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National Public Health Service for Wales Suicide prevention: Summary of the evidence

Suicide prevention:

Summary of the evidence

Version: 1 Date: February 2007 Status: Final draftAuthor: Sian Price Page: 1 of 64 Classification:


Further information: [email protected]

© 2007 National Public Health Service for WalesMaterial contained in this document may be reproduced without prior

permission provided it is done so accurately and is not used in a misleading context. Acknowledgement to the National Public Health Service for Wales to

be stated.


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TABLE OF CONTENTS

INTRODUCTION 4

LEVEL 1 PRIMARY PREVENTION – POPULATION LEVEL INTERVENTIONS

6

1.1 General mental health promotion and suicide prevention interventions

7

1.2 Specific mental health promotion programmes 111.3 Reducing access to means of suicide 161.4 Useful resources 17

LEVEL 2 EARLY IDENTIFICATION 182.1 Screening for suicide risk 192.2 Identification and management of depression 202.3 Management of drug and alcohol misuse 242.4 Management of mental illness 252.5 Preventing suicide in prisons and police custody 282.6 Physical illness 302.7 Useful resources 31

LEVEL 3 CRISIS INTERVENTION, MANAGING SUICIDAL BEHAVIOUR 343.1 Monitoring self harm 353.2 Interventions to reduce suicidal ideation 363.3 Assessment and short term management of people who self harm 373.4 Secondary prevention of self harm 413.5 The role of voluntary agencies 463.6 Useful resources 46

LEVEL 4 POSTVENTION 474.1 Reviewing completed suicides 484.2 Suicide of service users – Managing the impact on staff 504.3 Supporting those bereaved by suicide 514.4 Media portrayal of suicide 544.5 Monitoring suicide rates 574.6 Useful resources 58

CONCLUSION 60

APPENDICESI Risk factors associated with suicide 61II Summary of recommendations from the British Isles Suicide

Researchers Group63



INTRODUCTION

Suicide and deliberate self harm have significant personal, social and economic consequences. Whilst there seems to be a broad consensus that many suicide deaths are preventable, there is no clear way to predict which individuals are likely to die from suicide and there is no research that demonstrates how suicide can be prevented in any individual1. Many studies have identified factors associated with an elevated risk of suicide but none of these allow a level of prediction that is clinically useful1. Despite this an understanding of the risk factors associated with suicide is useful targeting interventions at groups with an elevated risk of suicide.

Suicide is a relatively rare event. Because of this and notwithstanding the ethical implications, very large numbers would be needed to conduct randomised controlled trials of interventions to prevent suicide. As a consequence much of the evidence around suicide prevention focuses on interventions designed to prevent repetition of self harm.

Recently there has been a shift in focus in efforts to prevent suicide and a public health model has been adopted. This has meant a move away from concentrating on the treatment of high risk patients towards a more population based approach. This approach attempts to reduce the risk in the whole population by changing attitudes, knowledge, behaviours and norms that might predispose people to suicide. It also looks to address behaviours in society such as substance abuse that are known to be linked with suicide

Using this model suicide prevention can be considered at four levels. These are;

1. Primary prevention, initiatives targeted at whole populations. These include general mental health promotion initiatives that aim to increase public and professional awareness, create a better understanding of mental illness, reduce stigma and encourage health seeking behaviour, specific mental health promotion initiatives targeted and primary prevention of mental ill health and substance abuse and measures to remove access to the means of suicide.

2. Early identification, this is also primary prevention but this level is more selective targeting interventions at groups who may be at a greater risk of suicide than the general population. This level includes the identification and management of depression, management of substance abuse and mental illness and suicide prevention in prisons.

3. Crisis intervention (secondary prevention). This level addresses interventions for those who have already demonstrated suicidal or self harming behaviour.

1 Goldney RD. Prediction of suicide and attempted suicide. In: Hawton K, Van Heeringen K editors. The international handbook of suicide and attempted suicide. Chichester: John Wiley; 2000.



4. Postvention (tertiary prevention). This level addresses the consequences of completed suicide. Interventions at this level may be targeted at specific individuals or at specific groups. This level includes helping those bereaved by suicide, the portrayal of suicide by the media and ‘learning the lessons’ from completed suicide.

This document summarises the evidence for activities and interventions that may be of benefit in preventing suicide. The evidence is set out according to the four levels described above.

The convention used in this document to indicate the type of evidence is;

Type 1 evidence: at least one good systematic review (including at least one randomised controlled trial)

Type II evidence: at least one good randomised controlled trial

Type III evidence: well designed interventional studies without randomisation

Type IV evidence: well designed observational studies

Type V evidence: expert opinion; influential reports and studies

Source: Barker J, Weightman A L, Lancaster J. Project for the enhancement of the Welsh Protocols for Health Gain: project methodology 2. Cardiff: Duthie Library;1997.

Where the type of evidence differs from this convention, details are given in the text.

The examples provided in this document are not exhaustive. The intention is to highlight the type of interventions that might be effective and provide examples of these. In order to implement any of these interventions further information will be needed. The ‘Useful resources’ boxes provide links to some of the evidence summarised in the document and other sources of information.

The NPHS Vulnerable Adults team has undertaken the evidence review to contribute to the development of policy and practice within Wales .



