Second victim experience in Spanish psychiatrists coping with patient suicide: A call for postvention.

BACKGROUND: Losing a patient by suicide may lead to psychological distress and mid/long-term personal and professional consequences for psychiatrists, becoming second victims. MATERIAL AND METHODS: The validated Spanish version of the Second Victim Experience and Support Tool (SVEST-E) questionnaire and a 30-item questionnaire created ad-hoc was administered online to psychiatrists from all over Spain to evaluate how patient suicide affects mental health professionals. RESULTS: Two hundred ninety-nine psychiatrists participated in the survey, and 256 completed the SVEST-E questionnaire. The results of the SVEST-E questionnaire revealed a negative impact of suicide on emotional and physical domains, although this seemed not to lead to work absenteeism. Most respondents desired peer support from a respected colleague and considered institutional support, although desirable, lacking. Almost 70% of surveyed stated that an employee assistance program providing free counseling to employees outside of work would be desirable. The ad-hoc questionnaire showed that up to 88% of respondents considered some suicides unavoidable, and 76% considered the suicide unexpected. Almost 60% of respondents reported no changes in the approach of patients with suicidal ideation/behavior, after losing a patient. However, up to 76% reported performing more detailed clinical evaluations and notes in the medical record. Up to 13% of respondents considered leaving or changing their job or advancing retirement after losing a patient by suicide. CONCLUSIONS: After a patient's suicide, psychiatrists often suffer the feelings of second victim, impacting personal and professional areas. The study results indicate the need for postvention strategies to mitigate the negative impact of patient suicide.

Evaluación de un Programa Intensivode Prevención de Reintento de Suicidio (PIPRS) en un Área de Salud de 430.000 personas / Evaluation of an Intensive-Reattempt-Prevention Programme based on problem solving therapy in a catchment area of 430.000 people in Madrid, Spain

Introducción. La prevención del suicidio es objetivo prioritario en salud mental. Tener un antecedente de intento de suicidio se considera factor de alto riesgo para la repetición. Este estudio persigue evaluar la efectividad de un programa de prevención de reintentos de suicidio en un área sanitaria de 430.000 habitantes. Metodología. Se realizó un estudio de seguimiento de 12 meses con todas (871) las personas que entre el 1 de enero de 2013 y el 31 de diciembre de 2015 habían realizado intentos de suicidio y solicitaron atención en salud mental del área. De estas, 292 recibieron tratamiento en un Programa Intensivo de Prevención de Reintentos de Suicidio (PIPRS) mediante terapia breve de solución de problemas y enfoque de gestión de caso y se compararon con 357 pacientes que recibieron tratamiento convencional (Treatment as usual, TAU). Resultados. Repitieron intento de suicidio el 9,0% en el PIPRS frente al 23,3% del TAU (Prueba exacta de Fisher p<0,001) y un NNT=7, IC 95% (5-11). El análisis multivariante de Regresión de Cox mostró que el grupo que recibió TAU tenía una HR= 2,68, IC 95% (1,65-4,35) respecto al grupo PIPRS. La ventaja del PIPRS se mantuvo al controlar por las características no homogéneas de los grupos. Conclusiones. La aplicación de un programa de prevención mediante psicoterapia breve y enfoque de gestión de caso, tras un intento de suicidio, reduce y retrasa en el tiempo la repetición de intentos durante el año siguiente. Destaca un esfuerzo clínico (NNT=7) muy rentable.(AU)

Background. Suicide prevention is a primary goal of mental health care and a past history of suicide attempts is considered a high-risk factor for subsequent attempts. This study aims to evaluate the effectiveness of an intensive suicide-reattempt-prevention program (ISRPP) in a health catchment area of 430.000 inhabitants. Methods. A 12-month follow-up study was conducted with all individuals who, between 1 January 2013 and 31 December 2015, had attempted suicide and sought mental health care in the area. Out of a total of 871 patients treated, 292 received treatment as part of ISRPP using short-term problem-solving therapy and a case management approach. Results were compared to those of 357 patients who received treatment as usual (TAU). Results. Attempted suicide was repeated by 9,0% in the ISRPP group, compared to 23,3% in the TAU (Fisher’s exact test p<0,001). The number needed to treat (NNT) was=7; 95% CI 95% (5-11). A multivariate Cox regression analysis showed that the TAU group had a hazard ratio (HR)=2,68; 95% CI (1,65-4,35) compared to the ISRPP group. The advantage of ISRPP was maintained when controlling for the non-homogeneous characteristics of the groups. Conclusions. Applied after a suicide attempt, an intensive prevention programme based on brief cognitive behavioural therapy (CBT) and case management reduces and delays repeat suicide attempts at one-year follow-up. The clinical effort is remarkable (NNT=7).(AU)

Cost-effectiveness of a Contact Intervention and a Psychotherapeutic Program for Post-discharge Suicide Prevention.

