- Email: [email protected]
Introduction to suicide and self-harm
Introduction
Introduction to suicide and self-harm
What’s new? • The rate of suicide in the UK is falling, but it remains a very important public health problem
Navneet Kapur
• National suicide prevention strategies have been introduced for all countries in the UK
Linda Gask
• Recent work suggests the most effective measures might involve restricting access to lethal methods of suicide and educating physicians to recognize and treat depression • With respect to self-harm, paracetamol overdoses have decreased but the rate of alcohol misuse has increased
Abstract Suicide is a major cause of death across the world. Self-harm refers to a deliberate non-fatal act, whether physical, drug overdose, or poisoning, carried out in the knowledge that it is potentially harmful. Self-harm is strongly associated with the risk of suicide but is an important public health problem in its own right. The epidemiology of suicide and selfharm is changing. Suicide in England and Wales is becoming less common, but rates for young men have doubled in the last 20 years. With respect to self-harm, paracetamol overdoses have decreased but alcohol misuse has increased. In most centres, almost as many men as women now present with self-harm. Risk factors for suicide and self-harm overlap to an extent, but the clinical prediction of these behaviours is difficult because they are comparatively rare outcomes. Two sets of guidelines on the management of self-harm have been published recently. They provide a consensus view of best practice, but the evidence base for them is weak. The National Suicide Prevention Strategy for England suggests both high-risk and population-based measures to reduce the rate of suicide. Recent work suggests the most effective strategies might involve restricting access to lethal methods of suicide and educating physicians to recognize and treat depression.
• The evidence base for current guidelines on the management of self-harm remains weak
Terminology Suicide describes an intentional self-inflicted act that has resulted in death.1 In most countries, possible suicides are reported to coroners or medical examiners. and an inquest is held. In England, Wales, and Northern Ireland, there is a strict definition of suicide, which requires proof of intention to die. In Scotland, all sudden unexpected deaths are investigated by the local procurator fiscal’s office and a consensus decision is made by the Crown Office. When there is doubt over the victim’s intent, a coroner is obliged to declare an open verdict or a verdict of accidental death. It is conventional in suicide research to include open verdicts as this gives a more accurate figure for overall suicides. Self-harm: a person who ‘attempts suicide’ is not always intent on ending his or her life. The literature has come to describe two distinct but overlapping groups, and has struggled to find the best terminology. The term ‘attempted suicide’ has been superseded by ‘parasuicide’, ‘self-poisoning’, and, more recently, ‘deliberate selfharm’ (DSH), which includes cutting, burning, and other self-mutilatory acts. Non-fatal deliberate self-harm has been defined as ‘A deliberate non-fatal act, whether physical, drug overdose or poisoning, done in the knowledge that it was potentially harmful. And in the case of drug overdose that the amount taken was excessive’.2 Recently, the prefix ‘deliberate’ has been dropped from ‘selfharm’ in response to the heterogeneous nature of the phenomenon and the concerns of service users.3,4 Self-harm is the term that will be used throughout this contribution.
Keywords attempted suicide; National Suicide Prevention Strategy; non-fatal self-harm; psychological autopsy; suicide
Navneet Kapur MBChB MMedSci MD FRCPsych is Professor of Psychiatry and Population Health & Head of Research at the Centre for Suicide Prevention, University of Manchester, UK. He is also Assistant Director of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. His research interests include the epidemiology, aetiology, and treatment of suicidal behaviour. Conflicts of interest: NK has been appointed Chair of the Guideline Development Group for the new NICE guidelines on self-harm.
Epidemiology
Linda Gask MBChB MSc PhD FRCPsych is Professor of Primary Care Psychiatry at the University of Manchester, and Honorary Consultant Psychiatrist at Salford Primary Care NHS Trust. UK. She is jointly appointed to the National Primary Care Research and Development Centre. She qualified in Edinburgh and trained in psychiatry in Manchester. Her research interests include clinical skills acquisition by mental health professionals and primary care workers, and research into the psychiatry of primary care. Conflicts of interest: LG is Research Director of the STORM initiative, based at the University of Manchester, which is a non-profit making venture to disseminate training in suicideprevention skills.
