Suicide and self-harm

Suicide
Suicide is a major public health concern.  Nationally the number of people who take their own lives has been reducing in recent years.  Nevertheless, about 4,200 people aged 15 and over took their own life in 2010 in England.  Suicide is often the end point of a complex pattern of risk factors and distressing events, and the prevention of suicide has to address this complexity.

Suicides are not inevitable; indeed most are preventable (WHO 2004).  There are many things that can be done in communities, outside hospital and care settings, to help those who think the only option is to end their own life.

The average cost of suicide for those of working age in England is estimated to be around £1.67m per case (at 2009 prices). If this estimate is applied to the North East of England the projected cost to the local economy is £345million for the 238 cases of suicide and undetermined injury in 2009.

Self-Harm
Self-harm is defined as ‘self-poisoning or self-injury, irrespective of the apparent purpose of the act’ (NICE, 2004). An individual episode of self-harm might be an attempt to end life.  However, many acts of self-harm are not directly connected to suicidal intent.

It must be recognised that the rate of suicide for people who have had an episode of self-harm is 100 times higher in the year following the episode than that of the general population.

The extent of economic burden associated with self-harm is significant dependent upon both how it is defined and the method of economic evaluation (Drummond et al., 1997).

The suicide and self-harm prevention agenda is cross-cutting and relates most closely to the following JSNA topics:

Offenders
Domestic Violence Victims
Ex-Forces Personnel
Alcohol Misuse
Illicit Drug use
Mental Health and Behavioural Disorders
Employment
Carers

Last updated: 2016-01-27 12:35:13
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1. What are the key issues?

  • Lack of clarity about the impact of local factors on suicide and self-harm – including:
    • Lack of understanding of the nature of local incidence
    • Lack of knowledge about how services and people respond
    • The dynamic changing economic landscape
  • The Suicide Prevention Taskforce needs to ensure the suicide alert system is robust and appropriate for needs.  An alert system identifying when deaths are possibly a result of suicide is vital to allow intelligence to be gathered, shared and discussed within a partnership approach to recognise and respond to any emerging increasing trends.
  • Need to optimise coordination and delivery of services to ensure an integrated and effective multi agency response.
  • Lack of services for those bereaved by suicide or affected by self-harm
  • Suicide prevention task force does not have funding to implement the action plan
  • Lack of understanding of the numbers of people who self-harm (current data is based on those attending A&E).
  • Stigma associated with self-harm and suicide prevents people from accessing help and support.
  • Some professionals lack confidence and awareness to discuss suicide and self-harm.

 

Last updated: 22/08/12

2. What commissioning priorities are recommended?

2012/01
Maintain and improve the early alert system to identify potential suicide clusters.

2012/02
Provide a comprehensive understanding of self-harm, suicide, and further identify levels of unmet need, building on existing local research evidence data.

2012/03
Put in place robust protocols to ensure integrated service provision between agencies.

2012/04
Map all existing services/pathways, compare them against examples of best practice, identify gaps and make recommendations for improvement.

  • Develop and commission a specific pathway of care for those people who are identified as “frequent flyers”.
  • Introduce a standardised tool for the assessment of risk in primary care and develop appropriate protocols.
  • Commission postvention services.
  • Explore options for a floating support provision for high risk individuals.

2012/05
The Tees Suicide Prevention taskforce to develop a revised suicide /self-harm prevention multi-agency action plan, including a communication plan.

2012/06
Agree a multi-agency pooled budget for the implementation of the plan.

2012/07
Agree future approach and commissioning intentions relating to awareness raising and skills development, based on a local training needs analysis.

2012/08
Ensure that Local HealthWatch organisations signpost to appropriate services for those at risk of suicide and self-harm.

Last updated: 22/08/12

3. Who is at risk and why?

The risk of suicide-related behaviour is thought to be determined by a complex interplay of biological, psychological and social issues.

Gender
Current statistics identify that men are three times more likely to die by suicide than women and this holds true for men in all age categories (ONS, 2009).

