Need to know - suicide and deliberate self harm
Suicide researchers Dr Nicola Swinson and Dr Kirsten Windfuhr answer Dr Linden Ruckert’s questions on suicide statistics, cutting, interventions that work and suicide in prison.
Suicide researchers Dr Nicola Swinson and Dr Kirsten Windfuhr answer Dr Linden Ruckert's questions on suicide statistics, cutting, interventions that work and suicide in prison.
1.Which countries have the highest risk of suicide and do we know why?
The difference in the suicide rates between countries with the highest and lowest rates is approximately 10-fold. However, reporting of suicide is variable between countries – so differences in national suicide rates should be interpreted cautiously.
Factors underpinning the variation in suicide rates between countries may include alcohol misuse, cultural differences in help-seeking behaviour, societal attitudes towards suicide, socio-economic upheaval, availability of highly lethal methods of suicide, and religion.
2. Other than asking questions and taking threats of suicide seriously, are there any simple interventions that have been shown to make a difference?
Suicidal ideation and attempts are often impulsive and transitory in nature and there is good evidence that reducing access to, and availability of, methods decreases suicide rates, although substitution of method can occur.
Suicidal thoughts are often associated with depressive illness and – despite recent controversy over SSRI antidepressant medication – appropriate and adequate treatment of depression remains a very important strategy for decreasing the risk.
In addition to antidepressant medication, research indicates that lithium treatment, and clozapine in schizophrenia, have specific anti-suicidal properties.
Optimum treatment of depression includes both pharmacological and psychotherapeutic interventions.
For patients who self-harm, problem-solving therapy can lead to clinical improvement. Brief psychodynamic interpersonal therapy, which explores interpersonal problems, has been shown to decrease both the frequency of self-harming behaviour and suicidal intent.
3. We've all had patients who were not sectionable – and may even present quite well – but we knew were planning to commit suicide despite denying it and eventually did kill themselves. Is there any work to suggest any interventions we might not have thought of?
Although a number of patients may present as high risk, the rarity of suicide means that accurate prediction of those who will go on to die by suicide is very difficult. There are no specific interventions in these patients other than comprehensive assessment of their risk and mental state, appropriate treatment of any underlying mental illness and essentially providing the best services possible to the greatest number of people.
4. How do you manage people who constantly take small overdoses or self-harm and use all sorts of services in a chaotic way? They often have a diagnosis of ‘borderline' or ‘personality' disorder and will either not engage with psychiatric services or services will not engage with them.
It is often difficult to engage with these patients, and maintain that engagement. Often, local mental health services will have individual care plans and communication with them and other services involved, including A&E, will help maintain a consistent approach to managing suicide risk and treating any underlying mental illness.
Research suggests that dialectical behavioural therapy, a specific and intensive form of therapy, is beneficial in such patients.
This is an intensive psychosocial treatment focusing on techniques for coping with stressful events and managing anger – as well as improving social skills. But interventions of this sort are not available within a primary care setting.
5. I am alarmed at what seems to be an epidemic of cutting in young women, often college students. Is this a real phenomenon and do we understand why?
There is no evidence of a marked increase in the rate of self-harm, although it is more common than expected in young people, with peak ages of 15 to 24 years in females and 25 to 34 years in males. Self-harm is more common in females, although recent epidemiological findings indicate that cutting is as common in men as in women.
Evidence regarding students and any increased risk of self-harm is equivocal. Many of the same factors associated with suicide are associated with self-harm – such as low social class, unemployment, being single, divorced, living alone, single parents and those lacking social support.
6. What is the best way of managing cutting? What is the prognosis?
There is a significant association between self-harm and eventual suicide. As many as one in 10 individuals who self-harm will die by suicide and around half of all people who die by suicide have a history of self-harming behaviour.
In those who self-harm by cutting, all research findings from people attending hospital suggest they are more likely to repeat self-harm, and earlier, than those who use other methods. There are indications that they may also have a higher risk of eventual mortality by suicide.
The general consensus view is that people who self-harm may have problem-solving or interpersonal difficulties, and focused brief therapies and cognitive behaviour approaches have been shown to be beneficial.
7. There is a lot of emphasis on psychosis and harming random members of the public. Is it true that those with chronic psychosis are more likely to harm themselves? Community psychiatric services are very stretched and we can no longer offer acute beds.