LEVEL 1 – PRIMARY PREVENTION, POPULATION LEVELINTERVENTIONS

This section summarises the evidence for;

General mental health promotion or suicide prevention initiatives that influence public and professional awareness

Specific mental health promotion interventions targeted at preventing mental ill health and substance misuse

Reducing access to the means of suicide



1.1: GENERAL MENTAL HEALTH PROMOTION AND SUICIDE PREVENTION INTERVENTIONS

General mental health promotion initiatives that influence public and professional awareness, aim to create better understanding of mental illness and suicide, reduce stigma and encourage health seeking behaviour.

Topic AreaNational Campaigns may increase public and professional understanding of mental illness, reduce stigma and discrimination and promote ‘help seeking’

Supporting evidence

1.1.1 The Royal College of Physicians ‘Changing Minds Campaign’ ran for five years from 1998 to 2003. The campaign targeted doctors, children and young people, employers, the media and the general public. It aimed to increase public and professional understanding of mental health problems and to reduce stigma and discrimination. A Tool Kit of materials was developed to help change minds and reduce stigma. These materials are now available on a website. A second website created by the Campaign provides in-depth articles about stigma by researchers, academics, mental health service users and carers. Following the official close of the Campaign the College has continued to develop the campaign website and distribute publications.

Type V evidence

http://www.rcpsych.ac.uk/campaigns/cminds/index.htm

Although a survey undertaken before the Campaign assessed public attitudes no follow up survey of its impact has been reported

1.1.2 The Royal Collage of General Practitioners and Royal College of Psychiatrists ran a ‘Defeat Depression’ Campaign from 1992 to 1996. It aimed to educate GPs to recognise and treat depression to reduce the stigma associated with depression and encourage early seeking of treatment by educating the public about the disorder and its treatment. To educate the public newspaper and magazine articles, radio and television programmes and other media activities were used. Positive attitude change in the public was achieved by the campaign. Surveys of public attitude were carried out by MORI in late 1991, early 1995 and mid 1997. These found significant positive change in attitudes regarding depression, reported experience of it, attitudes to antidepressants (and less consistently to treatment from GPs). Changes were in the order of 5 to 10%. Attitudes to depression and treatment by counselling were very favourable but antidepressants were seen as addictive and less effective.

Type IV evidence

Rix S, Paykel E S, Lelliott P, Tylee A, Freeling P, Gask L, Hart D. Impact of a national campaign on GP education: an evaluation of the Defeat Depression Campaign. BJGP 1999; 49: 99-102.

Paykel E S, Hart D, Priest RG. Changes in public attitudes to depression during the Defeat Depression Campaign. Br J Psychiatry 1998; 173:519-22.





Topic areaNationwide suicide prevention strategies with multiple objectives may be effective in reducing suicide

Supporting evidence

1.1.3 The Finnish suicide project involved a national network, mass media communication and regional planning of suicide prevention Specifically in involved three theme specific programmes;

Proper care of suicide attempters Support to survivors Project on depression “Keep your chin up”

And a range of other initiatives and actions Regional development of schools crisis

management Co-operation with schools Collaboration with the church Co-operation with the Finnish Defensive

Forces Support to young people Collaboration with the police Co-operation with the Ministry of Labour Support during a recessions crisis

o Development of occupational health services for the unemployed

Mutual help: male coping strategies Addressing substance abuse

Treatment of depression Development of a brochure on

depression and alcohol Early stage intervention by

occupational health services Substance abuse projects

Type V evidence

Upanne M, Hakanen J, Rautava M. Can suicide be prevented? The suicide project in Finland 1992 – 1996: Goals, implementation and evaluation. Helsinki,:STAKES National Research and Development Centre for Welfare and Health; 1999.

The Finnish suicide project ran from 1986 – 1996. It is the first nationwide project to be implemented and evaluated. The number of suicides in Finland reduced by 9% between 1987 and 1996.



Topic areaThe evidence supporting school curriculum based suicide prevention programmes for adolescents is equivocal and is insufficient to support the implementation of school curriculum based intervention programmes for adolescents

Supporting evidence1.1.4 Studies included in this review involved suicide

education and general coping skills training. Interventions ranged from a single 1 ½ hour session to 180 sessions of 55 minutes each delivered over a 10 month period. Interventions were usually provided by school teachers with additional training but school counsellors, social workers, mental health specialists and school nurses were also used.

Five studies showed that interventions might improve suicide related knowledge and attitudes and mental health indicators such as perceived stress, anger and self-esteem. Some negative programme effects were also identified, especially for males. Some studies found that programmes had detrimental effects on suicide related attitudes, hopelessness and coping.

Type III evidence Systematic review including type III and IV studies.

Ploeg J, Ciliska D, Brunton G, MacDonnell J, Apos O, Brien M A. The effectiveness of school-based curriculum suicide prevention programs for adolescents. Ontario: Ministry of Health, Region of Hamilton-Wentworth, Social and Public Health Services Division; 1999.

