Post by Admin on Sept 20, 2021 18:22:26 GMT
A Zero Suicide Goal Requires a Reimagining of Inpatient Care
A new article suggests that the goal of Zero Suicide calls for a radical reimagining of inpatient care to ensure privacy and autonomy.
By Samantha Lilly -September 18, 2021
www.madinamerica.com/2021/09/zero-suicide-goal-requires-reimagining-inpatient-care/
A new article published in the Australian and New Zealand Journal of Psychiatry argues that the newly popular ‘Zero Suicide’ movement within healthcare and mental healthcare settings “requires a radical reimagining of inpatient care” to be effective.
“In addition to being a target, Zero Suicide is a framework for system-wide, organizational commitment to safer care center on systemic approaches to quality improvement in the areas of leadership, training, engagement, and treatment,” the authors write.
journals.sagepub.com/doi/full/10.1177/00048674211025720
Introduction
The Zero Suicide movement champions the goal of eliminating suicide in mental healthcare. In addition to being a target, Zero Suicide is a framework for system-wide, organisational commitment to safer care centred on systematic approaches to quality improvement in the areas of leadership, training, engagement and treatment. In the March 2021 issue of the Australian and New Zealand Journal of Psychiatry (ANZJP), Turner et al. (2021) describe a local implementation of the Zero Suicide Framework.
Preparing for change
Last year in ANZJP, Malhi et al. (2020) introduced a conceptual shift in thinking by distilling evidence that suicidal behaviour results in reorganisation of the brain circuitry of the self and its relations. This reconceptualization of the drivers of repeated suicide behaviour proposes that suicides occur after a breakdown of connections with vital elements within one’s life (relationships, self-worth, current situation) and that these are mirrored in breaks in neural connections. The Turner and Malhi papers, respectively, describe novel ideas about clinical teams and the brains they care for. As the southern hemisphere’s premiere psychiatric journal, the Australian and New Zealand Journal of Psychiatry (ANZJP) hosts debates that can drive conceptual shifts and improvements in patient care. Here, we propose a complementary change to the structure of the built environments of mental healthcare that we believe might provide both a tipping point for improved team performance and a better starting point for the many different patient journeys to recovery.
Radical change is needed for inpatient care
The enormity of the task of eliminating suicide among psychiatric inpatients is illustrated by the current rates of suicide in care. A recent study found rates of 3000 per 100,000 person years in the first week of admission (Madsen et al., 2020), which is about 300 times higher than typical global suicide rates. Suicide rates remain very elevated over the course of an inpatient stay but then return in the week post-discharge to the same astonishing figure of 3000 per 100,000 person years – among people who are considered well enough to go home (Chung et al., 2019). We believe the reduction from these extraordinary numbers to anything like zero will require both the service improvements suggested by the Zero Suicide Framework and more radical reimagining of inpatient services.
In developed countries, mentally ill people who meet a threshold are temporarily segregated from the community in psychiatric facilities. This threshold is determined by clinicians who are guided by local mental health laws and practices, and is usually justified with a need for protection from serious harm. Despite this need for protection, inpatient and post-discharge suicide rates suggest little protection from suicide is achieved. Nor do psychiatric hospitals prevent harm to others. A recent meta-analysis of prevalence and risk factors for violence by psychiatric acute inpatients found that about one in five admitted people are violent during their admission (Iozzino et al., 2015), mostly to other patients and often repeatedly. Sometimes, and at greater rates than in the community, inpatient violence results in serious injuries or even a patient death. Currently, inpatient violence either seems to be semi-acceptable (particularly if the victims are other patients) or, if more severe, results in various actions including further segregation, sometimes to the point of temporary seclusion. The use of seclusion has rightly come under increasing scrutiny. However, no attention has been paid to the basic premise that we should admit people to common treatment, recreation, eating, and even bathroom spaces.
Rethinking assumptions and reimagining facilities
We would like to cast some doubt on the belief in intrinsic harms associated with people being treated away from other patients. We believe the harms associated with seclusion are mostly because our seclusion facilities are almost medieval and that it is the aggregation and collectivisation of mentally ill people in psychiatric facilities that is the underlying problem. Many people who are admitted to an acute mental health facility will either witness or become a victim of violence or aggression within 24 hours. Some will then become violent themselves perpetuating a vicious circle of contagious violence. This violence inures staff and patients to further violence and separates people from their friends and families. Psychiatric hospitalisation in its current form is traumatic, socially isolating and fosters stigma and self-stigma. We are at a loss to explain how current inpatient psychiatric care is acceptable to anyone, let alone to people with the vulnerabilities of pre-existing trauma, suicidality, and paranoia. The downsides to the aggregation of mentally ill people are self-evident. But where is the evidence that treating mentally ill people together advantages them? Elsewhere in medicine there is no expectation that people with similar illness should benefit from being cared for together. In fact the evidence suggests a steep decline in suicide rates in somatic hospitals to a contemporary rate of just under one suicide per million admissions as medicine has become more personalised and Florence Nightingale wards have been abandoned. From a scientific perspective, psychiatric hospitalisation is an accident of history, without any data supporting its safety or effectiveness.