Age
Adolescent girls are more likely than boys to harm themselves and women are more prone to harm themselves than men (Hawton & Harriss, 2008). Older people who harm themselves are more likely to do so in an attempt to end their life (NICE, 2004) with isolation, divorce or widowed being a contributing factor (Hawton & Harriss, 2006). Overall, among older people, in contrast to younger people, the main factor associated with self-harm and completed suicide is an underlying mental illness, most often depression (Dennis, 2009). People aged 40–49 now have the highest suicide rate. The suicide rate among teenagers continues to fall, and is below that in the general population. However, half of lifetime mental health problems (excluding dementia) begin to emerge by age 14 and three-quarters by the mid-20s, making this a crucial age group for the early identification of problems and swift and effective intervention.

Mental illness
People in the care of mental health services are more likely to take their own life (around 1,200 suicides per year in England), including in-patients.

Other groups at high risk of suicide and self-harm are:

  • People with a history of alcohol and drug misuse
  • People with a history of self-harm (around 950 suicides per year);
  • People in contact with the criminal justice system (around 80 self-inflicted deaths in prison per year)
  • Specific occupational groups, such as doctors, nurses, veterinary workers, farmers and agricultural workers.

Suicide rates are also significantly influenced by the state of the economy.  There is a rise during economic recessions and a fall during expansions with individuals of working age (25-64) most adversely affected by economic downturn.

Stressful life events can also play a part but for many people it is the combination of factors which is important rather than one single factor. Stigma, prejudice, harassment and bullying can also all contribute to increasing an individual’s vulnerability to suicide. 

In addition groups with particular vulnerabilities or issues of access to services are also at risk of suicide and self-harm. These are not discrete groups, and many individuals may fall into more than one of these groups. The groups identified are:

  • children and young people, including those who are vulnerable such as looked after children and care leavers;
  • survivors of abuse or violence in childhood, including sexual abuse;
  • veterans;
  • people with untreated depression;
  • people who are especially vulnerable due to social and economic circumstances;
  • people who misuse drugs or alcohol;
  • lesbian, gay and bisexual people;
  • black, Asian and minority ethnic groups and asylum seekers; and
  • other groups with protected characteristics.

Whilst evidence already exists on which to base preventative measures in the high risk groups, there is insufficient information about rates of suicide and also about what interventions might be helpful in relation to the groups with particular vulnerabilities.

Self-harm

Self-harm can occur at any age but is most common in adolescence and young adulthood.  Females are more likely to self-harm than males. It is estimated that in Great Britain between 4.6% and 6.6% of people have self-harmed (NICE, 2004). Self-harm is one of the top five causes of acute medical admission in the UK (NICE, 2004). However, even this might be an under-estimate. In a school survey, 13% of young people aged 15 or 16 reported having self-harmed at some time in their lives and 7% as having done so in the previous year. 

Following an act of self-harm the rate of suicide increases to between 50 and 100 times the rate of suicide in the general population and men who self-harm are more than twice as likely to die by suicide as women.  In addition the risk increases greatly with age for both men and women.

Other than direct contact with the health service, someone who has self-harmed may have contact with another agency non-health worker (e.g. counsellor, teacher, police) or through a helpline.  In 2001, the Samaritans had more than 3 million verbal contacts.  They estimate that their volunteers explored suicidal feelings with callers in more than one-quarter of these.  Someone may also have contact with a primary care team, ambulance staff and NHS Direct.  About one-half of people who attend an emergency department following self-harm will have visited their GP during the previous month and about the same proportion will do so in the two months afterwards.

The following can also precipitate an individual to self-harm or commit suicide:

Multiple Factors: Individual multiple elements can include personality traits, family experiences, education, housing, wider socioeconomic trends such as unemployment, life events, exposure to trauma, cultural beliefs, social isolation and income.

