4 th Annual Forum Wednesday 2 nd September 2009 Royal Hospital Kilmainham “Suicide Prevention – Working Together”

1. 4th Annual Forum Wednesday 2nd September 2009 Royal Hospital Kilmainham “Suicide Prevention – Working Together”

2. Trends in deliberate self harm in Ireland: New findings.U. Reulbach, E. Arensman, I. J. Perry

3. Definition of deliberate self harm • An act with non-fatal outcome • in which an individual deliberately initiates a non-habitual • behaviour, • that without intervention from others will cause • self-harm, • or deliberately ingests a substance in excess of • the prescribed or generally recognised therapeutic dosage, • and which is aimed at realising changes that the person desires • via the actual or expected physical consequences

4. Suicide Prevention: Reach Out strategy Targeted suicide prevention Suicide as the tip of the iceberg? (Eckersley) General population prevention

5. Study population • National Registry of • Deliberate Self Harm • (NRDSH)+ • WHSSB Registry of Self-Harm WHSSB HSE Dublin/ Mid-Leinster HSE Dublin/ North East HSE South HSE West Coverage: All 40 Hospital Emergency departments in the Republic of Ireland + all 3 Hospital Emergency Departments of the WHSSB

6. Prevalence of DSH in 2008 Men: 180 / 100,000 (+11%) Women: 223 / 100,000 (+4%) All: 200 / 100,000 (+6%)

7. Regional Differences in DSH

8. Regional Differences in DSH

9. Overdose acts and DSH

10. Number of tablets used in Overdose acts

11. Type of medication used in Overdose acts

12. Attempted hanging

13. Self-Cutting and DSH

14. The role of alcohol consumption in DSH acts Alcohol Consumption in Litres Per Capita: Ireland and EU, 1980 to 2005

15. Alcohol involvement in DSH

16. Alcohol involvement in DSH

17. Alcohol involvement in DSH

18. Thank you for your attention!

19. 4th Annual Forum Wednesday 2nd September 2009 Royal Hospital Kilmainham “Suicide Prevention – Working Together”

20. SPACE Supporting Parents and CarersSt. Frances’ ClinicChildren’s University HospitalTemple Street

21. Development of a Pilot Programme for parents/carers who are concerned about Self-harm

22. OVERVIEW • Service Context • Rationale behind this service development • Innovative approach undertaken • Current pilot programme • Preliminary Results

23. SERVICE CONTEXT-DSH in TSCUH • Children’s University Hospital, Temple St. (CUH)– tertiary referral teaching paediatric hospital in city centre, catchment area covering all of North Co. Dublin. • Marked increase in number of children & adolescents presenting to A&E with self-harm (DSH), over past decade; • In 1997 (audit), N=29 • In 2006, N=67 (> x2) • In 2007 N=74 • In 2008 to date N =160 • In 2009 up until 25/08/09 =107

24. Self - harm Team • Self-harm team was established in 2002 in response to increasing concern. • Based in St. Frances’ Clinic, Temple St. • Team members: • Consultant Child and Adolescent Psychiatrist • Senior Registrar; (rotating) • Psychiatrist-on-call • 2 Senior Psychiatric Social Workers • 2 CNM11 Child and Adolescent • Researchers (2009) (Lorna Power)

25. PROJECT PROPOSAL AIMS • To develop a parents programme whose content is specifically suited to its participants needs. • To evaluate the programme for its effectiveness

26. FOCUS GROUP MEETING Aim: Identify needs of parents/carers whose children have self-harmed. Ascertain what they felt should be included in programme. Recruitment: • Letters & leaflets sent to i) Parents (SFC)-(64), ii) Residential Centres (7), iii) CAMHS across Dublin (25), iv) Family Support Centres (10) • Total : 106 • Visit to CAMHS teams & Family Centres Inclusion Criteria: • Parents & Carers. • Children 16 years and under, at the point of recruitment. • Self-harm episode; suicidal ideation/thoughts; concerns around self-harm • Linked to service (treatment of child).

27. THEMES- NEEDS IDENTIFIED • Support • Feelings • Parenting • Information & statistics • Services • Family • School • Stigma • Practicalities of DSH Episode • Beliefs re. DSH • Internet

28. THEME-Support • Support: emerged as the most central theme put forward by parents and carers. i) Need for Support: to help cope with impact self-harm has on their lives. ‘...if there’s one thing this group could provide it’s support...’ ii) Lack of Support and Services: they described a lack of available services and support for all those impacted by DSH. ‘...when I left A/E I had nowhere to go...no idea what to do, where to go, how to get help...’ iii) Benefits of Peer Support:the palpable benefits of peer support were highlighted - learning from each other; supporting one another; and ‘normalising’ their experiences. ‘…knowing other people have the same situation really does help…the relief of knowing I’m not the only one…’

29. THEME – FEELINGS • i)Isolation: theyfelt overwhelmingly alone in coping with their problems, ‘...you’re just lost…’ ‘…the biggest thing is the isolation, terror and fear…it’s a very harsh journey…’ • iii)Guilt:participants admitted to blaming themselves, and feeling ashamed that this had happened to their child. ‘…the first thing you do as a parent is blame yourself...is it my fault…’  • iv) Low self-esteem / lacking in confidence: …feeling you’re no good as a parent…a failure...’ • v) Frustration/Anger:Not only towards the services, but directed at their child. …angry towards her… how dare you…its upsetting the whole house…’

30. THEME –PARENTING i)Communication:how to help their children express feelings‘ …not being able to read what she’s thinking…’ ii) Discipline: ‘…how to discipline… not knowing how she is going to react…without giving into her…’ v) Re-gaining confidence as a parent:‘over-analysising /reading into everything for fear that you’ll miss something …regain confidence…’

31. PARENTS PROGRAMME – ‘SPACE’ Content: Based on the Themes identified at Meeting. • Support • Information on Self-harm • Parent-Child Communication • Parenting Adolescents • Managing an episode of self-harm Audiovisual; powerpoint presentations; small and large group discussions; handouts; tea and coffee break. Structure: Run over 8 weeks, Tuesday 7.30-9pm.

