-text responses to an open-ended online survey. SETTING: Between March and November 2019, we recruited 88 patients (82% women) and 14 carers aged ≥18 years from 16 English mental health trusts, community organisations, and via social media. RESULTS: Psychosocial assessments were experienced as helpful on some occasions but harmful on others. Participants felt better, less suicidal and less likely to repeat self-harm after good-quality compassionate and supportive assessments. However, negative experiences during the assessment pathway were common and, in some cases, contributed to greater distress, less engagement and further self-harm. Participants reported receiving negative and stigmatising comments about their injuries. Others reported that they were refused medical care or an anaesthetic. Stigmatising attitudes among some mental health staff centred on preconceived ideas over self-harm as a 'behavioural issue', inappropriate use of services and psychiatric diagnosis. CONCLUSION: Our findings highlight important patient experiences that can inform service provision and they demonstrate the value of involving patients/carers throughout the research process. Psychosocial assessments can be beneficial when empathetic and collaborative but less helpful when overly standardised, lacking in compassion and waiting times are unduly long. Patient views are essential to inform practice, particularly given the rapidly changing service context during and after the COVID-19 emergency.

Evaluating the impact of patient and carer involvement in suicide and self-harm research: A mixed-methods, longitudinal study protocol.

BACKGROUND: Patient and public involvement (PPI) is becoming more commonplace in mental health research. There are strong moral and ethical arguments for good quality PPI. Few studies have documented and evaluated PPI in self-harm and suicide research. Inconsistent reporting of PPI makes it difficult to discern practices that deliver quality, effective and meaningful involvement. It is important to understand and address emotional support needs of PPI members contributing to sensitive topics such as suicide and self-harm. Therefore, this study will examine the effect of PPI on self-harm and suicide research and explore patients', carers' and researchers' experiences and views in relation to the quality of PPI practice and provision of appropriate support for PPI members. METHODS: This protocol outlines the longitudinal, mixed methodological approach that will be taken. Qualitative and quantitative data will be collected via baseline and repeated questionnaires, document review and semi-structured interviews. Both PPI members and researchers will be invited to participate in this study. The two-year data collection period will enable evaluation of PPI throughout the entire research cycle. An integrated approach will be taken to data analysis, using inductive thematic analysis and descriptive and repeated measures analyses, to address specified study aims. DISSEMINATION: Findings from this study will inform practical guidance to support self-harm and suicide researchers in effectively involving people with experiential knowledge in their research. Analyses will offer insight into the effect of PPI throughout the research process and assess changes in PPI members' and researchers' experiences of involvement across a two-year period.

Using my Demons to Make Good: The Short- and Long-Term Impact of Participating in Suicide-Related Research.

Participation in suicide-related research is generally associated with more positive than negative outcomes. However, sparse research has examined the longevity of any effects of participation. Here, we report the first qualitative examination of both the immediate and long-term views of participating in suicide-related research interviews. Thematic analysis indicated that participants had positive experiences, including increased altruism and self-understanding. For some participants, these benefits remained in the months post-participation. Follow-up data revealed that participants can be susceptible to short-term dips in mood, which may not emerge until a few hours/days post-participation. However, any negative effects of participation were confined to the days immediately following the study. Participant-informed recommendations were developed to support researchers in optimizing the well-being of participants in suicide-related research.

Insomnia as a mediating therapeutic target for depressive symptoms: A sub-analysis of participant data from two large randomized controlled trials of a digital sleep intervention.

Insomnia predicts the onset of depression, commonly co-presents with depression and often persists following depression remission. However, these conditions can be challenging to treat concurrently using depression-specific therapies. Cognitive behavioural therapy for insomnia may be an appropriate treatment to improve both insomnia and depressive symptoms. We examined the effects of a fully-automated digital cognitive behavioural therapy intervention for insomnia (Sleepio) on insomnia and depressive symptoms, and the mediating role of sleep improvement on depressive symptoms in participants from two randomized controlled trials of digital cognitive behavioural therapy for insomnia. We also explored potential moderators of intervention effects. All participants met criteria for probable insomnia disorder and had clinically significant depressive symptomatology (PHQ-9 ≥ 10; n = 3,352). Individuals allocated to treatment in both trials were provided access to digital cognitive behavioural therapy. Digital cognitive behavioural therapy significantly improved insomnia (p < .001; g = 0.76) and depressive symptoms (p < .001; g = 0.48) at post-intervention (weeks 8-10), and increased the odds (OR = 2.9; 95% CI = 2.34, 3.65) of clinically significant improvement in depressive symptoms (PHQ-9 < 10). Improvements in insomnia symptoms at mid-intervention mediated 87% of the effects on depressive symptoms at post-intervention. No variables moderated effectiveness outcomes, suggesting generalizability of these findings. Our results suggest that effects of digital cognitive behavioural therapy for insomnia extend to depressive symptoms in those with clinically significant depressive symptomatology. Insomnia may, therefore, be an important therapeutic target to assist management of depressive symptoms.

Learning from clinicians' views of good quality practice in mental healthcare services in the context of suicide prevention: a qualitative study.