Ethnicity: South Asian women have a higher than average rate of self-harm compared with other women in general (Bhugra & Desai, 2002). Reasons identified for this difference include isolation and family pressure from husbands demanding a less Westernised form of behaviour; interference from parents-in-law; arranged marriages or the rejection of an arranged marriage; isolation even within the wider community; cultural conflict, and problems at school, including racist bullying. Caribbean women aged less than 35 years also present a higher risk. 

Prisoners: Prisoners are unusually susceptible to self-harm and suicide. Male prisoners are five times more likely than men in the general public to die by suicide, while the rate among young offenders is 18 times higher (Fazel et al, 2005). Self-harming behaviour is also widespread in prisons, with rates higher than the general population for both sexes (Her Majesty’s Chief Inspector of Prisons for England and Wales, 2007; Cabinet Office;  Royal College of Psychiatrists, 2010).

Asylum seekers: Asylum seekers have often experienced traumatic events in their home country with studies consistently revealing high levels of mental health problems, especially anxiety, depression and Post-Traumatic Stress Disorder in detained asylum seekers. They therefore present higher rates of self-harm and suicide compared with the general population (Cohen, 2008).

Veterans: A study of 233,803 personnel leaving the UK military forces between 1996 and 2005 reported that men aged 24 and younger have been found to be at a particular, and persistent, risk of suicide – two to three times higher than for the same age groups in the general population and those still serving in the forces (Kapur et al, 2009). The risk is greater among males, those with a short service and those of lower rank.

Lesbian, gay and bisexual people: Lesbian, gay and bisexual people are subject to prejudice, discrimination and social exclusion (including within families). They may experience hostility and violence, and may internalise a sense of shame about their sexuality. Misuse of alcohol and drugs may also increase their vulnerabilities to mental disorder and self-harm.

Carers, friends and family members: caring for people who self-harm can expose carers to psychological distress. This is likely to be most acute for parents of young people who self-harm and for those who have been bereaved by suicide (Department of Health, 2008).

 

Last updated: 22/08/12

4. What is the level of need in the population?

Historically the North East has had a higher level of deaths from suicide and undetermined injury per 100,000 population than England, but since 2005 rates have tended to be lower.  Latest 3-year pooled data show Stockton-on-Tees has a rate below both a statistical neighbour and the North East and similar to  England, although the differences are not statistically significant.

Stockton mortality from suicide and injury undetermined 2008-10 and comparators

 

In Stockton-on-Tees suicide rates for men are higher than for women, a picture which is seen nationally.

Stockton suicide trend for males and females

 

Local audit 1997-2011

Local audit records suicides by date of death rather than by date of registration and is more inclusive with regard to verdicts (that is, it will include verdicts other than suicide or open verdicts following coroner data collection, for example, narrative, accidental verdicts). Data for 1997-1999 to 2008-10 are shown below.  The number of deaths from suicide has fallen since 1997-1999, but the apparent drop in the latest data may, at least in part, be due to incomplete data.  There are still verdicts for 2010 and 2011 which have not yet been reported.  Therefore these figures are subject to change.

Tees suicide audit trend in number of deaths

 

Local audit 2008-2010 Summary

Local audit currently indicates that 128 people took their own lives across Teesside between January 2008 and December 2010.  Of these:

  • 20 were from Hartlepool
  • 36 were from Stockton-on-Tees
  • 35 were from Middlesbrough
  • 37 were from Redcar & Cleveland

 

About two-thirds of deaths occured in those aged below 50 as per the figures across England.  Both Stockton and Redcar & Cleveland have slightly higher proportions aged over 50.

Tees suicide audit - age group

 

Compared to the national average of 1 female death for every 3 male deaths Teesside there is a ratio of 2.8 male deaths for each female death.  However this rate fluctuates across each of the Tees PCTs where male to female ratios vary                       

PCT   

Male to female ratios

Hartlepool

5.7 males   : 1 female

Stockton

2 males      : 1 female

Middlesbrough

3.25 males : 1 female

Redcar & Cleveland

2.6 males   : 1 female

 

The majority of the 128 suicides were single at time of death.  In Tees, about 29% of the adult population are single (never married), but 49% of people who died by sucide were single.  About 9% of the adult population is divorced compared with 19% of those who commited suicide.

