High Risk Mental Health Patients
Dr Robert Dudas
Consultant Liaison Psychiatrist
Dr John Hague
Member of Governing Body
Ipswich and East Suffolk CCG
1
What’s New?
• CMO Report on Mental Health
• National Confidential Enquiry into Suicide
in Primary Care
• Work in Detroit
2
CMO Report
• 4313 suicides in England in
2012
• Rates lowest ever in 2006/7
• Increased since ? Due
downturn
• 28% of these had MH
service contact in last year
• 14% MH Service contact in
last week
3
Suicide Rates in Europe 2013 – source WHO
4
Methods
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Hanging 60% men
Hanging 28% women
Hanging is increasing in both sexes
Year on year increase in use of helium
inhalation
• Internationally increased use of charcoal >
CO
• Reduction in self poisoning and car
exhaust
Suicide Data
• 3 x more men than women
• Peaks in middle age
• Half of all suicides in men >55
6
7
Messages for Primary Care
• Only a minority of suicides will have seen
MH services
• Restriction of means is worthwhile – e.g.
stopping co-proxamol prescription, and
reducing pack sizes of e.g. paracetamol
• I think that means restriction is something
we can be more active about
8
Firearms in Suffolk
Headline
and
picture
from
EADT
• In 2009 there were 7,569 licensed guns per
100,000 population in Suffolk
• The FOURTH HIGHEST number / 100,000 in
England and Wales
• OVER 55,000 guns in Suffolk
• Please don’t forget to restrict access to firearms
in people at risk
9
Data from Guardian online
Self Harm
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Self Harm
• Most episodes are self poisoning
• Injury is on increase
• 30-40 episodes of self harm for every
suicide
• Risk of suicide is 60 – 100 x the general
population risk in the year after self harm
• Brief CBT/ problem solving Rx can reduce
suicide in self harmers
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Self Harm
• The patient
handout in your
packs was written
for the CCG by a
Professor of
Psychiatry
• It is based on CBT
principles
12
National Confidential Enquiry 2002 - 2011
• 63% of suicides had seen GP
in year before
• Only 8% referred to MH
Services
• Although 25% in contact with
MH services
• Risk increases with number of
GP consultations, especially in
last 2-3 months
• 37% did not have a mental
health diagnosis recorded
• 52% NOT prescribed
psychotropics in year before
13
Risk of suicide
• Self harm in last year increases risk by
60 -100 x
• If consult PC > 24 x, increases risk by 12 x
• Prescribed > 1 drug increases risk by 11 x
• Combination of bezodiazepines with
antidepressants increases risk
• Lithium seems to be protective
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17
Detroit
• 13 years ago Henry Ford
Health Program had a suicide
rate of 89 per 100,000
• By comparison the UK rate
was about 23 per 100,000 in
the same year
• They then introduced ‘Perfect
Depression Care’, and a ‘Zero
Tolerance for Suicide’
• They faced very similar
challenges to the NHS
• Everyone said they were mad!
• For the 9 quarters recently
they had NO suicides of
patients under their care
18
Detroit
19
What Can we do?
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Assess risk using latest risk factors
Refer when you are worried
Don’t be afraid to be pushy
Watch out for new frequent attenders
Watch out for new DNA’s
Watch out for more than 1 drug
Remember self-harm raises risk
Restrict Means of Suicide
Treat depression well
Use the self harm / suicide risk patient card
Now lets hear from an expert how to do it
Preface
• Suicide is a rare event and highly
unpredictable with a huge impact
• The role of risk assessment & using
assessment tools
• Differences between self-harm and suicide
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RISK ASSESSMENT
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We always do it
Document RA & management plan to mitigate risk, update and share it
“fixed” vs “fluid risk factors, PAST – PRESENT - FUTURE
PAST
• Suicidal thoughts
– Context? Part of mental illness at the time? How coped/kept self safe?
• Self-harm
– Risk of accidental death? Indifferent to risk of dying?
• Suicide attempts
– How many? Context? Planned/impulsive? Intention to die? Believed to be lethal?
Avoided to be found? “final acts”? Violent? Sought help afterwards?
• Abuse
• FH of suicide
• Recent discharge from hospital/care
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RISK ASSESSMENT
PRESENT
• Situation now
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Low mood? Angry? Hopeless?
Mentally ill? Substance abuse?
