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Time to check the plan

Updating Suicide Safety Plans in light of the COVID-19 Pandemic

Article in Review: Pruitt, L., McIntosh, L. & Reger, G. (2020). Suicide Safety planning during a pandemic: The implications of COVID-19 on coping with a crisis. Suicide and Life-Threatening Behaviour, DOI: 10.1111/sltb.12641

Summary & Relevance: Research published in 2020 has provided some insight into the challenges of supporting people who are suicidal during a pandemic, particularly in light of social distancing and lockdown strategies. The suitability of and benefits associated with Suicide Safety Plans as a tool for at-risk individuals during the pandemic is considered.

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Impacts of the pandemic on mental health

COVID-19 has been with us for just over a year now. While immunisation programs have commenced in some countries, the number of infections globally continues to rise. We continue to see impacts on our economies and the overall health and wellbeing of our populations. We are still discovering the impacts of social distancing on behavioural health conditions such as depression and anxiety.

The unique context of a pandemic, which has sustained and complex impacts on people, may mean that those at risk of suicide may be disproportionally affected by the unintentional side effects of social distancing. Anxiety-related to the risk of infection and uncertainty around the expected duration of social distancing, rapidly changing guidance, and not knowing what the future may bring can mean that those already at risk might experience elevated fear levels or perceive impending doom. There may be increased feelings of loneliness and isolation; which are often contributors to suicidal thoughts.

Community health workers and clinicians are charged with the task of assisting those patients who are at risk of suicide to meet the demands of a socially distanced lifestyle. There is a need to respond with strategies that minimise the risk of harm.

Suicide Safety Plans

Suicide Safety Plans have been proven to provide an effective model for patients experiencing an elevated suicide risk. As an intervention model, the use of safety plans has demonstrated significant reductions in suicidal behaviours among people at risk. Stanley and Brown’s (2008) safety plan model suggests that the written plan should include:

  • Identification of suicide warning or risk signs
  • Coping strategies
  • Support people who can distract or help resolve the crisis
  • Contacts of professional supports
  • Strategies for the reduction of lethal means

Suicide Safety Plans are useful for patients who have:

  • A desire to cope with the suicidal crisis
  • An understanding about when to use the plan
  • An ability to access and follow the plan early in an emotional crisis
  • An ability to complete simple and effective coping strategies
  • An ability to be flexible with the plan in any situation or circumstance
  • An interest in creating and personalising content

This research has sought to understand:

  • Are the strategies for emotional regulation and behavioural activation of a safety plan still relevant and possible
  • Should information on existing safety plans be amended in the context of the pandemic
  • What can be done when long-standing effective crisis management strategies are not possible, create a risk to physical health (such as COVID-19 infection) or are in violation of local or state regulations and guidelines

Adapting safety plans to a COVID-19 context

Many common coping strategies are not suitable for a person who is required to maintain social distancing or is in lockdown. But there are many ways that coping strategies can be modified to be achievable in these circumstances. The use of technology for communication and interaction, along with conducting safe activities such as solitary exercise, cooking, crafting and watching or reading items of interest. In some cases, it creates an opportunity for creative thinking about social and educational opportunities that may not have been considered.

Access to regular medical health and mental health care may be limited or need to be provided differently, and an increasing number of services may need to be provided by video call. It is recommended that professionals speak early and often with at-risk patients about how they may need to amend their plans in light of an inability to attend appointments or visit others. The benefits of social media in acting as a tool of connection are discussed, but moderation is recommended. It is also important to recognise that older patients may not have the skills, capacity or interest to engage with others using technology. Including a mix of more traditional communication methods, such as telephone or letter writing, is recommended.

Lethal means safety is often covered in a Suicide Safety Plan and given they are American, the authors have made specific reference to the elimination or safe storage of firearms in the home. During a lockdown situation, there may be changes to the frequency with which medications can be delivered, and this may be something to be discussed with patients.

Benefits of a Suicide Safety Plan

Clinicians should expect an increase in the number of patients they see who might benefit from a Suicide Safety Plan. it is also worth considering the benefits of a Suicide Safety Plan to assist not only people who are suicidal but people who are could do with some support to maintain wellness and reduce anxiety and stress. It may be prudent to consider broadening the scenarios in which safety plans are used.

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