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11--suicide.pptx
- 2. 2 Contents (Self-harm/suicide) A. Introduction 10 mins B. Learning objectives C. Emergency medical treatment for act of self-harm 10 mins D. Key actions 1. Establish communication and build trust 10 mins 2. Conduct assessment 60 mins 3. Plan and start management 15 mins 4. Link with other services and supports 5 mins 5. Follow up 9 mins Total Time: 2 hours
- 3. 3 3 True or False • Asking people about suicide gives them the idea to commit suicide • Asking about self-harm does NOT provoke acts of self-harm. Asking often reduces anxiety associated with thoughts or acts of self-harm and helps the person feel understood FALSE
- 4. 4 Self-harm/suicide associated stigma • A single act of self-harm can have long-term effects on a person's family, social and working life • The person and the family can both experience stigma and discrimination • The person may have difficulty finding work and making friends • Have you seen examples of stigma and discrimination against someone who has attempted self-harm/suicide?
- 5. 5 5 Terminology • Suicide is the act of deliberately killing oneself • Suicidal intent means an intention of killing oneself, to end one's life, to die • Suicidal thoughts or ideation means having thoughts of killing oneself. They can be vague and non-persistent • Suicide plan means that someone has made a concrete plan to kill oneself, e.g. I will take my dad’s entire medication this weekend when my family goes to visit my grandparents
- 6. 6 6 Terminology • An act of self-harm without suicidal intent is deliberately harming oneself, e.g. cutting oneself • A suicide attempt is an act of self-harm with suicidal intent but not resulting in death • Both are to be taken very seriously because they are important risk factors for completed suicide in the future
- 7. 7 Why is it important for you to learn about self-harm/suicide? • Suicide can be prevented • Almost 1 million persons die from suicide every year • Suicide is among the three leading causes of death in the 15- 24 years old group in many countries • About one third of all suicides in the world are committed by self-poisoning with pesticides. • Suicide leaves a devastating legacy for those who have survived a loved one’s suicide • Suicide attempt is to be taken very seriously by health professionals 7
- 8. 8 Contents (Self-harm/suicide) A. Introduction B. Learning objectives C. Emergency medical treatment for act of self-harm D. Key actions 1. Establish communication and build trust 2. Conduct assessment 3. Plan and start management 4. Link with other services and supports 5. Follow up 8
- 9. 9 9 Learning Objectives • To be able to conduct emergency assessment and management after a medically serious act of self-harm • To be able to assess people with thoughts, plans, or acts of self-harm/suicide • To know that it is necessary to assess for other mhGAP conditions, chronic pain and acute emotional distress • To be able to manage people with thoughts, plans, or acts of self-harm/suicide • To be able to activate psychosocial support • To be able to keep contact and follow up
- 10. 10 Contents (Self-harm/suicide) A. Introduction B. Learning objectives C. Emergency medical treatment for act of self-harm D. Key actions 1. Establish communication and build trust 2. Conduct assessment 3. Plan and start management 4. Link with other services and supports 5. Follow up
- 11. 11 11 Emergency medical treatment: general principles • Treat medical injury or poisoning immediately • if there is acute pesticide intoxication, follow the WHO pesticide intoxication management document
- 12. 12 12 Emergency assessment of suicide attempt
- 13. 13 Recognizing a pesticide poisoned person • Be aware of the possible smell of a pesticide • The person may be unconscious, with slow breathing and low blood pressure. • People who are initially well need to be watched carefully for new signs (sweating, pinpoint pupils, slow pulse, and slow breathing).
