Huisman, A.

Kerkhof, A.J.F.M.

Robben, P.B.M.

DSpace at VU

PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ March 2009   Vol. 60   No. 3 405
LETTERS
Letters from readers are wel-
come. They will be published at
the editor’s discretion as space
permits and will be subject to ed-
iting. They should not exceed
500 words with no more than
three authors and five references
and should include the writer’s e-
mail address. Letters comment-
ing on material published in Psy-
chiatric Services, which will be
sent to the authors for possible
reply, should be sent to Howard
H. Goldman, M.D., Ph.D., Edi-
tor, Psychiatric Services, at ps
journal@psych.org. Letters re-
porting the results of research
should be submitted online for
peer review (mc.manuscriptcen
tral.com/appi-ps).
Use of Guidelines in 
Suicide Prevention
To the Editor: An interesting study
by Huisman and colleagues (1) in the
January issue described the suicide
audit system of the Dutch Health
Care Inspectorate. All suicides in the
Netherlands are reported to the in-
spectorate, which follows up on some
reports with requests for additional
information or with remarks or sug-
gestions for improving services. The
study investigated whether the feed-
back provided by the inspectorate
was in agreement with guidelines of
the American Psychiatric Association
(APA) (2) for assessment and treat-
ment of suicidal patients.
Because the study period was from
1996 until 2006, it is not realistic to
expect the responses of the Dutch
Health Care Inspectorate to follow
guidelines for most of the study
years, because the guidelines were
not published until 2003. The APA
guidelines appear to have been used
as a theoretically constructed gold
standard. However, this requires fur-
ther clarification.
As noted in the study, the Dutch
Health Care Inspectorate sometimes
gave quite detailed feedback to the
providers of care, such as emphasiz-
ing the importance of telling the pa-
tient about an elevated suicide risk in
the first weeks after starting antide-
pressant medication. However, it re-
mains to be seen to what extent
American guidelines are applicable in
the Netherlands at this level of detail.
For example, given restrictions on the
possession of firearms in the Nether-
lands, checking the accessibility of
firearms is less important, even
though it is repeatedly mentioned in
the APA guidelines.
Thirty percent of the persons who
committed suicide in the study sam-
ple were inpatients. It is important for
psychiatric hospitals to check that lig-
ature points are absent (3), although
this is not mentioned in the APA
guidelines because of the emphasis in
this document on the role of individ-
ual psychiatrists. Feedback to hospi-
tals from the inspectorate about the
need to check for the absence of liga-
ture points would reinforce the role of
this agency in suicide prevention.
The findings of the study would
have been even more impressive if a
standard of care based on the current
literature had been used to analyze
the responses of the inspectorate,
rather than the APA guidelines.
Dieneke Hubbeling, M.Sc.,
M.R.C.Psych.
Dr. Hubbeling is a consultant psychiatrist
at South West London and St. George’s
Trust, United Kingdom.
References
1. Huisman A, Robben PBM, Kerkhof AJFM:
An examination of the Dutch Health Care
Inspectorate’s supervision system for sui-
cides of mental health care users. Psychi-
atric Services 60:80–85, 2009
2. American Psychiatric Association: Practice
guideline for the assessment and treatment
of patients with suicidal behaviors. Ameri-
can Journal of Psychiatry 160(Nov suppl):
1–60, 2003
3. Gunnell D, Bennewith O, Hawton K, et al:
The epidemiology and prevention of suicide
by hanging: a systematic review. International
Journal of Epidemiology 34:433– 442, 2005
In Reply: We thank Dr. Hubbeling
for her response, and we are happy to
clarify our choice of the APA guide-
lines. First, no Dutch national guide-
lines for the treatment of suicidal pa-
tients exist. Therefore, we knew be-
forehand that we could expect that
the inspectorate’s notifications and
responses would not follow any exist-
ing guidelines. However, we needed a
standard of good clinical care for sui-
cidal patients so that we could evalu-
ate the inspectorate’s responses. For
this reason we conducted a literature
search and screened all guidelines
available internationally. The review
was published in Dutch in 2007 (1).
Because the APA guidelines are the
most extensive that we know of and
are partly evidence based, we chose
them as a gold standard, as Dr.
Hubbeling observed. However, it is
important to note that it was our in-
tention to use only the most global
recommendations and not to com-
pare the inspectorate’s responses with
every detail in the APA guidelines.
Most of the primary and general
points in the APA guidelines, such as
continuity of care and systematic risk
assessment, are very much in line
with major recommendations in the
other guidelines that we reviewed.
We agree that there are many more
important aspects to suicide preven-
tion, such as checking for the absence
of ligature points in inpatient facilities
and other more detailed recommen-
