Suicide and self harm - an information toolkit

Suicide and self harm- an information toolkit Frank Röhricht Associate Medical Director / ELFT Honorary Professor of Psychiatry

Key national documents: • Safety First, the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (2001). • The National Suicide Prevention Strategy for England (2002) sets out a comprehensive evidence-based strategy • The NIMHE “toolkit” for Mental Health Services (2003), to assist local services to review their current practice to ensure that good suicide prevention practices are in place. • The National Patient Safety Agency - Seven Steps to Patient Safety (2003). • The “Best practice in managing risk” guidance (2007) sets out a framework of principles that should underpin best practice across all mental health settings. • Preventing suicide through community and emergency healthcare: New suicide prevention toolkits for the NHS (National Patient Safety Agency’s / NPSA, 2011)

Historical perspective • “Suicide was once illegal in Britain. Suicide attempts were punishable by public execution…as late as 1860.” (Kelly & Dale 2011, APT) • Decriminalised in 1961 in England, Wales & Scotland (Suicide Act), in NI in 1966 • Current dilemma: assisted suicide and euthanasia debate

Content • 1. Self Harm • 1.1. Definition • 1.2. Facts and figures • 1.3. Selection of recent research publications • 2. Suicide • 2.1. Definition • 2.2. Facts and figures • 2.3. Suicide risk • 2.4. Assessment of suicidality / self harm • 2.5. Implications for prevention • 2.6. Selection of recent research publications • 3. DoH Best practice in managing risk (2007)

1.1. Definition of Self-HarmCatherine McLouglin, Chair national inquiry into Self-harm • Self-harm describes a wide range of things that people do to themselves in a deliberate and usually hidden way, which are damaging. • The most common methods of self-harm involve cutting of the skin and swallowing small amounts of toxic substances, other methods include burning, scalding, hitting, scratching and hair pulling.

1.2. Self-Harm: facts and figures1 • Not fully understood and until recently only very limited research has been carried out in the UK to find out how many people self-harm, why they do it and what can be done about it • Much of the current research and interest in self harm concentrates on self-harming behaviour with suicidal intent

Who self-harms? • About 1 in 10 young people will self-harm at some point, but it can occur at any age. • It is more common in young women than men. • Gay and bisexual people seem to be more likely to self-harm. • Sometimes groups of young people self-harm together - having a friend who self-harms may increase your chances of doing it as well. • Self-harm is more common in some sub-cultures – "goths" seem to be particularly vulnerable. • People who self-harm are more likely to have experienced physical, emotional or sexual abuse during childhood. Royal College of Psychiatrists website

Self-Harm: facts and figures2 • Rates of self-harm in the UK have increased over the past decade and are amongst the highest in Europe • More than 24000 teenagers are admitted to hospital in the UK each year after DSH • Each year an estimated 200.000 people present to A&E departments following an episode of DSH. • In the subsequent 12 months around 20% of patients go on to repeat self-harm and appr. 1% will die by suicide • In a cohort study, around half of the patients with DSH consulted their GP in the 4 weeks following the episode. Data suggest that there are potential opportunities for GP involvement in the prevention of repeat DSH. • More than 2 mill. people feel life is not worth living (Thomas, 2002)

More about figures: • ”Research probably under estimates how common self-harm is, and surveys find higher rates in communities and schools than in hospitals. Some types of self-harm, like cutting, may be more secret and so less likely to be noticed by other people. In a recent study of over 4000 self-harming adults in hospital, 80% had overdosed and around 15% had cut themselves. In the community, these statistics would probably be reversed.” Royal College of Psychiatrists website

1.3. Self harm:Selection of recent research publications (2006-2009)

Risk factors and correlates of DSH behavior: a systematic review. • 59 studies: SH may occur at all ages, yet adolescents and young adults are at a higher risk (e.g. >10% in prodromal psychosis). • Many studies report associations between current self-harm behavior and a history of childhood sexual abuse. • Adolescent and adult self-harmers experience more frequent and more negative emotions, such as anxiety, depression, and aggressiveness. • Two studies yield specific interactions between childhood trauma and current traits and states such as low emotional expressivity, low self-esteem, and dissociation with respect to a vulnerability to self-harm. Fliege et al. 2009, J. Psychosom. Res.