- 14. 14 14 • A person with possible pesticide poisoning must be treated immediately • For a pesticide poisoned person to be safe in a health care facility, a minimum set of skills and resources must be available. If they are not available, TRANSFER the person immediately to a facility that has the minimum set of skills and resources • We will discuss the minimum requirements on the next slide Treating pesticide poisoning
- 15. 15 Treating pesticide poisoning Minimum set of skills and resources: • skills and knowledge about how to resuscitate people and assess for clinical features of pesticide poisoning • skills and knowledge to manage the airway, in particular to intubate and support breathing until a ventilator can be attached • atropine and means for its intravenous (IV) administration if signs of cholinergic poisoning develop; • diazepam and means for its IV administration if the person develops seizures
- 16. 16 • DO NOT force the person to vomit • DO NOT give oral fluids • DO NOT leave the person alone • You may give activated charcoal if – The person is conscious – The person gives informed consent – The person presents within 1 hour of the poisoning 16 Treating pesticide poisoning: What not to do
- 17. 17 When medically stable • Assessment and management happen simultaneously in an emergency situation • Once the initial emergency situation has been resolved, before the person goes home you must return to do a full self-harm/suicide assessment and then manage according to the mhGAP-IG
- 18. 18 Contents (Self-harm/suicide) A. Introduction B. Learning objectives C. Emergency medical treatment for act of self-harm D. Key actions 1. Establish communication and build trust 2. Conduct assessment 3. Plan and start management 4. Link with other services and supports 5. Follow up
- 19. 19 Establish communication and build trust • Establish a relationship before asking self-harm questions • Ask openly about self-harm • When asking the person about suicide, the question should be asked with an appropriate transition from a previous point leading into this issue
- 20. 20 • Treat the person with respect and privacy • Be sensitive to emotional distress • Make sure to see the person alone if culturally possible • Include the carers in assessment and treatment if the person gives consent • Do not try to use moral or cultural values to make the person feel guilty about his or her suicidal thoughts, plans or acts Establish communication and build trust
- 21. 21 A. Introduction B. Learning objectives C. Emergency medical treatment for act of self-harm D. Key actions 1. Establish communication and build trust 2. Conduct assessment 3. Plan and start management 4. Link with other services and supports 5. Follow up 21 Contents (Self-harm/suicide)
- 22. 22 Process of assessment Does the presentation suggest a priority condition according to the master chart? Conduct assessment according to the module Go to relevant module(s) Develop a management plan NO End assessment If the person is presenting with multiple possible conditions, all must be assessed. Identify the condition and treatment
- 23. 23 +
- 24. 24 Assessing people with mhGAP conditions • There is a second scenario when you must assess for self- harm/suicide
- 25. 25
- 26. 26 Self-harm/Suicide - Assessment Make sure you never leave a person alone until you have finished your assessment and started your management plan
- 27. 27 How do you ask the questions? • Have you thought about hurting yourself? • Have you made any plans to end your life? • How are you planning to do it? • Do you have pesticides / a gun or other means readily available to you? • Have you considered when to do it?
- 28. 28 What is imminent risk?
- 29. 29 29 It is critical to assess for other priority conditions and All people with other priority condition should be asked about self-harm/suicide Assess for: Self-harm/Suicide - Assessment
- 30. 30 30 • All people with chronic pain should be asked about self-harm/suicide Self-harm/Suicide - Assessment
- 31. 31 Ask about: Self-harm/Suicide - Assessment
- 32. 32 Role play: Assessment • A young man comes into your consulting room. He sits down and explains that yesterday he fell off his motorcycle at a low speed and wants a check up. He hasn't noticed any major injuries but he is clearly very worried about something. He tells you that he found out that he had failed an important exam just before he got on his motorcycle. • Your assessment indicates he is very emotional but does not have depression • Your physical exam is normal other than a few minor bruises • You have never met this man before. Use your communication skills to start talking about self-harm/suicide
- 33. 33 33 Role play 2: Assessment • A middle-aged woman was brought urgently to the center by her husband after having drunk a bottle of pesticide • You managed to save her life (the minimum set of skills and resources were available in your facility) • Now, you come to see her on the ward after she is stable • Her name is Adwoa. She is a 43-year old woman who has been unhappy for two weeks. Adwoa's husband has already told you that she had her first child less than a month ago • What must you do before Adwoa leaves the hospital • Adwoa must be fully assessed for self-harm/suicide before she leaves the hospital. Split into groups to role play assessment Role play 2: Assessment
- 34. 34 Contents (Self-harm/suicide) A. Introduction B. Learning objectives C. Emergency medical treatment for act of self-harm D. Key actions 1. Establish communication and build trust 2. Conduct assessment 3. Plan and start management 4. Link with other services and supports 5. Follow up 34
- 35. 35 35 Management: Imminent risk of self-harm/suicide attempt • Place the person in a secure and supportive environment at the health facility, if possible, offer separate, quiet room while waiting • Do not leave the person alone • Remove the means of self-harm • If prescribing medication: – use medicines that are the least dangerous in case of overdose – give prescriptions for short periods of time (e.g. one week at a time) • Hospitalization in non-psychiatric services of general hospitals with the goal of preventing acts of self-harm is not recommended
- 36. 36 Management: Co-occurring conditions • If there is a concurrent mhGAP condition, e.g. depression, alcohol use disorder, manage according to the mhGAP-IG for the self-harm/suicide and also for the mhGAP condition • If there is chronic pain, you need to manage the pain. Consult a pain specialist if necessary • If the person has no mhGAP condition but has nonetheless severe emotional symptoms, then manage as explained in the module on Other emotional and medically unexplained complaints (OTH)
- 37. 37 37 • Consult a mental health specialist, if available • Offer and activate psychosocial support • Maintain regular contact and follow-up Management: All cases of thoughts, plans or acts of self-harm/suicide
- 38. 38 38 Management: Consult a mental health specialist • Find out whether a mental health specialist is available and make an appointment for the person • The specialist and the carers should both know when the appointment is and why the person needs the appointment • If a mental health specialist is not available, mobilize family, friends and other concerned individuals or available community resources to monitor and support the individual during the imminent risk period
- 40. 40 RECALL: How do you address psychosocial stressors • Offer the person an opportunity to talk, preferably in a private space. • Ask about current psychosocial stressors • Assess any situation of maltreatment, abuse (e.g. domestic violence) and neglect or bullying • Brain storm together for solutions or for ways of coping • Identify supportive family members and involve them as much as possible and appropriate. • Encourage involvement in self-help and family support groups, where available.