dations for specific treatment set-
tings. Also, we agree that further re-
search on good clinical practice is
necessary to develop and maintain an
up-to-date standard as a reference for
the inspectorate’s responses. Partly as
a consequence of our study of the sui-
cide notification procedure, a multi-
disciplinary guideline for the treat-
ment of suicidal patients, which will
be used by the inspectorate, is being
developed in the Netherlands.
Annemiek Huisman, M.Sc.
Paul B. M. Robben, Ph.D.
Ad J. F. M. Kerkhof, Ph.D.
Reference
1. Huisman A, Kerkhof AJFM, Robben PBM:
Guidelines for the treatment of suicidal pa-
tients: an overview [in Dutch], in Jaarboek
Voor Psychiatrie en Psychotherapie
2007–2008. Edited by Schene AH, Boer F,
Jaspers JPC, et al. Houten, Netherlands,
Bohn Stafleu van Loghum, 2007
Physical Injuries From 
Restrictive Interventions
To the Editor: The findings of the
study by Martin and colleagues (1) in
the December 2008 issue—that use
of restrictive interventions can be re-
duced through a collaborative prob-
lem-solving model—are both inter-
esting and exciting. Steps taken to de-
crease the use of such interventions
are to be welcomed and should be re-
inforced on an international scale. It
is unlikely, however, that such inter-
ventions will be completely eradicat-
ed from psychiatric services. There-
fore, debate and discussion on ways
to reduce the risks of such interven-
tions are important.
One reason for reducing the use of
restrictive interventions is that the ev-
idence base for their safety and effec-
tiveness is distinctly lacking (1). In ad-
dition, individuals who apply the in-
terventions and those to whom they
are applied may experience many ad-
verse psychological consequences (2).
Patients may view the interventions
as unwarranted and as punishment
for their actions (2). They may also re-
port that such interventions cause
pain, which all care providers should
seek to avoid. Staff may experience
anger and anxiety, and in some cases
staff may reawaken memories of their
own untoward experiences (2).
More recently, researchers have ex-
plored the physical consequences
that such interventions may have for
both parties. Clearly, the most serious
physical consequence is death, and
Martin and colleagues describe such
cases in the United States. Another
obvious consequence is injury to both
staff and patients. Research on this
important topic is limited, but one
U.K. study of a medium-secure unit
published in 2003 found that nearly
one in five incidents of physical re-
straint resulted in injury to staff or pa-
tients (3). Two more recent studies
found that the prevalence of such in-
juries was considerably lower (4,5),
even though the patients in these
studies, older adults and persons with
acquired brain injury, respectively,
typically have a far more complex
physical presentation than seen on a
general adult medium-secure ward. 
These studies found that employ-
ing a physical therapist who screened
all patients for physical ailments that
would increase the likelihood of in-
jury or pain was central to reducing
patients’ injuries. If any ailments or
restrictions on activity were identi-
fied, the physical therapist worked
with the hospital’s physical restraint
tutor on adopting pain-free tech-
niques. Restrictive measures must be
used with caution when they involve
children and adolescents because in
most cases their musculoskeletal sys-
tems are immature, which elevates
the risk of injury. Individuals who ap-
ply such interventions in populations
at risk of pain and injury might con-
sider involving a physical therapist to
reduce risk.
In summary, all staff should seek to
reduce the use of restrictive interven-
tions for the good of both patients and
staff. Employing a physical therapist
to screen patients is one way to re-
duce the risk of pain and injury. My
U.S. colleagues might consider taking
this approach.
Brendon Stubbs, B.Sc., P.G.Dip.
Mr. Stubbs is clinical specialist and lead
physiotherapist at St. Andrews Health-
care, Northampton, United Kingdom.
References
1. Martin A, Krieg H, Eposito F, et al: Reduc-
tion of restraint and seclusion through col-
laborative problem solving: a five-year
prospective inpatient study. Psychiatric
Services 59:1406–1412, 2008
2. Stubbs B, Leadbetter D, Patterson B, et al:
Physical intervention: a review of the liter-
ature on its use, staff and patient views and
the impact of training. Journal of Psychi-
atric and Mental Health Nursing 16:99–
105, 2009
3. Leggett J, Silvester J: Care staff attributions
for violent incidents involving male and fe-
male patients: a field study. British Journal
of Clinical Psychology 42:393–406, 2003
4. Stubbs B, Yorston G, Knight C: Physical in-
tervention to manage aggression in older
adults: how often is it employed? Interna-
tional Psychogeriatrics 20:855–857, 2008
5. Stubbs B, Alderman N: Physical interven-
tions in the management of aggression aris-
ing from brain injury: frequency of use and
injuries associated with implementation.
Brain Injury 22:691–696, 2008
PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ March 2009   Vol. 60   No. 3
LETTERS
406


