Overview of clinical risk: psychiatric emergencies
Description: Overview of clinical risk: psychiatric emergencies Training for Nurses Responsible Clinicians for contact: Frank Röhricht Associate Medical Director Lorraine Sunduza Deputy Director of Nursing Acknowledgments Development of this training
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slide1. Overview of clinical risk: psychiatric emergencies Training for Nurses Responsible Clinicians for contact:
Frank Röhricht
Associate Medical Director
Lorraine Sunduza
Deputy Director of Nursing<br>
slide2. Acknowledgments Development of this training was funded by Health Education North Central and East London and supported by Dr Geraldine Strathdee, National Clinical Director, Mental Health, and NHS England.
The teaching materials have been developed according to a curriculum that was collaboratively agreed between GP mental health leads and ELFT staff.
We would like to thank all those involved in the development of these materials:
-Professor Frank Röhricht
-Laura Pisaneschi, developer of materials
-Lorraine Sunduza
-Alex Obamwonyi<br>
slide3. Overview of Module: Clinical risk/Psychiatric emergencies It is anticipated that by attending this training you will have an impact on your patients’ outcomes.
These are that patients will:
Remain free from harm (where factors are in the control of the healthcare practioner)
Be referred to other appropriate health care professionals in a timely manner
Feel they are being treated in a non-stigmatising environment.<br>
slide4. Learning objectives Following completion of this training you will:
Be aware of what constitutes a psychiatric emergency
Have an awareness of the different types of self-harm and self-injury
Know the difference between self-harm and suicide
Be confident in:
Talking to a patient who has just divulged that they are self-harming
Assessing suicide risk
Dealing with violence and aggression<br>
slide5. What Is self-harm? Self-harm (also sometimes known as self- injury)describes a wide range of things that people do to themselves in a deliberate and usually hidden way.
Methods can include:
Cutting, burning or scalding of the skin
swallowing amounts of toxic substances
hitting
scratching and hair pulling<br>
slide6. Self-Harm and young adults About 1 in 10 young people will self-harm at some point, but it can occur at any age.
It is more common in young women than men.
Gay and bisexual people seem to be more likely to self-harm.
Sometimes groups of young people self-harm together - having a friend who self-harms may increase a young persons chance of self-harming too
More than 24000 teenagers are admitted to hospital in the UK each year after DSH<br>
slide7. Facts about self-harm People who self-harm are more likely to have experienced physical, emotional or sexual abuse during childhood
Rates of self-harm in the UK have increased over the past decade and are amongst the highest in Europe
Each year an estimated 200.000 people present to A&E departments following an episode of DSH.
In the subsequent 12 months around 20% of patients go on to repeat self-harm and approx. 1% will die by suicide
In a cohort study, around half of the patients with DSH consulted their GP in the 4 weeks following the episode. Data suggest that there are potential opportunities for GP involvement in the prevention of repeat DSH.<br>
slide8. NICE Guideline 16: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care NICE clinical guideline about self-harm: July 2004
People who have self-harmed should be treated with the same care, respect and privacy as any patient. In addition, healthcare professionals should take full account of the likely distress associated with self-harm.
All people who have self-harmed should be assessed for risk: this assessment should include identification of the main clinical and demographic features known to be associated with risk of further self-harm and/or suicide, and identification of the key psychological characteristics associated with risk, in particular depression, hopelessness and continuing suicidal intent.
The experience of care for people who self-harm is often unacceptable. All healthcare practitioners involved in the assessment and treatment of people who self-harm should ensure
that the care they offer addresses this as a priority<br>
slide9. NICE guideline continued When assessing people who self-harm, healthcare professionals should ask service users to explain their feelings and understanding of their own self-harm in their own words.
People who have self-harmed should be offered treatment for the physical consequences of self-harm, regardless of their willingness to accept psychosocial assessment or psychiatric treatment.
Self-harm is poorly understood by many NHS staff. All staff that come into contact with people who self-harm need dedicated training to improve both their understanding of self-harm and the treatment and care they provide.
Staff should provide full information about the treatment options, and make all efforts necessary to ensure that someone who has self-harmed can give, and has the opportunity to give, meaningful and informed consent before any and each procedure (for example, taking the person to hospital by ambulance) or treatment is initiated.
For the further management of people who have self-harmed, see 'Self-harm:
longer-term management' (NICE clinical guideline 133).<br>
slide10. NICE guideline continued : Management of self-harm in primary care Primary care has an important role in the assessment and treatment of people who self-harm. Careful attention to prescribing drugs to people at risk of self-harm, and their relatives, could also help in prevention.
