Implication for clinical settings
The increase that we observed in post-discharge suicides among patients with TRD is in line with global literature, which can be attributed to multiple factors related to psychiatric disorders and psychosocial stressors; therefore, mental health care professionals should be aware that suicide risk is not the same across all the
treatment phases. In addition, the clinical risk assessment could mislead clinicians into believing that patients are at low risk upon discharge. Following up with and regularly evaluating TRD patients after discharge is therefore imperative, especially for severely depressed patients who exhibit suicidal and treatment-refractory symptoms. Furthermore, a stronger emphasis on the secure transfer from the hospital to the community, which remains a critical challenge in Vietnam, should be added to this goal. Therefore, mental health professionals should consider methods that could increase transition safety, such as a pre-discharge safety plan, intervention promoting hope, self-efficacy, community integration, and routine assessment of psychological distress for inpatient to outpatient care.
Moreover, with limited mental healthcare resources available in the Vietnamese community mental health network, telephone follow-up by mental health nurses using a brief rating scale, such as the BSRS-5, will be a practical, reliable, and efficient method to reduce further suicide. More importantly, community integration performance should be evaluated sufficiently so that the deterioration of quality of life and suicide ideation can be prevented. Taken together, the potential of these protective factors may ameliorate hopelessness and psychological distress in the otherwise TRD population, with the possibility of lowering the suicide rate in TRD patients during the trajectory in the community.
Finally, given the long-term effects and cost burden of TRD, each suffering from TRD is a unique case requiring a thorough evaluation to identify the initial antidepressant response and make an accurate TRD diagnosis for treatment management and research purposes. Therefore, to optimize the management of TRD
patients, assessing risk factors for TRD and consensus defining TRD in Vietnam are critically important in guiding mental health professionals in developing an appropriate treatment plan for patients with TRD.
Implications for education or in-job training
Suicide is an issue that demonstrates the need for holistic care, which involves determining the purpose and meaning of the patients' and their families' lives.
Moreover, the core concept of nursing education is holistic nursing integrates the body, mind, and spirit into care (Boswell et al., 2013). Thus, the nurses are first-line gatekeepers to identify early signs of psychological distress or suicidal risk through daily nursing practice. Further, nursing professionals in non-psychiatric fields of community or hospital settings also play the crucial role of gatekeepers for early engagement and referral of high-risk patients with depression. Therefore, enhancing nurses’ ability to identify suicide risks, assessment, and provide appropriate care should be directed for Vietnamese clinical nurses in the future.
The suicide attempt, in general, requires medical attention, and it is reasonable for medical services to investigate the extent to which self-harm acts can be prevented. Our study showed that the service use, mainly psychiatric services maintained relatively high before one year of the study’s baseline and during follow-up. Thus, medical staff in clinical settings should be aware of this issue and aim to create or prepare a protective and supportive environment that may promote help-seeking where informal resources are insufficient. The research team maintains that the strategy of the “gatekeeper-training program,” which is one of the most prevalent
approaches in suicide prevention, is to recognize and assist persons who are at risk of engaging in suicidal behavior. Therefore, we can enhance the knowledge, attitude, and self-efficacy of medical staffs in suicide prevention and support from the public and possible facilitation of referral to appropriate medical services.
Future research suggestion
The study contributes to the literature investigating the etiology of potential protective and risk factors for suicide. Future longitudinal and intervention studies investigating psychological factors and community integration among TRD patients must investigate these factors as a risk modifier for suicide risk. Further randomized clinical trials involving newer psychotherapies targeting the promotion of hope, and community integration are required, given the demonstrated importance of truly adequate treatment to the long-term outcomes of patients with TRD. Cohort observation through longitudinal study should be considered for a more extended period to investigate the causal relationship between the exposures and suicide protective factors among TRD patients.
In the long-term recovery process, people with depression need intensive engagement and continual care for their symptoms and self-care progress. Evidence supports that nurses play a crucial role in maintaining patients’ conditions and in enhancing symptom- and self-management skills (Zimmerman et al., 2016). However, nursing studies related to TRD still exist rarely in the literature until now. This might explain why the term “TRD” still not identify widely among mental health and
psychiatric nursing professions. Even though nursing studies were scarce among patients with TRD, many nursing scholars have provided robust evidence related nurse-led care model for people with depression as a promising and effective strategy for the decrease of depressive symptoms (Nance, 2012). According to a systematic review and meta-analysis of randomized trials of nurse-led depression management, the mean effect size at follow-up was d=0.43 (95%CI: 0.34-0.52), representing a moderate impact on the severity of depression. These findings were consistent across studies and maintained in long-term nursing profession follow-up (Ekers et al., 2013).
Therefore, mental health and psychiatric nurses are ideally suited to provide these interventions, and additional research is necessary in this field.