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

3. 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)

4. 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

5. 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)

6. 1.1. Definition of Self-Harm Catherine 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.

7. 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

8. 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

9. 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)

10. 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

11. 1.3. Self harm: Selection of recent research publications (2006-2009)

12. 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.

13. 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

14. 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

15. 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

16. 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.

17. 1.4. Self harm: useful links….. http://www.nice.org.uk/nicemedia/pdf/CG01 6NICEguideline.pdf http://www.rcpsych.ac.uk/mentalhealthinfofo rall/problems/depression/self-harm.aspx http://selfharm.net/ http://www.thesite.org/healthandwellbeing/m entalhealth/selfharm http://www.mentalhealth.org.uk/information/ mental-health-a-z/self-harm/

18. 2. Suicide and suicidality

19. 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").metaphorical Suicide may occur for a number of reasons, including depression, shame, guilt, desperation, physical pain, emotional pressure, anxiety, financial difficulties, or other undesirable situations. depressionshameguiltdesperationanxiety 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.assisted suicideeuthanasiaright to dieethicalterminally illpainquality of lifeinjuryillnessSelf-sacrifice 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.modern medicine mental healthpsychologicaldepression sufferingfearmental disorders Wikipedia.org

20. 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)

21. 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

23. 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

24. 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

25. Lancet 2009

26. 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

27. National office of statistics demonstrates the changes in suicide rate

28. 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

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

30. 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

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

32. 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

33. 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).

36. East London PCT facts 2003-2008 SuicidePopulation (1000’s) Rates per 100k City & H.32226.42.83 Newham24257.31.86 Tower H.36221.43.25 ELFT92705.12.61

37. 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)

38. 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.

39. 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.

40. 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.

41. 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%).

42. 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.

43. 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.

44. 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.

45. 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.

46. 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).

47. 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 !!!!!

48. 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

49. 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

50. What needs to be done?

51. 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.

52. 2.4. Assessment of suicidality / self harm Level of intent Level of lethality Prior attempts!!!!! Young male or late life white divorced male Living alone Lack of sleep/agitation

53. Risk factors for suicide “sad persons” S - Sex A - Age D- Depression P - Psychiatric care E - Excessive drug use R - Rational thinking absent S - Single O - Organised attempt N - No supports (isolated) S - States future intent

54. Warning Signs Suicidal Talk “I Wish I Were Dead” “No One Cares About Me” “I Just Want All Of This To End” Preoccupation with Death Prior Suicide Gestures or Attempts Social Withdrawal Mood Changes

55. Alarming acute warning signs Suicide Preparation Notes Giving Away Personal Possessions Final Arrangements

56. Suicide Risk Assessment No combination of factors has completely accurate sensitivity or specificity to identify those who will go on to attempt suicide. Assessing current intent and predicting future intent. Assessing internal and external controls available to act against suicide. Your ability to elicit patient’s thoughts and feelings and then to make a good judgment is the key (rapport).

57. Assessment (cont.) Assess information provided by others: available support job stressors impulsive behavior safety of where pt will spend next 48 hours attitudes of family, friends, and command availability of chaplain, FSC, etc.. Don’t forget to discuss with senior psychiatrist!

58. Assessment: Myths versus facts-1 MYTH: People who talk about suicide don’t complete suicide. FACT: Many people who die by suicide have given definite warnings to family and friends of their intentions. Always take any comment about suicide seriously.

59. Assessment: Myths versus facts-2 MYTH: Suicide happens without warning. FACT: Most suicidal people give many clues and warning signs regarding their suicidal intention.

60. Assessment: Myths versus facts-3 MYTH: Asking a depressed person about suicide will push him/her to complete suicide. FACT: Studies have shown that patients with depression have these ideas and talking about them does not increase the risk of them taking their own life.

61. Assessment: Myths versus facts-4 MYTH: Improvement following a suicide attempt or crisis means that the risk is over. FACT: Most suicides occur within days or weeks of “improvement” when the individual has the energy and motivation to actually follow through with his/her suicidal thoughts.

62. 2.5. IMPLICATIONS FOR PREVENTION

63. National suicide prevention strategy 1. To reduce risk in key high risk groups. 2. To promote mental well-being in the wider population. 3. To reduce the availability and lethality of suicide methods. 4. To improve reporting of suicidal behaviour in the media. 5. To promote research on suicide and suicide prevention. 6. To improve monitoring of progress towards the Saving Lives: Our Healthier Nation target to reduce suicides.