In the assessment and management of self-injury in primary care, healthcare
professionals should refer service users for urgent treatment in an emergency
department, if assessment suggests there is a significant risk to the individual
who has self-injured.
In most circumstances, people who have self-poisoned and present to primary care should be urgently referred to the nearest emergency department,
because the nature and quantity of the ingested substances may not be clearly
known to the person who has self-poisoned, making accurate risk assessment
difficult.
If there is any doubt about the seriousness of an episode of self-harm, the GP
should discuss the case with the nearest A+E consultant, as management in secondary care may be necessary.<br>
slide11. Websites/links: self-harm http://www.nice.org.uk/nicemedia/pdf/CG016NICEguideline.pdf
http://www.rcpsych.ac.uk/mentalhealthinfoforall/problems/depression/self-harm.aspx
http://selfharm.net/
http://www.thesite.org/healthandwellbeing/mentalhealth/selfharm
http://www.mentalhealth.org.uk/information/mental-health-a-z/self-harm/<br>
slide12. What is suicide? Suicide is the intentional taking of one's own life.
Suicide may occur for a number of reasons, including depression, shame, guilt, desperation, shame, physical pain, emotional pressure, escapism, anxiety, financial difficulties, or other undesirable situations.
On average, a person dies every two hours in England as a result of suicide .
Suicide is the commonest cause of death in men under 35.
Over 4,000 suicides occur in the UK each year; 74 per cent of those who commit suicide are not known to mental health services.<br>
slide13. Facts about suicide There are an estimated 10 to 20 million non-fatal attempted suicides every year worldwide
Research shows that suicide risk is raised for virtually all mental health problems and substance abuse.
Depression, Anxiety and schizophrenia are most highly associated with suicide
Schizophrenia is associated with a suicide risk which is 8.5 times higher than that observed in the general population. Suicide appears to be most common in those under 30 years of age, and the risk is highest in the first year following diagnosis. Use of Clozapine has been shown to lower the risk of suicide.
Bipolar Affective Disorder incurs an average suicide risk which is 15 times that of the general population. The risk of suicide is increased by a past suicide attempt and alcohol abuse. Use of Lithium has been shown to lower the risk of suicide.<br>
slide14. Risk of suicide Demographic: being male, living alone, low socioeconomic status, unemployment, increasing age
long-term alcohol/drug misuse independent risk factor
The rate of suicide varies according to geographical area and social class
The National Suicide Prevention strategy has identified high risk occupation groups: nurses; medical practitioners, farmers , agricultural workers.
Rate of suicide for people who had an episode of suicide attempt or para-suicide is 100x higher in the year following than that of general population.<br>
slide15. Assessment of suicidal intent Level of intent
Level of lethality
Previous suicidal attempts or gestures
Young male or older white divorced male
Living alone
Lack of sleep/agitation
Suicidal Talk: “I Wish I was Dead”, “No one cares about me”, “I just want all of this to end”
Preoccupation with Death
Social Withdrawal
Mood Changes
Giving possession away/ writing wills<br>
slide16. Assessment of suicidal intent continued No combination of factors can defiantly state which individuals will go on to attempt suicide.
It is important to assess internal and external controls that the individual has to enable them to act out their suicidal intent.
As a healthcare professional in contact with an suicidal individual it is important to use your ability to elicit patient’s thoughts and feelings through rapport and then use this to form your clinical decision making.<br>
slide17. Myths and Facts about suicide MYTH: People who talk about suicide don’t complete suicide.
FACT: Many people who die by suicide have given definite warnings to family and friends of their intentions. Always take any comment about suicide seriously.
MYTH: Suicide happens without warning.
FACT: Most suicidal people give many clues and warning signs regarding their suicidal intention.<br>
slide18. Who is at risk of committing suicide? Demographic: being male, living alone, low socioeconomic status, unemployment, increasing age
long-term alcohol/drug misuse independent risk factor
The rate of suicide varies according to geographical area and social class
The National Suicide Prevention strategy has identified high risk occupation groups: nurses; medical practitioners, farmers , agricultural workers.