Major life stress, esp. loss, rejection, failure?
Painful physical condition? Recent loss of health?
Male? Young unemployed? Childless female? Single? Living alone?
• Suicidal THOUGHTS, PLAN, INTENTION, PREPARATION – clarify!
NB extended suicide!
• Access to means
– Farmer? Doctor? Vet? Chemist? Armed forces?
• Protective factors
– What kept you from doing it?
– Social support? Responsibility? Spiritual? Problem-solving skills?
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• Able to seek help?
RISK ASSESSMENT
FUTURE
• Planning for the future?
• Events looking forward to? Events worth living for?
• Upcoming stressful/anniversaries?
• Upcoming decisive events?
• Events after which no longer felt needed?
• Feels dying would be better from someone else as well?
• Planned suicide, e.g. on birthday/anniversary, suicide pact?
• Scheduled appointments with health/social care?
• Use collateral information
• Consider standardized tools (not to estimate risk!)
– Referral form + Ipswich Hospital Liaison Psychiatry Service Well-being Screen
– DICES
– Safe-T
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RISK ASSESSMENT
Yes
1
During the last two weeks, have you often been
bothered by feeling down, depressed or hopeless?
2
During the last two weeks have you often been
bothered by having little interest or pleasure in doing
things?
3
Over the past two weeks have you been
feelings nervous, anxious or on edge?
4
Over the past two weeks have you been unable to stop
or control worrying?
5
Would you like any help with these difficulties?
6
25
Do you feel hopeless about the present or future?
7
Have you had thoughts about taking your life?
8
When did you have these thoughts and did you
have a plan?
9
Have you ever attempted to harm yourself?
10
Do you have any such thoughts or intention now?
No
7. BIO-PSYCHO-SOCIAL RISK IDENTIFICATION
Lower Risk
?
Factor
Abstract ideation, no firm plan or
1. Suicidality
means, no recent prior attempts
& Self-Harm
No significant recent history of violence
or abusive behaviour
No known dependents, safeguarding
risks
No history of MH problems (NB: 1st
symptoms later in life may be a high risk
factor), no history in family
Little or no drug/alcohol use, no
significant physical co-morbidities
Positive, supportive relationships with
immediate family, mutual reciprocity and
dependable ‘caring’ duties
Socialises regularly, has access to and
uses community groups and networks
None, or minimal, significant negative
changes in circumstances in recent
history or near future
Has work (paid or unpaid) that is secure
and contributes to well-being and sense
of purpose
Has secure place to live (tenancy,
home), with no known threat to tenure,
rent or mortgage arrears, etc.
Consulting at appropriate intervals, with
no recent escalation
2a. Risk to others:
violence &
aggression
2b. Safeguarding
3. Mental Health
History
4. Co-morbidity
5. Relationships
6. Social Resources
7. Significant life
events
8. Employment
9. Accommodation
10. Frequency of
consultation
On no psychotropic drugs
11. Medication
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Higher Risk
Expresses preference to die or self-harm.
Concrete plans, has means, prior attempts
Has expressed plans, with means, to cause
harm, or through incapacity risks unintentional
neglect
Safeguarding risks
Has been under the care of specialist MH
services, especially In-patient/HTT, in last 2
years, history of SMI in family
Significant drug/alcohol use, physical health
problems
Strained or broken down with partner, parents,
children, siblings, close friends, significant
others
Socially isolated, with little or no access to social
opportunities and low desire to attain
One or more significant events that might add to
distress: e.g. death, illness, divorce, relationship
breakdown, changes at 8 – 10
No employment, imminent threat to employment
or works in role that’s contributes to distress
No secure place to live, sleeps rough, ‘sofa
surfs’, living conditions contributes to distress,
tenure imminently at risk
Frequent consultation, with increase in last year
(especially if 15 or more times in a year) ,
or non-attendance
On psychotropic drugs, with more than one
psychotropic, or combination of antidepressants
with benzodiazepines being a higher risk
Means of suicide not controlled
Means of suicide or self harm removed
(means of hanging or poisoning)
Are any firearms inaccessible or
removed?
?
