Suicide Prevention in Gloucestershire

1. Suicide Prevention in Gloucestershire Sola Aruna 30.06.10

2. Policy Context • NSF for Mental Health – 7 standards: • 7th standard (Preventing Suicide) which depends on the other six standards: • 1: Mental Health Promotion • 2 & 3: Primary care & access to services: • 4 & 5: Effective services for people with severe mental illness • 6: Caring about carers • And: • Preventing suicide in prisoners • Competence in assessing risk of suicide • Local systems for suicide audits • New Horizons: towards a shared vision for mental health • Improve mental health & well being of population • Improve quality & accessibility of services for people with poor mental health • Lifespan approach

3. Suicide in Gloucestershire Mortality from Suicides and Undetermined Injury. DSR for al lAges, 2006-08 Source: NCHOD

4. 2010 reduction target of 20% from 1995-97 baseline = 6.56 per 100,000 population With current trend – 7.90 SW target of 7/100,000 by 2013 Suicide reduction target

5. Suicide Audits • Population-based • ONS, Coroner, GHT, 2FT, Primary Care • Identification of trends/local risks • Informs preventive activities • Learning • Broad-based including primary care level • Recommendations • Broad-based including primary care level • Gaps – data on sexual orientation, ethnicity

6. Suicide patterns in Gloucestershire Method of suicide

7. Why do people take their lives? • Reasons very complex • Risk/protective factors • Different levels – individual, social, contextual • Modifiable/non-modifiable • Relationship not a straight forward one • Individual, social, contextual

8. Risk and Protective Factors for Suicide

9. How can knowledge of risk factors help prevent suicide? • Identification of: • existing risk factors present for individual/group • individuals most likely to be badly affected/resilient • modifiable factors (to reduce risk) • Focus on specific groups/populations at risk rather than individuals • Focus on groups of risk/protective factors

10. Protective factors • Research into this not as long standing as those that increase vulnerability or exposure to suicidal thinking • Recent research on what builds resilience and the ability to cope with adverse life events • (Beautrais, 2006; Beautrais et al. 2005, 2007; Brent & Mann, 2006; Bridge, 2006; Knox et al. 2003; Mann et al. 2005; Page et al. 2006a; Qin et al. 2002b; Robinson et al. 2006; Rehkopf & Buka, 2006; WHO, 2002). • Many theories on what gives an individual the resilience to cope with and bounce back from adverse life events • Individuals will respond to potentially traumatic events in four different ways: • resilience accompanied by mild disruption (~ 60% of people) • initial shock followed by recovery over time (~ 20% of people) • delayed intense emotional reaction (~ 10% of people) • chronic disruption and ongoing mental disorder (~ 10% of people) - Bonanno, 2004

11. Health and Well being & Suicide Prevention • Individuals develop sense of self & way of coping with life from birth • Factors that influence resilience include: • Individual health & well being (see next slide) • Predisposing/individual factors - genes; gender and gender identity; personality; ethnicity/culture; socioeconomic background; and social/ geographic inclusion or isolation • Life history & experience - Family history and context; previous physical and mental health; exposure to trauma; past social and cultural experiences; and history of coping • Social & community support - Support and understanding from family, friends, local doctor, local community, school; level of connectedness; safe and secure support environments; and availability of sensitive professionals/carers and mental health practitioners (Beautrais, 1998; Kumpfer, 1999; Maslow, 1943; Rudd, 2000)

12. Health and Well being & Suicide Prevention • Strengthened health & well being depends on • Sense of self: self-esteem; secure identity; ability to cope; and mental health and wellbeing • Social skills: life skills; communication; flexibility; and caring. • Sense of purpose: motivation; purpose in life; spirituality; beliefs; and meaning • Emotional stability: emotional skills; humour; and empathy • Problem-solving skills: planning; problem solving; help-seeking; and critical and creative thinking • Physical health: health; physical energy; and physical capacity

13. Mental illness & Suicide • Strong relationship with suicidal behaviour (Tayloret al. 2005); BUT only ~ 25%; not everyone who takes own life has mental/emotional illness/problems • There may be a strong link between mental illness, genetic factors and life events (Caspi et al. 2003; Rutter et al. 2006) - ↑ depression due to acculated stressful life events involving threat, loss, humiliation, personal defeat • Complex circular relationship between mental health, other risk factors and suicide e.g. having a mental illness may give rise to events that exacerbates suicidal thoughts: mania → reckless decisions → unbearable stress → suicidal thoughts • Some mental illnesses are associated with suicide related behaviours and/or suicide – clinical depression, bipolar disorder, schizophrenia, alcohol or other drug abuse, borderline personality disorder, behavioural disorders

14. Mental illness & Suicide • Suicide: • Commoner cause of death in people with Schizophrenia and mood disorders • Higher risk in psychiatric in-patients (especially immediatly after discharge from hospital or A&E) • Higher risk (acting on suicidal thoughts) in people in early recovery phase of depression –delayed response to treatment • Treating 50% of the people with 3 most relevant mental disorders (depression, alcohol/drug/substance abuse disorders and schizophrenia) will reduce suicides by ~ 20% (Bertolote et al. 2004) • Treatment plus providing a sense of caring, better social connectedness and creating a secure, safe and empathetic environment

15. Personal factors/Live events & Suicide

16. Personal factors/Live events & Suicide

17. Precipitating events Warning signs Tipping point Imminent risk Risk factors

18. Prevention • Focus on: • Individual health & well being • Suicide-specific person-centred approach • Universal interventions • Selective interventions – specific at-risk population • Indicated interventions – specific high-risk individuals showing early signs of suicidality • Limited evidence of effectiveness of interventions • Symptom identification • Care & support • Early intervention • Standard treatment • Longer term treatment & support • On-going care & support

20. Evaluation • Very few interventions have been evaluated fro effective and impact • Challenges with choice of appropriate measure – rare event needing huge sample size if reduction in suicide rate is to be measured (15% reduction in national rate will need 13 million sample (Gunnell & Frankel, 1994). • Measures used should include: • the prevalence of suicide attempts • suicide-related behaviours; thinking or communication; • changes in predisposing vulnerabilities and protective factors (Beautrais et al. 2007; Headey et al. 2006; Mann et al. 2005; Maris et al. 2000). • Evaluation important - suicide prevention is inexact process based on limited evidence (De Leo, 2002)

21. So……. • Interventions should be multi-modal and complementary, targeting a wide range of high risk groups. • WHY • there is no single, readily identifiable, high-risk population that constitutes a sizeable proportion of overall suicides and yet is small enough to target easily and have an effect (Gunnel & Frankel, 1994