PSYCHIATRY 8:7
Suicide The average annual suicide rate for England and Wales is around 10.0 per 100,000 population, accounting for about 5000 deaths per year. Since the late 1990s, the overall rate has been falling steadily and the latest official figures report a rate of 8.3 per 100,000.5 However, in the past 20 years the suicide rate in young males has doubled, although more recently there is evidence of a sustained decline. In males under the age of 35 years, suicide remains the commonest cause of death. In all groups, men are at greater risk than women. 233
© 2009 Elsevier Ltd. All rights reserved.
Introduction
Methods used vary with access and availability but also with sex.5 Men are more likely to use violent methods such as hanging and shooting; women tend to use either prescribed medication (the older antidepressants are particularly lethal) or over-thecounter medications such as paracetamol. Before the change in the domestic gas supply from coal gas to natural gas in the 1970s, carbon monoxide self-poisoning usually took place in the home. More recently, car exhaust fumes have been used. There is good evidence that both the change to natural gas and the introduction by car manufacturers of catalytic converters have resulted in a decrease in deaths by carbon monoxide poisoning and a small decrease in the overall suicide rate.6,7 Geographical variations in the incidence of suicide suggest that area-based factors such as deprivation and lack of social integration may be associated with suicide rates.8 The relative rates of suicide in urban and rural areas have varied over time, but recent work suggests the biggest increases in suicide among 15–44-year-olds have occurred in areas remote from the main centres of population. In the past it was reported that the majority of people who killed themselves had seen their general practitioner within the previous month. This is still true for those over the age of 35 but not for those under 35 years, the group in which the rate of increase is greatest.
a monitoring system in place. This may change in the future – a multicentre monitoring project of self-harm has recently been initiated as part of the English Suicide Prevention Strategy. There was a massive increase in the rate of self-harm in the 1960s and 1970s; the current incidence of hospital-treated selfharm is between 300 and 500 per 100,000 per year. Self-harm is one of the commonest reason for acute medical admission and this may help to explain some of the negative attitudes often encountered among doctors and nurses to people who harm themselves. The majority of cases (85%) involve self-poisoning, and paracetamol is ingested in 30–50% of these episodes. Paracetamol overdose appears to be becoming less common following legislation limiting pack sizes. Overall, there has been a steady decrease in the female:male ratio; whereas formerly twice as many women as men harmed themselves, currently the numbers are almost equal in many centres. Peak ages are 15–24 years for women and 25–34 years for men. There are some suggestions of an increased incidence in certain ethnic groups; for example, women of South Asian origin may be 1.5 times more likely to harm themselves than white women.11 Suicidal behaviour in South Asians is discussed further on pages 261–4 (in this issue).
Why do people kill themselves?
Non-fatal self-harm The full extent of self-harm is unknown and most epidemiological data have been obtained from studies of attendance at emergency departments. Large-scale population surveys have suggested that 4.4% of individuals in the UK have harmed themselves pre viously.9 Although some people who harm themselves do not see a doctor, secondary care is probably the first point of contact for most of those who do choose to seek medical help.10 The epidemiology of self-harm is changing in the UK, but it is difficult to obtain accurate data because very few centres have
a. Suicide and mental disorders in 15,629 cases of suicide worldwide
14%
Based on ‘psychological autopsy’ research, in which all available information is collected after a person’s suicide and key informants are interviewed, there is evidence that more than 90% of people who kill themselves are mentally ill. A review of 31 studies involving 15,629 cases of suicide reported that 98% had ICDor DSM-defined mental disorder.12 Figure 1a shows the primary psychiatric diagnoses for these subjects. But how applicable are these findings to a British health service setting? Figure 1b shows the primary psychiatric diagnoses for a 4-year national sample of
b. Suicide and mental disorders in 4,859 suicides in England and Wales who had been in psychiatric contact in the 12 months before their death
11%
11% 3%
6%
20%
11%
12%
4%
35%
9% 22%
42%
Schizophrenia
Alcohol dependence
Anxiety disorders
Mood disorders
Drug dependence
Other disorders
Substance disorders
Personality disorders
Figure 1 Suicide and mental illness.
PSYCHIATRY 8:7
234
© 2009 Elsevier Ltd. All rights reserved.
Introduction
suicides in recent contact with mental health services in England and Wales. Mood disorder was the most common diagnosis in both groups. Further discussion of the relationship between mental disorder and suicide can be found on pages 257–60 (in this issue). A range of factors known to be associated with suicide is shown in Box 1. Certain occupational groups (e.g. doctors and publicans) are at higher risk, and there has been concern recently over the increasing suicide rate in farmers.