Firearms accessible
12. Means
BRIEF DETAILS
RISK MANAGEMENT
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Some more mutable than others – do our best at treating what we are good
at treating and delegate the rest appropriately
Distinguish long-term and acute risk (NICE CG16 and CG 133)
↑ protective factors
↓ risk factors
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Detect and treat depression/
mental illness
Warn about initial potential ↑ in
suicidal thoughts/agitation
Limit prescriptions to 1/52
Return unused/stockpiled meds
Remove sharps/means of suicide
Monitor response at least weekly
Safety plan agreed with patient
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Who to contact in crisis?
What to do to avert suicidal thoughts?
How to occupy self during the day?
Reduce substance abuse
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Psychological support (CBTbased, problem-solving)
Explore likely impact on others
Enlist the support of family and
friends
Religious/spiritual support
Refer to secondary care
RISK MANAGEMENT
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discuss with the patient and family if consents the assessment and plan
Involve AAT/IDT, HTT if indicated
Invite disagreement from colleagues (!)
If risk unmanageable in the community  admission to hospital
***
If things do go wrong, try not to blame yourself – it is the nature of working with
risk. Also, to err is human and if we made a mistake our responsibility is to
learn from it.
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Depression Care
• Don’t forget the Suffolk Wellbeing Service
• The idea is that we have at least 15% of
our patients with anxiety or depression
seeing them every year
• This year very few surgeries have
managed that
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Suffolk Wellbeing Service – to July this year
Variance YTD from plan
30
20
10
0
-10
Variance
-20
-30
-40
-50
-60
Variance YTD from plan
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Suffolk Wellbeing Service
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Offers NICE approved talking treatments, including Cognitive Behaviour Therapy, counselling,
Interpersonal Therapy
The wellbeing service offers direct access to one-off workshops on managing stress, improving
sleep and mindfulness, patients can phone up and book one near them.
24/7 online support via Big White Wall
A more detailed assessment, and telephone (which is effective and accessible), or face to face
treatment is available, if needed – but in many cases is not needed.
There are no waiting lists
Please would GPs and other healthcare professionals encourage self referral via the website or
offer do this in the surgery with the patient. The service doesn’t need a letter or lots of detail.
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twitter: @NHSWellbeing
Facebook : www.facebook.com/NHSWellbeing
web: www.readytochange.org.uk
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Please ensure that the wellbeing slides are on your surgery Amscreens (accessed via the CCG)
and a link to the service is on your surgery website
Suggest to patients that they may benefit from ‘talking treatment’, mention the brilliant workshops
as a likely first intervention – the idea of a ‘stress control workshop’ is much less frightening to
most people. The sites above are regularly updated with workshop venues and times
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Suffolk Wellbeing Service
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The workshops offer a rapidly accessible, very effective, entry into treatment, and often are the
only treatment that people need.
They are backed up by a large amount of written and DVD material that is given to patients.
Patients often find the anonymity of the groups comforting
They are more akin to going to a lecture or cinema, and do not involve sitting around in a circle of
chairs
Even patients who have had face to face counselling or CBT before find the workshops and
groups helpful – recommend them with confidence
The treatments offered by SWS are about as effective as giving an SSRI
Consider asking patients to self-refer BEFORE you prescribe (Obviously assessing severity and
risk, and referring patients with significant risk to the Access and Assessment Team)
The CCG monitors and performance manages the effectiveness of the service on a monthly basis
Recovering patients will pick up very useful skills to help prevent relapse
Basically, if your patient has depression or any anxiety disorder, at any stage, suggest that they
contact the wellbeing service
If you have a pharmacy or dispensary attached to your surgery, why not put a wellbeing leaflet or
card in every order that is given to a patient containing a box of SSRI’s ?
Brilliant self help resources available via www.readytochange.org.uk
www.ntw.nhs.uk/pic/selfhelp/
Suffolk Wellbeing Service
Workshop on Stress/ Anxiety
and introduction to other
options
Courses on:
• Improve Your Mood
• Dealing With Worry
• Confidence and
Assertiveness
• Living well with Long
Term Conditions
• Mindfulness
Individual Guided Self Help
• CBT
• IPT
• CAT
• EMDR
• Counselling
• Online Therapy
Assessment
24/7 Support with
Big White Wall
Stress Control 4 week
Course
Wellbeing for Carers Course
(with Suffolk Family carers)
One Off Workshops
• Improving Sleep
• Relaxation
• Mindfulness
• Managing Stress
Thank you
• Any Questions?
• Dr John Hague
• johnhague@nhs.net
• 07771 734572