Today, October 10, is World Mental Health Day, an opportunity to focus much needed attention on one of the most devastating consequences of mental health problems: the elevated risk of death by suicide.
Mental health professionals work hard to prevent suicide. This is a difficult task which involves predicting the who, when and how of self-injurious behaviour. Predicting and perhaps ultimately preventing suicides is greatly facilitated by routine reporting and investigating.
There is a real need here in the UAE to develop systematic, nonpunitive reporting mechanisms for suicidal behaviours. Such systematised reporting, investigation and analysis will lead to improved risk identification, and the implementation of comprehensive suicide prevention strategies grounded in the UAE experience.
In one of my previous roles within the UK's National Health Service (NHS) I was responsible for investigating what we call "patient safety incidents", a euphemism meaning when things go horribly wrong, resulting in patient death or severe injury. Within the mental health services a large number of what we classed patient safety incidents involved suicide or attempted suicide.
The first suicide I ever investigated involved a young man who had been hospitalised for severe depression. The parents of this teenager had brought him to the hospital after his depression had worsened. His thoughts had become increasingly morose, and his behaviour increasingly bizarre.
This was the young man's first hospitalisation for a psychiatric complaint, and his parents were understandably apprehensive about having him admitted.
On the ward at that time were several fairly disturbed patients, one of whom began to bully and harass the young man. He phoned his parents to complain of the bullying, and of the general lack of clinical attention he was receiving. However, he also told them he'd resolved to stick it out and hoped to get better soon.
Early the next morning the parents called the ward to speak to their son. A nurse went to fetch him, but he wasn't in his room. A search of the ward ensued, followed by a search of the hospital grounds - to no avail. The parents , whose apprehension was rapidly turning to panic, were told that their son was no longer within the hospital and that the police had been notified about his absence without leave.
Later that day the police called the hospital informing them that a man fitting their missing patient's description had died from injuries sustained after throwing himself off the roof of a local bus station.
One of the care delivery issues (another euphemism) that came to light while investigating this case was that the patient had not received an adequate risk assessment. Such assessments will generally inform the clinical team about the level of risk the patients pose to themselves or others. This enables the team to respond appropriately; in cases where risk is high this may mean placing a patient under around-the-clock observation. The general idea, though, is to predict and prevent as efficiently and as effectively as possible. This is all about proportionality; higher risk brings bigger effort.
In the case of our young man it was later discovered that he had written a suicide note. This melancholic farewell was painful to read, full of apologies to his loving parents. Ironically, his suicide note was written on the back of a blank risk-assessment form. The same form he should have completed with a member of the clinical team on admission.
Could this suicide have been prevented? In retrospect the answer is nearly always "yes". In this particular case, had the risk assessment been undertaken the patient might have been placed on observation and prevented from leaving the ward.
However, avoiding the blame game we looked at the broader context of the incident; the ward was understaffed, risk-assessment training had lapsed and access to the bus station roof was dangerously easy. Delving deeper into these issues we discovered that the hospital experienced a spike in patient safety incidents every April going back as far as records existed. It also transpired that April was the time of year when lots of staff took holidays. This mass exodus of staff around April was due to a policy stipulating that annual leave not taken before April 30 would be lost. This was fixed by changing the policy, which ensured the ward was never again dangerously understaffed at particular times of the year. This small change made the whole hospital a safer place and contributed to the prevention of future suicides.
Our investigation also discovered that the bus station in question had previously been used for several suicide attempts. The local authorities were able to make some simple modifications to the building that would prevent its future use as a suicide hot-spot, contributing to the prevention of future suicides.
These preventative initiatives were born from a process of reporting, investigation and systems-focused analysis. Preventing suicide and improving the quality of mental health services in the UAE might benefit from a similar approach, which is worth remembering every day of the year.
Justin Thomas is an assistant professor of psychology at Zayed University