While we believe that we should stop aggregating and traumatising mentally ill people in conventional psychiatric facilities, we also acknowledge that many mentally ill people do need the tertiary care of a hospital and cannot be managed in the community. The solution is a radical rethinking and redesign of inpatient care. We suggest that instead of an admission to a common space, people should be admitted to single-person facilities with acceptable floor space, amenity, comfort and privacy. These spaces should be hopeful, open and welcoming to family and friends. They should foster optimism, recovery and ultimately even neural plasticity while minimising stigma and trauma. There is no need for non-consensual contact between patients, including the contagion of interpersonal violence or, for that matter infectious contact such as COVID 19. There is no need for psychiatric care to be noisy and foreboding. While such an arrangement would require imagination and money, it would allow genuinely individualised treatment, would lessen stigma, would provide better protection and, if done properly, would foster social connectedness.
Next steps
Malhi et al. highlighted changes to the neuronal structure of the brain following a suicide attempt after a person has broken their connection with life itself, a step taken only after ‘appraisal of many critical factors, including the evaluation of one’s self worth, one’s relationships with others, and one’s current situation in life’. Treating patients within collectivised psychiatric settings seems uniquely designed to do just that. Every breach of privacy, episode of aggression and unwanted physical or sexual contact pushes people away from their vital connections. What improvement science can do is foster the accurate recording and publication of the adversities of patient experiences in all units within Australasia. Confronted with these results, policymakers might just provide the investment needed to radically reimagine inpatient care.
Conclusion
Iatrogenic harm within inpatient facilities is the neglected side effect of a deeply flawed assumption about the need for collective psychiatric care. The shared spaces in psychiatric wards deny any modicum of the safety and privacy that is needed for recovery. A successful leap towards zero suicides can only happen after we abandon outdated notions of collective psychiatric treatment.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.
A new article suggests that the goal of Zero Suicide calls for a radical reimagining of inpatient care to ensure privacy and autonomy.
By Samantha Lilly -September 18, 2021
www.madinamerica.com/2021/09/zero-suicide-goal-requires-reimagining-inpatient-care/
A new article published in the Australian and New Zealand Journal of Psychiatry argues that the newly popular ‘Zero Suicide’ movement within healthcare and mental healthcare settings “requires a radical reimagining of inpatient care” to be effective.
“In addition to being a target, Zero Suicide is a framework for system-wide, organizational commitment to safer care center on systemic approaches to quality improvement in the areas of leadership, training, engagement, and treatment,” the authors write.
journals.sagepub.com/doi/full/10.1177/00048674211025720
Introduction
The Zero Suicide movement champions the goal of eliminating suicide in mental healthcare. In addition to being a target, Zero Suicide is a framework for system-wide, organisational commitment to safer care centred on systematic approaches to quality improvement in the areas of leadership, training, engagement and treatment. In the March 2021 issue of the Australian and New Zealand Journal of Psychiatry (ANZJP), Turner et al. (2021) describe a local implementation of the Zero Suicide Framework.
Preparing for change
Last year in ANZJP, Malhi et al. (2020) introduced a conceptual shift in thinking by distilling evidence that suicidal behaviour results in reorganisation of the brain circuitry of the self and its relations. This reconceptualization of the drivers of repeated suicide behaviour proposes that suicides occur after a breakdown of connections with vital elements within one’s life (relationships, self-worth, current situation) and that these are mirrored in breaks in neural connections. The Turner and Malhi papers, respectively, describe novel ideas about clinical teams and the brains they care for. As the southern hemisphere’s premiere psychiatric journal, the Australian and New Zealand Journal of Psychiatry (ANZJP) hosts debates that can drive conceptual shifts and improvements in patient care. Here, we propose a complementary change to the structure of the built environments of mental healthcare that we believe might provide both a tipping point for improved team performance and a better starting point for the many different patient journeys to recovery.