- 41. 41 RECALL: How do you help someone problem-solve 1. Identify the problems 2. Prioritize the problems 3. Select the problem to be addressed 4. Think about all possible solutions to the problem 5. Select the most appropriate solution 6. Implement the solution 41
- 42. 42 Contents (Self-harm/suicide) A. Introduction B. Learning objectives C. Emergency medical treatment for act of self-harm D. Key actions 1. Establish communication and build trust 2. Conduct assessment 3. Plan and start management 4. Link with other services and supports 5. Follow up 42
- 43. 43 Link with other services and supports • What local resources and services are available to help people who may self-harm or who have committed an act of self-harm? • Identify and mobilize possible sources of social and community support in the local area, including educational, housing and vocational supports • For children and adolescents, coordinate with schools to mobilize educational and social support • Encourage involvement in self-help and family support groups
- 44. 44 44 Activate psychosocial support • Mobilize family, friends, to monitor the person and to restrict access to means of self-harm • Inform carers that asking about suicide will often reduce the anxiety surrounding the feeling; the person may feel relieved and better understood • Carers often experience severe stress. Provide emotional support to carers as needed
- 45. 45 • Optimize social support from available community resources – Religious leaders – Formal community resources – Crisis centers and local mental health centers • What type of supports are available here to help a person with thoughts, plans or a previous attempt of self- harm/suicide? 45 Activate psychosocial support Activate psychosocial support
- 46. 46 Reactivate social networks • Identify prior social activities that, if reinitiated, may provide psychosocial support • family gatherings, • outings with friends, • visiting neighbors, • sports, • community activities • Encourage the person to resume these social activities • Advise the family members that these activities can help with recovery Reactivate social networks
- 47. 47 Contents (Self-harm/suicide) A. Introduction B. Learning objectives C. Emergency medical treatment for act of self-harm D. Key actions 1. Establish communication and build trust 2. Conduct assessment 3. Plan and start management 4. Link with other services and supports 5. Follow up 47 Contents (Self-harm/suicide)
- 48. 48 Follow up • You will need frequent contact initially (e.g. weekly for the first 2 months) and less frequent contact as the person improves (e.g. once every 2–4 weeks). • But you will need to follow up for as long as suicide risk persists • At every contact, routinely assess thoughts, plans and acts of self-harm/suicide
- 49. 49 Follow up • How do you usually follow up people with self-harm/suicide attempt? • Can you think of any other follow up methods that would be culturally acceptable? • Any follow up MUST include another full assessment of self- harm/suicide Follow up
- 50. 50 Key messages • Everyone with thoughts, plans, or acts of self-harm/suicide must be assessed for mhGAP conditions • Anyone with a mhGAP condition must be assessed for self- harm/suicide • The means of suicide must be removed from the individual • Psychosocial support should be offered to the person and family • Follow up is essential • If your facility does not have the skills and resources to manage pesticide poisoning, transfer a person with pesticide poisoning immediately Key messages
Editor's Notes
- For comments and suggestion on this guide, please email to mhgap-info@who.int
- Limit the discussion of this statement to 2 minutes maximum. Ask the question before revealing the answer.
- After going through the bullets, ask the question at the end. Limit the discussion of this statement to a few minutes maximum.
- Ask if there are any questions about the definitions.
- The facilitator can add information that is relevant to the community here as appropriate. Make sure that everyone understands the importance of asking about self-harm/suicide. Explain that we will go into detail about when you should ask.
