Suicide Prevention

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Reform group to improve safety

In the fall of 2017, a reform group was established at Landspítali to improve safety in the psychiatric wards following serious incidents. The objective of the improvements was to standardise the environment of inpatient psychiatric wards in Landspítali according to evidence-based knowledge.

An extensive search was made for helpful material at the beginning of the project. A literature search revealed that no standards exist for the design and layout of psychiatric wards. A checklist designed for military hospitals in the United States (The Mental Health Environment of Care Checklist) proved helpful, along with studies on the frequency and extent of suicide attempts and suicides. No assessment tool or adequate standards for safety in psychiatric wards were found. Therefore, definitions and minimum safety requirements for psychiatric wards at Landspítali were made based on evidence-based knowledge. Inpatient units were also classified into risk levels 1 - 3, depending on the nature and scope of the service. Still, the risk may differ depending on the specialisation of each inpatient unit, the number of incidents, and the urgency of each location. Wards at risk level 1 are closed wards for persons assessed as dangerous to themselves and/or others.

Research

Every year, about a million people worldwide die by suicide (Kozel, Grieser, Abderhalden, and Cutcliffe, 2016). In Iceland, approximately 30-50 people die by suicide every year. Research on suicide attempts and suicides has shown that it is possible to reduce the frequency of suicide attempts and suicides in psychiatric wards and residential institutions for individuals assessed as dangerous to themselves and others, with increased knowledge of suicidal behaviour and risk in the environment of psychiatric wards.

A study by James, Stewart, Wright and Bowers (2012) examined 500 recorded cases of self-harming behaviour and suicide attempts in psychiatric inpatients in England and Wales. Their results showed that women (65%) attempted suicide or showed self-harming behaviour more often than men (35%), but men's suicide attempts were often more severe. Most self-harm and suicide attempts were made by cutting oneself (38.8%), narrowing the airway (20.1%), hitting or banging one's head against a wall (14.5%), and poisoning (8.9%). The study also found that most incidents took place in the patient's room (21%), in the bathroom (9.2%), and in the toilet (4.2%). Doors and windows were most commonly used for suicide attempts or self-harm (21.7%). Still, other things were also used, such as clothing (8.7%), razors (8.7%), kitchen utensils (8.5%), medicines (7.8%), furnishings (2%), electrical cords (2%), plastic bags (1.6%), bedding (1.3%) and poison (0.7%). Most attempts were made between 8-11 p.m., but no significant difference was found between the days of the week and the months. The consequences of suicide attempts were mostly minor, but serious harm was recorded in 0.2% of cases.

Another study conducted in the US military psychiatric ward from 1999-2011 examined 243 diagnoses of suicide and suicide attempts. The study results showed that most of the incidents occurred in the patient‘s room (42,1%) and in toilets or bathrooms (28,1%). The methods used were hanging (43.6%), cutting oneself (22.6%), obstructing the airway (15.6%), and using drugs or poisoning (7.8%). Of those who succeeded, hanging was the most common method (75.9%) (Mills, King, Watts, and Hemphill, 2013).

In 2007, the Mental Health Environment of Care Checklist was implemented by the VHA in all military hospitals to increase safety and reduce the number of inpatient suicides in psychiatric wards. In the first two years after the implementation of the checklist, 8,298 risks were identified in the psychiatric ward environment, and the number of inpatient suicides decreased significantly. The suicide rate was previously 2.64 per 100,000 admissions, but after the implementation of the checklist, the number of suicides decreased to 0.87 per 100,000 admissions. The study showed that with the use of the checklist, there was an 87% reduction in the likelihood of suicide in psychiatric patients (Watts et al., 2012).