Tees suicide audit - partnership status

 

A high proportion of suicides occur in people who live alone.  In 2001, about 12% of Teesside's population lived alone, but 45% of deaths by suicide are in people who live alone.

Tees suicide audit - living arrangements

 

People who committed suicide in Teesside were most likely to be unemployed.  In Tees Valley, 6.8% of the population were unemployed in January 2012, but 39% of people who committed suicide were unemployed at time of death.

Tees suicide audit - employment status

 

The method of suicide used most often was hanging or strangulation.

Tees suicide audit - method of suicide

 

The National Suicide Prevention Strategy for England Annual Report on Progress 2008 (National Mental Health Development Unit, July 2009) indicates that hanging and suffocation are the most common methods of suicide for men, accounting for more than half of all male suicide deaths. This is followed by drug-related and other poisoning deaths.  Among women, drug-related poisoning is still the most common method of suicide, but hanging and suffocation now account for over one-third of all female suicides and is the second most common method used.

Self-poisoning comprising multiple substances is seen in 75% of cases. Anti-depressants and analgesics are the mostly commonly used substances. 

 

Locality hot spots

The majority of suicides occur within the person’s home. However, other geographical hotspots have been identified where suicides occur away from the person's home.

 

Alcohol

Two-thirds of deaths by sucide in Teesside had alcohol detected at time of death.  Of these: 41% were over the legal drink driving limit.

 

Criminal Justice

A review of contact within 3 months of suicide showed a high rate of contact with police for either arrest or reporting crime (Linsley et al, 2007) and in nearly 25% of all cases of suicide the person had had a criminal justice contact within 3 months of their death.  Locally 69 of the 128 suicides (54%) were known to the police; of these 69 over one quarter (20) had contact with the police within the 3 months prior to death.

Tweny-two cases (17%) had a history of contact with the prison service at some point in their lives.  Twenty-nine (23%) were known to have had contact with the probation service at some point within their lives.

 

Contact with Primary Care

Around 40% of people who committed suicide in Teesside were known to have been to see a GP within 3 months prior to death.  Reason for last contact involved mental health in 42% of these cases.

The most common current and/or ongoing diagnosis include depressive illness and anxiety.

The National Confidential Inquiry into Suicides report in 2011 found that 26% of general population suicides were identified as patient suicides, that is, the person had  been in contact with mental health services in the 12 months prior to death. The proportion of cases seen within the year prior to death in Tees was 36.5%. 

Just over half (52%) of cases were known to secondary mental health services at some point in their lives.  Of these about two-thirds had contact within 3 months prior to death. Depressive illness/bipolar affective disorder was the most prevalent diagnosis with anxiety showing up as a component within 5 of the 6 cases with multiple diagnosis.

Last updated: 06/12/13

5. What services are currently provided?

A range of mental health services support suicide and self-harm prevention and intervention. These are delivered in line with the stepped care model for mental health:

  Stepped care model

A brief overview of the available services provided in Teesside is provided below:

Public Mental Health
  • Teeswide multi-agency Suicide Prevention Taskforce
  • A range of interventions to improve mental well-being at a population level, e.g. whole school approach, workplace mental health, lifestyle programmes etc
  • Social Prescribing Identification and Brief Intervention
  • Mental Health First Aid/Youth Mental Health First Aid, accessed by a diverse range of organisations
  • Applied Suicide Intervention Skills Training (ASIST) Programme
  • Safe Talk – awareness raising and signposting
  • Multi-agency self-harm protocols and pathways
Voluntary and Community Services
  • Samaritans, Mind, Carers Service, New Horizons, Stamp revisited
  • Job Centre Plus
  • Children’s Centres
  • Citizens Advice Bureau (CAB)
  • Cruse – bereavement service
  • A wide range of services are available from the volutary and community sector (VCS) that help deliver mental health support and advocacy
  • NHS Community Services, e.g. Health Visiting, School Nurses, etc
  • Teesside Positive Action