Use of guidelines in suicide prevention.

NARCIS 

VU Research Portal

VU Research PortalUse of guidelines in suicide prevention.Huisman, A.; Robben, P.B.M.; Kerkhof, A.J.F.M.published inPsychiatric Services2009DOI (link to publisher)10.1176/appi.ps.60.3.405document versionPublisher's PDF, also known as Version of recordLink to publication in VU Research Portalcitation for published version (APA)Huisman, A., Robben, P. B. M., & Kerkhof, A. J. F. M. (2009). Use of guidelines in suicide prevention.Psychiatric Services, 60(3), 405. https://doi.org/10.1176/appi.ps.60.3.405General rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.            • Users may download and print one copy of any publication from the public portal for the purpose of private study or research.            • You may not further distribute the material or use it for any profit-making activity or commercial gain            • You may freely distribute the URL identifying the publication in the public portal ?Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.E-mail address:vuresearchportal.ub@vu.nlDownload date: 23. May. 2021PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ March 2009   Vol. 60   No. 3 405LETTERSLetters from readers are wel-come. They will be published atthe editor’s discretion as spacepermits and will be subject to ed-iting. They should not exceed500 words with no more thanthree authors and five referencesand should include the writer’s e-mail address. Letters comment-ing on material published in Psy-chiatric Services, which will besent to the authors for possiblereply, should be sent to HowardH. Goldman, M.D., Ph.D., Edi-tor, Psychiatric Services, at psjournal@psych.org. Letters re-porting the results of researchshould be submitted online forpeer review (mc.manuscriptcentral.com/appi-ps).Use of Guidelines in Suicide PreventionTo the Editor: An interesting studyby Huisman and colleagues (1) in theJanuary issue described the suicideaudit system of the Dutch HealthCare Inspectorate. All suicides in theNetherlands are reported to the in-spectorate, which follows up on somereports with requests for additionalinformation or with remarks or sug-gestions for improving services. Thestudy investigated whether the feed-back provided by the inspectoratewas in agreement with guidelines ofthe American Psychiatric Association(APA) (2) for assessment and treat-ment of suicidal patients.Because the study period was from1996 until 2006, it is not realistic toexpect the responses of the DutchHealth Care Inspectorate to followguidelines for most of the studyyears, because the guidelines werenot published until 2003. The APAguidelines appear to have been usedas a theoretically constructed goldstandard. However, this requires fur-ther clarification.As noted in the study, the DutchHealth Care Inspectorate sometimesgave quite detailed feedback to theproviders of care, such as emphasiz-ing the importance of telling the pa-tient about an elevated suicide risk inthe first weeks after starting antide-pressant medication. However, it re-mains to be seen to what extentAmerican guidelines are applicable inthe Netherlands at this level of detail.For example, given restrictions on thepossession of firearms in the Nether-lands, checking the accessibility offirearms is less important, eventhough it is repeatedly mentioned inthe APA guidelines.Thirty percent of the persons whocommitted suicide in the study sam-ple were inpatients. It is important forpsychiatric hospitals to check that lig-ature points are absent (3), althoughthis is not mentioned in the APAguidelines because of the emphasis inthis document on the role of individ-ual psychiatrists. Feedback to hospi-tals from the inspectorate about theneed to check for