OBJECTIVE: To determine the cost-effectiveness of 2 strategies for post-discharge suicide prevention, an Enhanced Contact intervention based on repeated in-person and telephone contacts, and an individual 2-month long problem-solving Psychotherapy program, in comparison to facilitated access to outpatient care following a suicide attempt. METHODS: We conducted a cost-effectiveness analysis based on a decision tree between January and December 2019. Comparative effectiveness estimates were obtained from an observational study conducted between 2013 and 2017 in Madrid, Spain. Electronic health care records documented resource use (including extra-hospital emergency care, mortality, inpatient admission, and disability leave). Direct cost data were derived from Madrid's official list of public health care prices. Indirect cost data were derived from Spain's National Institute of Statistics. RESULTS: Both augmentation strategies were more cost-effective than a single priority outpatient appointment considering reasonable thresholds of willingness to pay. Under the base-case scenario, Enhanced Contact and Psychotherapy incurred, respectively, €2,340 and 6,260 per averted attempt, compared to a single priority appointment. Deterministic and probabilistic sensitivity analyses showed both augmentation strategies to remain cost-effective under several scenarios. Enhanced Contact was slightly cost minimizing in comparison to Psychotherapy (base-case scenario: €-196 per averted attempt). CONCLUSIONS: Two post-discharge suicide prevention strategies based on Enhanced Contact and Psychotherapy were cost-effective in comparison to a single priority appointment. Increasing contacts between suicide attempters and mental health-care providers was slightly cost minimizing compared to psychotherapy.

A Real-World Effectiveness Study Comparing a Priority Appointment, an Enhanced Contact Intervention, and a Psychotherapeutic Program Following Attempted Suicide.

OBJECTIVE: To determine the comparative effectiveness of 3 real-practice preventive programs aimed at lowering the relapse risk following a suicide attempt: a single priority appointment with an outpatient psychiatrist, an enhanced contact intervention, and an individual psychotherapy program. METHODS: This observational study was conducted in a sample of 1,492 suicide attempters from 3 catchment areas in Madrid, Spain, between 2013 and 2017. Relapse was defined as an emergency department return after a new attempt within a 1-year follow-up. Kaplan-Meier survival functions were obtained by intervention, and Cox proportional hazard regression models were used to estimate unadjusted and adjusted risks of relapse by intervention. Sex- and age-stratified analyses were also conducted. Covariates were age, sex, history of suicide attempts, history of psychiatric disorders, main ICD-10 psychiatric diagnostic groups, medical comorbidities, and family support. RESULTS: A total of 133 subjects (8.9%) relapsed. The psychotherapy group had a lower presence of known risk factors for suicide attempt. Individual psychotherapy and enhanced contact were more effective than a single priority appointment at reducing suicide reattempt, with a 40% lower relapse risk in adjusted models. Results did not differ after sex and age stratification. CONCLUSIONS: In a naturalistic clinical setting, patients exposed to individual psychotherapy or an enhanced contact intervention had a similar, lower relapse risk than the single priority appointment group.

Factor structure and psychometric properties of the TFEQ in morbid obese patients, candidates to bariatric surgery.

BACKGROUND: To analyze the factor structure and psychometric properties of the TFEQ in a morbid obese Spanish sample of bariatric surgery candidates. METHOD: Multi-trait/ multi-item analyses and alpha coefficients were conducted to test the convergent /discriminant validity and the internal consistency reliability. Principal components analyses (varimax) were used to explore the factor structure. Sub-group factor analyses by gender, age and body mass index (BMI) were conducted to identify unstable items. RESULTS: The internal structure of the original TFEQ factors was unsatisfactory, especially the Disinhibition Scale. Most Disinhibition and Hunger items were grouped on one factor labeled “Dysregulation Eating”. Cognitive Restraint was split into two factors. The first one, related to the behavioral component of Restraint, labeled “Restrained Behaviour” and the second one related to weight and eating concerns called “Predisposition to Restraint”. CONCLUSIONS: The original factor structure of the TFEQ was not replicated. A revised 23-item instrument, representing the three new derived factors is offered as a valid screening instrument for severely obese patients.

Factors associated with hospitalization after suicide spectrum behaviors: results from a multicenter study in Spain.