- Read out the bullet points as displayed Explain that we will now go into detail about each point.
- Ask the group to open their mhGAP-IGs to page 68. Make sure that the participants can see the displayed image in the mhGAP-IG. Explain that assessment and management must happen at the same time in an emergency. These assessment steps must happen very quickly.
- Explain that we will now talk specifically about pesticide poisoning. Make sure to emphasize that pesticide poisoning is important to consider in someone who may have attempted self-harm/suicide It is a method of suicide attempt with a high fatality rate, and it is sometimes the most frequently employed method in a country.
- Explain that a person with possible pesticide poisoning needs to be treated immediately If your facility does not have the necessary resources or you are uncomfortable managing pesticide poisoning, transfer immediately The following slides on pesticide intoxication management are very simple. Make sure to refer to the "Clinical Management of Acute Pesticide Intoxication" document and ideally have copies of it printed out. Background knowledge See WHO document Clinical Management of Acute Pesticide Intoxication: http://www.who.int/mental_health/prevention/suicide/pesticides_intoxication.pdf
- If you do not have ALL FOUR of these resources, then you should refer immediately Cholinergic poisoning signs Pinpoint pupil Dizziness Disorientation Cough/wheezing Sneezeing Difficulty breathing Drooling Tremors/ twitching/seizure
- Stress the importance of avoiding the actions displayed.
- We will now make a transition from the emergency scenario to explaining the principles of self-harm/suicide assessment in a non-emergency situation. Make sure to emphasize that EVERY person must have a full assessment after a self-harm/suicide attempt.
- Explain that the group will now discuss the assessment of self-harm/suicide is a person who is medically stable.
- Make clear in the training that questions about self-harm/suicide should be brought up in an appropriate manner. £ For example, do not ask "Do you have a headache?" and next "Do you want to kill yourself?," but rather when the person is talking about feelings of sadness or hopelessness make a transition to a question about suicide, according to flow of the interview.
- Go through each of the bullet points and answer questions as they arise. Give examples of each point as appropriate.
- Remind participants that this slide was discussed in the general session to explain the sequence for using the mhGAP-IG.
- Point out the section of the master chart that is used to suspect self-harm/suicide.
- Make sure to emphasize that there are two points of entry for self-harm/suicide assessment. Using the master chart to identify a presentation that suggests self-harm/suicide Assessing for self-harm/suicide for anyone who has an mhGAP condition, chronic pain, or acute emotional distress
- Explain that this is the sequence for assessing someone for self-harm/suicide
- Make sure that all the participants are on mhGAP-IG page 69. Explain that "imminent risk" means that the person is a at high risk of self-harm/suicide if you do not take action. Walk through the steps of the assessment giving examples and answering questions as appropriate.
- This discussion should not be longer than 5 minutes. Ask the group if they think that these are culturally appropriate ways to ask these questions. If there is disagreement, ask for other ideas about how to ask. Remind the participants that these questions must be asked at an appropriate time. The transition to these issues should not come out of the blue.
- Ask the participants. "What is the next step?" Make sure to take all the time necessary to go through the conditions.
- The next step is asking for chronic pain: This can be due to e.g. cancer, HIV/AIDS, etc.
- This is the last step, which is assessing for severe and acute emotional distress: There can be loss of a loved one, loss of employment, intense family conflict, problems at school, intimate partner violence, physical or sexual abuse or uncertainty of sexual orientation, etc. You can explore these issues, e.g. by asking people to talk about their problems.
