Understanding the impact of children's and young people's self-harm on parental well-being: a systematic literature review of qualitative and quantitative findings.

BACKGROUND: Self-harm in children and young people is increasing. Parents are vital in supporting young people; however, parents may experience distress linked to the self-harm. Previous reviews have highlighted the emotional impact and need for information and support, however, have not elucidated the relationships between these themes, nor examined the quantitative data examining parents' well-being. METHODS: We conducted a mixed methods review, with qualitative meta-synthesis focusing on links between themes and quantitative synthesis of parental well-being findings, including pooled means. PsycInfo, Medline, EMBASE, AMED, CINHAL and Web of Science were searched to identify relevant records. References of included studies were also searched. Every abstract was screened by two authors. Data were extracted by one author and checked by another. RESULTS: We identified 39 reports of 32 studies: 16 with qualitative data and 17 with quantitative data (one had both). Qualitative findings showed how parents' emotions were associated to their knowledge and beliefs about self-harm. Parents' emotions often evidenced the need to self-care, but emotions of guilt reduced engagement in self-care. How parents supported their young person was linked to their knowledge, and the management of their own emotions, and influenced if they could engage in self-care. Quantitative findings were mixed, however suggested poor general mental health amongst these parents. CONCLUSIONS: Further good quality quantitative studies are needed, with measurement of psychological mechanisms that may underpin parental distress. Current evidence supports peer-support and interventions that go beyond information provision to address the connected factors of knowledge, emotion, self-care, and parenting behaviours.

Assessing Suicide Prevention Apps' Responsiveness to Help-Seeking Needs of Individuals Connected with Mental Health Services.

This paper maps suicide help-seeking needs identified in the literature, on to the features and functionalities of suicide prevention mobile apps using the adapted ecological model, thereby revealing existing gaps between help-seeking needs and available apps. This paper builds upon previous work by our team, which includes 1) a rapid scoping review aimed at identifying barriers and facilitators of help-seeking related to suicide within psychiatric populations, and 2) a review of suicide prevention apps, including a content analysis of app features and functionalities.

Self-Harm by Nurses and Midwives - A Study of Hospital Presentations.

Background: Nursing professionals are an occupational group at increased risk of suicide, but little is known about self-harm in this population. Aims: To investigate the characteristics of nurses and midwives who present to hospital following self-harm. Method: We used data from the Oxford Monitoring System for Self-Harm to identify nurses and midwives who presented to the general hospital in Oxford during 2010-2020 following an episode of self-harm and received a psychosocial assessment. Results: During the eleven-year study period, 107 presentations of self-harm involving 81 nurses and midwives were identified. Self-poisoning was the most common self-harm method (71.6%), with antidepressants and paracetamol most frequently involved. Many had consumed alcohol before (43.8%) or during (25.3%) the self-harm act. Some individuals had high or very high suicide intent scores (22/70, 31.4%). Common problems preceding self-harm included problems with a partner (46.9%), psychiatric disorder (29.6%), and problems with employment (27.2%), family (24.7%), and alcohol (23.5%). A range of aftercare options were offered following presentation. Limitations: This study was limited to data from a single hospital. Conclusion: Prevention and management of self-harm within this occupational group requires preventative strategies and availability of interventions addressing the range of factors that may contribute to self-harm, especially relationship problems, psychiatric disorders, employment problems, and alcohol misuse.

Experiences and needs of adult informal carers of adults at risk of suicide: A systematic review with mixed methods analysis.

AIM: To systematically review and synthesize primary research on experiences and needs of adult informal caregivers of adults at risk of suicide. DESIGN: Systematic review with a data-based convergent synthesis. DATA SOURCES: MEDLINE, PsychINFO and CINAHL were searched in April 2022 and February 2023. English language research focusing on experiences of adult carers of adults was included. METHODS: Articles were screened by title (n = 9077) and abstract (n = 132) with additional articles (n = 6) obtained via citation and hand searching. Thirty-one included studies were quality assessed using the Mixed Methods Appraisal Tool and study data were systematically extracted prior to thematic synthesis. RESULTS: Five interconnected themes resulted: transitions; living with fear and uncertainty; changing relationships; interface with healthcare professionals and services; what carers need and want. Caring impacts mental, physical and social wellbeing. Relationships are affected in ways which might not be evident when caring for a minor. Repeated suicidal behaviour is particularly challenging with ongoing hypervigilance contributing to burden, burnout and interpersonal strain. Poor carer support exacerbates negative effects; carers need to feel informed, educated, involved and holistically supported. CONCLUSION: Timely support for carers is essential. Interventions should address emotional responses, relational changes and effective care recipient support. Longitudinal research is required to understand effects of ongoing caring where there are multiple suicide attempts. IMPLICATIONS: Nurses can provide carers with early support and information and longer term psychosocial interventions. If carers are adequately equipped and supported patient safety and wellbeing will be improved. IMPACT: Findings of this systematic review include relational changes due to carer hypervigilance reducing autonomy and living with the possibility of suicide. Clinician awareness of the potential for relational shifts will help them prepare and support carers. PATIENT OR PUBLIC CONTRIBUTION: There was no patient or public contribution.

