Homeless youth: Barriers and facilitators for service referrals.

Young people who are homeless and experiencing mental health issues are reluctant to use relevant services for numerous reasons. Youth are also at risk of disengaging from services at times of referral to additional or alternative services. This study aimed to identify barriers and facilitators for inter-service referrals for homeless youth with mental health issues who have already engaged with a service. Qualitative, semi-structured interviews were conducted with homeless youth (n = 10), homelessness support workers (n = 10), and mental health clinicians (n = 10). Barriers included: resource shortages; programs or services having inflexible entry criteria; complexity of service systems; homeless youth feeling devalued; and a lack of communication between services, for example, abrupt referrals with no follow up. Referral facilitators included: services providers offering friendly and client-centred support; supported referrals; awareness of other services; and collaboration between services. Relationships with service providers and inter-service collaboration appeared essential for successful referrals for homeless youth. These facilitating factors may be undermined by sector separation and siloing, as well as resource shortages in both the homelessness and mental health sectors. Service transitions may be conceptualised as a genuine service outcome for homeless youth, and as a basis for successful future service provision.

Repeated Suicide Attempts and Suicide Among Individuals With a First Emergency Department Contact for Attempted Suicide: A Prospective, Nationwide, Danish Register-Based Study.

OBJECTIVE: Emergency departments are important, albeit underutilized, sites for suicide prevention. Preventive strategies and interventions could benefit from a greater understanding of factors influencing the course of suicide risk after emergency department contact due to attempted suicide. The aim of our study was 2-fold: to identify predictors of repeated suicide attempts and suicide and to investigate the timing of these events. METHODS: Data from Danish nationwide, longitudinal registers were used in this prospective, population-based study of all individuals first presenting to an emergency department after attempted suicide (index attempt) between January 1, 1996, and December 31, 2011 (N = 11,802). Cox regression analysis identified predictors, and Kaplan-Meier survival analysis modeled the time to repeated suicide attempts and suicide. RESULTS: Sixteen percent of the sample repeated suicide attempt, and 1.4% died by suicide. Repetition was less likely among men than women (adjusted hazard ratio [AHR] = 0.70; 95% CI, 0.63-0.79), whereas those most prone to repeated attempts were individuals with recent psychiatric treatment (AHR = 2.19; 95% CI, 1.97-2.43) and those with recent psychiatric treatment (AHR = 2.19; 95% CI, 1.97-2.43). Predictors of suicide included age over 35 years (AHR = 5.56; 95% CI, 2.89-10.69); hanging, strangling, or suffocation as the method of the index attempt (AHR = 2.55; 95% CI, 1.29-5.01); and receiving psychiatric hospitalization for the index attempt (AHR = 1.74; 95% CI, 1.22-2.49). The cumulative rates of repeated attempts and suicide deaths in the total sample were particularly high within the first week of the index attempt, reaching 3.6% and 0.1%, respectively. CONCLUSIONS: Preventive efforts need to target the period close to discharge from emergency departments.

Suicidal behaviours during treatment for first-episode psychosis: towards a comprehensive approach to service-based prevention.

AIM: Suicidal behaviours (suicide attempts and suicides) are common among individuals experiencing, or having recently experienced, a first-episode psychosis (FEP). Current interventions for suicidal behaviours are crisis driven and focused on hospital admission of patients at imminent risk of ending their lives. This paper aims to describe ideas for universal, selective and indicated strategies that may complement existing practices to suicide risk management in first-episode patients. METHODS: Key findings from the Suicidal Behaviours in FEP Project were used to develop suggested interventions. The project examined the temporal course of suicide risk, common characteristics of suicidal behaviours and predictors of suicidal behaviours in 699 patients with FEP. RESULTS: Key findings included: (i) 12% of FEP cohort engaged in suicidal behaviours during treatment (up to 3 years); (ii) first month of treatment conferred the highest suicide risk; (iii) 64% of suicidal behaviours were overdoses, usually on antipsychotics; (iv) 20% of suicidal behaviours occurred on psychiatric units and all involved hanging/strangulation; (v) most suicidal behaviours were impulsive, precipitated by psychosocial stressors and with serious intent; and (vi) proximal non-suicidal self-injurious behaviour and proximal negative life events were the strongest predictors. CONCLUSION: Comprehensive approach by mental health services to prevention of suicidal behaviours among first-episode patients could be facilitated by: delineating safe quantities of prescribed medications available to outpatients; regular audits of fixtures on inpatient units; enhancing risk recognition by family members; routinely monitoring suicide risk levels; developing crisis cards with all new FEP patients to facilitate help seeking during distress; and skills training programs targeting distress tolerance, interpersonal effectiveness and problem-solving.

