Suicide risk assessments as we know them look set to be phased out of mental health care, following the release of new prevention frameworks launched today.
New guidelines have been issued by the National Collaborating Centre for Mental Health, part of the Royal College of Psychiatrists, in collaboration with Health Education England.
The professional frameworks have been designed with a view to the approaches advocated by the Centre being reflected into areas spanning mental health professional education right through to training, practice, supervision, service commissioning and clinical governance.
The frameworks are being rolled out just weeks after the appointment of the government's first Suicide Prevention Minister.
The "self harm and suicide prevention framework for adults and older adults" guidelines, produced following a comprehensive review of research into suicide prevention methodology, signals a significant shift in mental health care responses for England and Wales, possibly beyond.
"Evidence suggests that risk assessment tools and scales do not have predictive value and their use can also cause the person to disengage from support," the authors write.
"Our ability to accurately predict risk is limited. This means that it is possible to both over-estimate and under-estimate the actual risk of suicide in a person at a given moment in time."
"Research suggests moving away from prediction to focusing on the needs of the person and seeing assessment as informing management rather than as a stand-alone activity."
"[Risk assessment tools] tend to be in a checklist format, which means that people may be asked about matters that are not relevant to them and may not be given the opportunity to raise matters of personal significance."
"This can contribute to feelings of not being listened to or not having an open space in which to discuss concerns."
On signposting, the framework says professionals should not only identify sources of support, but also facilitate their uptake by the person, as well as their family and carers if they require support.
The framework quotes Rachel Rowan, who works in research and training on mental health from a lived experience perspective and helped inform the frameworks.
"I would like to have guidance or frameworks as something to point to when something isn’t going right with my care," she says. "I want to know that, when I am not treated well, it is not my fault and I don’t blame myself."
Recommended routes to recovery
Mental health care professions are advised in the framework to follow the latest strong evidence that psychological therapies, specifically dialectical behaviour therapy (DBT) and cognitive behavioural therapy (CBT), can effectively prevent the repetition of self-harm by adults.
The authors acknowledge that DBT is unavailable in some areas. No reference is made to the fact that the choice of intervention is narrower than some service users have previously expressed they would like.
"The suggested treatments reflect the evidence base," Professor Nav Kapur told Mental Health Today. "But of course a needs based assessment is the most important thing and has to take into account underlying conditions. For some patients who have a depressive illness or other psychiatric disorder, evidence based pharmacological treatment may be very helpful."
Three other frameworks were launched today. They outline best practice for practitioners working with children and young people, service user and carer representatives, and non-specialists respectively.
The government has laid down expectations over the last year that detention rates should fall and that all suicides are preventable.
"Suicide prevention has never had a higher priority in the United Kingdom," added Professor Kapur, representing the Royal College of Psychiatrists and Manchester University.
"We should do all we can as clinicians to prevent suicide deaths and its vital that we don’t view suicide as inevitable. But suicide is a very complex phenomenon with many underlying causes, so to say every single death is preventable may not always be helpful and could lead to a blame culture."
Today's guidelines have been issued in the run up to the December release of recommendations around how the Mental Health Act might be redrawn.