Radical change is needed for inpatient care
The enormity of the task of eliminating suicide among psychiatric inpatients is illustrated by the current rates of suicide in care. A recent study found rates of 3000 per 100,000 person years in the first week of admission (Madsen et al., 2020), which is about 300 times higher than typical global suicide rates. Suicide rates remain very elevated over the course of an inpatient stay but then return in the week post-discharge to the same astonishing figure of 3000 per 100,000 person years – among people who are considered well enough to go home (Chung et al., 2019). We believe the reduction from these extraordinary numbers to anything like zero will require both the service improvements suggested by the Zero Suicide Framework and more radical reimagining of inpatient services.
In developed countries, mentally ill people who meet a threshold are temporarily segregated from the community in psychiatric facilities. This threshold is determined by clinicians who are guided by local mental health laws and practices, and is usually justified with a need for protection from serious harm. Despite this need for protection, inpatient and post-discharge suicide rates suggest little protection from suicide is achieved. Nor do psychiatric hospitals prevent harm to others. A recent meta-analysis of prevalence and risk factors for violence by psychiatric acute inpatients found that about one in five admitted people are violent during their admission (Iozzino et al., 2015), mostly to other patients and often repeatedly. Sometimes, and at greater rates than in the community, inpatient violence results in serious injuries or even a patient death. Currently, inpatient violence either seems to be semi-acceptable (particularly if the victims are other patients) or, if more severe, results in various actions including further segregation, sometimes to the point of temporary seclusion. The use of seclusion has rightly come under increasing scrutiny. However, no attention has been paid to the basic premise that we should admit people to common treatment, recreation, eating, and even bathroom spaces.
Rethinking assumptions and reimagining facilities
We would like to cast some doubt on the belief in intrinsic harms associated with people being treated away from other patients. We believe the harms associated with seclusion are mostly because our seclusion facilities are almost medieval and that it is the aggregation and collectivisation of mentally ill people in psychiatric facilities that is the underlying problem. Many people who are admitted to an acute mental health facility will either witness or become a victim of violence or aggression within 24 hours. Some will then become violent themselves perpetuating a vicious circle of contagious violence. This violence inures staff and patients to further violence and separates people from their friends and families. Psychiatric hospitalisation in its current form is traumatic, socially isolating and fosters stigma and self-stigma. We are at a loss to explain how current inpatient psychiatric care is acceptable to anyone, let alone to people with the vulnerabilities of pre-existing trauma, suicidality, and paranoia. The downsides to the aggregation of mentally ill people are self-evident. But where is the evidence that treating mentally ill people together advantages them? Elsewhere in medicine there is no expectation that people with similar illness should benefit from being cared for together. In fact the evidence suggests a steep decline in suicide rates in somatic hospitals to a contemporary rate of just under one suicide per million admissions as medicine has become more personalised and Florence Nightingale wards have been abandoned. From a scientific perspective, psychiatric hospitalisation is an accident of history, without any data supporting its safety or effectiveness.
While we believe that we should stop aggregating and traumatising mentally ill people in conventional psychiatric facilities, we also acknowledge that many mentally ill people do need the tertiary care of a hospital and cannot be managed in the community. The solution is a radical rethinking and redesign of inpatient care. We suggest that instead of an admission to a common space, people should be admitted to single-person facilities with acceptable floor space, amenity, comfort and privacy. These spaces should be hopeful, open and welcoming to family and friends. They should foster optimism, recovery and ultimately even neural plasticity while minimising stigma and trauma. There is no need for non-consensual contact between patients, including the contagion of interpersonal violence or, for that matter infectious contact such as COVID 19. There is no need for psychiatric care to be noisy and foreboding. While such an arrangement would require imagination and money, it would allow genuinely individualised treatment, would lessen stigma, would provide better protection and, if done properly, would foster social connectedness.
Next steps
Malhi et al. highlighted changes to the neuronal structure of the brain following a suicide attempt after a person has broken their connection with life itself, a step taken only after ‘appraisal of many critical factors, including the evaluation of one’s self worth, one’s relationships with others, and one’s current situation in life’. Treating patients within collectivised psychiatric settings seems uniquely designed to do just that. Every breach of privacy, episode of aggression and unwanted physical or sexual contact pushes people away from their vital connections. What improvement science can do is foster the accurate recording and publication of the adversities of patient experiences in all units within Australasia. Confronted with these results, policymakers might just provide the investment needed to radically reimagine inpatient care.
Conclusion
Iatrogenic harm within inpatient facilities is the neglected side effect of a deeply flawed assumption about the need for collective psychiatric care. The shared spaces in psychiatric wards deny any modicum of the safety and privacy that is needed for recovery. A successful leap towards zero suicides can only happen after we abandon outdated notions of collective psychiatric treatment.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship and/or publication of this article.