Hospital admissions for SH after discharge from psychiatric inpatient care: cohort study • 75 401 people were discharged from psychiatric inpatient care over the study period (2 years) in England • 4935 (6.5%) of whom were admitted at least once for self harm in the following 12 months. • Risk of self harm was greatest in the four weeks after discharge; one third (32%, n=1578) of admissions for self harm occurred in this period. • The strongest risk factor for self harm after discharge was admission for self harm in the previous 12 months • The risk of self harm was also higher in females, younger people, those with diagnoses of depression, personality disorders, and substance misuse, and those with short lengths of stay. Gunnell et al. 2008, BMJ

Hospital care and repetition following self-harm: multicentre comparison of self-poisoning and self-injury • prospective cohort study, involving 10,498 consecutive episodes of self-harm at six English teaching hospitals • Compared with those who self-poisoned, people who cut themselves were more likely to have self-harmed previously and to have received support from mental health services, but they were far less likely to be admitted to the general hospital or receive a psychosocial assessment • Although only 17% of people repeated self-harm during the 18 months of study, repetition rate of 33% in the year following an episode: 47% after episodes of self-cutting and 31% after self-poisoning (P<0.001) Lilley et al. 2008, Br. J. Psychiatry

Psychosocial interventions following self-harm: systematic review of their efficacy in preventing suicide • systematic review and meta-analysis of data from randomised controlled trials of interventions for people following SH. • suicide data from 18 studies with a total population of 3918 • 18 suicides occurred among people offered active treatment and 19 among those offered standard care • The overall rate of suicide among people participating in trials was similar to that reported in observational studies of people who self-harm. • Results of this meta-analysis do not provide evidence that additional psychosocial interventions following self-harm have a marked effect on the likelihood of subsequent suicide. Crawford et al. 2007, Br. J. Psychiatry

Psychosocial assessment following self-harm: results from the multi-centre monitoring of self-harm project • 7344 individuals presented with 10,498 episodes of self-harm during the study period (18 months) • 60% of episodes resulted in a specialist psychosocial assessment • Factors associated with an increased likelihood of assessment included age over 55 years, current psychiatric treatment, admission to a medical ward, and ingestion of antidepressants • Factors associated with a decreased likelihood of assessment included unemployment, self-cutting, attending outside normal working hours, and self-discharge • no overall assoc. between assessment and SH repetition, differences between hospitals - assessments protective in one hospital but increased risk of repetition in another. Kapur et al. 2008, J. Affect. Disord.

1.4. Self harm: useful links….. • http://www.nice.org.uk/nicemedia/pdf/CG016NICEguideline.pdf • http://www.rcpsych.ac.uk/mentalhealthinfoforall/problems/depression/self-harm.aspx • http://selfharm.net/ • http://www.thesite.org/healthandwellbeing/mentalhealth/selfharm • http://www.mentalhealth.org.uk/information/mental-health-a-z/self-harm/

2. Suicide and suicidality

2.1 Suicide? Definition • Suicide is the intentional taking of one's own life. Many dictionaries also note the metaphorical sense of "willful destruction of one's self-interest" (e.g., "political suicide"). • Suicide may occur for a number of reasons, including depression, shame, guilt, desperation, physical pain, emotional pressure, anxiety, financial difficulties, or other undesirable situations. • Medically assisted suicide (euthanasia, or the right to die) is currently a controversial ethical issue involving people who are terminally ill, in extreme pain, and/or have minimal quality of life through injury or illness. Self-sacrifice for others is not usually considered suicide, as the goal is not to kill oneself but to save another. • The predominant view of modern medicine is that suicide is a mental health concern, associated with psychological factors such as the difficulty of coping with depression, inescapable suffering or fear, or other mental disorders and pressures. Wikipedia.org

2.2. Facts and Figures Suicide UK:The scale of the problem • On average, a person dies every two hours in England as a result of suicide . • Suicide is the commonest cause of death in men under 35. It is the main cause of premature death in people with MI. • Over 4,000 suicides occur in the UK each year; 74 per cent of suicide victims are not known to mental health services. • In the last 20 years or so, suicide rates have fallen in older men and women, but risen in young men (Substance abuse, depression, stressful life events and media influence)

Global Perspective of Suicide1 • Suicide is now one of the three leading causes of death among those aged 15–34 years worldwide (814000 in 2000), new estimates: 1 Mill. per year accounting for 1-2% of total global mortality. • Self-inflicted death accounts for 1·5% of all deaths and is the tenth leading cause of death worldwide. • This means that globally one person dies by suicide every 40 seconds. The long term rate of suicide had been increasing steadily from 1950 especially in young men • There are an estimated 10 to 20 million non-fatal attempted suicides every year worldwide