The studies used in review were all based in Canada therefore the findings may not apply to other school/education systems



Topic areaInterventions that aim to change social norms about seeking help and incorporate training in suicide prevention may promote mental health and reduce risk of suicide

Supporting evidence1.1.5 The US Air Force suicide programme was

introduced in response to an increase in suicide rates amongst Air Force personnel. The intervention aimed to remove the stigma of seeking help for mental health or psychosocial problems, enhance understanding of mental health and to change policies and social norms. The initiatives included;

Suicide awareness education and training included in squadron commander courses

Suicide prevention incorporated into professional military education curriculum

Guidelines for commanders on use of mental health services to improve referral of active duty members for mental health evaluation, emphasis on mental health professionals being seen by commanders as partners in improving duty performance

Strengthening preventative role of mental health personnel

Community education and training for non-professionals in understanding suicide, intervention skills and referral procedures for people potentially at risk

Changes in policies to ensure individuals under investigation for legal problems are assessed for suicide risk

Establishment of critical incident stress management team to respond to traumatic events including completed suicides

Type IV evidence

Knox K L, Litts D A, Talcott G W, Catalano Feig J, Caine E D. Risk of suicide and related adverse outcomes after exposure to a suicide prevention programme in the US Air Force: cohort study. BMJ 2003; 327: 1376.This study found that implementation of the programme was associated with a sustained decline in the rate of suicide and other adverse outcomes such as domestic violence .A 33% relative risk reduction was observed for suicide after the intervention.Consideration needs to be given to whether similar results would be found in different populations. 84% of the population in this study were male. In addition this was a multilayered intervention so it is not possible to know whether using separate or different combinations of elements of the programme would be effective.



1.2. SPECIFIC MENTAL HEALTH PROMOTION PROGRAMMES

Specific mental health promotion interventions targeted at primary prevention of mental ill health and substance misuse.

Topic areaInterventions to improve mental health may have a role in preventing problems such as depression, anxiety, substance misuse and suicidal behaviour

Supporting evidence1.2.1 The mental health briefing produced by the

Health Education Board for Scotland for the Scottish Executive summarises the evidence of effectiveness of interventions to improve the mental health of the following groups;

Early years Young people: in school and community

settings Primary care Workplace Communities and neighbourhoods Older people People with mental health problems

Systematic review of studies of types II to IV

Mentality. Mental health improvement: What works? A briefing for the Scottish Executive. Edinburgh: Health Education Board for Scotland; 2001/2.

1.2.2 A review of the effectiveness of mental health promotion interventions undertaken by the Health Education Authority addressed the question What interventions have been shown to be effective in;

preventing specified mental disorders and related outcomes

promoting positive wellbeing developing the major intermediate factors

associated with mental health/prevention of mental disorder

Findings in the report are summarised by life stage;

Childhood Youth Adulthood Older age

Review of evidence of types I to IV

Tilford S, Delaney F, Vogels MEffectiveness of mental health promotion interventions: a review.London: Health Education Authority; 1997.

1.2.3 This briefing paper is designed to support and strengthen mental health promotion practice. It provides a summary of effective mental health promotion interventions and discusses issues that are raised around the evidence base for mental health promotion. It summarises findings from studies using a range of methodologies.

Type V evidence

Friedli L. Making it effective: a guide to evidence based mental health promotion. Radical mentalities. London: mentality; 2003.

Topic area



Alcohol dependence is recognised as a risk factor for suicide and there is some evidence that early drinking experiences are linked to later alcohol dependence. Primary prevention of alcohol misuse in young people may reduce suicide risk in later life.

Supporting evidence1.2.4 The Strengthening Families programme and

culturally focused skills training may be effective in primary prevention of alcohol misuse in young people

Systematic review including evidence of types II and III

Foxcroft DR, Ireland D, Lowe G, Breen R. Primary prevention of alcohol use in young people. The Cochrane Database of Systematic Reviews 2002, Issue 3.

These interventions may be effective over the longer term but require further evaluation

Topic areaAlcohol dependence is recognised as a risk factor for suicide. Interventions that are effective in reducing alcohol misuse may be effective in preventing suicide

Supporting evidence1.2.5 This briefing paper summarises the evidence

for effective interventions to prevent and reduce alcohol misuse. It summarises the evidence to support interventions to reduce hazardous drinking delivered in a range of healthcare settings and interventions to reduce alcohol impaired driving

Review of systematic reviews, meta-analyses and non-systematic reviews containing evidence of types I to V

Mulvihill C, Taylor L, Waller S Naidoo B, Thom B. Prevention and reduction of alcohol misuse. London: Health Development Agency; 2005.

Topic areaDrug misuse is a recognised risk factor for suicide. Prevention of drug use in young people may be effective in reducing suicide.

Supporting evidence1.2.6 This evidence briefing summarises evidence on

prevention and/or reduction of drug use among young people. It addresses;

School based interventions Police officer, teacher, peer and parent

led approaches

Review of systematic reviews, meta-analyses and non-systematic reviews containing evidence of types I to V

Canning U, Milward L, Raj T, Warm D. Drug use prevention among young people: a review of reviews. London: Health Development Agency; 2004.



Topic areaPeople who experience poor social environments or severe adverse life events may be particularly vulnerable to mental health problems. Interventions to alleviate the impact of these may prevent development of mental health problems in the longer term.

Supporting evidence1.2.7 This review considers interventions for;

Children living in poverty Children with behavioural difficulties Children experiencing divorce and

bereavement Adults undergoing divorce or separation Adults experiencing unemployment Depression in pregnancy Bereavement Long-term carers of people who are

highly dependentThe review concluded;

High quality pre-school education and support visits for new parent can improve mental health in children and parents in disadvantaged communities

School-based interventions and parent training programmes for children showing behavioural problems can improve conduct and mental well being

Mental health problems in children of separating parents can be reduced by providing cognitive skills training and emotional support

Social support and problem solving or cognitive – behavioural training in the unemployed can improve mental health and employment outcomes

Mental health problems often experienced by long-term carers can be prevented by respite care and some forms of psycho-social support

Counselling, by itself, has not been shown to produce sustained benefit in a variety of groups at risk

The primary health care team has an important role in identifying and co-ordinating the management of people at high risk. Structured multi-sectoral co-ordination of strategies targeting those most likely to benefit are needed

Type 1 evidence

Mental health promotion in high risk groups. Effective Health Care Bulletin 1997; 3 (3).



