Suicide and Self-harm in Gloucestershire

Alice Walsh

Acting Director of Public Health

Contents of presentation • Definitions

• Contributory factors

• Addressing the issue (nationally & locally)

• Patterns of suicide in Gloucestershire

• Suicide in Children and Young People

• Preventing suicide – what the evidence says

• Self harm / patterns of self harm in Gloucestershire

• Suicide – precipitating events (triggers)

• Suicide prevention model

• Conclusions

Definition

Suicide – intentionally ending one’s life

• Coroner pronouncement, clear evidence

• Official statistics: suicides and open verdicts (undetermined injuries)

Self-harm – intentionally damaging or injuring one’s body

• Coping with distress

• Different degrees of risk to life

Contributory Factors in suicide

Varied and complex – no single preventive measure. Factors include:

• Gender

• Age

• Mental illness

• Physically disabling/painful illnesses

Substance misuse

Job loss

Imprisonment

Debt

Living alone/social exclusion/isolation

Family breakdown & conflict/family

Addressing the Issue of Suicide National :

• Suicide Prevention Strategy 2012 with twin objectives:

• Reduction in suicide rate in general population

• Better support for people bereaved/affected by suicide

Local:

• Gloucestershire Suicide Prevention Strategy 2011-15

• Gloucestershire Health and Wellbeing Strategy

• Gloucestershire Mental Health & Wellbeing Strategy

Governance Structure 1. Gloucestershire Suicide prevention Partnership Forum (GSPPF)

-Key stakeholders across statutory and VCS

-Develop and deliver strategy and action plan

-Task & Finish Groups

2. Gloucestershire Mental Health Local Implementation Team/Gloucestershire Mental Health and Wellbeing Partnership

-Gloucestershire Mental Health and Wellbeing Strategy

-Receives report of GSPPF

3. Joint Commissioning Partnership

-Receives report of Mental Health LIT/Mental Health & Wellbeing Partnership

4. Health and Wellbeing Board

Pattern of Suicide in Gloucestershire Mortality from Suicide and Injury Undetermined,

15years and older, Persons, 1993/1995 to 2010/2012

Mortality from Suicide and Injury Undetermined, Directly Standardised Rate per 100,000, Persons, 15 years and

above, 2010-2012

Pattern of Suicide in Gloucestershire (2009-2012) (1)

Suicides and Injury Undetermined in Gloucestershire by Age Band, 2009-2012

Suicide Methods in Gloucestershire, 2009-2012

Pattern of Suicide in Gloucestershire (2009-2012) II

Where in Gloucestershire?* • 60% occur at home

‘Hotspot’ areas include: • Rivers

• canals

• multi storey car parks

• railway tracks

• stations

• 66.3% did not have any known previous contact with mental health services

• 31% had a lifetime history of self harm

• 74% no previous suicide attempt

NB: Coroners comments:

• 72% not related to mental illness

*2008-2010 time period

Suicides in Young People (I) Max. two or three annually – six deaths in a year in the past,

Four suspected suicides in 2012

Child Death Review Process (deaths in children up to 18 years in 2012 & 2013:

Information from most recent 7 deaths from the Child Death Review Process (CDRP) (up to 18 years) shows:

• 6 were male

• Family discord / relationship problems and bullying were thought to be factors in 57% of deaths

• A few were known to MH services –note CDRP did not think mental illness was a factor in these specific deaths

Suicides in Young People (Jan 2008-Jan 2013)(2) Other important factors (across SW region):

• Concerns in various settings about emotional or mental health

• Evidence for low self-worth

• Relationship difficulties

• Previous threat of self-harm or suicidal ideation

• Previous self-harm

• Being known to police/courts/social care

• Internet searches for suicide methods

• Some discussion within their peer group about suicide

• Triggering event – family row, worsening of relationship difficulties

‘Near Misses’ in Young People

Monitoring by C&YP T&F Group following 2012 deaths – of 15 incidents since then:

• No obvious gender differences

• 87% attempted hanging/strangulation

• One third under 15 years

• 60% had not presented to mental health services

• Other factors: child protection concerns, family discord, sibling history of suicide, previous admission for overdose/self-harm

Preventing Suicide – What the evidence says

• Broad international consensus that many suicides are preventable at a population level

• No clear ways to predict and prevent suicidal behaviour at individual level

Most effective strategies:

• combine with wider work addressing social and other determinants of poor health

• Build population resilience and social connectedness in communities

• Increase individual resilience across the life course

Examples of Action to prevent suicide by CYP T&F Group • Working with schools providing resources and sources of

support

• Developing curriculum resources (Key Stage 4 resources and ‘Safe, healthy relationship’ curriculum (Key Stage 1-5)

• Resources for professional (little Red Book)

• Developing referral pathways for all professionals

• Surveillance – through On Line Pupil Survey

• Developing Suicide prevention ‘app’ focussing on CYP

• Expand Youth Mental Health First Aid Training

• PH Campaign May 2014

Suicide methods most amenable to intervention

• Hanging/strangulation in CJS & in-patient settings

• Self Poisoning

• Deaths at high risk locations

• Deaths on the rail or underground networks

Local work:

• 2g NHSFT – constantly implementing measures to prevent suicide

• CCG; GHFT & 2g NHSFT – reviewing self harm clinical pathways

• ‘Hotspots’ multi-agency T&F Group established under GSPPF

Self Harm – All Ages

• Common – often hidden problem

• Admission data shows tip of the iceberg

• Increased risk of suicide (3-4% of self harm admissions will die of suicide in 10-12 years)

• Rates higher in females

• Across all ages and social classes, some high risk groups

• Incidence increasing over last 20 years

Patterns of Self Harm in Gloucestershire County self harm rates are significantly worse than English average

Districts comparisons with England average:

• Gloucester, Cheltenham & Stroud = significantly worse

• Cotswold, FOD = significantly better

• Gloucestershire has shown sustained increase in admissions since 2005

• Mostly (60%) female; 85% by poisoning

• Age: Peak in teenagers, secondary peak in late 20’s and 40’s

• Deprivation: 49% from most deprived deciles in county

Suicide - Precipitating Events (Triggers)

• Risk Factors e.g: MH problems / gender / family problems / substance misuse

• Warning Signs: e.g: Hopelessness / feeling trapped/ social withdrawal / no sense of purpose etc.

• Tipping Point: e.g: relationship ending/loss of status/ debilitating physical illness/ abused bullying etc.

• Imminent Risk: e.g: Expressed intent to die; plan in mind; access to lethal means; impulsive, aggressive behaviour

Source: Department of Health and Ageing, Australian Government

Suicide prevention model Evidence suggests suicide prevention model should include

activities aimed at:

• The broader population

• Specific ‘at risk’ groups

• Individuals who may be at risk

And informed by knowledge of:

• Risk and protective behaviours (individual; social & contextual)

• Resilience and vulnerability

• Impact of interaction of personal factors, life events, including MH

• Warning signs and tipping points

Conclusion (1)

• Causes of suicide are varied and complex

• Rates of suicide & self harm are increasing nationally, regionally and locally

• Most not in contact with MH services in 12 months before death

• No single preventative factor – evidence strongly suggests association with unemployment

• No clear ways to predict and prevent suicidal behaviour at individual level

• Interventions need to address wider determinants & be wide ranging

Conclusion (2)

• Increasing demand for CYP MH services generally is challenging supply and is being explored

• Need to build population resilience across life course

• Intervening at an individual level is more challenging

• There is local awareness of issues

• Work is underway and monitored within existing partnership structures