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High Risk Mental Health Patients Dr Robert Dudas Consultant Liaison Psychiatrist Dr John Hague Member of Governing Body Ipswich and East Suffolk CCG 1.

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Presentation on theme: "High Risk Mental Health Patients Dr Robert Dudas Consultant Liaison Psychiatrist Dr John Hague Member of Governing Body Ipswich and East Suffolk CCG 1."— Presentation transcript:

1 High Risk Mental Health Patients Dr Robert Dudas Consultant Liaison Psychiatrist Dr John Hague Member of Governing Body Ipswich and East Suffolk CCG 1

2 What’s New? CMO Report on Mental Health National Confidential Enquiry into Suicide in Primary Care Work in Detroit 2

3 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

4 Suicide Rates in Europe 2013 – source WHO 4

5 Methods 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 5

6 Suicide Data 3 x more men than women Peaks in middle age Half of all suicides in men >55 6

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8 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

9 Firearms in Suffolk 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 Headline and picture from EADT Data from Guardian online

10 Self Harm 10

11 Self Harm Most episodes are self poisoning Injury is on increase 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 11

12 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

13 National Confidential Enquiry % 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

14 Risk of suicide Self harm in last year increases risk by 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 14

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18 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

19 Detroit 19

20 What Can we do? 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 20

21 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 21

22 RISK ASSESSMENT 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 22

23 RISK ASSESSMENT PRESENT Situation now –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? Able to seek help? 23

24 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 24

25 RISK ASSESSMENT YesNo 1During the last two weeks, have you often been bothered by feeling down, depressed or hopeless? 2During 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? 4Over the past two weeks have you been unable to stop or control worrying? 5Would you like any help with these difficulties? 6Do you feel hopeless about the present or future? 7Have you had thoughts about taking your life? 8When did you have these thoughts and did you have a plan? 9Have you ever attempted to harm yourself? 10Do you have any such thoughts or intention now? 25

26 26 7. BIO-PSYCHO-SOCIAL RISK IDENTIFICATION Lower Risk? Factor ?Higher RiskBRIEF DETAILS Abstract ideation, no firm plan or means, no recent prior attempts 1. Suicidality & Self-Harm Expresses preference to die or self-harm. Concrete plans, has means, prior attempts No significant recent history of violence or abusive behaviour 2a. Risk to others: violence & aggression Has expressed plans, with means, to cause harm, or through incapacity risks unintentional neglect No known dependents, safeguarding risks 2b. Safeguarding Safeguarding risks No history of MH problems (NB: 1 st symptoms later in life may be a high risk factor), no history in family 3. Mental Health History Has been under the care of specialist MH services, especially In-patient/HTT, in last 2 years, history of SMI in family Little or no drug/alcohol use, no significant physical co-morbidities 4. Co-morbidity Significant drug/alcohol use, physical health problems Positive, supportive relationships with immediate family, mutual reciprocity and dependable ‘caring’ duties 5. Relationships Strained or broken down with partner, parents, children, siblings, close friends, significant others Socialises regularly, has access to and uses community groups and networks 6. Social Resources Socially isolated, with little or no access to social opportunities and low desire to attain None, or minimal, significant negative changes in circumstances in recent history or near future 7. Significant life events One or more significant events that might add to distress: e.g. death, illness, divorce, relationship breakdown, changes at 8 – 10 Has work (paid or unpaid) that is secure and contributes to well-being and sense of purpose 8. Employment No employment, imminent threat to employment or works in role that’s contributes to distress Has secure place to live (tenancy, home), with no known threat to tenure, rent or mortgage arrears, etc. 9. Accommodation No secure place to live, sleeps rough, ‘sofa surfs’, living conditions contributes to distress, tenure imminently at risk Consulting at appropriate intervals, with no recent escalation 10. Frequency of consultation Frequent consultation, with increase in last year (especially if 15 or more times in a year), or non-attendance On no psychotropic drugs 11. Medication On psychotropic drugs, with more than one psychotropic, or combination of antidepressants with benzodiazepines being a higher risk Means of suicide or self harm removed (means of hanging or poisoning) Are any firearms inaccessible or removed? 12. Means Means of suicide not controlled Firearms accessible

27 RISK MANAGEMENT ↓ risk factors 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 –Who to contact in crisis? –What to do to avert suicidal thoughts? –How to occupy self during the day? Reduce substance abuse ↑ protective factors Psychological support (CBT- based, problem-solving) Explore likely impact on others Enlist the support of family and friends Religious/spiritual support Refer to secondary care 27 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)

28 RISK MANAGEMENT 28 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.

29 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 29

30 Suffolk Wellbeing Service – to July this year

31 Suffolk Wellbeing Service 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. Facebook : web: 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

32 Suffolk Wellbeing Service 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

33 Suffolk Wellbeing Service Courses on: Improve Your Mood Dealing With Worry Confidence and Assertiveness Living well with Long Term Conditions Mindfulness Workshop on Stress/ Anxiety and introduction to other options Individual Guided Self Help CBT IPT CAT EMDR Counselling Online Therapy Assessment One Off Workshops Improving Sleep Relaxation Mindfulness Managing Stress 24/7 Support with Big White Wall Stress Control 4 week Course Wellbeing for Carers Course (with Suffolk Family carers)

34 Thank you Any Questions? Dr John Hague


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