BACKGROUND: Suicide and non-fatal self-harm represent key patient safety events in mental healthcare services. However, additional important learning can also be derived by highlighting examples of optimal practice that help to keep patients safe. In this study, we aimed to explore clinicians' views of what constitutes good practice in mental healthcare services in the context of suicide prevention. METHODS: Data were extracted from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) database, a consecutive case series study of suicide by people in contact with mental healthcare services. A large national sample of clinicians' responses was analysed with a hybrid thematic analysis. RESULTS: Responses (n = 2331) were submitted by clinicians across 62 mental healthcare providers. The following five themes illustrated good practice that helps to: 1) promote safer environments, 2) develop stronger relationships with patients and families, 3) provide timely access to tailored and appropriate care, 4) facilitate seamless transitions, and 5) establish a sufficiently skilled, resourced and supported staff team. CONCLUSION: This study highlighted clinicians' views on key elements of good practice in mental health services. Respondents included practice specific to mental health services that focus on enhancing patient safety via prevention of self-harm and suicide. Clinicians possess important understanding of optimal practice but there are few opportunities to share such insight on a broader scale. A further challenge is to implement optimal practice into routine, daily care to improve patient safety and reduce suicide risk.

Short sleep duration and poor sleep quality predict next-day suicidal ideation: an ecological momentary assessment study.

BACKGROUND: Sleep problems are a modifiable risk factor for suicidal thoughts and behaviors. Yet, sparse research has examined temporal relationships between sleep disturbance, suicidal ideation, and psychological factors implicated in suicide, such as entrapment. This is the first in-the-moment investigation of relationships between suicidal ideation, objective and subjective sleep parameters, and perceptions of entrapment. METHODS: Fifty-one participants with current suicidal ideation completed week-long ecological momentary assessments. An actigraph watch was worn for the duration of the study, which monitored total sleep time, sleep efficiency, and sleep latency. Daily sleep diaries captured subjective ratings of the same sleep parameters, with the addition of sleep quality. Suicidal ideation and entrapment were measured at six quasi-random time points each day. Multi-level random intercept models and moderation analyses were conducted to examine the links between sleep, entrapment, and suicidal ideation, adjusting for anxiety and depression severity. RESULTS: Analyses revealed a unidirectional relationship whereby short sleep duration (both objective and subjective measures), and poor sleep quality, predicted the higher severity of next-day suicidal ideation. However, there was no significant association between daytime suicidal ideation and sleep the following night. Sleep quality moderated the relationship between pre-sleep entrapment and awakening levels of suicidal ideation. CONCLUSIONS: This is the first study to report night-to-day relationships between sleep disturbance, suicidal ideation, and entrapment. Findings suggest that sleep quality may alter the strength of the relationship between pre-sleep entrapment and awakening suicidal ideation. Clinically, results underscore the importance of assessing and treating sleep disturbance when working with those experiencing suicidal ideation.

Understanding the role of sleep in suicide risk: qualitative interview study.

OBJECTIVE: Sleep problems are associated with increased risk of suicide, independent of depression. This analysis explores narrative accounts of the role of sleep in relation to suicidal thoughts and behaviours. DESIGN: Qualitative study, based on in-depth semistructured interviews which were analysed with an inductive, latent thematic analysis. PARTICIPANTS: A maximum variation sample of 18 people with experience of a major depressive episode, and suicidal thoughts and behaviours. SETTING: Primary care, North West England. RESULTS: Respondents emphasised the importance of sleep for recovery and management of their mental well-being. Moreover, three inter-related pathways were identified, whereby beliefs about sleep contributed to suicidal thoughts and behaviours. First, being awake during the biological night heightened risk of suicidal behaviours, as this was perceived to be an opportune time for a suicide attempt due to the decreased chances that a friend of family member would intervene during a suicide attempt. Additionally, the reduction in available support at night added to suicide risk. Second, failure to achieve good sleep was perceived to make life harder through contributing to core features of depression, such as negative thinking, attention difficulties and inactivity. Third, sleep acted as an alternative to suicide, by providing an escape from problems, including mental health problems, in waking life. However, this desire to sleep to escape was associated with excessive daytime sleeping, which subsequently may reinforce disturbed sleeping patterns. CONCLUSIONS: Sleep problems should be an important treatment target when working with suicidal clients. More broadly, night-time service provision should be considered when developing suicide prevention initiatives.

Nightmares and Suicide in Posttraumatic Stress Disorder: The Mediating Role of Defeat, Entrapment, and Hopelessness.

STUDY OBJECTIVES: Although nightmares appear to be related to suicidal behaviors, the mechanisms which underpin this relationship are unknown. We sought to address this gap by examining a multiple mediation hypothesis whereby nightmares were predicted to have an indirect effect on suicidal behaviors through perceptions of defeat, entrapment, and hopelessness. METHODS: Data were collected from 91 participants who had experienced trauma and symptoms of posttraumatic stress disorder (PTSD). Nightmares were measured by summing the frequency and intensity ratings of relevant items on the Clinician-Administered PTSD Scale. Participants also completed questionnaire measures of suicidal behavior, hopelessness, defeat, and entrapment. Given the interrelations between insomnia, PTSD, and suicide, a measure of insomnia was included as a covariate. Furthermore, analyses were conducted with and without those participants who had comorbid depression. RESULTS: Suicidal behaviors were higher in those participants who experienced nightmares (62%), in comparison to those who did not (20%). Bootstrapped analyses provided support for the hypothesized multistep mediational model. Specifically, nightmares were both directly and indirectly associated with suicidal behaviors, through perceptions of defeat, entrapment, and hopelessness, independent of comorbid insomnia and depression. CONCLUSIONS: For the first time we show that the relationship between nightmares and suicidal behaviors is partially mediated by a multistep pathway via defeat, entrapment, and hopelessness. Clinically, our work highlights the importance of monitoring and targeting nightmares and perceptions of defeat, entrapment, and hopelessness when working with clients who have experienced trauma. COMMENTARY: A commentary on this article appears in this issue on page 289.