Factors associated with non-fatal self-harm • Female sex • Divorced • Under 25 years old • Social class V (i.e. unskilled workers) • Unsuitable, overcrowded accommodation • Unemployment • Debt • At present address for less than 1 year
The aetiology of non-fatal self-harm A range of factors known to be associated with self-harm is shown in Box 2. Although early studies suggested that only a minority of self-harming patients had clinically important psychiatric illness, more recent work suggests that as many as 90% may have psychiatric disorder according to research criteria.13 The most common diagnosis is affective disorder (70%). However, such disorders may be self-limiting. Eating disorders (bulimia nervosa) and personality disorders (antisocial or borderline) are also associated with self-harm, and alcohol misuse is common (present in 25–50% of patients). There are suggestions that alcohol and drug misuse are becoming more common in this patient group. In most cases, individuals report that the episode was precipitated by interpersonal or social problems.
Box 2
• working with and challenging hopelessness and the issues that may be making it difficult to make progress. Therapeutic approaches that have been demonstrated to be effective in those who deliberately self-harm are discussed on pages 246–51 (in this issue). Self-mutilation is difficult to treat, but behavioural approaches have been used with some success. A number of guidelines on the management of self-harm have been produced and 2004 saw the publication of two sets of guidance. The evidence base on which these are based is weak but the guidelines do provide a consensus view of current best practice. Both can be accessed via the Royal College of Psychiatrists’ website (http://www.rcpsych.ac.uk). The National Institute of Health and Clinical Excellence (NICE) guideline considers both the physical and the psychosocial management of self-harm. There seems to be a growing recognition of the value of assessments of need rather than just a preoccupation with assessments of risk. The Royal College of Psychiatrists’ guideline4 on assessment following self-harm in adults updates an earlier document published in 1994. The guideline describes clinical competencies that might be expected of staff. It also describes standards of service provision in a variety of settings. Both guidelines are discussed further on pages 246–51 (in this issue).
Assessment of people who may be at risk of harming themselves Basic skills and strategies for assessment are discussed on pages 241–5 (in this issue). Questionnaires are used by some clinicians but are no substitute for being able to broach the topic sensitively face to face. The phenomenon of apparent improvement in mood just before finally carrying out suicide has been observed, and probably occurs as the person feels calmer for having disengaged from problems and made the decision to end his or her life.
Management issues Working with suicidal patients is difficult and taxing on the mental health professional. Important general themes include: • the need for consistency and regularity • sharing and acknowledgement of pain and suffering
Prognosis of non-fatal self-harm Two main outcomes are of particular importance for self-harm: repetition of self-harm and suicide.
Factors associated with suicide
Repetition of self-harm: the 1-year repetition rate for self-harm is in the region of 16%, and repetition tends to occur quickly: 25% of patients repeat within 3 weeks and the median time to repetition is only 12 weeks. Those who are more likely to repeat the behaviour tend to be people who: • have done it before • have personality difficulties • have been in psychiatric treatment • are unemployed • are in social class V (i.e. unskilled workers) • misuse alcohol and/or drugs • have a criminal record or history of violence • are aged between 24 and 35 years • are single, divorced, or separated.
• Male sex • Depression • Alcohol- or drug-related problems • Separated, widowed, or divorced • Social isolation • Recent discharge from psychiatric care • Serious physical illness • Impending or recent job loss • Current involvement with police • Prison • Certain occupations (e.g. farmer, doctor, dentist, lawyer) Box 1
PSYCHIATRY 8:7
235
© 2009 Elsevier Ltd. All rights reserved.
Introduction
Suicide following self-harm: follow-up studies have shown rates of suicide to be 0.5–2% in the year after an episode of self-harm (or 50–200 times the general population rate). Longer-term studies have found rates of suicide of 3% at 5 years and around 7% for periods longer than 10 years. Those who do kill themselves tend to be: • older • male • have a mental illness • have poor physical health. They may also have made repeated attempts in the past. Much has been made of so-called risk factors for repetition and suicide, but these are of limited usefulness in everyday practice because of their poor predictive value.