Global Perspective of Suicide2 • The ‘hot spots’ with high rates of suicide are shown to be Eastern Europe, parts of Western Europe, Asia and Australia • In comparison to other Western European countries, England has a moderate suicide rates, similar to North America • The absence of data from Africa is a likely reflection of shortage of resources for data collection as well as the strong stigmatization that still surrounds suicide

Global Perspective of Suicide3 • unnatural deaths in rural areas of India, where suicide is illegal, suggested a 9-10 -fold underestimation of suicide rates. • In many Islamic countries, the view of suicide as a criminal offence might affect registration practices. • Suicide is a major concern in former Soviet • More than 30% of suicides worldwide happen in China (3·6% of all deaths). • Ethnic patterns in suicide rates: e.g. lower rates of suicide in Hispanic and African Americans

Lancet 2009

More facts: Deaths from suicide and undetermined injury in London: • There are over 600 deaths attributed to suicide and undetermined injury in London each year. This equates to a rate of around 8.3 per 100,000 people which is similar to the England rate • London has the second lowest suicide rate in the 9 English regions (after East of England). • Suicide rates in London have dropped by 8% since 1995-97 and 15% since 1997-99 • It is estimated that around 33,000 people in London attempt suicide each year

National office of statistics demonstrates the changes in suicide rate

In contrast to the decline that has been noted in suicide rates in the elderly, suicide rates in young males have been rising in many developed countries

WHO trends in average suicide rates from its member countries in 2000.

Trends in suicide methods- Our healthier nation 2001 • 3 main methods of suicide: strangulation/ hanging (44% men, 27% women); drug poisoning (20% men, 46% women) and other poisoning (10% men) or drowning (7% women) • Inpatient risk factors: admission under MHA, involvement with police, presence of depressive symptoms, history of SH and violence, going absent without leave

Mood Disorders Suicide Attempts 15% of mood disorder subsequently suicide 10% of attempts subsequently suicide within 10 years Suicides 45-70% of suicides have mood disorder 19-24% of suicides have a prior suicide attempt

London facts-1 (coroners/centre for suicide prevention Manchester ) • 1993-96 2734 suicides = 10.1 (4.7-20.8) per year per 100k population (Newham 10.5) • ELCMHT: 1996-2002 (6 years) 389 suicides with 19% in contact with MH services within one year prior to death = 74 (=12.3 per year per 750k), only minority inpatients and 22% within three months after discharge

London facts-2 • In London there are four boroughs with significantly higher rates of suicide than the England average (8.3 per 100k): Camden (13.3 per 100,000), Islington (13.5), Tower Hamlets (12.2) and Westminster (11.8). • These boroughs are also at the top end of the MINI2k scores for predicted admissions for schizophrenia. • Boroughs with significantly low suicide rates include: Croydon (6.1), Havering (5.4), Redbridge (6.6), Richmond upon Thames (5.9), and Sutton (5.3).

East London PCT facts 2003-2008

Newham facts • Newham (2000-2003: male appr. 36.75 (per 100k people 14.7, range 10.8 - 23.3); female appr. 14 (per 100k people 5.6, range 5.2 – 13.8), total appr. N=50 • so N=17 per year equals appr. 29% of total population of suicides • In mental health services in Newham from 2003 – 2004: N=10 (5 male / 5 female) = appr. five per year = 2 per 100k people (compared with 23.9 per 100k people on average per year in England)

Safety First (NcI; 1996-2001) • Appr. 25% of suicides in UK had been in contact with mental health services in the year before death; this represents around 1,500 cases/year. • Younger suicides more often had a history of schizophrenia, PD, drug/alcohol misuse, violence. • MH teams in England and Wales regarded 22% of the suicides as preventable…75% identified factors that could have reduced risk, mainly improved patient compliance and closer supervision.

Safety First-cont. • 23%-30% of suicide inquiry cases in UK died within three months of discharge. • Post-discharge suicides were at a peak in the first 1-2 weeks following discharge. • 35-66% of post-discharge suicides in UK occurred before the first follow-up appointment. • Compared to all community cases, post-discharge suicides were associated with final admissions lasting less than seven days, re-admissions within three months of previous discharge and self-discharge.

