Suicide, self-harm and risk in clinical services

Suicide, self-harm and risk in clinical services Faculty of General Adult Psychiatry Annual Conference SAGE, Gateshead October 2017 Nav Kapur Professor of Psychiatry and Population Health The Centre for Suicide Prevention, University of Manchester UK

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Outline Trends Policy context Recent research

Outline Trends Policy context Recent research

Trends

Hospital presentations for self-harm Source: Multi-centre study of self-harm

Trends

Over 50% of children and young people who died by suicide had a history of self-harm

Over 50% of children and young people who died by suicide had a history of self-harm 30-50 times greater risk of suicide increased in the year after selfharm

Outline Trends Policy context Recent research

Policy Context

Local context The North East Higher rates of suicide than England as a whole (12.4 vs 10.1 per 100 000 per year) https://healthierlives.phe.org.uk/topic/suicide-prevention Higher rates of depression More people admitted for self-harm or alcohol related problems Higher rates of long term unemployment

Outline Trends Policy context Recent research

1) Interventions for self-harm

1) Interventions for self-harm

2) Safety in mental health services National policies and recommendations Removal of ligature points Assertive outreach 24-hour crisis team 7-day follow-up Non-compliance Dual diagnosis Criminal justice information sharing Multi-disciplinary review Training in suicide risk management Safety First, 2001 12 Steps to a Safer Service

Questions Do mental health services implement policies? Do they make a difference?

Suicide rate per 10,000 patients in contact (exact Poisson 95% CI) Do policies make a difference? 13 24-hour crisis team Dual diagnosis policy Multidisciplinary review 12 11 10 9 8 before after before after before after (While et al Lancet, 2012)

Suicide rate vs non-medical staff turnover (%)

Suicide Rate per 10,000 patients per year in contact (exact Poisson 95% CI) 16 15 14 13 Policy on multi-disciplinary review information sharing with families high turnover low turnover 12 11 10 9 8 7 6 before after (Kapur et al Lancet, Psychiatry 2016) Non-medical staff turnover (%)

Safer care in mental health services

3) Risk tools and scales Risk tools and scales to predict suicide after self-harm: Positive Predictive Value less than 5% So they are wrong 95% of the time And they miss suicide deaths in the large low risk group

Risk tools and scales UK NICE Guidelines: Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm. Do not use risk assessment tools and scales to determine who should and should not be offered treatment or who should be discharged. Risk assessment tools may be considered to help structure, prompt, or add detail to assessment.

Method 5 hospitals in England Consecutive presentations of selfharm patients aged 18 or over to psychiatric liaison teams Clinicians determine eligibility MANCHESTER DERBY Quantitative episode based analysis Qualitative evaluation BRISTOL OXFORD Outcome: repeat self-harm at six months BRIGHTON 26

Global scales 27

Sensitivity Cohort study: Area under the Curve 1.0 0.8 ROC Curve Source of the Curve Clinician GS MSHR Total Patient GS ReACT Total BIS Total MSPS Total SAD Total Reference 0.6 0.4 0.2 0.0 0.0 0.2 0.4 0.6 1 - Specificity 0.8 Diagonal segments are produced by ties. 1.0 AUC Clinician GS: 0.74, CI95: 0.69, 0.79 MSHR: 0.72, CI95: 0.67, 0.77 Patient GS: 0.72, CI95: 0.67, 0.76 ReACT: 0.70, CI95: 0.65, 0.75 BIS: 0.62, CI95: 0.57, 0.68 MSPS: 0.58, CI95: 0.53, 0.64 SAD: 0.55, CI95: 0.50, 0.61 28

The assessment of risk and safety in mental health services YOUR views on risk assessment and risk assessment tools and how that can be improved Please complete a 5 minute anonymous survey bit.ly/2jiubvb

Outline Trends Policy context Recent research - Interventions for self-harm - Safety in mental health services - Risk assessment tools

Acknowledgements Funding: NICE & NPSA PRP and NIHR programmes from UK Department of Health, Manchester Mental Health and Social Care Trust Manchester Centre for Suicide Prevention staff: Louis Appleby, Harriet Bickley, James Burns, Matthew Carr, Caroline Clements, Huma Daud, Iain Donaldson, Sandra Flynn, Julie Hall, Isabelle Hunt, Saied Ibrahim, Rebecca Lowe, Sharon McDonnell, Pearl Mok, Thabis Nyasi, Leah Quinlivan, Shaiyan Rahman, Carol Rayegan-Tafreshi, Cathryn Rodway, Alison Roscoe, Jenny Shaw, Sarah Steeg, Philip Stones, Su-Gwan Tham, Pauline Turnbull, Roger Webb, Kirsten Windfuhr, David While Collaborators: David Gunnell, Keith Hawton, Helen Bergen, Sue Simkin, Deborah Casey, Keith Waters, Jenny Ness, Damien Longson, Allan House, Galit Geulayov, Ellen Townsend This presentation discusses independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1247, RP-PG-0610-10026) and Policy Research Programme. The views expressed in this presentation are those of the author and not necessarily those of the NHS, the NIHR or the Department of Health.