the absence of liga-ture points would reinforce the role ofthis agency in suicide prevention.The findings of the study wouldhave been even more impressive if astandard of care based on the currentliterature had been used to analyzethe responses of the inspectorate,rather than the APA guidelines.Dieneke Hubbeling, M.Sc.,M.R.C.Psych.Dr. Hubbeling is a consultant psychiatristat South West London and St. George’sTrust, United Kingdom.References1. Huisman A, Robben PBM, Kerkhof AJFM:An examination of the Dutch Health CareInspectorate’s supervision system for sui-cides of mental health care users. Psychi-atric Services 60:80–85, 20092. American Psychiatric Association: Practiceguideline for the assessment and treatmentof patients with suicidal behaviors. Ameri-can Journal of Psychiatry 160(Nov suppl):1–60, 20033. Gunnell D, Bennewith O, Hawton K, et al:The epidemiology and prevention of suicideby hanging: a systematic review. InternationalJournal of Epidemiology 34:433– 442, 2005In Reply: We thank Dr. Hubbelingfor her response, and we are happy toclarify our choice of the APA guide-lines. First, no Dutch national guide-lines for the treatment of suicidal pa-tients exist. Therefore, we knew be-forehand that we could expect thatthe inspectorate’s notifications andresponses would not follow any exist-ing guidelines. However, we needed astandard of good clinical care for sui-cidal patients so that we could evalu-ate the inspectorate’s responses. Forthis reason we conducted a literaturesearch and screened all guidelinesavailable internationally. The reviewwas published in Dutch in 2007 (1).Because the APA guidelines are themost extensive that we know of andare partly evidence based, we chosethem as a gold standard, as Dr.Hubbeling observed. However, it isimportant to note that it was our in-tention to use only the most globalrecommendations and not to com-pare the inspectorate’s responses withevery detail in the APA guidelines.Most of the primary and generalpoints in the APA guidelines, such ascontinuity of care and systematic riskassessment, are very much in linewith major recommendations in theother guidelines that we reviewed.We agree that there are many moreimportant aspects to suicide preven-tion, such as checking for the absenceof ligature points in inpatient facilitiesand other more detailed recommen-dations for specific treatment set-tings. Also, we agree that further re-search on good clinical practice isnecessary to develop and maintain anup-to-date standard as a reference forthe inspectorate’s responses. Partly asa consequence of our study of the sui-cide notification procedure, a multi-disciplinary guideline for the treat-ment of suicidal patients, which willbe used by the inspectorate, is beingdeveloped in the Netherlands.Annemiek Huisman, M.Sc.Paul B. M. Robben, Ph.D.Ad J. F. M. Kerkhof, Ph.D.Reference1. Huisman A, Kerkhof AJFM, Robben PBM:Guidelines for the treatment of suicidal pa-tients: an overview [in Dutch], in JaarboekVoor Psychiatrie en Psychotherapie2007–2008. Edited by Schene AH, Boer F,Jaspers JPC, et al. Houten, Netherlands,Bohn Stafleu van Loghum, 2007Physical Injuries From Restrictive InterventionsTo the Editor: The findings of thestudy by Martin and colleagues (1) inthe December 2008 issue—that useof restrictive interventions can be re-duced through a collaborative prob-lem-solving model—are both inter-esting and exciting. Steps taken to de-crease the use of such interventionsare to be welcomed and should be re-inforced on an international scale. Itis unlikely, however, that such inter-ventions will be completely eradicat-ed from psychiatric services. There-fore, debate and discussion on waysto reduce the risks of such interven-tions are important.One reason for