Suicide prevention is discussed in more detail on pages 272–5 (in this issue). ◆
References 1 Maris RW. Suicide. Lancet 2002; 360: 319–26. 2 Morgan HG. Death wishes? The understanding and management of deliberate self-harm. Chichester: Wiley, 1979. 3 National Collaborating Centre for Mental Health. Self-harm: the short term physical and psychological management and secondary prevention of self-harm in primary and secondary care. Clinical guideline 16. London: Gaskell & British Psychological Society, 2004. 4 Royal College of Psychiatrists. Assessment following self-harm in adults. London: Royal College of Psychiatrists, 2004. 5 National Institute for Mental Health in England. National Suicide Prevention Strategy for England: annual report 2007. London: Department of Health, 2008. 6 Gunnell D, Middleton N, Frankel S. Method availability and the prevention of suicide – a reanalysis of secular trends in England and Wales 1950–1975. Soc Psychiatry Psychiatr Epidemiol 2000; 35: 437–43. 7 Amos T, Appleby L, Kiernan K. Changes in rates of suicide by car exhaust asphyxiation in England and Wales. Psychol Med 2001; 31: 935–9. 8 Middleton N, Whitley E, Frankel S, Dorling D, Sterne J, Gunnell D. Suicide risk in small areas in England and Wales, 1991–1993. Soc Psychiatry Psychiatr Epidemiol 2004; 39: 45–52. 9 Meltzer H, Lader D, Corbin T, et al. Non-fatal suicidal behaviour among adults aged 16–74 in Great Britain. London: The Stationery Office, 2002. 10 Crawford M, Wessely S. The changing epidemiology of deliberate self-harm – implications for service provision. Health Trends 1998; 30: 66–8. 11 Bhui K, McKenzie K, Rasul F. Rates, risk factors & methods of self harm among minority ethnic groups in the UK: a systematic review. BMC Public Health 2007; 7: 336. 12 Bertolotte JM, Fleischmann A. Suicide and a psychiatric diagnosis: a world-wide perspective. World Psychiatry 2002; 1: 181–5. 13 Haw C, Hawton K, Houston K, Townsend E. Psychiatric and personality disorders in deliberate self-harm patients. Br J Psychiatry 2001; 178: 48–54. 14 Department of Health. National Suicide Prevention Strategy for England. London: The Stationery Office, 2002. 15 Gunnell D, Frankel S. Prevention of suicide: aspirations and evidence. Br Med J 1994; 308: 1227–33. 16 Hawton K, Simkin S, Deeks J, et al. UK legislation on analgesic packs: before and after study of long term effect on poisonings. Br Med J 2004; 329: 1076–80. 17 Sandilands EA, Bateman ND. Co-proxamol withdrawal has reduced suicide from drugs in Scotland. Br J Clin Pharmacol 2008; 66: 290–3. 18 Hawton K, Simkins S, Deeks JJ, et al. Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study. Br Med J 1999; 318: 972–7. 19 Mann J, Apter A, Bertolote J, et al. Suicide prevention strategies. A systematic review. J Am Med Assoc 2005; 294: 2064–74.
Preventing suicide Can professionals intervene to lower the suicide rate? The latest Government target is a reduction of 20% by 2010. How might this be achieved? There are, broadly speaking, two potential approaches to prevention: the high-risk strategy (targeting highrisk groups) and the population-based strategy (preventing suicide in whole populations).
The National Suicide Prevention Strategy The National Suicide Prevention Strategy for England suggests a combination of high-risk and population-based approaches.14 Key high-risk groups include those with mental disorder (see also pages 257–60 (in this issue), those who have harmed themselves, and young men, but the strategy also aims to promote mental well-being in the wider population. Scotland has its own prevention strategy, which is based on similar principles. There is fairly good evidence that reducing the availability of methods of suicide has a significant impact on suicide rates.15 Specific examples from the strategy include: • reducing potential ligature points in in-patient settings • restricting the availability of commonly used analgesics (e.g. paracetamol16 and salicylates). More recently the withdrawal of the opiate analgesic co-proxamol may have reduced suicide by this method in Scotland.17 Media representation has been shown to influence suicidal behaviour.18 The strategy suggests that the media should follow guidelines to promote responsible reporting of suicidal behaviour. The media’s influence on suicidal behaviour is discussed further on pages 269–71 (in this issue). Finally, the strategy suggests increased research on the prevention of suicidal behaviour, and improved monitoring of progress towards achieving the targets for the reduction in suicide rates. A systematic review of suicide prevention strategies from around the world concluded that restricting access to lethal methods of suicide and educating physicians to recognize and treat depression might be the most effective measures in reducing rates of suicide.19
PSYCHIATRY 8:7
236
© 2009 Elsevier Ltd. All rights reserved.