Topic areaPatterns of emotional, cognitive and social functioning established early in a child’s life will influence their later development and in particular their mental health. Parenting programmes may have a role to play in improving the emotional and behavioural adjustment of children

Supporting evidence1.2.8 There is some evidence to support the use of

group based parenting programmes to improve the emotional and behavioural adjustment of children under 3 years.

Type 1 evidence

Barlow J, Parsons J. Group-based parent-training programmes for improving emotional and behavioural adjustment in 0-3 year old children. The Cochrane Database of Systematic Reviews 2003, Issue 2.

The evidence as to whether results are maintained over time is equivocal. Further input may be required at a later stage in development; further research on this aspect is required.

Topic areaThe origins of many mental health problems may lie in infancy and childhood. There is evidence that maternal psychological health may have a significant impact on the mother-infant relationship and this may have consequences for the long and short-term psychological health of the child.

Supporting evidence1.2.9 Parenting programmes using five theoretical

approaches were shown to be effective in improving a range of aspects of maternal psychosocial functioning (These included measures of maternal anxiety, depression and self-esteem). The programme categories were;

Behavioural Cognitive-behavioural Multi-modal Behavioural-humanistic Rational-emotive

All the programmes reviewed were successful in producing positive change in maternal psychosocial health

Type 1 evidence

Barlow J, Coren E, Stewart-Brown SSB. Parent-training programmes for improving maternal psychosocial health. The Cochrane Database of Systematic Reviews 2003, Issue 4.

Overall the results of the review were positive but some studies showed no effect. Further research is needed to assess which factors of these contribute to successful outcomes.



Topic areaThere is a recognised link between depression and suicide. Depression is common and has a significant impact on the functioning of young people who develop it. There is some evidence that psychological depression prevention programmes are effective in preventing depression in young people.

Supporting evidence1.2.10 Psychological depression prevention

programmes were shown to be effective in short - term reduction of depressive symptoms and diagnosis of depressive illness.

Type 1 evidence

Merry S, McDowell H, Hetrick S, Bir J, Muller N. Psychological and/or educational interventions for the prevention of depression in children and adolescents. The Cochrane Database of Systematic Reviews 2004, Issue 2.

There were methodological problems with the studies included in the review and there were very few studies of educational interventions. The results are described as encouraging but the authors recommend that further research is undertaken to confirm these results before depression prevention programmes are introduced

Topic areaMany factors in the workplace can affect the mental health of employees. Understanding and addressing these factors is complex but may have a range of benefits

Supporting evidence1.2.11 The Toolkit for Mental Health in the

Workplace has been developed to help organisations address some of the issues around mental health at work and to provide a framework for action

Type V evidence

Hughes S. A toolkit for mental health promotion in the workplace. Trent Mental Health in the Workplace Project. London: mentality; 2002.



1.3. REDUCING ACCESS TO MEANS OF SUICIDE

Interventions that have an impact on the environment and reduce access to the means to commit suicide

Topic areaThere is evidence to support the effectiveness of providing safety barriers to prevent suicide by jumping, for example, from bridges

Supporting evidence1.3.1 This case study describes how in 1996 suicide

safety barriers were removed from a central city bridge after having been in place for 60 years. Removal of the barriers was followed by a substantial increase in suicides by jumping from the site. In the period 1992 – 1995 there were three suicides, from 1997-2000 there were fifteen. Following the removal of the barriers the rate of suicides by jumping in the city did not change but the pattern changed significantly with more suicides from the bridge in question and fewer at other sites.

Type IV evidence

Beautrais A L. Effectiveness of barriers at suicide jumping sites: a case study. Aust N Z Psychiatry 2001; 35:557-62.

1.3.2 The pattern of suicides in the Bristol area is affected by the presence of the Clifton Suspension Bridge. A study demonstrated that suicide by jumping in this area is significantly more common that in England and Wales as a whole. The Clifton Suspension Bridge (at the time of the study) did not have safety barriers designed to prevent suicide.

Type III evidence

Nowers M, Gunnell D. Suicide from the Clifton Suspension Bridge. J Epidemiol Community Health 1996;50:30-2.

Topic areaThere is evidence that suggests reducing pack sizes of paracetamol and aspirin sold over the counter may reduce suicide deaths by poisoning.

Supporting evidence1.3.3 Legislation on the packaging of paracetamol

and salicylates was introduced in September 1998; this restricted the number of tablets that could be sold in one transaction. This legislation is associated with a decline in mortality and morbidity from self poisoning with these drugs.

Type IV evidence

Hawton K, Townsend E, Deeks J, Appleby L, Gunnell D, Bennewith O, Cooper J. Effects of legislation restricting pack sizes of paracetamol and salicylate in the United Kingdom: before and after study. BMJ 2001; 322:1203 – 07.

Topic areaUsing blister packs rather than loose preparations may reduce suicide from self poisoning

Supporting evidence1.3.4 In a study of eighty patients admitted to

hospital after paracetamol overdose 69% of those who had taken 25 or more tablets had used a lose preparation rather than a blister pack (odds ratio = 3.0, 95% CI 1.12 to 9.95, P = 0.028).