Suicidal thoughts and behaviours among student nurses and midwives: A systematic review.

AIM: To synthesize research investigating suicide, suicide attempts, self-harm and suicide ideation in nursing and midwifery students, a group of interest due to high rates of suicide among qualified nurses. Specific areas of interest for this review included prevalence, factors which may contribute to or mitigate risk and suicide prevention interventions. DESIGN: A systematic review was conducted, and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. DATA SOURCES: Three electronic databases were searched, and additional articles identified using hand-searching. Studies were included if they examined suicide, suicide attempts, self-harm or suicide ideation in nursing or midwifery students. REVIEW METHODS: Studies were deduplicated and assessed for inclusion. Data from included studies were extracted, quality of studies assessed and data synthesized, informed by study focus, design and assessed quality. RESULTS: About 46 studies of largely moderate to low quality were identified. A high-quality study demonstrated increased risk of suicide in Swedish female nursing students, and increased risk of self-harm in nursing students of both sexes. Prevalence of suicide ideation did not appear to differ across course year, or between nursing students and students on other programmes. Psychiatric conditions, particularly depression, were associated with suicide ideation. Three studies related to suicide prevention interventions were identified. Integration of wellness initiatives into the curriculum and peer support were preferred interventions among nursing students and teaching staff. CONCLUSIONS: To understand the extent of suicide and self-harm among nursing and midwifery students there is a need for further epidemiological research stratified by programme of study. To develop prevention interventions and initiatives for nursing students, high-quality longitudinal studies should examine characteristics associated with suicide and self-harm. IMPACT: Current findings suggest interventions could include support for students experiencing mental health difficulties, foster peer support, and help develop wellness. No patient or public contribution.

Experiences of clinical staff who work with patients who self-harm by ligature: An exploratory survey of inpatient mental health service staff.

WHAT IS KNOWN ON THE SUBJECT: Self-harm by ligature is common within inpatient mental healthcare settings and is a dangerous method of self-harm. Most fatal and non-fatal suicidal behaviours in inpatient settings are a result of ligature use. There is a lack of research which has explored the experiences of staff members who work within inpatient settings where patients may self-harm by ligature. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE: Key issues related to self-harm by ligature reported by staff included (1) understaffing increasing risk of ligature incidents, (2) spreading of self-harm by ligature within inpatient settings and (3) negative attitudes of staff related to patients who self-harm by ligature. Working with self-harm by ligature can have negative impacts on staff's personal (e.g. fear of blame) and professional lives (e.g. increased cautiousness). Many staff members currently feel underprepared by training related to working with self-harm by ligature, and unsupported after responding to a ligature incident. WHAT ARE THE IMPLICATIONS FOR PRACTICE: Training about self-harm by ligature needs to be improved and be accessible for all inpatient mental healthcare staff. Training should be coproduced, and could include practical components, education on potential reasons for self-harm, and acknowledgement of the emotional impact on staff. Support for staff members who respond to ligature incidents should be available for all staff members who respond to self-harm by ligature incidents. Stigma associated with accessing support should be challenged, alongside blame cultures within the workplace. ABSTRACT: INTRODUCTION: Self-harm by ligature is a common form of self-harm within inpatient mental health services in England, where most suicides within inpatient settings involve hanging or suffocation. However, little research has examined the experiences of staff members working with this method of self-harm. AIM: We explored the experiences of clinical staff who work with patients who self-harm by ligature. METHOD: A staff survey was developed and disseminated to clinical staff working in inpatient settings in England. Quantitative data were analysed using descriptive statistics, and qualitative data using the framework approach. The study was STROBE checklist compliant. RESULTS: 275 staff members participated. Challenges most frequently reported about working with self-harm by ligature included understaffing (210, 76.6%), spreading of ligature incidents (198, 72.8%) and negative attitudes held by clinical staff towards such patients (185, 68.5%). Participants' responses indicated that this work could have significant impacts on their professional and personal lives. Staff often reported inadequate training and lack of preparedness, alongside insufficient support opportunities following ligature incidents. DISCUSSION: Staff had a diverse range of professional and personal experiences and identified multiple challenges associated with working with patients who have self-harmed by ligature. IMPLICATIONS FOR PRACTICE: There is a need to improve accessibility, format and content of training and support for staff working within inpatient settings where patients may self-harm by ligature.