Introduction to suicide and self-harm
What’s new? • The rate of suicide in the UK is falling, but it remains a very important public health problem
Navneet Kapur
• National suicide prevention strategies have been introduced for all countries in the UK
Linda Gask
• Recent work suggests the most effective measures might involve restricting access to lethal methods of suicide and educating physicians to recognize and treat depression • With respect to self-harm, paracetamol overdoses have decreased but the rate of alcohol misuse has increased
Abstract Suicide is a major cause of death across the world. Self-harm refers to a deliberate non-fatal act, whether physical, drug overdose, or poisoning, carried out in the knowledge that it is potentially harmful. Self-harm is strongly associated with the risk of suicide but is an important public health problem in its own right. The epidemiology of suicide and selfharm is changing. Suicide in England and Wales is becoming less common, but rates for young men have doubled in the last 20 years. With respect to self-harm, paracetamol overdoses have decreased but alcohol misuse has increased. In most centres, almost as many men as women now present with self-harm. Risk factors for suicide and self-harm overlap to an extent, but the clinical prediction of these behaviours is difficult because they are comparatively rare outcomes. Two sets of guidelines on the management of self-harm have been published recently. They provide a consensus view of best practice, but the evidence base for them is weak. The National Suicide Prevention Strategy for England suggests both high-risk and population-based measures to reduce the rate of suicide. Recent work suggests the most effective strategies might involve restricting access to lethal methods of suicide and educating physicians to recognize and treat depression.
• The evidence base for current guidelines on the management of self-harm remains weak
Terminology Suicide describes an intentional self-inflicted act that has resulted in death.1 In most countries, possible suicides are reported to coroners or medical examiners. and an inquest is held. In England, Wales, and Northern Ireland, there is a strict definition of suicide, which requires proof of intention to die. In Scotland, all sudden unexpected deaths are investigated by the local procurator fiscal’s office and a consensus decision is made by the Crown Office. When there is doubt over the victim’s intent, a coroner is obliged to declare an open verdict or a verdict of accidental death. It is conventional in suicide research to include open verdicts as this gives a more accurate figure for overall suicides. Self-harm: a person who ‘attempts suicide’ is not always intent on ending his or her life. The literature has come to describe two distinct but overlapping groups, and has struggled to find the best terminology. The term ‘attempted suicide’ has been superseded by ‘parasuicide’, ‘self-poisoning’, and, more recently, ‘deliberate selfharm’ (DSH), which includes cutting, burning, and other self-mutilatory acts. Non-fatal deliberate self-harm has been defined as ‘A deliberate non-fatal act, whether physical, drug overdose or poisoning, done in the knowledge that it was potentially harmful. And in the case of drug overdose that the amount taken was excessive’.2 Recently, the prefix ‘deliberate’ has been dropped from ‘selfharm’ in response to the heterogeneous nature of the phenomenon and the concerns of service users.3,4 Self-harm is the term that will be used throughout this contribution.
Keywords attempted suicide; National Suicide Prevention Strategy; non-fatal self-harm; psychological autopsy; suicide
Navneet Kapur MBChB MMedSci MD FRCPsych is Professor of Psychiatry and Population Health & Head of Research at the Centre for Suicide Prevention, University of Manchester, UK. He is also Assistant Director of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. His research interests include the epidemiology, aetiology, and treatment of suicidal behaviour. Conflicts of interest: NK has been appointed Chair of the Guideline Development Group for the new NICE guidelines on self-harm.
Epidemiology
Linda Gask MBChB MSc PhD FRCPsych is Professor of Primary Care Psychiatry at the University of Manchester, and Honorary Consultant Psychiatrist at Salford Primary Care NHS Trust. UK. She is jointly appointed to the National Primary Care Research and Development Centre. She qualified in Edinburgh and trained in psychiatry in Manchester. Her research interests include clinical skills acquisition by mental health professionals and primary care workers, and research into the psychiatry of primary care. Conflicts of interest: LG is Research Director of the STORM initiative, based at the University of Manchester, which is a non-profit making venture to disseminate training in suicideprevention skills.
PSYCHIATRY 8:7
Suicide The average annual suicide rate for England and Wales is around 10.0 per 100,000 population, accounting for about 5000 deaths per year. Since the late 1990s, the overall rate has been falling steadily and the latest official figures report a rate of 8.3 per 100,000.5 However, in the past 20 years the suicide rate in young males has doubled, although more recently there is evidence of a sustained decline. In males under the age of 35 years, suicide remains the commonest cause of death. In all groups, men are at greater risk than women. 233
© 2009 Elsevier Ltd. All rights reserved.