Safety First-cont. • 75% (15,777) were male, giving a male to female ratio of 3:1, the ratio of males to females was highest in the 25–34 year olds in whom 82% were male and lowest in those over 75 in whom 62% were male. • Major affective disorders occurred in 42% of all cases, the other principal diagnoses being schizophrenia and related disorders (20%), PD (11%) and alcohol dependence (9%). • Fifty-two per cent also had at least one secondary diagnosis, most commonly depressive illness, personality disorder and alcohol or drug dependence.

Safety first – last contact • 19% of suicides were in contact with services in the 24 hours before death, 49% in the week before death (mainly GPs), in most cases (70%) the contact was routine rather than urgent. • In nearly all (93%), this was a face-to-face contact, usually with a consultant or junior psychiatrist or mental health nurse. A key worker was present at the meeting in around half of the cases (51%). Most (87%) staff present at final contact had received training in risk assessment. • Assessments revealed abnormalities of mental state or recent behaviour in 63%. Most commonly this was emotional distress (35%) or depression (28%).

2.3. Suicide Risk • Research shows that suicide risk is raised for virtually all mental health problems and substance abuse. • Depression, Anxiety and schizophrenia are most highly associated with suicide, with relative risks of 20, 8.5 and 6 times higher than that observed in the general population respectively. • I was shown that 90% of those dying by suicide have one or more psychiatric disorders at the time they kill themselves.

Suicide Risk - Specific Disorders • schizophrenia is associated with a suicide risk which is 8.5 times higher than that observed in the general population. Suicide appears to be most common in those under 30 years of age, and the risk is highest in the first year following diagnosis. • bipolar disorder incurs an average suicide risk which is 15 times that of the general population. The risk of suicide is increased by a past suicide attempt and alcohol abuse. Lithium is a treatment which is shown to lower the risk of suicide.

Suicide risk specific cont. • people diagnosed with major depression have a 20-fold increased risk of suicide. The risk is highest in the first few weeks following discharge. • Less severe forms of depression show a reduced suicide risk. For people diagnosed with major depression, the lifetime risk of suicide may be as high as 6%. For people seen as outpatients or treated by GPs, risks are much lower. • Through retrospective examination of people who have killed themselves, 70% of recorded suicides are judged to have been by people experiencing depression.

Suicide risk specific cont. • Anxiety states also show higher suicide risk (appr. 6x higher than the overall population), combining studies which have looked at anxiety, agoraphobia, OCD and panic disorder shows that anxiety states in general have a 10-fold increased risk of suicide. • Studies on personality disorders showed that people who had received psychiatric in-patient treatment for this problem (therefore had a severe problem) were at seven times the expected risk of suicide. • Personality disorders have also been found to be common in people who have been seen at hospital for self-harm.

Suicide risk specific cont. • Studies on people referred to medical or psychiatric departments with anorexia nervosa show that they are at 23 times the risk of suicide in comparison to the overall population. (97% women. • suicide risk of people with dementia, usually Alzheimer's disease: few studies show that there have been no suicides amongst this group. But people who have recently been diagnosed with dementia and still have some insight may have increased suicide risk (no research to date).

General Risk factors-1 • demographic: being male, living alone, low socioeconomic status, unemployment, increasing age • long-term alcohol/drug misuse independent risk factor • The rate of suicide varies according to geographical area and social class, with the highest rates of suicide occurring among people in social class V • The National Suicide Prevention strategy has identified high risk occupation groups: • nurses; medical practitioners, farmers,agricultural workers. • Rate of suicide for people who had an episode of suicide attempt or parasuicide is 100x higher in the year following than that of general population !!!!!

General Risk factors-clinical • Clinical: MI including PD • Physical illness (especially chronic conditions and/or those associated with pain/functional impairment • Recent contact with psychiatric services • Recent discharge from psychiatric in-patient facility • Psychological: Hopelessness, Impulsiveness, Low self-esteem, Life event, Relationship instability

General Risk factors-history • Deliberate self harm (especially with high suicide intent) • Childhood adversity (e.g. sexual abuse) • Family history of suicide • Family history of mental illness • Lack of social support

What needs to be done?

What needs to be done? • White paper: Saving Lives: Our Healthier Nation target of reducing the death rate from suicide by at least 20% by 2010 and by at least 33% in the group of severely mentally ill people (from 9.2 deaths per 100k population to 7.4). • The PSA target rates for London and England are 7.2 and 7.4 per 100,000 by 2010.

Suicide and self harm - an information toolkit