32. RESEARCH – SERVICE EVALUATION Proposed Outcomes: • Provide social support • Reduce levels of parental stress • Improve communication & problem-solving abilities between parents and their child. • Deliver a service which parents find beneficial and enable them to achieve their own defined goals. Methodology • Questionnaires before, after & at 6 month follow-up. • Voluntary participation & Informed consent. Measures: • General Health Questionnaire; Parent Stress Scale; Strengths & Difficulties Questionnaire; Multidimensional Scale of Perceived Social Support; Behaviour & Goals Scale; McMaster Family Assessment; Kansas Parenting Satisfaction Scale Statistical Analysis • SPSS

33. Methodology • Participants: • 84 parents/carers of children and adolescents (aged 16 years and under) who were attending mental health services having engaged in or expressed thoughts of DSH • 17 were child care staff – differed on baseline measures • Resulting sample of 67 parents, of whom 69% (N = 46) were mothers and 31% (N = 21) fathers • Recruited from CAMHS, Temple Street Hospital and family centres around Dublin

34. Results

35. CONCLUSION • Lower levels of psychological distress, parental stress and parental reporting of child’s difficulties • Increased parental satisfaction • Lower ratings of parents own defined challenges and higher ratings of their goals

36. Further Information • An introductory evening for parents wishing to attend SPACE will take place on Tuesday 22nd September in Wynn’s Hotel for 7.30 pm to 9.00pm. There will be two upcoming programmes following this meeting – one which begins in October 09 and one which will commence in January 2010. In order to facilitate the evaluation of the programme, parents will be randomly assigned to one of these programmes at the introductory meeting. • For further information and registration please contact: • Lorna Power, Course Co-ordinator, Tel: 01-7166321 or Lorna.Power@cuh.ie • Please note there is no attendance fee for the SPACE Programme as it is kindly supported by the Fundraising Department in Temple Street Hospital and Electric Aid.

37. 4th Annual Forum Wednesday 2nd September 2009 Royal Hospital Kilmainham “Suicide Prevention – Working Together”

38. Suicide Crisis Assessment Nurse (SCAN):- From a Pilot Service to a mainstreamMental Health Service_____________________________ Aim of session: To inform delegates of a new approach to the assessment and care of those in Suicide Crises. Objectives: • Provide an overview of the SCAN pilot services. (Poster) • Present the accomplishments of SCAN from a Pilot project to a mainstream Mental Health Service. • Facilitate question and answer session with delegates.

40. S.C.A.N – The drivers: • Needs:- Local self harm incidence & suicide tragedies Press reports, Family & Community lobbying!!! • Policy:- REACH OUT: Action Points 11.1 to 11.5 Recognise the unique opportunity for primary care to be pro-active in matters of early diagnosis, intervention, treatment and enhanced suicide prevention for those experiencing personal crises and distress. Also: Vision for Change Primary Care Strategy Transformation Program House of the Oireachtas Joint report

41. S.C.A.N. : An overview of service Areas Suicide Crisis Assessment Nurse ‘Improving Integrated Mental Health Care for those experiencing a suicidal crisis – a partnership approach’ Target Areas Wex: GP’s = circa 45 practices Dublin: GP’s = circa 67 practices Population = circa 132,000 Population = 183,000 - New Ross - Blackrock - Wexford Town - Dunlaoghre - Rosslare - Shankill - Enniscorthy - Dundrum - Gorey - Kilmacud - Arklow - Mt Merrion

42. SCAN Accomplishments Partnership of Cluain Mhuire, Wexford & NOSP– supporting an urban/rural comparative study. Network & partnership approach with 90% of locality GP’s. Weekday service with SCAN response within 24 hours of referral – & assessments undertaken within GP surgery. Accessing those patients ‘below the surface of the iceberg’ (A different cohort requiring a different care approach) ‘Next care’ pathway [Mental Health Services; Counselling: Social Networks/Vol Groups] ‘Minding the gap’ – SCAN nurse link role in maintaining contact with patients until they engage with ‘next care’ services. Ongoing analysis and evaluation of the service – consulting GP’s, Mental Health Colleagues & Service Users.

45. Effect of introduction of SCAN service On patient care and CMHT

46. Vision for Change Evaluation Cluain Mhuire Committee • 68% of GPs in Catchment were aware of SCAN service • Of those who had used the service - 100% responded they were satisfied with SCAN service

47. Dublin: Dublin Solution: Training 3 Community Psychiatric Nurses to deliver the Primary Care Suicide Crisis Assessment Nurse model Wexford: Wexford Solution: provision of a 7 day Wexford General Hospital liaison nursing service and a 5 day County wide Primary Care Suicide Crisis Assessment Nurse Service. Mainstreaming SCAN:The challenge?Achieving viable, clinically effective , quality, responsive and accessible Primary Care Suicide Crisis Assessment Service to meet local service needs

48. Mainstreaming SCAN:The challenge?Achieving viable, clinically effective , quality, responsive and accessible Primary Care Suicide Crisis Assessment Service to meet local service needs Nationally: Sharing know-how with other community psychiatric services Incorporating SCAN skills into advanced nurse practitioner training Informing service planners of benefits to patients and cost savings

49. Discussion.

50. 4th Annual Forum Wednesday 2nd September 2009 Royal Hospital Kilmainham “Suicide Prevention – Working Together”