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Suicide, Self-Harm & Occupational Health

Suicide, Self-Harm & Occupational Health. Dr G E P Vincenti MBBS, LLB, DOccMed, FRCPsych Consultant Psychiatrist. Learning Objectives. What facts do I need to know? How do I assess risk? When should I be worried? What is the significance of self-harm? What role can OH realistically play?

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Suicide, Self-Harm & Occupational Health

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  1. Suicide, Self-Harm & Occupational Health Dr G E P Vincenti MBBS, LLB, DOccMed, FRCPsych Consultant Psychiatrist

  2. Learning Objectives • What facts do I need to know? • How do I assess risk? • When should I be worried? • What is the significance of self-harm? • What role can OH realistically play? • What can the employer do to help? • Stimulate further reading

  3. Yorkshire Post – 23rd August • Senior hospital clinician from Leeds committed suicide • Initial media reports assumed work related stress • In fact key issues were to do with personal factors • Take care not to rush to assumptions!!

  4. Egypt Air Flight 990 from LA to Cairo, Oct 1999

  5. Key facts on suicide • National confidential inquiry into suicides & homicides by mentally ill people – July 2012 • England: 8.7 per 100,000 population • Wales: 10.7 • Scotland: 16.5 • Northern Ireland: 17.5

  6. Suicide in England • North West:10.5 per 100,000 population • London: 8.1 • Suicide rate has been falling since 2000, with a blip in 2008

  7. Suicide in England

  8. Suicide in England • Hanging (incl. strangulation)** • Self poisoning • Jumping from height, multiple trauma (i.e. railway suicides) • Drowning • Carbon monoxide (incl. BBQ in car) • Firearm • Cutting or stabbing injury ** (has increased since 2000)

  9. Suicide in England • Successful overdose: • Opiates: 21% • Tricyclics: 16% • Paracetamol/Opiate combinations: 13%

  10. Suicide in England • “Patient suicide”: - in contact with MH services in past 12 months • 27% • Reducing in ages 16-45y, static >65y • Increasing in 45-64y especially men

  11. Suicide in England • Inpatient suicides (2000 – 2010) - Fell from 196 to 74 • Hanging on wards (2000 – 2010) • Fell from 41 to 19 - ?

  12. Suicide in England • Crisis and intensive home treatment teams CIHTT • 18 suicides in 2000 • 195 suicides in 2009 • 150 suicides in 2010 • 2006: more suicides in CIHTT than on inpatient units

  13. Suicide & psychiatric disorder • 90%: psychiatric diagnosis evident at psychiatric autopsy: • Affective disorder 74% (15% of hospitalised depressed pts will go on to kill themselves, esp. depressive psychosis) • Personality disorder 46% • Stress related disorders 26% • Alcohol disorder 24% • Drug misuse 3.6% • Schizophrenia 4.5% (early in illness)

  14. Suicide & psychiatric disorder • But not all suicide is linked with psychiatric disorder • Altruism • “I am just going outside and may be some time” – Capt Laurence Oates

  15. Suicide & occupation • Doctors (females, anaesthetists & psychiatrists) • Farmers • Hotel & bar staff • Police officers • Lawyers • NOT the military, in spite of access to ready means

  16. How do I assess risk? • “Prediction is very difficult, especially about the future” – Neils Bohr • “Risk assessment is now part of routine clinical practice in many areas, but the assessment of risk does not enable mental health professionals to predict the future” – Crawford M; Advances in Psychiatric Treatment (2004); 10: 434-438

  17. Risk assessment for suicide • Structured clinical assessment • Numerical (Worthing NHS Trust) • Actuarial (FACE) - Patient allocated to a risk category, high, medium or low

  18. Risk assessment for suicide • BUT • 86% of completed suicides occur in low risk groups, because although these groups contain individuals at low risk, they contain many more members, and suicide is a very rare event. • A study identified 3 risk factors. 2.9% of subjects died by suicide, but the sub-population with all 3 risk factors made up only 5.4% of the suicide group (Undrill G; Adv in Psych Treatment (2007); 13: 191-7)

  19. Risk assessment for suicide • “Accurate risk assessment is never possible at an individual level….risk assessment should be seen as an assessment of the current situation, not as a predictor of a particular event” – CR150 RCPsych 2008 • Morgan L, Large M (2013): Does the emphasis on risk in psychiatry serve the interests of patients or the public? BMJ; 16 Feb 2013: 346: 20-21 • Savage v South Essex Partnership NHS Trust [2008] UKHL 74 • Rabone v Pennine Care NHS Trust [2012] UKSC 2

  20. When should I be worried??

  21. Red flags • Profound hopelessness • Detailed suicide planning • Acts of preparation • Active psychosis • Malignant alienation, no social support • Recent near miss • Bizarre self injury or mutilation

  22. What is the significance of self harm? • Significant risk factor for completed suicide • 30 fold increase in risk of suicide over 4y compared with general population Cooper et al (2005), Am J Psychiatry; 162: 297-303 • 1% commit suicide in first year, 3-5% within 5y. Risk is greatest within 6 months or multiple episodes, esp. self cutting • Assess each event on its own merits (NICE)

  23. What is the significance of self harm? • Suggests some degree of emotional vulnerability: possible occupational implications for role/responsibility • Association with personality disorder if repetitive (borderline) • Confusing array of terms: • Parasuicide • Deliberate self harm • Self harm • Attempted suicide • Non-suicidal self injury (Br J Psychiatry 2013; 202: 324-8): DSM 5

  24. The role for OH Suicide of employee at home - Most common, often on sick leave Suicide of employee at work (v rare) Serviceman with firearm Doctor in anaesthetic room Suicide by member of public at the workplace - Railway suicide

  25. The role for OH • Screening for mental illness (depression) • Sickness > 4 weeks • Enquiry into suicidal ideation • Screening questionnaires (PHQ9) • Look for red flags • Signpost to services, liaise with GP • www.rcpsych.ac.uk - Leaflets on web: Feeling on the edge, Feeling overwhelmed, U Can Cope • Training • Post incident support and audit (very good for reflective practice, but can destroy teams so handle with care)

  26. The role for OH • Training: managers and employees - Open Minds Alliance • www.connectingwithpeople.org • Share concerns if worried • Compassion (Kevin Hines, Bay Bridge San Francisco 2000) • Non judgemental approach – NICE, RCPsych, DoH • Myth busting • Those who talk about it never do itX • Talking about it gives people the ideaX • You can’t stop someone anywayX

  27. What role for the employer • Culture of the organisation (uniformed services) • HSE risk assessment management standards • Planning procedures and policies with mental health in mind (i.e.. Xmas letters, unemployment notices) (Economic recession & suicide: BMJ 21/9/13; 347: 9) • EAP • Funding of treatment • Post incident support – policies & procedures • Facilitate training • Publicity material (i.e. Samaritans at railway stations)

  28. To End • “Suicide is a permanent solution to a temporary problem” – a CPN • “The main cause of unhappiness is rarely the situation but your thoughts about it” – Michael Neill, life coach & author • “I beseech you in the bowels of Christ, think it possible you may be mistaken” – Oliver Cromwell

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