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? What can the employer do to help? Stimulate further reading

Yorkshire Post – 23 rd 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!!

Egypt Air Flight 990 from LA to Cairo, Oct 1999

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

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

Suicide in England Males Females Total

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)

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

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

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

Suicide in England Crisis and intensive home treatment teams CIHTT 18 suicides in suicides in suicides in : more suicides in CIHTT than on inpatient units

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)

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

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

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:

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

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)

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: Savage v South Essex Partnership NHS Trust [2008] UKHL 74 Rabone v Pennine Care NHS Trust [2012] UKSC 2

When should I be worried??

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

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: % 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)

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

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

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 - 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)

The role for OH Training: managers and employees - Open Minds Alliance 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 it X - Talking about it gives people the idea X - You can’t stop someone anyway X

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)

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