Yvonne Awenat

Cognitive Behavioural Prevention of Suicide in Psychosis : A treatment manual

This practical and informative text lays out the product of a number of years of clinical research into suicide behaviour and its prevention. While the focus is on non-affective psychosis and the schizophrenia-spectrum disorders, the mechanisms underlying suicide behaviour in this group may well underlie or at least influence suicide behaviour in other disorders. The authors describe methods of assessment through individual formulation, and a cognitive behavioural intervention through case studies, to reduce the risk of suicide.This book argues that:� Suicide behaviour lies on a cognitive-behavioural continuum from ideation, through intention to action. � Mechanisms based on biased information processing systems, the development of suicide schema, and appraisal styles are likely to be fruitful in explaining suicidal thoughts and behaviours.� A psychological theory of suicide behaviour is needed in order to develop a mechanism of suicide and to understand the components of suicidal thoughts and behaviours.� Suicide risk can be reduced through the use of the intervention methods described within the text Cognitive Behavioural Prevention of Suicide in Psychosis evaluates practical applications of contemporary research on this topic, and will therefore be of interest to practitioners, post-graduates in training, and researchers studying suicide and/or psychosis.

The moderating effects of coping and self-esteem on the relationship between defeat, entrapment and suicidality in a sample of prisoners at high risk of suicide

BACKGROUND Research is sparse which examines pathways to suicide, and resilience to suicide, in people who are particularly vulnerable to suicide, for example, prison inmates. The purpose of this study was to examine the ways in which perceptions of self-esteem and coping ability interacted with defeat and entrapment to both amplify suicidal thoughts and feelings, and to act as a buffer against suicidal thoughts and feelings. METHODS Participants were 65 male prisoners at high risk of suicide. A cross-sectional questionnaire design was used. Questionnaire measures of depression, defeat, entrapment, self-esteem, coping ability and suicidal probability were administered. RESULTS For the hopelessness component of the suicide probability measure, high levels of coping ability together with low levels of defeat resulted in the lowest levels of suicidality indicative of a resilience factor. In contrast, low levels of coping skills together with high levels of entrapment were a high risk factor for this hopelessness component of suicide. This pattern of results pertained when controlling for depression levels. CONCLUSIONS This is the first study to examine interactions between defeat, entrapment and appraisals of self-esteem and coping ability. Therapeutic interventions would benefit from boosting perceptions and appraisals of coping ability, in particular, in people who are at high risk for suicide.

Cognitive-behavioural suicide prevention for male prisoners: a pilot randomized controlled trial.

BACKGROUND Prisoners have an exceptional risk of suicide. Cognitive-behavioural therapy for suicidal behaviour has been shown to offer considerable potential, but has yet to be formally evaluated within prisons. This study investigated the feasibility of delivering and evaluating a novel, manualized cognitive-behavioural suicide prevention (CBSP) therapy for suicidal male prisoners. METHOD A pilot randomized controlled trial of CBSP in addition to treatment as usual (CBSP; n = 31) compared with treatment as usual (TAU; n = 31) alone was conducted in a male prison in England. The primary outcome was self-injurious behaviour occurring within the past 6 months. Secondary outcomes were dimensions of suicidal ideation, psychiatric symptomatology, personality dysfunction and psychological determinants of suicide, including depression and hopelessness. The trial was prospectively registered (number ISRCTN59909209). RESULTS Relative to TAU, participants receiving CBSP therapy achieved a significantly greater reduction in suicidal behaviours with a moderate treatment effect [Cohens d = -0.72, 95% confidence interval -1.71 to 0.09; baseline mean TAU: 1.39 (S.D. = 3.28) v. CBSP: 1.06 (S.D. = 2.10), 6 months mean TAU: 1.48 (S.D. = 3.23) v. CBSP: 0.58 (S.D. = 1.52)]. Significant improvements were achieved on measures of psychiatric symptomatology and personality dysfunction. Improvements on psychological determinants of suicide were non-significant. More than half of the participants in the CBSP group achieved a clinically significant recovery by the end of therapy, compared with a quarter of the TAU group. CONCLUSIONS The delivery and evaluation of CBSP therapy within a prison is feasible. CBSP therapy offers significant promise in the prevention of prison suicide and an adequately powered randomized controlled trial is warranted.