Type IV evidence

Hawton K, Ware C, Mistry H, Hewitt J, Kingsbury S, Roberts D, Weitzel H. Paracetamol self-poisoning. Characteristics, prevention and harm reduction. Br J Psychiatry 1996; 168: 43-8.



1. 4 USEFUL RESOURCES

These are web links to some of the resources and documents referred to in the text and other useful sources of information

www.changingminds.co.ukwww.stigma.org/everyfamily Websites for the ‘Changing Minds’ campaign

http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOMEThe Cochrane Library

http://www.hebs.com/researchcentre/cr/crscripts/FTReportTocM.cfm?TxtTCode=1395&Nav=1&sc=specialist&SA=WWMental Health Improvement: What works? A briefing for the Scottish Executive

http://www.hda-online.org.uk/Documents/effective_mentalhealth.pdfEffectiveness of mental health promotion: a review. Health Education Authority

http://www.mentality.org.uk/services/resources/toolkit.htmLink to order “Mental Health in the workplace toolkit”

http://www.stakes.fi/verkkojulk/pdf/mu161.pdfEvaluation and report of the Finnish Suicide Prevention Project

http://www.york.ac.uk/inst/crd/ehc33.pdfEffective Health Care Bulletin. Mental health promotion in high risk groups

http://www.hda.nhs.uk/Documents/drug_use_prevention.pdfHealth Development Agency evidence briefing. Drug use prevention among young people: a review of reviews

http://kc.nimhe.org.uk/upload/NationalFramework1.pdfMaking it possible: Improving Mental Health and Well-being in England. National Institute for Mental Health in England

http://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf World Health Organisation report. Prevention of mental disorders: effective interventions and policy options: a summary report

www.york.ac.uk/inst/crd/pdf/4ment.pdfA National Contract for Mental Health.

www.york.ac.uk/inst/crd/pdf/5Educ.pdfSummarises findings of systematic reviews including health promotion programmes.Evidence from systematic reviews of research relevant to implementing the ‘wider public health’ agenda. Centre for Reviews and Dissemination. August 2000

http://www.show.scot.nhs.uk/publicationsindex.htmLink to ‘Equal Minds’ National programme for improving mental health and well-being in Scotland


http://www.show.scot.nhs.uk/publicationsindex.htm

http://www.york.ac.uk/inst/crd/pdf/5Educ.pdf

http://www.york.ac.uk/inst/crd/pdf/4ment.pdf

http://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf

http://kc.nimhe.org.uk/upload/NationalFramework1.pdf

http://www.hda.nhs.uk/Documents/drug_use_prevention.pdf

http://www.york.ac.uk/inst/crd/ehc33.pdf

http://www.stakes.fi/verkkojulk/pdf/mu161.pdf

http://www.mentality.org.uk/services/resources/toolkit.htm

http://www.hda-online.org.uk/Documents/effective_mentalhealth.pdf

http://www.hebs.com/researchcentre/cr/crscripts/FTReportTocM.cfm?TxtTCode=1395&Nav=1&sc=specialist&SA=WW

http://www.hebs.com/researchcentre/cr/crscripts/FTReportTocM.cfm?TxtTCode=1395&Nav=1&sc=specialist&SA=WW

http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME

http://www.stigma.org/everyfamily

http://www.changingminds.co.uk/

National Public Health Service for Wales Suicide Prevention: Summary of evidence

LEVEL 2: EARLY IDENTIFICATION

This section is concerned with primary prevention of suicide and self harm and considers interventions targeted at groups who may be at greater risk of suicide than the general population. Interventions at this level aim to identify at risk groups and address the factors that put them at risk of suicide. A table of risk factors associated with suicide is included at appendix I.

This section summarises the available evidence for; Screening for suicide risk Identification and management of depression Management of drug and alcohol misuse Management of mental illness Preventing suicide in prisons and police custody Suicide prevention in people with physical illness

Version: 1 Date:February 2007 Status: DraftAuthor: Sian Price Page: 19 of 64 Classification:


2.1. SCREENING FOR SUICIDE RISK

Topic areaSuicide risk is assessed along a continuum ranging from suicidal ideation alone (relatively less risk) to suicidal ideation with a plan (relatively greater risk).Mood and other mental disorders, co-morbid substance abuse, a history of deliberate self-harm and suicide attempts are among the factors associated with an increased risk of suicide. There is however, no research that enables suicide or suicidal behaviour to be accurately predicted in individuals.

Supporting evidence

2.1.1 The United States Preventative Services Task Force (USPSTF) has concluded that there is insufficient evidence to recommend for or against routine screening by primary care clinicians to detect suicide risk in the general population.

Evidence based guideline based on systematic literature review -only 1 study providing limited evidence was identified.Gaynes B N, West S L, Ford C A, Frame P, Klein J, Lohr K N. Screening for suicide risk: recommendation and topic area. Ann Intern Med 2004; 140: 820-1.

2.1.2 A 10 year prospective study of patients who had been admitted to hospital with suicidal thinking found that a score of 10 or more on the Beck Hopelessness Scale correctly identified 91% of eventual suicides. However the number of true positives (that is individuals who scored 10 or more and eventually died by suicide) was 10 but there were 76 false positives. The high proportion of false positive limits the clinical usefulness of the scale.