Rate of suicide for people who had an episode of suicide attempt or para-suicide is 100x higher in the year following than that of general population.<br>
slide19. Risk factors Mental illness including a diagnosis of personality disorder
Physical illness (especially chronic conditions and/or those associated with pain/functional impairment)
Recent contact with psychiatric services
Recent discharge from psychiatric in-patient facility
Feelings of hopelessness, Impulsiveness, low self-esteem, recent life event (i.e. bereavement), relationship instability
Deliberate self harm (especially with high suicide intent)
Childhood adversity (e.g. sexual abuse)
Family history of suicide
Family history of mental illness
Lack of social support<br>
slide20. Assessment of suicidal intent Level of intent
Level of lethality
Previous suicidal attempts or gestures
Young male or older white divorced male
Living alone
Lack of sleep/agitation
Suicidal Talk: “I Wish I was Dead”, “No one cares about me”, “I just want all of this to end”
Preoccupation with Death
Social Withdrawal
Mood Changes
Giving possession away/ writing wills<br>
slide21. Assessment of suicidal intent continued No combination of factors can defiantly state which individuals will go on to attempt suicide.
It is important to assess internal and external controls that the individual has to enable them to act out their suicidal intent.
As a healthcare professional in contact with an suicidal individual it is important to use your ability to elicit patient’s thoughts and feelings through rapport and then use this to form your clinical decision making.<br>
slide22. Myths and Facts about suicide MYTH: People who talk about suicide don’t complete suicide.
FACT: Many people who die by suicide have given definite warnings to family and friends of their intentions. Always take any comment about suicide seriously.
MYTH: Suicide happens without warning.
FACT: Most suicidal people give many clues and warning signs regarding their suicidal intention.<br>
slide23. Myths and Facts continued MYTH: Asking a depressed person about suicide will push him/her to complete suicide.
FACT: Studies have shown that patients with depression have these ideas and talking about them does not increase the risk of them taking their own life
MYTH: Improvement following a suicide attempt or crisis means that the risk is over.
FACT: Most suicides occur within days or weeks of “improvement” when the individual has the energy and motivation to actually follow through with his/her suicidal thoughts<br>
slide24. Violence and aggression Commonest psychiatric disorders that present with violence are psychotic disorders, drug abuse (e.g. stimulants) and alcohol abuse
Of violent people with schizophrenia 71% are substance abusers (12 times risk violence)
Organic brain syndromes may also present with aggressive behaviour<br>
slide25. Risk factors for violence Male, Young (<40)
Poverty, unemployment
Mental illness – psychotic illness, personality disorder
Alcohol or substance use
The best predictor of violence is previous violence<br>
slide26. Management of Violent Patient Ensure safety of patient and staff
To determine if ideation or behavior stems from specific psychiatric illness
Warn third parties of a serious threat of harm if present
To effect an appropriate treatment / management plan (“delivering despite difficulties”)<br>
slide27. Any questions?<br>
Frank Röhricht
Associate Medical Director
Lorraine Sunduza
Deputy Director of Nursing<br>
slide2. Acknowledgments Development of this training was funded by Health Education North Central and East London and supported by Dr Geraldine Strathdee, National Clinical Director, Mental Health, and NHS England.
The teaching materials have been developed according to a curriculum that was collaboratively agreed between GP mental health leads and ELFT staff.
We would like to thank all those involved in the development of these materials:
-Professor Frank Röhricht
-Laura Pisaneschi, developer of materials
-Lorraine Sunduza
-Alex Obamwonyi<br>
slide3. Overview of Module: Clinical risk/Psychiatric emergencies It is anticipated that by attending this training you will have an impact on your patients’ outcomes.
These are that patients will:
Remain free from harm (where factors are in the control of the healthcare practioner)
Be referred to other appropriate health care professionals in a timely manner
Feel they are being treated in a non-stigmatising environment.<br>
slide4. Learning objectives Following completion of this training you will:
Be aware of what constitutes a psychiatric emergency
Have an awareness of the different types of self-harm and self-injury
Know the difference between self-harm and suicide
Be confident in:
Talking to a patient who has just divulged that they are self-harming
Assessing suicide risk
Dealing with violence and aggression<br>
slide5. What Is self-harm? Self-harm (also sometimes known as self- injury)describes a wide range of things that people do to themselves in a deliberate and usually hidden way.
Methods can include:
Cutting, burning or scalding of the skin
swallowing amounts of toxic substances
hitting
scratching and hair pulling<br>
slide6. Self-Harm and young adults About 1 in 10 young people will self-harm at some point, but it can occur at any age.
It is more common in young women than men.
Gay and bisexual people seem to be more likely to self-harm.
Sometimes groups of young people self-harm together - having a friend who self-harms may increase a young persons chance of self-harming too
More than 24000 teenagers are admitted to hospital in the UK each year after DSH<br>
slide7. Facts about self-harm People who self-harm are more likely to have experienced physical, emotional or sexual abuse during childhood
Rates of self-harm in the UK have increased over the past decade and are amongst the highest in Europe
Each year an estimated 200.000 people present to A&E departments following an episode of DSH.