 

Primary Care
  • Access to support therapies and counselling
  • GP Practice assessment, support and treatment
  • Significant Event Audit
Specialist Services (* statutory)
  • Improving Access to Psychological Therapies (IAPT)
  • Criminal Justice Services*
  • Social Care and Community Mental Health Services*
  • Tees Esk & Wear Valley Mental Health Foundation Trust*
  • NHS Acute Hospitals*
  • Specialist CAMHS
  • Crisis Intervention Service
  • Liaison Psychiatry
  • Substance and Alcohol Misuse Services
  • Children and Families Service for Alliance Psychology
  • Forensic Services
Other
  • Coroners Office/Coroners Officers
  • Chaplaincy
     
Last updated: 06/12/13

6. What is the projected level of need?

Forecasting suicides is complex, and it is difficult to incorporate significant influences such as economic conditions.  Using historical data for suicide and injury undetermined, the variability is a striking feature in Stockton-on-Tees.  Applying and exponential ‘best fit’ curves to data from 1993 shows that male suicide is declining at a greater rate than female suicide.

Stockton suicide forecast males and females

 

Factors that increase risk of suicide and self-harm have been discussed earlier in this topic.  The Projecting Adult Needs and Service Information System (PANSI) forecasts risks such as mental disorders, alcohol dependence and drug dependence.  However, little change is seen over time and any changes are due to the changing population structure; no account is taken of varying factors affecting risk.

Stockton suicide and self-harm risk forecast

 

Last updated: 06/12/13

7. What needs might be unmet?

Professional Issues

  • Workforce Development
    • Awareness of suicide prevention/mental health
    • Knowledge of services/pathways
    • Providing support to individuals in need
    • Improving confidence to raise the issue of suicide prevention and self-harm
  • Commissioning issues e.g. non-recurrently funded services, (lack of ability to plan) services commissioned on traditional opening hours, lack of robust evaluations.

Patient Issues

  • Postvention Services and counselling
  • Inconsistent pathway development and awareness between services
  • Robust pathways for those in transition between services e.g. children to adults
  • No floating support services to provide immediate input whilst patients are waiting to be seen by other services
  • Lack of services/pathways for people with long-term conditions and those with untreated depression
  • Integrated pathway for dual diagnosis

Population Issues

  • Raising awareness and tackling stigma with the local population
  • Suspected under reporting of self-harm in BME, Asylum Seekers and LGBT communities
  • Males are less likely to access traditional health services
  • Media engagement

 

Last updated: 22/08/12

8. What evidence is there for effective intervention?

General Evidence

No Health without Mental Health: A cross-government mental health outcomes strategy for people of all ages Department of Health (2011)

National Suicide Prevention Strategy for England Department of Health (2002)

Self-harm: longer-term management. NICE (2011)

Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. NICE (2004).

Avoidable Deaths: five year report of the national confidential inquiry into suicide and homicide by people with mental illness. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2006)

Effectiveness of Interventions to Prevent Suicide and Suicidal Behaviour: A Systematic Review. Scottish Government Social Research (2008)

Risk and Protective Factors for Suicide and Suicidal Behaviour: A Literature Review. Scottish Government Social Research (2008)

Suicide Prevention Strategies: A Systematic Review. JAMA (2005)

 

Population sub-groups

Youth suicide prevention - Evidence briefing. Health Development Agency (2005)

Risk-taking behaviour in men: Substance use and gender. Health Development Agency (2003)

Young men and suicide prevention: a scoping exercise for a review of the effectiveness of health promotion interventions of relevance to suicide prevention in young men. Evidence for Policy and Practice (EPPI) Centre (2002)

Older People and Suicide. Care Services Improvement Partnership and the Centre for Ageing and Mental Health, Staffordshire University (2006)