Introduction
Methods used vary with access and availability but also with sex.5 Men are more likely to use violent methods such as hanging and shooting; women tend to use either prescribed medication (the older antidepressants are particularly lethal) or over-thecounter medications such as paracetamol. Before the change in the domestic gas supply from coal gas to natural gas in the 1970s, carbon monoxide self-poisoning usually took place in the home. More recently, car exhaust fumes have been used. There is good evidence that both the change to natural gas and the introduction by car manufacturers of catalytic converters have resulted in a decrease in deaths by carbon monoxide poisoning and a small decrease in the overall suicide rate.6,7 Geographical variations in the incidence of suicide suggest that area-based factors such as deprivation and lack of social integration may be associated with suicide rates.8 The relative rates of suicide in urban and rural areas have varied over time, but recent work suggests the biggest increases in suicide among 15–44-year-olds have occurred in areas remote from the main centres of population. In the past it was reported that the majority of people who killed themselves had seen their general practitioner within the previous month. This is still true for those over the age of 35 but not for those under 35 years, the group in which the rate of increase is greatest.
a monitoring system in place. This may change in the future – a multicentre monitoring project of self-harm has recently been initiated as part of the English Suicide Prevention Strategy. There was a massive increase in the rate of self-harm in the 1960s and 1970s; the current incidence of hospital-treated selfharm is between 300 and 500 per 100,000 per year. Self-harm is one of the commonest reason for acute medical admission and this may help to explain some of the negative attitudes often encountered among doctors and nurses to people who harm themselves. The majority of cases (85%) involve self-poisoning, and paracetamol is ingested in 30–50% of these episodes. Paracetamol overdose appears to be becoming less common following legislation limiting pack sizes. Overall, there has been a steady decrease in the female:male ratio; whereas formerly twice as many women as men harmed themselves, currently the numbers are almost equal in many centres. Peak ages are 15–24 years for women and 25–34 years for men. There are some suggestions of an increased incidence in certain ethnic groups; for example, women of South Asian origin may be 1.5 times more likely to harm themselves than white women.11 Suicidal behaviour in South Asians is discussed further on pages 261–4 (in this issue).
Why do people kill themselves?
Non-fatal self-harm The full extent of self-harm is unknown and most epidemiological data have been obtained from studies of attendance at emergency departments. Large-scale population surveys have suggested that 4.4% of individuals in the UK have harmed themselves pre viously.9 Although some people who harm themselves do not see a doctor, secondary care is probably the first point of contact for most of those who do choose to seek medical help.10 The epidemiology of self-harm is changing in the UK, but it is difficult to obtain accurate data because very few centres have
a. Suicide and mental disorders in 15,629 cases of suicide worldwide
14%
Based on ‘psychological autopsy’ research, in which all available information is collected after a person’s suicide and key informants are interviewed, there is evidence that more than 90% of people who kill themselves are mentally ill. A review of 31 studies involving 15,629 cases of suicide reported that 98% had ICDor DSM-defined mental disorder.12 Figure 1a shows the primary psychiatric diagnoses for these subjects. But how applicable are these findings to a British health service setting? Figure 1b shows the primary psychiatric diagnoses for a 4-year national sample of
b. Suicide and mental disorders in 4,859 suicides in England and Wales who had been in psychiatric contact in the 12 months before their death
11%
11% 3%
6%
20%
11%
12%
4%
35%
9% 22%
42%
Schizophrenia
Alcohol dependence
Anxiety disorders
Mood disorders
Drug dependence
Other disorders
Substance disorders
Personality disorders
Figure 1 Suicide and mental illness.
PSYCHIATRY 8:7
234
© 2009 Elsevier Ltd. All rights reserved.
Introduction
suicides in recent contact with mental health services in England and Wales. Mood disorder was the most common diagnosis in both groups. Further discussion of the relationship between mental disorder and suicide can be found on pages 257–60 (in this issue). A range of factors known to be associated with suicide is shown in Box 1. Certain occupational groups (e.g. doctors and publicans) are at higher risk, and there has been concern recently over the increasing suicide rate in farmers.
