THE FOLLOWING ARE OUR RECOMMENDATIONS:
BY THE WHITE WREATH ASSOCIATION LTD & PETER NEAME WHITE WREATH ASSOCIATION RESEARCH OFFICER AND BOOK AUTHOR.
1a. All patients should have a full physiological/neurological examination, not just a “mental health assessment”, “psycho-social assessment” and “risk assessment”. For example, when burn marks and frequent cut/slash marks are noticed on the patients’ skin and the patients say that they have never self-harmed/attempted suicide, it is tempting to say that they are hiding/lying – attention-seeking, have personality disorders etc., etc. The truth may well be that the patients are in fact very ambivalent about their self-harming behaviour. At one interview they will admit to self-harm and at another interview, they will deny that they will self-harm.
1b. The fact that they can burn or cut themselves without pain is a feature of both localized reduction in pain sensation and disturbance of the limbic/serotonergic system of the central nervous system (i.e. the brain).
At present, the tendency is for professionals to interpret signs of self-harm as wilful attention-seeking by manipulative, antisocial, personality disordered patients. Rejection by the Mental
Health System leads to further suicide attempts and a high completed suicide rate. The fact is that any mental illness from anorexia to schizophrenia can involve self-harm/self-destructive behaviour.
2. Self-referral and/or referral by relatives should be treated as an emergency – if the patient refuses admission, then compulsory provisions of the Mental Health Act should be used.
3. Public safety is paramount and when one talks about patients’ safety, this must automatically mean public safety.
The link between suicide and murder is almost without exception ignored by researchers and planners in relation to suicide policies and responses.
Professor Hughes in “Suicide and Violence Assessment in Psychiatry”. Gen Hospital Psychiatry, 1996, wrote “It is estimated 17% of Psychiatric Emergency Service patients are suicidal, 17% are homicidal and 5% are both suicidal and homicidal”.
“Murder is one of the strongest predictors of suicide with a 30% suicide rate found amongst murderers in England”. Source: “Serotonin, suicide and aggression. Clinical Studies”. Golden, Gilmore, Corrigan, Eketrom, Knight and Carbutt. Journal of Clinical Psychiatry, 1991.
Recent high-profile murders, murder-suicides and at least one mass killing in Queensland were all preceded by one or more suicide attempts. In the worst killing, the person was regarded as an “attention seeker”.
4. Threats of suicide and self-harm, including actual self-harm, should be treated as if they were actually attempted suicides. In simple terms, people are either suicidal or they are not suicidal. Personal judgements about highly, moderately, vaguely, or possibly, suicidal should not be used. They are dangerously misleading.
5. Prisons have best practice for suicide prevention. Key features are:
- If an individual or family member says that the individual is suicidal, he/she is treated as suicidal.
- No one grandiose professional can make an arbitrary decision that a patient who was seriously suicidal one day is no longer suicidal the next.
- High-risk assessment teams made up of five people determine the change in the observation category for the patient. Each individual on the team must personally feel safe about the patient before there is a change in the observation category. In simple terms, no senior clinician is able to heavy other disciplines/members to agree with him or her, as currently happens in the mental health system. We believe that this is a good model to follow and we would be happy to assist you and help to set up such a system. (This could put Queensland up there with best practice suicide prevention).
6. All terms must be defined. For example, risk means the risk of suicide, murder and violence. Assessment means a step-by-step process starting with a disciplined, outward physical examination/observation before any verbal questions are asked. Again, we are happy to take part in training professionals. This is a practical skill and needs to be taught on the job/ in the workplace, possibly with the assistance of a training video. If one is honest, assessment skills as they are currently taught in universities and places of training are appalling. In reality, many professionals miss obvious suicidal behaviours/clues. An accurate assessment is a rock on which the service rests. Safety, patient safety, means public safety, therefore part of this issue is asking the family/loved ones if they are happy with the plan of action. Minimum periods of observation should be a least five days in the hospital, for example, beginning with 48 hours category red or constant observation. Refer also to the high-risk assessment teams mentioned earlier. Suicide literally means “self-murder”.
7. In more than 80% of completed suicides and other mental health disasters, someone close to the patient and/or the patient themselves, has tried, in good faith, to get help from professionals, but has been turned away.
This is both an attitude and a training problem/issue.
Our concerns are reinforced by the real-life experiences of our members and supporters.
8. >History Taking: Currently, patients are asked only about their immediate family whereas patients should be asked if there is a history of “nervous breakdowns” (the term “mental illness” means “raving lunatic” to most people and they will simply deny it), early death suicide, self-harm, drug and alcohol use to the point where it destroys family life, for at least three generations – that is, grandparents and as further back as possible. Family history, anywhere, is one of the strongest indicators in suicide and murder.
9. Suicide is special, and specially prepared professionals should always be called in before patients are turned away / released.
10. Professionals must be held accountable or nothing will change; many psychiatrists see suicide as a nuisance and a “red herring”.
11. Mental Health Act legislation must have provisions written in to ensure early admissions for suicidal patients as was always the case for hundreds of years, such provisions being removed only as part of the de-institutionalisation / anti-psychiatry policies of the last 20 years.
12. The hard scientific or factual evidence is that suicide, violence and murder are caused by morphological changes in the brain combined with low serotonin. The structure, function and chemistry of the brain are simply not normal.
The newer Selective Serotonin Re-Uptake Inhibitor drugs (S.S.R.I.s) are said to be safer in terms of it being harder to overdose on them. However, recent suggestions are that S.S.R.I.s such as Zoloft, Prozac, Effexor etc. etc., may cause up to three to five times the rate of suicide in young people, particularly those below 20 years of age. There are a number of lawsuits against drug companies and at least one murder in Australia was said, in Court, to have been caused by one of these drugs.
Depression is widely promoted as the major epidemic of the modern age and this in turn has led to a massive rise in the use of S.S.R.I.s, “…. In 1998, doctors wrote 8.2 million anti-depressant prescriptions compared with 5.1 million in 1990 ….” Source: “The New Abuse Excuse” by Claire Harvey and Monica Videnieks in Australian, 25 May 2001.
There is no scientific evidence that serious mental illness is increasing. It occurs at the rate of 3% of the general population everywhere regardless of drug use, child abuse, child-rearing practices, stress, modern life pressures youth of today, on and on ad nauseum. There is evidence that depression is the “in disease” and that the prescribing of all psychotropic medication is increasing.
We recommend that anyone who is to be commenced on medication that alters mood, feeling and thinking ability (psychotropic medication) should be commenced on this medication in the hospital. The reality is that it is extremely difficult to get the right medication for the right patient.
Practically all of the newer anti-depressant and anti-psychotic medication takes 4 to 6 weeks to reach therapeutic levels. All psychotropic, psychoactive substances have serotonergic effects on the brain – that is, all drugs from alcohol to street drugs, from speed to Prozac. This, combined with scientific evidence that there is a cause and effect relationship between low serotonin and suicide, murder and violence, in our view, means that these drugs should be commenced in hospital where patients are under observation and being protected in a place of safety. It is also a clinical observation that in the first few days of commencing an anti-depressant, the suicide rate dramatically increases.
13.Most of what we have said requires very little “New Money”. If you are really serious about suicide, then all of these areas must be covered.