In the subsequent 12 months around 20% of patients go on to repeat self-harm and approx. 1% will die by suicide
In a cohort study, around half of the patients with DSH consulted their GP in the 4 weeks following the episode. Data suggest that there are potential opportunities for GP involvement in the prevention of repeat DSH.<br>
slide8. NICE Guideline 16: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care NICE clinical guideline about self-harm: July 2004
People who have self-harmed should be treated with the same care, respect and privacy as any patient. In addition, healthcare professionals should take full account of the likely distress associated with self-harm.
All people who have self-harmed should be assessed for risk: this assessment should include identification of the main clinical and demographic features known to be associated with risk of further self-harm and/or suicide, and identification of the key psychological characteristics associated with risk, in particular depression, hopelessness and continuing suicidal intent.
The experience of care for people who self-harm is often unacceptable. All healthcare practitioners involved in the assessment and treatment of people who self-harm should ensure
that the care they offer addresses this as a priority<br>
slide9. NICE guideline continued When assessing people who self-harm, healthcare professionals should ask service users to explain their feelings and understanding of their own self-harm in their own words.
People who have self-harmed should be offered treatment for the physical consequences of self-harm, regardless of their willingness to accept psychosocial assessment or psychiatric treatment.
Self-harm is poorly understood by many NHS staff. All staff that come into contact with people who self-harm need dedicated training to improve both their understanding of self-harm and the treatment and care they provide.
Staff should provide full information about the treatment options, and make all efforts necessary to ensure that someone who has self-harmed can give, and has the opportunity to give, meaningful and informed consent before any and each procedure (for example, taking the person to hospital by ambulance) or treatment is initiated.
For the further management of people who have self-harmed, see 'Self-harm:
longer-term management' (NICE clinical guideline 133).<br>
slide10. NICE guideline continued : Management of self-harm in primary care Primary care has an important role in the assessment and treatment of people who self-harm. Careful attention to prescribing drugs to people at risk of self-harm, and their relatives, could also help in prevention.
In the assessment and management of self-injury in primary care, healthcare
professionals should refer service users for urgent treatment in an emergency
department, if assessment suggests there is a significant risk to the individual
who has self-injured.
In most circumstances, people who have self-poisoned and present to primary care should be urgently referred to the nearest emergency department,
because the nature and quantity of the ingested substances may not be clearly
known to the person who has self-poisoned, making accurate risk assessment
difficult.
If there is any doubt about the seriousness of an episode of self-harm, the GP
should discuss the case with the nearest A+E consultant, as management in secondary care may be necessary.<br>
slide11. Websites/links: self-harm http://www.nice.org.uk/nicemedia/pdf/CG016NICEguideline.pdf
http://www.rcpsych.ac.uk/mentalhealthinfoforall/problems/depression/self-harm.aspx
http://selfharm.net/
http://www.thesite.org/healthandwellbeing/mentalhealth/selfharm
http://www.mentalhealth.org.uk/information/mental-health-a-z/self-harm/<br>
slide12. What is suicide? Suicide is the intentional taking of one's own life.
Suicide may occur for a number of reasons, including depression, shame, guilt, desperation, shame, physical pain, emotional pressure, escapism, anxiety, financial difficulties, or other undesirable situations.
On average, a person dies every two hours in England as a result of suicide .
Suicide is the commonest cause of death in men under 35.
Over 4,000 suicides occur in the UK each year; 74 per cent of those who commit suicide are not known to mental health services.<br>
slide13. Facts about suicide There are an estimated 10 to 20 million non-fatal attempted suicides every year worldwide
Research shows that suicide risk is raised for virtually all mental health problems and substance abuse.
Depression, Anxiety and schizophrenia are most highly associated with suicide
Schizophrenia is associated with a suicide risk which is 8.5 times higher than that observed in the general population. Suicide appears to be most common in those under 30 years of age, and the risk is highest in the first year following diagnosis. Use of Clozapine has been shown to lower the risk of suicide.
Bipolar Affective Disorder incurs an average suicide risk which is 15 times that of the general population. The risk of suicide is increased by a past suicide attempt and alcohol abuse. Use of Lithium has been shown to lower the risk of suicide.<br>
slide14. Risk of suicide Demographic: being male, living alone, low socioeconomic status, unemployment, increasing age
long-term alcohol/drug misuse independent risk factor
The rate of suicide varies according to geographical area and social class
The National Suicide Prevention strategy has identified high risk occupation groups: nurses; medical practitioners, farmers , agricultural workers.