New guidance for self-harm: an opportunity not to be missed.

In this editorial we, as members of the 2022 NICE Guideline Committee, highlight and discuss what, in our view, are the key guideline recommendations (generated through evidence synthesis and consensus) for mental health professionals when caring for people after self-harm, and we consider some of the implementation challenges.

Suicide, self-harm, and suicide ideation in nurses and midwives: A systematic review of prevalence, contributory factors, and interventions.

BACKGROUND: Nurses have been identified as an occupational group at increased risk of suicide. This systematic review examines the prevalence of, and factors influencing, suicide and related behaviours among nurses and midwives (PROSPERO pre-registration CRD42021270297). METHODS: MEDLINE, PsycINFO, and CINAHL were searched. Articles published from 1996 onwards exploring suicidal thoughts and behaviours among nurses and midwives were included. Quality of included studies was assessed. Articles were subjected to narrative synthesis informed by suicide data examined, study design, and quality. PRISMA guidelines were followed. RESULTS: A total of 100 studies were eligible for inclusion in the review. Articles examining suicide exclusively among midwives were absent from the literature. Several studies confirmed that nursing professionals, especially female, are at increased risk of suicide, particularly by self-poisoning. Factors contributing to risk include psychiatric disorders, alcohol and substance misuse, physical health problems, and occupational and interpersonal difficulties. In studies of non-fatal suicidal behaviours, including during the COVID-19 pandemic, psychiatric, psychological, physical and occupational factors were contributory. There has been little investigation of interventions for prevention of suicide in nurses. LIMITATIONS: Only articles published in English language were reviewed. CONCLUSIONS: The findings highlight the risk of suicide in nurses. They also show a combination of factors contribute to suicide and non-fatal suicidal behaviour in nurses, with psychiatric, psychological, physical health, occupational and substance misuse (especially alcohol) problems being particularly important. The limited evidence regarding prevention measures indicates a major need to develop primary and secondary interventions for this at-risk occupational group, for example, education regarding enhancing wellbeing and safe alcohol use, alongside accessible psychological support.

Effects of patient deaths by suicide on clinicians working in mental health: A survey.

In the UK, at least a quarter of suicides occurs in patients whilst under the care of mental health services. This study investigated the effects of such deaths on non-medical mental health clinicians. An online survey was conducted within a single NHS mental health Trust to elicit both quantitative and qualitative responses from staff across a range of professions. The survey focused on personal and professional impacts and available support. Participants reported significant negative emotional and professional effects that were long-lasting for some. These included mental health difficulties, loss of confidence regarding clinical responsibilities, and actual or contemplated career change. However, there was also some evidence of positive effects and professional growth. Support from colleagues and line managers is clearly important following deaths of patients by suicide. Clinicians' experiences of the support they had received in the workplace were polarized, suggesting that there is no single nor ideal approach that will meet everyone's needs. Participants made recommendations for the types of support that may be helpful. Most commonly, clinicians desired opportunities for focused reflection and support and help with the formal processes following the death. Sensitivity around how clinicians are notified about the death was highlighted as being particularly important. Conclusions are drawn as to how training institutions and employers can help staff to be better prepared for the potential occurrence of patient suicides and the formal processes that follow, with a view to mitigating risks of more serious harm to staff and hence indirectly to patients, and potential loss of highly trained clinicians to the workforce.

News reporting of suicide in nurses: A content analysis study.