- Role play Duration: 15 minutes including discussion Purpose: This role play gives participants an opportunity to practice the assessment of person with possible risk of self-harm/suicide. Instructions: The facilitator will play the young man. (PG 69) A participant will play the healthcare worker. If there is another facilitator, this person will monitor the role play and provide feedback. Both the young man and the healthcare worker will be seated across from each other at the front of the room. The facilitator should instruct the healthcare worker to concentrate the assessment on self-harm/suicide. However, the healthcare worker should try to find an appropriate sequence in the conversation to ask about self-harm/suicide The healthcare worker should not start the conversation by asking about self-harm/suicide bluntly. The healthcare worker should Initiate the conversation by asking about how the young man is feeling. Continue the assessment using the mhGAP-IG as a guide until self-harm/suicide has been fully assessed. The facilitator monitoring the role play should interrupt as appropriate after about 3 minutes of conversations and should Ask the healthcare worker how things are going. What is going well? What could be better? Ask the group how things are going. What is going well? What could be better? Provide some feedback on appropriate raising the subject of self-harm/suicide The facilitator should then allow the conversation to continue for another 3 minutes and then repeat the process of feedback If there is time, another participant can attempt the role of the healthcare worker. Notes for the facilitator playing the young man It is important to remember that the young man will not want to talk about ideas of suicide right away Do your best to play this role naturally. You have never met this healthcare worker before. You don't think you have any major injuries, but you thought you should get checked out You were riding along and hit the curb because you were not paying attention. You know you shouldn't have gotten on your motorcycle because you were very upset at the time You are extremely upset about your result on the exam You are concerned that you will never get a decent job and that your family will be disappointed You have been able to sleep or eat since you found out about the exam You feel like it would be easier to die than face the shame for you and your family You have thought about getting back on your bike and driving off the bridge
- Role play Duration: 20 minutes including discussion Purpose: This role play gives participants an opportunity to practice the assessment of person with possible risk of self-harm/suicide. Instructions: Split the participants into groups of 3 One participant is the healthcare worker. One participant is a Adwoa One participant will be Adwoa's husband. This participant will just observe and make sure all areas are covered. The role play should begin with the person already seated with the healthcare worker. The healthcare worker should begin the conversation and move into an assessment of self-harm/suicide. Encourage the healthcare worker to use the mhGAP-IG during the assessment. Allow the assessment to go for 10 minutes and give a 2 minute warning. The facilitator should move around the groups monitoring progress and making sure that everyone understands the instructions. After the role play, allow the healthcare worker to reflect on what was done well and what could have been done better. The observer and the participant playing Adwoa should both offer feedback to the healthcare worker. Allow 5 minutes. Then bring the group back together and ask everyone how it went. Ask if there are any questions or comments. Notes for the participant playing Adwoa The facilitator should give the participant playing Adwoa a handout which following scenario: You should act very sad and quiet. Do not look the healthcare worker in the eyes. You might have depression, but you have no other priority condition. You do not have chronic pain Adwoa has been feeling worse and worse since her baby was born. The baby cries all the time and she can't sleep at all. She doesn't know what to do. She has been feeling down and irritable. She has no desire to hold her baby. All she wants to do is stay in bed and sleep She says she is “tired all the time”. She has no appetite and has little interest in her normal activities. She has been thinking about killing herself for the last two weeks She doesn't see the point of living life anymore For the past week she has been thinking about hanging herself or drinking the cleaning supplies in the house
- You should explain the following to your trainees: *If a person with self-harm must wait for treatment, offer an environment that minimizes distress, if possible in a separate, quiet room with supervision and regular contact with a named staff member or a family member to ensure safety. **If admission to a general (non-psychiatric) hospital for management of medical consequences of an act of self-harm is necessary, monitor the person closely to prevent subsequent self-harm in the hospital.
- These are overarching principles for management in all cases, including in those where there is no imminent risk of suicide but where there has been a relevant history of thoughts, plans or acts of self-harm/suicide. We will go into each area in greater depth.
- When talking about “Explore reasons and ways to stay alive”, you should be careful as to what to say and not to say. It may be a mistake to tell the persons like Najwa that they should stay alive for the sake of their child, as it may make her feel more guilty. The best reason that one can give a person for living is the assurance that the person can be helped to feel better. When exploring for reason and ways to stay alive, one should listen well to the person and try to understand what matters most for the person,
- Limit the time for recall to 3 minutes. Ask for participants to recall as much as they can about addressing psychosocial stressors before revealing the answers.
- Limit the time for recall to 3 minutes. Ask for participants to recall as much as they can about problem solving before revealing the answers.
- Ask the group for some examples of possible local resources. Limit the discussion to 3 minutes. Linking people to available resources is an important part of maximizing recovery A healthcare worker should know what is available. – social worker. Trained health professionals
- It is also important to address the stigma that the family might receive and the misconceptions the family might have about suicide, and educate them (e.g. talk about the misconceptions).
- The facilitator should do some background research and have some answers for this question ready The facilitator should put the answers on this slide
- Explain that getting people involved in their communities again is critical to avoid further self-harm/suicide
- Follow up needs to be frequent, but often depends on clinical judgement The person needs to be followed up as long as there is risk
- Different methods can be used to follow up: scheduling another appointment at the center, home visit, phone call, text message. These different methods vary depending on the resources available and on the cultural acceptability. Discuss the options with the participants and write them down on the flipchart. If there are no answers, provide some of the examples mentioned above to start a discussion.
- For the last point, ask the group what the minimum skills and resources are for managing pesticide poisoning Finish the module by asking if there are any questions or comments