reducing the use ofrestrictive interventions is that the ev-idence base for their safety and effec-tiveness is distinctly lacking (1). In ad-dition, individuals who apply the in-terventions and those to whom theyare applied may experience many ad-verse psychological consequences (2).Patients may view the interventionsas unwarranted and as punishmentfor their actions (2). They may also re-port that such interventions causepain, which all care providers shouldseek to avoid. Staff may experienceanger and anxiety, and in some casesstaff may reawaken memories of theirown untoward experiences (2).More recently, researchers have ex-plored the physical consequencesthat such interventions may have forboth parties. Clearly, the most seriousphysical consequence is death, andMartin and colleagues describe suchcases in the United States. Anotherobvious consequence is injury to bothstaff and patients. Research on thisimportant topic is limited, but oneU.K. study of a medium-secure unitpublished in 2003 found that nearlyone in five incidents of physical re-straint resulted in injury to staff or pa-tients (3). Two more recent studiesfound that the prevalence of such in-juries was considerably lower (4,5),even though the patients in thesestudies, older adults and persons withacquired brain injury, respectively,typically have a far more complexphysical presentation than seen on ageneral adult medium-secure ward. These studies found that employ-ing a physical therapist who screenedall patients for physical ailments thatwould increase the likelihood of in-jury or pain was central to reducingpatients’ injuries. If any ailments orrestrictions on activity were identi-fied, the physical therapist workedwith the hospital’s physical restrainttutor on adopting pain-free tech-niques. Restrictive measures must beused with caution when they involvechildren and adolescents because inmost cases their musculoskeletal sys-tems are immature, which elevatesthe risk of injury. Individuals who ap-ply such interventions in populationsat risk of pain and injury might con-sider involving a physical therapist toreduce risk.In summary, all staff should seek toreduce the use of restrictive interven-tions for the good of both patients andstaff. Employing a physical therapistto screen patients is one way to re-duce the risk of pain and injury. MyU.S. colleagues might consider takingthis approach.Brendon Stubbs, B.Sc., P.G.Dip.Mr. Stubbs is clinical specialist and leadphysiotherapist at St. Andrews Health-care, Northampton, United Kingdom.References1. Martin A, Krieg H, Eposito F, et al: Reduc-tion of restraint and seclusion through col-laborative problem solving: a five-yearprospective inpatient study. PsychiatricServices 59:1406–1412, 20082. Stubbs B, Leadbetter D, Patterson B, et al:Physical intervention: a review of the liter-ature on its use, staff and patient views andthe impact of training. Journal of Psychi-atric and Mental Health Nursing 16:99–105, 20093. Leggett J, Silvester J: Care staff attributionsfor violent incidents involving male and fe-male patients: a field study. British Journalof Clinical Psychology 42:393–406, 20034. Stubbs B, Yorston G, Knight C: Physical in-tervention to manage aggression in olderadults: how often is it employed? Interna-tional Psychogeriatrics 20:855–857, 20085. Stubbs B, Alderman N: Physical interven-tions in the management of aggression aris-ing from brain injury: frequency of use andinjuries associated with implementation.Brain Injury 22:691–696, 2008PSYCHIATRIC SERVICES ♦ ps.psychiatryonline.org ♦ March 2009   Vol. 60   No. 3LETTERS406

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Use of guidelines in suicide prevention.

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