Media impact on suicide is well-established. Groups at heightened risk of suicide, such as nurses, may be particularly influenced by poor news reporting. This study aimed to examine UK newspaper reporting of suicide of nurses and student nurses, including during the COVID-19 pandemic. Print and online newspaper reports about suicide in nurses (including students) published in the UK between January 2018 and August 2021 were obtained and data extracted for analysis in collaboration with Samaritans' media advisory team. Content and quality of newspaper reports were examined using a content analysis approach. The study was compliant with the STROBE checklist. Nurse or student nurse suicides were reported in 134 articles, including 50 individual suicides. Most articles were acceptable against Samaritans' media guidelines. However, common problems included absence of signposting to support organizations and lack of suicide prevention messages. A minority of articles included methods of suicide within article headlines (18, 13.4%) and sensationalist or romanticizing language (14, 10.7%). Most contained occupation-related content. Many named the individual's specific hospital or university and a substantial proportion included occupation-related images. Working on the frontline was the most reported link between COVID-19 and nurse suicide. While reporting on suicide among nurses and students was largely acceptable, quality of reporting was variable. Occupation was often discussed, and most articles published during COVID-19 linked suicide to the pandemic. The research findings can help shape guidance on reporting of suicide in specific professions and occupations, including nursing, to encourage responsible reporting and reduce inadvertent promotion of suicide.

Assessment of suicide risk in mental health practice: shifting from prediction to therapeutic assessment, formulation, and risk management.

Suicide prevention in psychiatric practice has been dominated by efforts to predict risk of suicide in individual patients. However, traditional risk prediction measures have been shown repeatedly in studies from high income countries to be ineffective. Several factors might contribute to clinicians' preoccupation with risk prediction, which can have negative effects on patient care and also on clinicians where prediction is seen as failing. The model of therapeutic risk assessment, formulation, and management we outline in this article regards all patients with mental health problems as potentially at increased risk of suicide. It is aimed at reducing risk through use of a person-centred approach. We describe how a move towards therapeutic risk assessment, formulation, and risk management, including collaborative safety planning, could help clinicians develop a more tailored approach to managing risk for all patients, incorporating potentially therapeutic effects as well as helping to identify other risk reduction interventions. Such an approach could lead to enhanced patient safety and quality of care, which is more acceptable to patients.

Might Informal Carers of Adults With Enduring Suicidality Experience Anticipatory Loss?

Carers of loved ones who repeatedly express suicidal intent and/or engage in suicidal behavior may experience a sense of anticipation of eventual suicide due to the potential of a fatal act of self-harm. An understanding of John Rolland's concept of anticipatory loss may help clinicians understand and attend to the experiences of carers of adults who engage in repeated suicidal behavior. Indeed, there appear to be some similarities between this model of anticipatory loss and experiences of informal carers, indicating that the phenomenon, which is hitherto under-explored in the suicidology field, may merit further consideration.

Evidence to support magnetic resonance conditional labelling of all pacemaker and defibrillator leads in patients with cardiac implantable electronic devices.

AIMS: Many cardiac pacemakers and defibrillators are not approved by regulators for magnetic resonance imaging (MRI). Even following generator exchange to an approved magnetic resonance (MR)-conditional model, many systems remain classified 'non-MR conditional' due to the leads. This classification makes patient access to MRI challenging, but there is no evidence of increased clinical risk. We compared the effect of MRI on non-MR conditional and MR-conditional pacemaker and defibrillator leads. METHODS AND RESULTS: Patients undergoing clinical 1.5T MRI with pacemakers and defibrillators in three centres over 5 years were included. Magnetic resonance imaging protocols were similar for MR-conditional and non-MR conditional systems. Devices were interrogated pre- and immediately post-scan, and at follow-up, and adverse clinical events recorded. Lead parameter changes peri-scan were stratified by MR-conditional labelling. A total of 1148 MRI examinations were performed in 970 patients (54% non-MR conditional systems, 39% defibrillators, 15% pacing-dependent) with 2268 leads. There were no lead-related adverse clinical events, and no clinically significant immediate or late lead parameter changes following MRI in either MR-conditional or non-MR conditional leads. Small reductions in atrial and right ventricular sensed amplitudes and impedances were similar between groups, with no difference in the proportion of leads with parameter changes greater than pre-defined thresholds (7.1%, 95% confidence interval: 6.1-8.3). CONCLUSIONS: There was no increased risk of MRI in patients with non-MR conditional pacemaker or defibrillator leads when following recommended protocols. Standardizing MR conditions for all leads would significantly improve access to MRI by enabling patients to be scanned in non-specialist centres, with no discernible incremental risk.