Research has shown that the association between violence and mental disorder is small, in contrast to the public perception. There is evidence to show that mentally ill people are six times more likely to be the victim of a homicide than the general population.
Generally, people with mental illness are at high risk of dying by homicide and suicide, in particular people with severe mental illness like schizophrenia or affective psychoses.
People who commit stranger homicides are more likely to be young men under 25, and the offence is likely to involve alcohol or drug misuse. The perpetrator is also likely to have previous convictions for violent offences. In contrast, the victims in homicides by people with schizophrenia are more likely to be family members or carers.
8. Have there been any changes in care in prisons since the loss of large psychiatric hospitals? It seems the mentally ill are over-represented in the prison population and with crowded remand facilities, what's being done to decrease the risk of suicide in this context?
Major reforms in prison mental health services over the past decade have included the development of the National Offender Management Service (NOMS) and the devolution of all healthcare services in prison to the NHS.
The prison population is rising and a high proportion of prisoners are vulnerable individuals with health and social inequalities. Research indicates that as many as 90% have some form of mental disorder or drug or alcohol abuse problem.
Despite legislation that mentally disordered offenders need specialist care and should be diverted from the criminal justice system, a high proportion remain in custody.
An estimated 40% of prisoners on healthcare wings would be more appropriately placed in NHS secure mental health services. There are many reasons for this, including inadequate screening and detection of mental illness, availability of NHS beds and protracted delays in transfer.
Primary healthcare provision in prisons is variable, often criticised as being under-resourced and inadequate. Secondary mental health services are provided by
In-reach teams but these are often overwhelmed by referrals and prison is a difficult environment in which to provide consistent mental health care.
Although there has been a recent decrease in the prison suicide rate, rates remain very high, around 10 times that of the general population.
Risk factors include being on remand, in the early stages of reception into prison and being charged with or convicted of a violent offence, as well as having a history of mental illness, drug or alcohol misuse or self-harm.
One of the recent reforms to address suicide prevention is the Assessment, Care in Custody and Teamwork (ACCT) approach to suicide and self-harm risk assessment, which includes case management, care planning and multidisciplinary involvement. This can be initiated by any member of staff who is concerned that the prisoner is at risk and is regularly reviewed.
Other strategies include a forum for sharing and learning about deaths in custody and prisoner peer support through listener schemes.
9. Are there any specific services or any good books or websites that you can recommend to relatives of those who commit suicide?
The Department of Health has produced a pack for people bereaved by suicide, titled Help is at Hand: A resource for people bereaved by suicide and other sudden, traumatic death. All the material is downloadable here (left).
Other useful resources include:
10. Have there been any changes in the demographics of who is most at risk of suicide and the methods they choose?
The effect of age has changed substantially in the last 30 years. There has been a marked decrease in the rate of suicide in over-65s. At the same time, there has been a dramatic increase in the suicide rate among young males and the highest rates of suicide are now among males aged 25 to 44. However, in recent years, suicide prevention strategies in some countries – such as the National Suicide Prevention Strategy for England – have contributed to falling rates in young males.
Methods of suicide have changed over the past few decades. For example, deaths by car exhaust fumes declined following the introduction of the catalytic converter in the early 1990s. There has also been a noticeable decline in paracetamol poisoning with the introduction of legislation restricting pack sizes.
Currently in the UK, the two most common methods of suicide are hanging and poisoning; with hanging most popular in men and poisoning among women.
Dr Nicola Swinson is clinical research fellow and Dr Kirsten Windfuhr senior project manager at the Centre for Suicide Prevention, University of Manchester.
Competing interests None declaredWhat I will do now What I will do now
Dr Ruckert considers the answers to her questions
I find the problem with suicidal ideas – even if they are brief and transitory – is ensuring they are not acted on, especially when many inner-city patients are isolated.
Crisis teams and residential community facilities have helped, but assessing risk remains difficult.
It seems to me that cutting – in young women in particular – has become much more prevalent and is often very difficult to help. I am not sure there is a great deal out there for the most affected.
We need to reinforce the idea that people with mental illness are more likely to die themselves through homicide or suicide.
The problem of alcohol and drug co-morbidity remains a big challenge, as I have a number of patients who have only been violent when using them.
I was shocked to read that 90% of the prison population have a significant form of mental illness. The solution is one not just for us but for the Government, and adult psychiatric services in the community do not have enough resources.
Dr Linden Ruckert is a GP in north London