64. What can be done to prevent suicide? Population and high risk strategies Not either/or – both Neither are easy Population strategies may bring about better results – Prevention paradox: While those at ‘high risk’ are most likely to kill themselves, there are far fewer of them than those who are at low risk (Gunnell & Frankel, 1994; Lewis, et al. 1997)

65. Population strategies Availability of means Detoxification of domestic gas probably resulted in 6,700 fewer suicides in Britain in the 1960s; paracetamol o.d. decreased by 60% in year following change to sales – (Hawton et al 2001) Car exhaust fumes – main method in men Media Reporting Decreased suicides on underground following media restrictions on reporting. Increased even when reported in a negative light.

66. Suicide prevention strategy (2002) Targeting young men when in distress Developing audit toolkit to support reduction amongst those in contact with MH services Suicide prevention training pilots Reviewing coroners’ records Studies of DSH NICE guidance on short-term management and secondary prevention of SH

67. SUICIDE FOLLOWING IP TREATMENT 1 Rate of suicide 130x that of the general population in the month following an episode of inpatient treatment But still a rare event, 1 in 330 patients More often those who live alone, past history of DSH, current suicidal ideation, unplanned discharge, significant professional carer on leave (King et al, 2001) But, again insufficient predictive power to pursue a high risk strategy

68. Important……………… Suicide rates following DSH are high, especially in the year following DSH Previous history of DSH confers an increase risk of suicide that remains throughout the remainder of a person’s life Interventions aimed at patients who DSH have the potential to help reduce the national rate of suicide

69. IMPLICATIONS FOR INTERVENTION Getting evidence is difficult Treatment of depression reduces the incidence of suicidal ideation (Salkovskis et al, 1990; Montgomery et al, 1995) The important role of Lithium and Clozapine (Meltzer et al. 2003, Cipriani et al. 2005) CMHTs vs. standard hospital care (Tyrer et al, 2001)

70. IMPLICATIONS FOR RISK ASSESSMENT Recognition that mental health services manage a high risk population Recognition of the poor predictive powers of high quality risk assessments The importance of co-morbidity (Foster, et al, 1997) Mental illness, substance misuse and personality (?interventions for co-morbidity). Vulnerable periods – post discharge, following DSH, communication of suicidal ideation respond robustly when care plans break down

71. Finally… Clinical common sense and action may be one of the most effective strategy Mental health services contribute to suicide reduction but suicide will continue to occur even when high quality services are provided

72. PREVENTING SUICIDE: A TOOLKIT FOR MENTAL HEALTH SERVICES NIMHE: eight standards

73. Standard one: appropriate level of care 1. Patients at risk are allocated to the enhanced level of the Care Programme Approach (CPA). 2. CPA documentation forms part of case notes and is not maintained separately. 3. These standards are monitored through clinical governance. 4. Patients with schizophrenia with complex needs if convicted of an offence are normally treated in hospital rather than the prison service.

74. Standard two: in-patient suicide prevention 1. Wards are audited at least annually to identify and minimise opportunities for hanging or other means by which patients could harm themselves. 2. Likely ligature points on in-patient units have been removed or covered. 3. A protocol has been developed to allow potential ligatures to be removed from patients at high risk of suicide. 4. Environmental difficulties in observing patients are made explicit and remedial action is taken as far as possible. 5. Observation policy and practice reflects current evidence about suicide risk. 6. Patients under any form of increased observation are not allowed leave or time off the ward.

75. Standard three: post discharge prevention of suicide 1. Prior to discharge in-patient and community teams carry out a joint case review. 2. Discharge care plans specify arrangements for promoting compliance / engagement with treatment. 3. Care plans take into account the heightened risk of suicide in the first three months after discharge and make specific reference to the first week. 4. Patients who have been at high risk of suicide during the period of admission are followed up within 48 hours of discharge by an agreed member of the clinical team. 5. Assertive outreach teams have been established to prevent loss of contact with vulnerable and high-risk patients.

76. Standard four: family / carer contact 1. Families/carers, with patient consent, are given a clear mechanism for making contact with an informed member of the clinical team at all times. 2. Families/carers are given appropriate information promptly following a suicide or homicide.

77. Standard five: appropriate medication Patients at risk of suicide receive the right medication in the right amounts.

78. Standard six: co- morbidity/dual diagnosis. 1. A strategy exists for the comprehensive care of people with co-morbidity/dual diagnosis, i.e. people with mental health problems who also engage in alcohol and/or substance misuse. 2. Staff who provide care to people at risk of suicide are given approved training in the clinical management of cases of co- morbidity/dual diagnosis. 3. Statistics for co-morbidity/suicide are collected and used to inform decision making on resources.

79. Standard seven: post- incident review. 1. Suicides and serious suicide attempts are reviewed in a multi-disciplinary forum, including as far as possible all staff involved in the care of the patient. 2. All staff, patients and families/carers affected by a suicide or serious attempt are given prompt and open information and the opportunity to receive appropriate and effective support as soon as they require it.