Rate of suicide for people who had an episode of suicide attempt or para-suicide is 100x higher in the year following than that of general population.<br>
slide15. Assessment of suicidal intent Level of intent
Level of lethality
Previous suicidal attempts or gestures
Young male or older white divorced male
Living alone
Lack of sleep/agitation
Suicidal Talk: “I Wish I was Dead”, “No one cares about me”, “I just want all of this to end”
Preoccupation with Death
Social Withdrawal
Mood Changes
Giving possession away/ writing wills<br>
slide16. Assessment of suicidal intent continued No combination of factors can defiantly state which individuals will go on to attempt suicide.
It is important to assess internal and external controls that the individual has to enable them to act out their suicidal intent.
As a healthcare professional in contact with an suicidal individual it is important to use your ability to elicit patient’s thoughts and feelings through rapport and then use this to form your clinical decision making.<br>
slide17. Myths and Facts about suicide MYTH: People who talk about suicide don’t complete suicide.
FACT: Many people who die by suicide have given definite warnings to family and friends of their intentions. Always take any comment about suicide seriously.
MYTH: Suicide happens without warning.
FACT: Most suicidal people give many clues and warning signs regarding their suicidal intention.<br>
slide18. Who is at risk of committing suicide? Demographic: being male, living alone, low socioeconomic status, unemployment, increasing age
long-term alcohol/drug misuse independent risk factor
The rate of suicide varies according to geographical area and social class
The National Suicide Prevention strategy has identified high risk occupation groups: nurses; medical practitioners, farmers , agricultural workers.
Rate of suicide for people who had an episode of suicide attempt or para-suicide is 100x higher in the year following than that of general population.<br>
slide19. Risk factors Mental illness including a diagnosis of personality disorder
Physical illness (especially chronic conditions and/or those associated with pain/functional impairment)
Recent contact with psychiatric services
Recent discharge from psychiatric in-patient facility
Feelings of hopelessness, Impulsiveness, low self-esteem, recent life event (i.e. bereavement), relationship instability
Deliberate self harm (especially with high suicide intent)
Childhood adversity (e.g. sexual abuse)
Family history of suicide
Family history of mental illness
Lack of social support<br>
slide20. Assessment of suicidal intent Level of intent
Level of lethality
Previous suicidal attempts or gestures
Young male or older white divorced male
Living alone
Lack of sleep/agitation
Suicidal Talk: “I Wish I was Dead”, “No one cares about me”, “I just want all of this to end”
Preoccupation with Death
Social Withdrawal
Mood Changes
Giving possession away/ writing wills<br>
slide21. Assessment of suicidal intent continued No combination of factors can defiantly state which individuals will go on to attempt suicide.
It is important to assess internal and external controls that the individual has to enable them to act out their suicidal intent.
As a healthcare professional in contact with an suicidal individual it is important to use your ability to elicit patient’s thoughts and feelings through rapport and then use this to form your clinical decision making.<br>
slide22. Myths and Facts about suicide MYTH: People who talk about suicide don’t complete suicide.
FACT: Many people who die by suicide have given definite warnings to family and friends of their intentions. Always take any comment about suicide seriously.
MYTH: Suicide happens without warning.
FACT: Most suicidal people give many clues and warning signs regarding their suicidal intention.<br>
slide23. Myths and Facts continued MYTH: Asking a depressed person about suicide will push him/her to complete suicide.
FACT: Studies have shown that patients with depression have these ideas and talking about them does not increase the risk of them taking their own life
MYTH: Improvement following a suicide attempt or crisis means that the risk is over.
FACT: Most suicides occur within days or weeks of “improvement” when the individual has the energy and motivation to actually follow through with his/her suicidal thoughts<br>
slide24. Violence and aggression Commonest psychiatric disorders that present with violence are psychotic disorders, drug abuse (e.g. stimulants) and alcohol abuse
Of violent people with schizophrenia 71% are substance abusers (12 times risk violence)
Organic brain syndromes may also present with aggressive behaviour<br>
slide25. Risk factors for violence Male, Young (<40)
Poverty, unemployment
Mental illness – psychotic illness, personality disorder
Alcohol or substance use
The best predictor of violence is previous violence<br>
slide26. Management of Violent Patient Ensure safety of patient and staff
To determine if ideation or behavior stems from specific psychiatric illness
Warn third parties of a serious threat of harm if present
To effect an appropriate treatment / management plan (“delivering despite difficulties”)<br>
slide27. Any questions?<br>