Factors associated with non-fatal self-harm • Female sex • Divorced • Under 25 years old • Social class V (i.e. unskilled workers) • Unsuitable, overcrowded accommodation • Unemployment • Debt • At present address for less than 1 year
The aetiology of non-fatal self-harm A range of factors known to be associated with self-harm is shown in Box 2. Although early studies suggested that only a minority of self-harming patients had clinically important psychiatric illness, more recent work suggests that as many as 90% may have psychiatric disorder according to research criteria.13 The most common diagnosis is affective disorder (70%). However, such disorders may be self-limiting. Eating disorders (bulimia nervosa) and personality disorders (antisocial or borderline) are also associated with self-harm, and alcohol misuse is common (present in 25–50% of patients). There are suggestions that alcohol and drug misuse are becoming more common in this patient group. In most cases, individuals report that the episode was precipitated by interpersonal or social problems.
Box 2
• working with and challenging hopelessness and the issues that may be making it difficult to make progress. Therapeutic approaches that have been demonstrated to be effective in those who deliberately self-harm are discussed on pages 246–51 (in this issue). Self-mutilation is difficult to treat, but behavioural approaches have been used with some success. A number of guidelines on the management of self-harm have been produced and 2004 saw the publication of two sets of guidance. The evidence base on which these are based is weak but the guidelines do provide a consensus view of current best practice. Both can be accessed via the Royal College of Psychiatrists’ website (http://www.rcpsych.ac.uk). The National Institute of Health and Clinical Excellence (NICE) guideline considers both the physical and the psychosocial management of self-harm. There seems to be a growing recognition of the value of assessments of need rather than just a preoccupation with assessments of risk. The Royal College of Psychiatrists’ guideline4 on assessment following self-harm in adults updates an earlier document published in 1994. The guideline describes clinical competencies that might be expected of staff. It also describes standards of service provision in a variety of settings. Both guidelines are discussed further on pages 246–51 (in this issue).
Assessment of people who may be at risk of harming themselves Basic skills and strategies for assessment are discussed on pages 241–5 (in this issue). Questionnaires are used by some clinicians but are no substitute for being able to broach the topic sensitively face to face. The phenomenon of apparent improvement in mood just before finally carrying out suicide has been observed, and probably occurs as the person feels calmer for having disengaged from problems and made the decision to end his or her life.
Management issues Working with suicidal patients is difficult and taxing on the mental health professional. Important general themes include: • the need for consistency and regularity • sharing and acknowledgement of pain and suffering
Prognosis of non-fatal self-harm Two main outcomes are of particular importance for self-harm: repetition of self-harm and suicide.
Factors associated with suicide
Repetition of self-harm: the 1-year repetition rate for self-harm is in the region of 16%, and repetition tends to occur quickly: 25% of patients repeat within 3 weeks and the median time to repetition is only 12 weeks. Those who are more likely to repeat the behaviour tend to be people who: • have done it before • have personality difficulties • have been in psychiatric treatment • are unemployed • are in social class V (i.e. unskilled workers) • misuse alcohol and/or drugs • have a criminal record or history of violence • are aged between 24 and 35 years • are single, divorced, or separated.
• Male sex • Depression • Alcohol- or drug-related problems • Separated, widowed, or divorced • Social isolation • Recent discharge from psychiatric care • Serious physical illness • Impending or recent job loss • Current involvement with police • Prison • Certain occupations (e.g. farmer, doctor, dentist, lawyer) Box 1
PSYCHIATRY 8:7
235
© 2009 Elsevier Ltd. All rights reserved.
Introduction
Suicide following self-harm: follow-up studies have shown rates of suicide to be 0.5–2% in the year after an episode of self-harm (or 50–200 times the general population rate). Longer-term studies have found rates of suicide of 3% at 5 years and around 7% for periods longer than 10 years. Those who do kill themselves tend to be: • older • male • have a mental illness • have poor physical health. They may also have made repeated attempts in the past. Much has been made of so-called risk factors for repetition and suicide, but these are of limited usefulness in everyday practice because of their poor predictive value.