80. Standard eight: training of staff. 1. All care staff in contact with patients at risk of self-harm or suicide receive training in the recognition, assessment and management of risk at intervals of no more than 3 years. 2. The training is approved by the organisation. 3. The training is comprehensive the quality and effectiveness of the training is continuously evaluated.

81. INTERVENTIONS AIMED AT HIGH RISK GROUPS suicide following dsh 1.2.8% commit suicide in the 12 months following DSH (Hawton, 1988) 2.Jenkins, et al. 2002: 22 year follow-up of 233 patients seen in St. Mary’s hospital in 1977-1980. 140 identified, 25 (18%) had died, 12 (9%) probable suicide

82. RISK FACTORS FOR SUICIDE FOLLOWING DSH Demographic – as with suicide (older, socially isolated men esp. with mental illness and/or substance misuse, poor physical health, family history of suicide) Degree of suicidal intent – isolation at time of DSH, attempts to avoid discovery, no help seeking following DSH, violent methods, final acts (will, possessions given away), overt communication before attempt

83. UNCERTAINTY ABOUT WHAT WORKS BEST FOR WHOM Systematic review and meta-analysis – Hawton et al (1998) BMJ 317, 441-447 20 randomised controlled trials Trend towards positive effects for: problem solving therapy, ‘crisis card’, and DBT for borderline personality disorder and recurrent self-harm.

84. NEW INTERVENTIONS 1 Crisis ‘Green’ Card (Evans et al (1999) BJPsych 175, 23-27) 827 patients. 24hr crisis telephone consultation (if before DSH) and within 6 months of the episode  20% increase in DSH with card  slight decrease in those with first episode  implications for ‘self-harm contracts’

85. NEW INTERVENTIONS 2 Manualised CBT (Tyrer et al Psychological Medicine 1 1999 29, 19-25) Pilot study of 34 patients with PD and past history of repeated DSH. RCT. Six sessions of CBT with a booklet.  56% ET and 76% CT had repeated DSH  Cost of care with CBT 60% less…  Multicentre RCT – data being analysed

86. NEW INTERVENTIONS 3 Brief interpersonal psychotherapy Guthrie et al (2001) BMJ 323 135-138)  4 weekly sessions delivered at home by trained nurse therapist. RCT 119 patients  Decreased suicidal ideation at 6 months. Increased satisfaction with care  Rate of repetition – ET = 9%, CT = 28% (95% CI = 9.30%)

87. WHO SHOULD RECEIVE INTERVENTION? All those willing to accept them. Because risk assessment tools are insufficiently precise to reliably identify those who will harm themselves again. People identified as high risk will be more likely to repeat self-harm, but those judged to have low risk will also harm themselves again.

88. SUICIDE FOLLOWING IP TREATMENT 2 Interventions that will reduce suicide in the period following admission to a psychiatric hospital have not been established. While this is a high risk period for suicide, it effects only a small minority. Would need over 35,000 people in a trial! Meanwhile: Suicide will continue to occur

89. SUICIDE FOLLOWING IP TREATMENT 3 Basic principles make sense: ensuring patients are aware of sources of support, do not have unnecessary access to means of self-harm (repeat prescriptions) and have planned discharge

90. Suicidality: useful links….. http://www.merseycare.nhs.uk/managing_cli nical_risk/ Practice guidelines for the asessment and treatment of patients with suicidal behaviours: Supplement to American J. Psychiatry November 2003 http://www.who.int/topics/suicide/en/ http://www.mind.org.uk/Information/Factshe ets/Suicide/

91. 2.6. Suicide: Selection of recent research publications (2006-2012)

92. Childhood predictors of completed and severe suicide attempts: findings from the Finnish 1981 Birth Cohort Study 5302 Finnish people born in 1981 who were examined at the age of 8 years to gather information about psychopathologic conditions, school performance, and family demographics from parents, teachers, and children. Of all 24 deaths among males between 8 and 24 years of age, 13 were suicides, whereas of 16 deaths among females, only 2 were suicides. Fifty-four males and females (1%) had completed suicide or made attempt. Males: completed or serious suicide attempt predicted at the age of 8 years by living in a nonintact family; psychological problems as reported by the primary teacher; or conduct, hyperkinetic, and emotional problems. self-reports of depressive symptoms at age 8 did not predict suicide outcome. No predictive associations between the study variables measured at the age of 8 years and suicide outcome were found among females. Sourander et al. 2009, Arch. Gen. Psychiatry