Type IV evidenceBeck A T, Steer R A, Kovacs M, Garrison B. Hopelessness and Eventual Suicide: A 10-Year Prospective Study of Patients Hospitalized With Suicidal Ideation. Am J Psychiatry 1985; 142: 559-63.

2.1.3 A 7 year prospective study of psychiatric outpatients showed that a score of 9 or above on the Beck Hopelessness scale correctly identified 16 of the 17 patients who died by suicide during the follow up period. However the group with this score included 1145 individuals who did not die by suicide. Using the Beck Depression Score and a cut-off score of 23 or above identified a group of 743, 13 of whom died by suicide during the follow up period. The high number of false positives identified by these scales limits their clinical application.

Type IV evidenceBeck A T, Brown G, Berchick R J, Stewart B L, Steer R A. Relationship between hopelessness and ultimate suicide: a replication with psychiatric outpatients. Am J Psychiatry 1990; 147:190-95.



2.2 IDENTIFICATION AND MANAGEMENT OF DEPRESSION

Topic areaDepression is a well recognised risk factor for suicide. Screening adults in primary care might improve identification and treatment of depression thus reducing the risk of suicide.

Supporting evidence2.2.1 The United States Preventative Services Task

Force (USPSTF) recommends screening adults for depression in clinical practices with systems in place to ensure accurate diagnosis, effective treatment and follow up. They found good evidence that this improves the accurate identification of depressed patients in primary care settings and that treatment of these patients decreases morbidity.

The USPSTF concluded that there is insufficient evidence to recommend for or against routine screening of children or adolescents for depression.

Type I evidencePignone M P, Gaynes B N, Rushton J L, Mills Burchell C, Orleans C T, Mulrow C D, Lohr K N. Screening for depression in adults: a summary of the evidence for the U.S. Preventative Services Task Force. Ann Intern Med 2002; 136: 765-76.The overall quality of evidence was graded as ‘fair’ meaning that the evidence was sufficient to determine effects on health outcomes but the strength of evidence was limited by the number, quality or consistency of the individual studies.

2.2.2 The Canadian Task Force on Preventative Health Care makes the following recommendations;

There is fair evidence that screening adults in the general population for depression in primary care settings that have integrated programmes for feedback and treatment.

There is insufficient evidence to recommend for or against screening adults in the general population for depression in primary care settings where effective follow up and treatment are not available.

There is insufficient evidence to recommend for or against routine screening for depression among children or adolescents in primary care settings.

Type I evidenceMacmillan H L, Patterson J S, Wathen C N and the Canadian Task Force on Preventative Health Care. Screening for depression in primary care: recommendations statement from the Canadian Task Force on Preventative Health Care. Canadian Medical Association Journal 2005; 172: 33-5.

2.2.3 In the United Kingdom the policy of the National Screening Committee (as of May 2005 due for review in May 2006) is that routine screening of the population or subsets of the population for depression is not recommended.

Type V evidenceThe evidence upon which this recommendation was made is unclear.National Screening Committee Policy. Depression screening. 2006.http://rms.nelh.nhs.uk/screening/viewResource.asp?categoryID=1337&uri=http%3A//libraries.nelh.nhs.uk/common/resources/%3Fid%3D60968


http://rms.nelh.nhs.uk/screening/viewResource.asp?categoryID=1337&uri=http%3A//libraries.nelh.nhs.uk/common/resources/%3Fid%3D60968




Topic areaEducation should improve the ability of primary care practitioners to identify and manage depression; however the evidence for this is equivocal.

Supporting evidence2.2.4 A randomised controlled trial was used in 60

primary care practices in an English health district to assess the effectiveness of an educational programme based on a clinical practice guideline for improving the recognition and outcome of depression.

Although the programme was well received it did not lead to improvements in recognition of, or patient’s recovery from, depression.

Type II evidenceThompson C, Kinmonth A L, Stevens L, Peveler R C, Stevens A, Ostler K J, Pickering R M, Baker N G, Henson A, Preece J, Cooper D, Campbell M J. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Lancet 2005; 355: 185-91.

2.2.5 In Sweden an educational programme for GPs on the symptoms, diagnosis, prevention and treatment of depression was associated with a decrease in the number of suicides (and a decrease in the number of suicides of individuals unknown to either GPs or psychiatrists), a decrease in the use of inpatient care for depressive disorders, an increase in the prescription of antidepressants and a decrease in the prescription of major tranquilisers, sedatives and hypnotics.

Three years after the project ended inpatient care for depressive disorders had increased, the prescription of antidepressants had stabilised and the suicide rate had returned almost to baseline. These results suggest that the education programme had an effect on the detection and management of depression in the short term. Further research would be necessary to assess whether regular repetition of an educational programme would have long term effects.

Type III evidenceRutz W, Walinder J, Eberhard G, Holmberg G, von Knorring A L, Wistedt B, Aberg-Wistedt A. An educational program on depressive disorders for general practitioners on Gotland: background and evaluation. Acta Psychiatry Scand 1989; 79: 19-26

Rutz W, von Knorring L, Walinder J. Long-term effects of an educational program for general practitioners given by the Swedish Committee for the Prevention and Treatment of Depression. Acta Psychiat Scand 1992; 85: 83-8.