A systematic review of service-user reasons for adherence and nonadherence to neuroleptic medication in psychosis

People diagnosed with psychosis, such as those with schizophrenia-related disorders, are routinely prescribed neuroleptic medication as a primary treatment. Despite reported benefits of neuroleptic treatment for symptom remission and relapse prevention, discontinuation rates are high. Research examining factors associated with neuroleptic non-adherence report inconsistent findings. Reasons for adherence to neuroleptic medication are under-researched. The current review aimed to synthesise evidence exploring service-user self-reported reasons for adherence and non-adherence to neuroleptic medication. A systematic literature search of databases and reference list searching identified 21 studies investigating service-user accounts of reasons for adherence and/or non-adherence to neuroleptic medication. Qualitative, quantitative and mixed-method studies were included in the review. Several themes of reasons were identified. Reasons for both adherence and non-adherence were largely similar; medication efficacy, compatibility with personal medication or religious beliefs, side-effects and the influence of relationships with other people. Experiences of stigma and economic difficulties were generally identified as reasons for non-adherence only while experiences of fear and coercion were identified as reasons for adherence only. The review identified crucial factors which may aid service providers in bettering treatment for people with psychosis and will provide evidence which could contribute to future prescribing guidelines.

Beyond beliefs: A qualitative study of people’s opinions about their changing relations with their voices

This study sought to develop further understandings of the relationships that people can develop with the voices they hear, and to explore the development of these relationships over time. Qualitative data was gathered from 12 people attending peer support groups. A semi-structured interview was used to facilitate the interviews and analysis of the transcripts was guided by the principles of Thematic Analysis. Four themes emerged and suggested that the relationships between hearers and their voices can have a variable trajectory which is influenced by stress, talking with and about voices, and the acceptance of voices and/or resistance. Clinically, the findings have implications for the training of frontline staff, the provision of peer support and the adaptation of psychological therapies. Future studies should assess whether our findings generalise to more diverse samples of voice hearers and use longitudinal qualitative and quantitative designs to explore change processes in-depth from early to later stages of psychosis.

Effect of hopelessness on the links between psychiatric symptoms and suicidality in a vulnerable population at risk of suicide.

The aim of this study was to examine the impact of two risk factors working together on a measure of suicide probability in a highly vulnerable group who were male prisoners identified as being at risk of self harm. The first risk factor was psychiatric symptoms, including general psychiatric symptoms and symptoms of personality disorder. The second risk factor was psychological precursors of suicidal thoughts and behaviours which were defeat, entrapment, and hopelessness. Sixty-five male prisoners from a high secure prison in NW England, UK, were recruited, all of whom were considered at risk of suicide by prison staff. General psychiatric symptoms and symptoms of personality disorders predicted the probability of suicide. Hopelessness amplified the strength of the positive relationship between general psychiatric symptoms and suicide probability. These amplification effects acted most strongly on suicidal ideation as opposed to negative self evaluations or hostility. In contrast, defeat, entrapment and hopelessness did not affect the relationship between personality disorders and suicide probability. Clinical assessments of highly vulnerable individuals, as exemplified by prisoners, should include measures of a range of general psychiatric symptoms, together with measures of psychological components, in particular perceptions of hopelessness.

Staff experiences and perceptions of working with in-patients who are suicidal: qualitative analysis

Background Suicidal behaviour is frequent in psychiatric in-patients and much staff time and resources are devoted to assessing and managing suicide risk. However, little is known about staff experiences of working with in-patients who are suicidal. Aims To investigate staff experiences of working with in-patients who are suicidal. Method Qualitative study guided by thematic analysis of semi-structured interviews with mental health staff with experience of psychiatric in-patient care. Results Twenty staff participated. All had encountered in-patient suicide deaths or attempts. Three key themes were identified: (a) experiences of suicidality, (b) conceptualising suicidality and (c) talking about suicide. Conclusions Suicidal behaviour in psychiatric wards has a large impact on staff feelings, practice and behaviour. Staff felt inadequately equipped to deal with such behaviours, with detrimental consequences for patients and themselves. Organisational support is lacking. Training and support should extend beyond risk assessment to improving staff skills in developing therapeutic interactions with in-patients who are suicidal.