Classification Algorithm for the Determination of Suicide Attempt and Suicide (CAD-SAS). Development and psychometric properties.

BACKGROUND: One methodological difficulty in research into suicide attempts and suicide is distinguishing these phenomena from nonsuicidal self-harming behaviors and accidents. This is problematic because a reliable assessment of the presence or absence of the outcome variable is fundamental for the validity of the findings. AIMS: To develop a standardized rating system, the Classification Algorithm for the Determination of Suicide Attempt and Suicide (CAD-SAS), and to investigate its psychometric properties. METHODS: To examine the test-retest reliability, one investigator rated 217 narratives of real-life self-harming incidents at initial assessment and 4 weeks later. To establish the interrater reliability, three independent raters assessed a random sample of 70 narratives using the CAD-SAS. To examine the validity, one investigator using the CAD-SAS compared ratings to clinical judgments made by a consultant psychiatrist without the CAD-SAS on the same random set of 70 narratives. RESULTS: Test-retest reliability was excellent (97.2% agreement) and interrater reliability was substantial (70.0% agreement, κ = 0.70). Agreement in the classification of incidents with the "real-world" clinical judgments supports the validity of the CAD-SAS (64.3% agreement, κ = 0.46). CONCLUSIONS: The reliability and validity of future studies can be enhanced through the standardized assessment and classification of incidents.

Characteristics of suicide attempts in young people undergoing treatment for first episode psychosis.

OBJECTIVES: Understanding the characteristics of suicide attempts in people undergoing treatment for first episode psychosis (FEP) may have implications for risk management at a service level and local suicide prevention strategies. Although studies have focused on identifying individual-level risk factors for suicide attempts in this patient group, none have yet conducted an in-depth profile of suicide attempts. The aim of the present study was to examine the characteristics of suicide attempts in young people during the initial 18 months of treatment for FEP. METHOD: A retrospective medical record audit study of a cohort of patients accepted for treatment at a specialist FEP service between 1/12/2002 and 30/11/2005. RESULTS: Of 607 patients, 73 (12%) attempted suicide during treatment. Of these 73, most (72.6%) attempted suicide on one occasion. The majority of attempts (85.3%) occurred when patients were treated as outpatients and were in regular contact with the service. Suicide attempts tended to be impulsive (77.6%), triggered by interpersonal conflict or distress due to psychotic symptoms. Two thirds involved self-poisoning, usually by overdose of prescribed medications. All inpatient suicide attempts were by hanging or strangulation. Individuals infrequently sought help immediately before or after the attempt; if help-seeking occurred, informal sources of support were contacted. CONCLUSIONS: To reduce the number of suicide attempts among individuals treated for FEP, psychiatric services could consider: restricting the amount of medication prescribed per purchase; individualised suicide risk management plans for all newly admitted patients, including those who do not appear to be at risk; stringent reviews of inpatient psychiatric units for potential ligature points; providing information and psycho-education for significant others in recognition and response to suicide risk; fostering patients' problem solving and conflict resolution skills; and regular risk assessment and close monitoring of patients, particularly during the high risk period of 3 months after a suicide attempt.

Temporal pattern of suicide risk in young individuals with early psychosis.

Individuals with a first episode of psychotic illness are known to be at high risk of suicide, yet little is understood about the timing of risk in this critical period. The present study aimed to examine the temporal pattern of suicide risk in patients with early psychosis (EP) and to determine whether discrete periods of significantly elevated risk can be identified up to 24 months after commencing treatment. Suicidality ratings collected each month as part of patient routine assessment at the Early Psychosis Prevention and Intervention Centre (EPPIC) were retrieved from the service database for patients treated between December 2002 and December 2005 (N=696). Time-series analysis was performed on suicide risk estimated from the aggregated data of 94 individuals who met the study inclusion criteria. Suicide risk was highest in the first month of treatment, decreasing rapidly over the next 6 months and declining slightly thereafter. A power function adequately described this curvilinear trend. Fluctuations around the trend were unpredictable, except for a mild tendency to reverse from month to month, and did not reach statistical significance. The findings suggest limited scope for preventative interventions driven by chronology alone. Intensive routine suicide screening across the course of treatment may facilitate identification and early management of EP patients at suicide risk.