Topic areaEffective treatment of depression in primary and secondary care may reduce the occurrence of suicide and self harm

Supporting evidence2.2.6 The National Institute for Clinical Excellence has

issued guidance on the management of depression. This covers the treatment and management of depression as defined by ICD-10, this encompasses;

Mild depression Moderate depression Severe depression Severe depression with psychotic

symptoms

Evidence based guideline includes evidence of types I to IV and good practice points. National Institute for Clinical Excellence Depression. Management of depression in primary and secondary care. London: NICE; 2004.

2.2.7 The National Institute for Clinical Excellence has issued guidance on the identification and management of depression in children and young people in primary, community and secondary care

Evidence based guideline includes evidence of types I to IV and good practice points. National Institute of Clinical Excellence Depression in children and young people. Identification and management in primary, community and secondary care. London: NICE; 2005.



Topic areaSuicide is the leading cause of maternal death in the UK2. Early identification and treatment of postnatal depression may reduce the risk of maternal suicide. The evidence supporting the accuracy of screening for postnatal depression is equivocal

Supporting evidence2.2.8 In the United Kingdom the National Screening

Committees policy on screening for postnatal depression is that the available evidence does not support the use of screening tools. The Committee recommends that the Edinburgh postnatal depression scale should not be used as a screening tool but could be used as a checklist as part of the mood assessment for postnatal mothers when used in conjunction with professional judgement and a clinical interview

Type V evidence http://libraries.nelh.nhs.uk/screening/viewResource.asp?searchText=Postnatal+depression&searchZone=%2Fscreening%2FsearchResponse.asp&uri=http%3A//libraries.nelh.nhs.uk/common/resources/%3Fid%3D60978This policy was adopted on the basis of the evidence supporting the NICE Routine Antenatal Care Guideline. National Institute for Clinical Evidence/National Collaborating Centre for Women’s and Children’s Health. Antenatal Care: Routine care for the healthy pregnant woman. London: RCOG; 2003.

2.2.9 The Scottish Intercollegiate Guidelines Network has issued guidelines on postnatal depression and puerperal psychosis. These address;

Diagnosis, screening and prevention Management Prescribing issues in pregnancy and

lactation

These guidelines recommend that that the Edinburgh postnatal depression scale (EPDS) should be offered to women as part of a screening programme for postnatal depression. The guidelines state that the EPDS is not a diagnostic tool and that diagnosis of postnatal depression requires clinical evaluation. The guideline developers found some evidence that, in research settings, combining the EPDS with the General Health Questionnaire may be more effective than using either tool alone.

Evidence based guideline containing evidence of Types I to IV and good practice pointsScottish Intercollegiate Guidelines Network. Postnatal depression and puerperal psychosis. Edinburgh: SIGN; 2002.

2.2.10 The National Institute for Health and Clinical Excellence guidance on antenatal and postnatal mental health makes recommendations for the prediction, detection and treatment of mental disorders in women during pregnancy and the postnatal period.

Evidence based guideline includes evidence of types I to IV and good practice points. National Institute for Health and Clinical Excellence. Antenatal and postnatal mental health. Clinical Management and Service guidance .NICE clinical guideline 45. London: NICE; 2007.

2 Royal College of Obstetricians and Gynaecologists. Why mothers die 2000-2002. The sixth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG; 2004.


http://libraries.nelh.nhs.uk/screening/viewResource.asp?searchText=Postnatal+depression&searchZone=%2Fscreening%2FsearchResponse.asp&uri=http%3A//libraries.nelh.nhs.uk/common/resources/%3Fid%3D60978




2.3 MANAGEMENT OF DRUG AND ALCOHOL MISUSE

Topic areaPeople with drug and alcohol problems are at greater risk of suicide and self-harm than the general population. Effective management of these problems may reduce this risk although currently there is little direct evidence of this

Supporting evidence2.3.1 There is evidence that alcohol problems are

more prevalent in people with depression than in the general population and this group may be at greater risk of suicide than those with depression alone. The evidence concerning the effect of alcohol on the course of depression is equivocal although it is associated with a worse depression course, an increased risk of relapse and less likelihood of recovery; however antidepressants can be effective in this group.

Type I evidenceSullivan L E, Fiellin D A, O’Connor P G The prevalence and impact of alcohol problems in major depression: A systematic review. American J Med 2005; 118: 330-41.This review identified a limited number of studies of variable quality. Most studies addressed those with severe alcohol problems in inpatient care.

2.3.2 Guidelines for the management of harmful drinking and alcohol dependence in primary care have been developed by the Scottish Intercollegiate Guidelines Network. They address;

Detection and assessment Brief interventions for hazardous and

harmful drinking Detoxification Referral and follow up Advising families Information for discussion with patients

and carers

Evidence based guideline includes evidence of types I to V and good practice points.Scottish Intercollegiate Guidelines Network. The management of harmful drinking and alcohol dependence in primary care. Edinburgh: SIGN; 2003.

2.3.3 The Department of Health has published guidelines to support organisations in developing and implementing programmes that can improve the care of hazardous, harmful and dependent drinkers.

Good Practice GuidanceIncludes evidence of types II to V.Department of Health. Alcohol misuse interventions guidance on developing a local programme of improvement. London: DOH; 2005.

2.3.4 The Department of Health, Scottish Office Department of Health, Welsh Office and Department of Health and Social Services, Northern Ireland have published clinical guidelines on managing drug misuse and dependence. These guidelines are primarily for members of the medical profession

Type V evidenceDepartment of Health, Scottish Office Department of Health, Welsh Office, Department of Health and Social Services, Northern Ireland (1999) Drug misuse and dependence – guidelines on clinical management. London: Stationery Office; 1999.