Suicide prevention is discussed in more detail on pages 272–5 (in this issue). ◆
References 1 Maris RW. Suicide. Lancet 2002; 360: 319–26. 2 Morgan HG. Death wishes? The understanding and management of deliberate self-harm. Chichester: Wiley, 1979. 3 National Collaborating Centre for Mental Health. Self-harm: the short term physical and psychological management and secondary prevention of self-harm in primary and secondary care. Clinical guideline 16. London: Gaskell & British Psychological Society, 2004. 4 Royal College of Psychiatrists. Assessment following self-harm in adults. London: Royal College of Psychiatrists, 2004. 5 National Institute for Mental Health in England. National Suicide Prevention Strategy for England: annual report 2007. London: Department of Health, 2008. 6 Gunnell D, Middleton N, Frankel S. Method availability and the prevention of suicide – a reanalysis of secular trends in England and Wales 1950–1975. Soc Psychiatry Psychiatr Epidemiol 2000; 35: 437–43. 7 Amos T, Appleby L, Kiernan K. Changes in rates of suicide by car exhaust asphyxiation in England and Wales. Psychol Med 2001; 31: 935–9. 8 Middleton N, Whitley E, Frankel S, Dorling D, Sterne J, Gunnell D. Suicide risk in small areas in England and Wales, 1991–1993. Soc Psychiatry Psychiatr Epidemiol 2004; 39: 45–52. 9 Meltzer H, Lader D, Corbin T, et al. Non-fatal suicidal behaviour among adults aged 16–74 in Great Britain. London: The Stationery Office, 2002. 10 Crawford M, Wessely S. The changing epidemiology of deliberate self-harm – implications for service provision. Health Trends 1998; 30: 66–8. 11 Bhui K, McKenzie K, Rasul F. Rates, risk factors & methods of self harm among minority ethnic groups in the UK: a systematic review. BMC Public Health 2007; 7: 336. 12 Bertolotte JM, Fleischmann A. Suicide and a psychiatric diagnosis: a world-wide perspective. World Psychiatry 2002; 1: 181–5. 13 Haw C, Hawton K, Houston K, Townsend E. Psychiatric and personality disorders in deliberate self-harm patients. Br J Psychiatry 2001; 178: 48–54. 14 Department of Health. National Suicide Prevention Strategy for England. London: The Stationery Office, 2002. 15 Gunnell D, Frankel S. Prevention of suicide: aspirations and evidence. Br Med J 1994; 308: 1227–33. 16 Hawton K, Simkin S, Deeks J, et al. UK legislation on analgesic packs: before and after study of long term effect on poisonings. Br Med J 2004; 329: 1076–80. 17 Sandilands EA, Bateman ND. Co-proxamol withdrawal has reduced suicide from drugs in Scotland. Br J Clin Pharmacol 2008; 66: 290–3. 18 Hawton K, Simkins S, Deeks JJ, et al. Effects of a drug overdose in a television drama on presentations to hospital for self poisoning: time series and questionnaire study. Br Med J 1999; 318: 972–7. 19 Mann J, Apter A, Bertolote J, et al. Suicide prevention strategies. A systematic review. J Am Med Assoc 2005; 294: 2064–74.
Preventing suicide Can professionals intervene to lower the suicide rate? The latest Government target is a reduction of 20% by 2010. How might this be achieved? There are, broadly speaking, two potential approaches to prevention: the high-risk strategy (targeting highrisk groups) and the population-based strategy (preventing suicide in whole populations).
The National Suicide Prevention Strategy The National Suicide Prevention Strategy for England suggests a combination of high-risk and population-based approaches.14 Key high-risk groups include those with mental disorder (see also pages 257–60 (in this issue), those who have harmed themselves, and young men, but the strategy also aims to promote mental well-being in the wider population. Scotland has its own prevention strategy, which is based on similar principles. There is fairly good evidence that reducing the availability of methods of suicide has a significant impact on suicide rates.15 Specific examples from the strategy include: • reducing potential ligature points in in-patient settings • restricting the availability of commonly used analgesics (e.g. paracetamol16 and salicylates). More recently the withdrawal of the opiate analgesic co-proxamol may have reduced suicide by this method in Scotland.17 Media representation has been shown to influence suicidal behaviour.18 The strategy suggests that the media should follow guidelines to promote responsible reporting of suicidal behaviour. The media’s influence on suicidal behaviour is discussed further on pages 269–71 (in this issue). Finally, the strategy suggests increased research on the prevention of suicidal behaviour, and improved monitoring of progress towards achieving the targets for the reduction in suicide rates. A systematic review of suicide prevention strategies from around the world concluded that restricting access to lethal methods of suicide and educating physicians to recognize and treat depression might be the most effective measures in reducing rates of suicide.19
PSYCHIATRY 8:7
236
© 2009 Elsevier Ltd. All rights reserved.