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

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

Entering and adjusting to a different and uncertain world: experiences and support needs of adult family members, partners and friends in England who care for an adult at risk of suicide

Background: Mental health services in England are dependent on family and friends to support patients who may be at risk of suicide. However, support for these informal caregivers is lacking despite evidence of caregiver burden, poor health outcomes, and difficult encounters with mental health services. Stigmatising experiences have been unearthed in qualitative studies although perceived stigma relating to suicidal behaviour has not been formally assessed in carers. To date, minimal research specifically investigating carers of adults at risk of suicide has been conducted in England and there is a dearth of mixed methods inquiry in the field. Aim: This exploratory mixed methods research aimed to develop an understanding of the experiences and support needs of adult informal caregivers of adults at risk of suicide. Methods: An online survey of 101 self-selecting adult carers of an adult at risk of suicide assessed perceived stigma of suicide attempt, quality of life and helpfulness of support services, as well as obtaining qualitative data on experiences and support needs. Semi structured interviews were carried out with 15 of the survey participants. Statistical analyses were conducted with quantitative data, summative content analysis was used for qualitative survey data and reflexive thematic analysis for interview data. The three data sets were integrated, and, through a process of abduction, mixed methods interpretations were achieved. Results: The overarching theme of ‘entering and adjusting to a different and uncertain world’ was generated, with uncertainty being the main response of carers. The finding of uncertainty is explained by the Uncertainty in Illness Theory. Carer uncertainty was acute on entry to the different world, enduring in the longer term, and inherent in perspectives on the future. Uncertainty manifested emotionally, psychologically, interpersonally and behaviourally, was perpetuated by difficult encounters with healthcare providers, and had detrimental effects on mental and physical wellbeing. Stress was propagated by lack of support from mental health services, which were the least helpful support agency. Perceived stigma was inversely associated with carer support, caring choice and carer stress, and accounts indicated experiences of provider-based stigma. Carers demonstrated an adept ability to balance uncertainty with hope, which helped them to tolerate uncertainty and sustain their caring role. Identified support needs included recognition, information and education, authentic collaboration and tailored peer support and psychosocial interventions. Conclusion: The Uncertainty in Illness Theory provides a helpful framework for caregivers and clinicians to make sense of carers experiences including how uncertainty can be perpetuated by healthcare providers. This understanding should be used to inform coproduced resources and interventions for carers and education for mental health clinicians. There is a need for further research with this population of carers, particularly longitudinal studies, with a view to developing and evaluating tailored psychosocial interventions to help carers tolerate the longstanding uncertainty caring for someone at risk of suicide entails

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

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

Effects of ketamine treatment on suicidal ideation: a qualitative study of patients’ accounts following treatment for depression in a UK ketamine clinic

Objective It is recognised that ketamine treatment can reduce suicidal ideation (SI) in people with depression, at least in the short term. However, information is lacking on patients’ perspectives on such effects. Studying these can contribute to greater understanding of the mechanisms underlying impact of ketamine treatment on SI. The aim of this study was to investigate patients’ reports of the impact of treatment on their SI, the duration of effects and possible mechanisms. Design and setting This qualitative study consisted of semi-structured interviews with patients who had received ketamine treatment for depression. Interview data were analysed thematically. Participants Fourteen patients (8 females, 6 males, aged 24–64 years) who had received treatment with ketamine for treatment-resistant depression, and had SI at the initiation of treatment. Two participants also had a diagnosis of bipolar type 1 and two of emotionally unstable personality disorder. Eight had a history of self-harm. Results SI reduced following ketamine treatment in 12 out of 14 participants for periods of a few hours following a single treatment to up to three years with ongoing treatment. Reduction of SI was variable in terms of extent and duration, and re-emergence of suicidal thoughts often occurred when treatment ceased. Participants’ accounts indicated that reduced SI was associated with improved mood and reduced anxiety, as were clarity of thought, focus and concentration, and ability to function. Participants reported experiencing some or all of these effects in various orders of occurrence. Conclusion Generally, ketamine treatment was experienced as effective in reducing SI, although duration of effects varied considerably. Patients’ perspectives indicated similarities in the mechanisms of reduction in SI, but some differences in their manifestation, particularly in relation to chronology. Experiences of this cohort suggest that reduced anxiety and improvement in ability to think and function were important mechanisms alongside, or in some cases independently of, improvement in mood. Further studies of patients’ experiences are required to gain enhanced understanding of the variability of effects of ketamine on SI and functionality

Ketamine treatment for individuals with treatment-resistant depression: a 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 six 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 two or more months later. Data were analysed thematically. Results Most participants hoped that ketamine would provide respite from their depression. All experienced improvement in mood following initial treatments, ranging from negligible to dramatic, and eight 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. The transient nature and cost of treatment were problematic. Eleven participants experienced side-effects, which in two cases were significant. 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 of associated increased hopelessness and suicidality

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

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