Self-harm and the COVID-19 pandemic: A study of factors contributing to self-harm during lockdown restrictions.

INTRODUCTION: The COVID-19 pandemic and resulting public health measures may have major impacts on mental health, including on self-harm. We have investigated what factors related to the pandemic influenced hospital presentations following self-harm during lockdown in England. METHOD: Mental health clinicians assessing individuals aged 18 years and over presenting to hospitals in Oxford and Derby following self-harm during the period March 23rd to May 17, 2020 recorded whether the self-harm was related to the impact of COVID-19 and, if so, what specific factors were relevant. These factors were organized into a classification scheme. Information was also collected on patients' demographic characteristics, method of self-harm and suicide intent. RESULTS: Of 228 patients assessed, in 46.9% (N = 107) COVID-19 and lockdown restrictions were identified as influencing self-harm. This applied more to females than males (53.5%, N = 68/127 v 38.6%, N = 39/101, χ2 = 5.03, p = 0.025), but there were no differences in age, methods of self-harm or suicide intent between the two groups. The most frequent COVID-related factors were mental health issues, including new and worsening disorders, and cessation or reduction of services (including absence of face-to-face support), isolation and loneliness, reduced contact with key individuals, disruption to normal routine, and entrapment. Multiple, often inter-connected COVID-related factors were identified in many patients. CONCLUSIONS: COVID-related factors were identified as influences in nearly half of individuals presenting to hospitals following self-harm in the period following introduction of lockdown restrictions. Females were particularly affected. The fact that mental health problems, including issues with delivery of care, predominated has implications for organisation of services during such periods. The contribution of isolation, loneliness and sense of entrapment highlight the need for relatives, friends and neighbours to be encouraged to reach out to others, especially those living alone. The classification of COVID-related factors can be used as an aide-memoire for clinicians.

The fatal consequence of inappropriate therapy in a single VF zone primary prevention defibrillator.

We report a case of inappropriate implantable cardioverter defibrillator (ICD) therapy due to single ventricular fibrillation (VF) zone programming leading to patient death. A remote transmission was received from a patient with a cardiac resynchronization therapy-defibrillator showing sinus tachycardia in the VF detection zone initiating inappropriate shocks and resulting in shock refractory VF. This case report highlights the importance of manufacturer specific ICD programming. In devices without discrimination in the VF zone, a higher rate single VF detection zone and/or addition of a ventricular tachycardia zone with supraventricular tachycardia discrimination should be considered.

Ketamine treatment for individuals with treatment-resistant depression: longitudinal qualitative interview study of patient experiences.

BACKGROUND: Ketamine has recently received considerable attention regarding its antidepressant and anti-suicidal effects. Trials have generally focused on short-term effects of single intravenous infusions. Research on patient experiences is lacking. AIMS: To investigate the experiences over time of individuals receiving ketamine treatment in a routine clinic, including impacts on mood and suicidality. METHOD: Twelve fee-paying patients with treatment-resistant depression (6 females, 6 males, age 21-70 years; 11 reporting suicidality and 6 reporting self-harm) who were assessed as eligible for ketamine treatment participated in up to three semi-structured interviews: before treatment started, a few weeks into treatment and ≥2 months later. Data were analysed thematically. RESULTS: Most participants hoped that ketamine would provide respite from their depression. Nearly all experienced improvement in mood following initial treatments, ranging from negligible to dramatic, and eight reported a reduction in suicidality. Improvements were transitory for most participants, although two experienced sustained consistent benefit and two had sustained but limited improvement. Some participants described hopelessness when treatment stopped working, paralleled by increased suicidal ideation for three participants. The transient nature and cost of treatment were problematic. Eleven participants experienced side-effects, which were significant for two participants. Suggestions for improving treatment included closer monitoring and adjunctive psychological therapy. CONCLUSIONS: Ketamine treatment was generally experienced as effective in improving mood and reducing suicidal ideation in the short term, but the lack of longer-term benefit was challenging for participants, as was treatment cost. Informed consent procedures should refer to the possibilities of relapse and associated increased hopelessness and suicidality.