A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. King, Semlyen, See Tai et al (2008)

Engendered Penalties: Transgender and Transsexual People’s Experiences of Inequality and Discrimination. The Equalities Review (2007)

Suicide in the homeless within 12 months of contact with mental health services - A national clinical survey in the UK. Social Psychiatry and Psychiatric Epidemiology (2006)

Reaching Out, the evaluation report of three mental health promotion initiatives aimed at reducing suicides in young men. National Institute for Mental health in England (2006)

 

Cause-specific evidence

Cheers? Understanding the relationship between alcohol and mental health. Mental Health Foundation (2008)

Our Invisible Addicts: Older People’s Substance Misuse. Working Group of the Royal College of Psychiatrists (2011)

Last updated: 22/08/12

9. What do people say?

An internal audit of service user feedback with Tees, Esk and Wear Valley (TEWV) NHS Trust will be completed during 2012.

Comments from North East Together (NETs) service user and carer group who cover both Northumberland, Tyne and Wear (NTW) and TEWV areas:

  • Suicide prevention -  suggestion that it would be helpful to talk to and learn lessons from  those who have tried and failed to kill themselves – this could be done through the service user network.
  • Anecdotal reports of people hoarding medication.

 

Last updated: 22/08/12

10. What additional needs assessment is required?

There are hidden vulnerable groups where additional information is required.  These may include young carers, looked after children, BME, LGBT,  those with long-term conditions.

Comprehensively identify the education and training needs of local population and workforce.

Understand why certain high risk groups (e.g males) do not access traditional services.

Consideration of the misuse of alcohol use in suicide and self-harm.

Last updated: 22/08/12

Key contact

Name: To be advised

Job title:

e-mail:

Phone number:

 

References

 

Local strategies and plans

Tees, Esk and Wear Valleys NHS Foundation Trusts (2011). Partnership Suicide Prevention Strategy

 

National strategies and plans

Department of Health (2011) No Health without Mental Health: A cross-government mental health outcomes strategy for people of all ages

Department of Health (2002) National Suicide Prevention Strategy for England

The Scottish Government (2008). Risk and Protective Factors for Suicide and Suicidal Behaviour: A literature review.

 

Other references

WHO (2004). The World Health report: Changing History

Drummond et al (1997). Users' Guides to the Medical Literature XIII. How to Use an Article on Economic Analysis of Clinical Practice A. Are the Results of the Study Valid?

ONS (2009). Suicide rates in the United Kingdom, 2000–2009

Dennis (2009). Suicide and self harm in older people. Social Care Institute for Excellence

Hawton, K., Harriss, L. (2008) The changing gender ratio in occurrence of deliberate self-harm across the life-cycle. Crisis, 29, 4-10.

Hawton, K., Harriss, L. (2006) Deliberate self harm in people aged 60 years and over: characteristics and outcome of a 20 year cohort. International Journal of Geriatric Psychiatry, 21, 572-581.

NICE (2004) Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care.

Bhugra, D. & Desai, M. (2002). Attempted Suicide in South Asian Women. Advances in Psychiatric Treatment, 8, 418–423.

Fazel, S., Benning, R. & Danesh, J. (2005) Suicides in male prisoners in England and Wales, 1978–2003. Lancet, 366, 1301–1302.

Her Majesty's Chief Inspector for Prisons (2007) The mental health of prisoners.

Royal College of Psychiatrists (2002) Suicides in prison. Council Report CR99

Royal College of Psychiatrists (2010). Self-harm, suicide and risk: helping people who self-harm. College Report CR158

Cohen, J. (2008) Safe in our hands? A study of suicide and self-harm in asylum seekers. Journal of Forensic and Legal Medicine, 15, 235–244.

Kapur, N., White, D., Blatchley, N., et al (2009) Suicide after leaving the UK Armed Forces – a cohort study. PLoS Medicine.

Department of Health (2008) Help is at Hand. A Resource for People Bereaved by Suicide and Other Sudden, Traumatic Death.