The objective of this study was to identify factors associated with hospital admission after suicide spectrum behaviors. Patients' characteristics, the nature of the suicidal behavior, admission rates between centers, and factors associated with admission have been examined in suicide spectrum presentations to emergency departments in 3 Spanish cities. The intent of the suicidal behavior had the greatest impact on hospitalization. Older age, living alone, self-harm method not involving drug overdose, previous history of suicide spectrum behaviors, and psychiatric diagnosis of schizophrenia, mood, or personality disorder were independently associated with being admitted. There was a 3-fold between-center difference in the rate of hospitalization. Widespread differences in the rate of hospitalization were primarily accounted for by characteristics of the individual patients and their suicidal behavior.

Prevención del suicidio en médicos / Suicide prevention in doctors

Se sabe que la tasa de suicidio en médicos es mayor que en la población general. La salud de los médicos ha recibido escasa atención de sus colegas, a pesar de la considerable y creciente evidencia de que la morbilidad es alta en la profesión. Cuidar de otras personas genera estrés en los cuidadores. El estrés por la incertidumbre clínica y el temor al fracaso son rasgos importantes de la cultura médica. La paradoja es que el cuidado de los pacientes genera estrés pero es también la fuente de gratificación más importante del médico. Se sabe que aquellos que cuidan de los demás a menudo tienen grandes dificultades para buscar y recibir ayuda para ellos mismos. Las tasas de suicidio de los médicos en Estados Unidos, Inglaterra y otros países son más altas que las de la población general y las de otras profesiones. La tasa de suicidio de los médicos es ligeramente mayor que la de la población general, mientras que la de las médicas es claramente superior. Esta tendencia es más pronunciada entre psiquiatras y anestesistas. Los médicos tienen unas necesidades asistenciales específicas por sufrir elevados niveles de alcoholismo, dependencia de drogas, rupturas matrimoniales, enfermedad mental y suicidio. La automedicación es muy frecuente entre los médicos, en especial con hipnóticos, antidepresivos y analgésicos opiáceos. Muchas de estas dificultades están relacionadas con el estrés, elevada responsabilidad y tiempo insuficiente para trabajar y vivir conciliando las demandas laborales y familiares. Muchos médicos tienen grandes dificultades para discutir sus problemas con los colegas y se tratan a ellos mismos, de forma notablemente peligrosa. El fácil acceso de los médicos a las drogas implica que el abuso de drogas sea un riesgo ocupacional potencial de hombres y mujeres (AU)

The rate of suicide in physicians is known to be higher than that of the general public. The health of doctors has always received scant attention from their colleagues, in spite of considerable and increasing evidence that morbidity and mortality are high in the profession. Caring for others imposes considerable strains on the careers. The stress by clinical uncertainty and the fear of failure are important parts of the medical ethos. It is recognized that those who do care for others often have great difficulty in asking for, and receiving, care for themselves. Suicide rates for doctors in the United States, United Kingdom and other countries are higher than general population and other professions. The suicide rate of male physicians is slightly higher than that of the general population, while that of their female colleagues is clearly higher. This tendency is most pronounced in female psychiatrist and anesthetists. Doctors have specific needs for health care by suffer abnormally high levels of alcoholism, drug dependence, marital breakdown, mental illness and suicide. The self-medication is common among doctors, particularly sleeping tablets, antidepressants and opiate analgesics. Many of the difficulties are related to stress, high responsibility and insufficient time to do the work and to live reconciling demands between work and family. Many doctors show an increased impediment for discuss their problems with colleagues, and treat themselves, which is notoriously hazardous. Doctors' easy access to drug makes drug abuse a potential occupational hazard for men and women (AU)

Maintenance of attention and pathological gambling.

In the study of addiction, attentional bias refers to the observation that substance-related cues tend to capture the attention of experienced substance users. Attentional bias is a cognitive intermediate in the conditioned association between drug-related cues, craving, and relapse. Numerous studies have documented the existence of attentional bias for cues associated with substances. By contrast, few studies have investigated attentional bias in individuals with pathological gambling (PG) or problematic gambling. In this study, we sought to assess attentional bias at the level of maintenance of attention in a sample of pathological gamblers. Twenty-three pathological gamblers and 21 healthy volunteers performed the Visual Probe Task to compare attentional bias with gambling-related cues between individuals with PG and healthy volunteers. The measured of attentional bias was based on their reaction times (RTs) to probes replacing neutral and gambling-related cues (images). Second, we examined the correlation between PG severity and degree of attentional bias among individuals with PG. Results show that pathological gamblers, but not healthy volunteers, had attentional bias for gambling-related cues with exposure times that assess maintenance of attention. There was no correlation between PG severity and degree of attentional bias. Theoretical and clinical implications of these results are discussed.