93. Community mental-health services and suicide rate in Finland: a nationwide small-area analysis A wide variety of outpatient services, prominence of outpatient versus inpatient services, and 24-h emergency services were associated with decreased death rates from suicide. However, after adjustment for socioeconomic factors, only the prominence of outpatient services was associated with low suicide rate (0.94, 0.90-0.98). Well-developed community mental-health services are associated with lower suicide rates than are services oriented towards inpatient treatment provision. These data are consistent with the idea that population mental health can be improved by use of multifaceted, community-based, specialised mental-health services. Pirkola et al. 2009, Lancet

94. Antidepressants and the risk of suicide, attempted suicide, and overall mortality in a nationwide cohort A total of 15 390 patients with a mean follow-up of 3.4 years. In the entire cohort, fluoxetine use was associated with the lowest risk and venlafaxine with the highest risk of suicide. A substantially lower mortality was observed during selective serotonin reuptake inhibitor use and this was attributable to a decrease in cardiovascular- and cerebrovascular-related deaths. Among subjects who had ever used any antidepressant, the current use of medication was associated with a markedly increased risk of attempted suicide (39%), but also with a markedly decreased risk of completed suicide (-32%) and mortality (-49%), when compared with no current use of medication. Tilhonen et al. 2006, Arch. Gen. Psychiatry

95. Implementation of mental health service recommendations in England & Wales and suicide rates, 1997-2006 Average number of recommendations implemented increased from 0.3 per service in1998 to 7.2 in 2006 Implementation was associated with lower suicide rates The provision of 24 hour crisis care was associated with the biggest fall in suicide rates Local policies on patients with dual diagnosis and multidisciplinary review after suicide were also associated with falling rates Services that did not implement recommendations had little reduction in suicide While et al. 2012, Lancet

96. Conclusions Population strategies may be those most likely to reduce suicide rates All those in contact with mental health services are at increased risk of suicide Risk is further increased among those with comorbidity, in the period following discharge from hospital and following DSH Treatment reduces the likelihood of suicidal ideation and DSH among depressed

97. 3. DoH (2007) Best Practice in Managing Risk Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services

98. Introduction (16 best practice points) 1. Best practice involves making decisions based on knowledge of the research evidence, knowledge of the individual service user and their social context, knowledge of the service user’s own experience, and clinical judgement.

99. Fundamentals 1 2. Positive risk management as part of a carefully constructed plan is a required competence for all mental health practitioners. 3. Risk management should be conducted in a spirit of collaboration and based on a relationship between the service user and their carers that is as trusting as possible.

100. Fundamentals 2 4. Risk management must be built on a recognition of the service user’s strengths and should emphasise recovery. 5. Risk management requires an organisational strategy as well as efforts by the individual practitioner.

101. Basic ideas in risk management 1 6. Risk management involves developing flexible strategies aimed at preventing any negative event from occurring or, if this is not possible, minimising the harm caused. 7. Risk management should take into account that risk can be both general and specific, and that good management can reduce and prevent harm. 8. Knowledge and understanding of mental health legislation is an important component of risk management.

102. Basic ideas in risk management 2 9. The risk management plan should include a summary of all risks identified, formulations of the situations in which identified risks may occur, and actions to be taken by practitioners and the service user in response to crisis. 10. Where suitable tools are available, risk management should be based on assessment using the structured clinical judgement approach. 11. Risk assessment is integral to deciding on the most appropriate level of risk management and the right kind of intervention for a service user.

103. Working with service users and carers 12. All staff involved in risk management must be capable of demonstrating sensitivity and competence in relation to diversity in race, faith, age, gender, disability and sexual orientation. 13. Risk management must always be based on awareness of the capacity for the service user’s risk level to change over time, and a recognition that each service user requires a consistent and individualised approach.

104. Individual practice and team working 14. Risk management plans should be developed by multidisciplinary and multiagency teams operating in an open, democratic and transparent culture that embraces reflective practice. 15. All staff involved in risk management should receive relevant training, which should be updated at least every three years. 16. A risk management plan is only as good as the time and effort put into communicating its findings to others.

105. Lessons for life: Experiences of people who attempt suicide, a qualitative research reportLessons for life: Experiences of people who attempt suicide, a qualitative research report (2015). Australia: SANE and University of New England People who attempt to take their own lives provide valuable lessons for suicide prevention. This research from Australia explores their experiences, and what can be learned from them to save lives now and in the future.

106. Suicide prevention and recovery guide: A resource for mental health professionals – 2nd edition Suicide prevention and recovery guide: A resource for mental health professionals – 2nd edition (2014). Australia: SANE Australia This guide is unique because it examines suicide prevention through the lens of recovery. This is particularly relevant as the management of suicide risk, especially when it leads to involuntary hospitalisation, may be perceived at times to conflict with recovery principles encouraging services to support consumer choice and decision making.