Personal Accounts of Discontinuing Neuroleptic Medication for Psychosis

We conducted this study to explore personal accounts of making choices about taking medication prescribed for the treatment of psychosis (neuroleptics). There are costs and benefits associated with continuing and discontinuing neuroleptics. Service users frequently discontinue neuroleptics; therefore, we specifically considered these decisions. We used a grounded theory approach to analyze transcripts from interviews with 12 participants. We present a preliminary grounded theory of the processes involved in making choices about neuroleptic medication. We identified three tasks as important in mediating participants’ choices: (a) forming a personal theory of the need for, and acceptability of taking, neuroleptic medication; (b) negotiating the challenges of forming alliances with others; and (c) weaving a safety net to safeguard well-being. Progress in the tasks reflected a developmental trajectory of becoming an expert over time and was influenced by systemic factors. Our findings highlight the importance of developing resources for staff to facilitate service user choice.

Premature Death Among Primary Care Patients With a History of Self-Harm

PURPOSE Self-harm is a public health problem that requires a better understanding of mortality risk. We undertook a study to examine premature mortality in a nationally representative cohort of primary care patients who had harmed themselves. METHODS During 2001–2013, a total of 385 general practices in England contributed data to the Clinical Practice Research Datalink with linkage to Office for National Statistics mortality records. We identified 30,017 persons aged 15 to 64 years with a recorded episode of self-harm. We estimated the relative risks of all-cause and cause-specific natural and unnatural mortality using a comparison cohort of 600,258 individuals matched on age, sex, and general practice. RESULTS We found an elevated risk of dying prematurely from any cause among the self-harm cohort, especially in the first year of follow-up (adjusted hazard ratio for that year, 3.6; 95% CI, 3.1–4.2). In particular, suicide risk was especially high during the first year (adjusted hazard ratio, 54.4; 95% CI, 34.3–86.3); although it declined sharply, it remained much higher than that in the comparison cohort. Large elevations of risk throughout the follow-up period were also observed for accidental, alcohol-related, and drug poisoning deaths. At 10 years of follow-up, cumulative incidence values were 6.5% (95% CI, 6.0%–7.1%) for all-cause mortality and 1.3% (95% CI, 1.2%–1.5%) for suicide. CONCLUSIONS Primary care patients who have harmed themselves are at greatly increased risk of dying prematurely by natural and unnatural causes, and especially within a year of a first episode. These individuals visit clinicians at a relatively high frequency, which presents a clear opportunity for preventive action. Primary care patients with myriad comorbidities, including self-harming behavior, mental disorder, addictions, and physical illnesses, will require concerted, multipronged, multidisciplinary collaborative care approaches.

Psychological Characteristics and Predictors of Suicide Probability in High-Risk Prisoners

Suicidal thoughts and behaviors are highly prevalent in prisoners. Nevertheless, there have been scant attempts to understand suicidality in prisoners from a psychological perspective. The goals of this study were to characterize a prison sample at high risk of suicide in terms of hopelessness, defeat, and entrapment, and to determine which of these variables predicted suicidality. A cross-sectional questionnaire design was used. Measures of hopelessness, defeat, entrapment, and suicide probability were administered to male prison inmates in the United Kingdom. Defeat and hopelessness, especially the affective component of hopelessness, predicted the probability of suicide in this sample, but entrapment was not a significant predictor. Suicide risk assessment procedures in prisons tend to be sparse. Such procedures would benefit from using measures of hopelessness and defeat. Future work should aim to understand how the impact of these psychological constructs on suicidality in prisoners can be attenuated.