2.3.5 The British Association for Psychopharmacology has developed guidelines for the treatment of substance misuse, addiction and comorbidity with psychiatric disorders. The primary focus of these guidelines is on pharmacological management

Evidence based guideline includes evidence of types I to IV. Lingford-Hughes A R, Welch S, Nutt D J. Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2004; 18: 293-335.



2.4 MANAGEMENT OF MENTAL ILLNESS

People with a mental illness are at greater risk of suicide and suicidal behaviour than the general population. Effective identification and management of mental illness may reduce this risk.

Topic areaThe National Confidential Inquiry into Suicide and Homicide by People with Mental Illness makes recommendations on clinical practice and policy that may reduce the risk of suicide by people under mental health care.

Supporting evidence2.4.1 The most recent report ‘Avoidable Deaths’

makes the following recommendations. Mental health services should take steps to;

Reduce absconding from in-patient units

Strengthen transition from ward to community

Ensure that high risk patients receive enhanced CPA, backed up by peer review in the highest risk cases

Respond robustly when care plans breakdown

Accept that prevention is possible in many cases, particularly for in-patient suicides

Strengthen observation procedures on the wards

Further improve the physical environment on wards

Develop services for dual diagnosis patients

Give greater emphasis to risk management in older people’s services

Type V evidenceAvoidable Deaths. Five year report of the National Inquiry into Suicide and Homicide by People with Mental Illness. London: Department of Health; 2006.

Supporting evidence2.4.2 The 2001 report ‘Safety First’ identified the

following common antecedents to suicide in patients with recent contact with mental health services; Adverse life events – 44% Suicidal ideation – 29% Disengagement – 27% Deliberate self harm - 25% Non-compliance with treatment - 19% Increased alcohol misuse - 18% Bereavement - 5% Clear evidence of relapse – 27%

Type V evidenceSafety First. Five year report of the National Inquiry into Suicide and Homicide by People with Mental Illness. London: Department of Health; 2001.



Topic areaStudies suggest that continuity of contact following discharge from psychiatric inpatient care may reduce the risk of suicide

Supporting evidence2.4.3 A case-control study of suicides in recent

inpatients found that discontinuity of care from a significant professional was associated with an increased risk of suicide. The highest risk of suicide occurred immediately after leaving hospital. The authors suggest that flexible community support should be made available at this stage in an effort to reduce this risk.

Type IV evidenceKing EA, Baldwin DS, Sinclair JMA, Baker NG, Campbell MJ, Thompson C. The Wessex Recent In-Patient Suicide Study 1. Case-control study of 234 recently discharged psychiatric patient suicides. Br J Psychiatry 2001; 178: 531-36.

2.4.4 Reductions in care were found to be strongly associated with suicide in people discharged from inpatient psychiatric care. In a case-control study of 149 people those who died from suicide were more likely to have had their care reduced at their final appointment before death (odds ratio 3.7 95% CI 1.8 – 7.6). The authors argue that maintaining care beyond the point of clinical recovery is important in protecting those who are at high risk of suicide.

Type IV evidenceAppleby L, Dennehey JA, Thomas CS, Faragher EB, Lewis G (1999) Aftercare and clinical characteristics of people with mental illness who commit suicide: a case-control study. Lancet 1999; 353: 1397-1400.



Topic areaPeople with a mental illness are at greater risk of suicide and suicidal behaviour than the general population. Effective identification and management of mental illness may reduce this risk.

Supporting evidence2.4.5 Community mental health team management is

more effective than standard care (usually hospital outpatient care) for people with severe mental illness in terms of promoting greater acceptance of treatment and reducing inpatient admissions and deaths by suicide.

Type I evidenceCoid J, Simmonds S, Joseph P, Marriot S, Tyrer P. Community Mental health teams (CMHTs) for people with severe mental illnesses and disordered personality. The Cochrane Database of Systematic Reviews, 1998, Issue 4.

2.4.6 Long-term treatment with clozapine may reduce the risk of suicide and suicidal behaviour in people with schizophrenia.

Type I evidenceHennen J, Baldessarini R J (2005) Suicidal risk during treatment with clozapine: a meta-analysis. Schizophr Res 2005; 73: 139-45. This review found a 3 fold reduction in the risk of suicidal behaviours in those who were treated long-term with clozapine however the authors stated that well designed studies are rare and that the only RCT did not find a reduced risk of completed suicide.

2.4.7 Long-term treatment with lithium may reduce the risk of suicide and suicidal behaviour in people with a major affective illness

Type I evidenceTondo L, Hennen J, Baldessarini R J. Lower suicide risk with long-term lithium treatment in major affective illness: a meta-analysis. Acta Psychiatr Scand 2001; 104: 163-72.

Cipriani A, Pretty H, Hawton K, Geddes J R (2005) Lithium in the prevention of suicidal behaviour and all-cause mortality in patients with mood disorders: A systematic review of randomized trials. Am J Psychiatr 2005;162: 1805 - 19.

Topic areaSuicide prevention training for carers of people with mental illness may reduce the likelihood of self harm and suicide

Supporting evidence2.4.8 ASIST (Applied Suicide Intervention Skills Training)

a two-day intensive, interactive and practice-dominated workshop designed to help care givers recognise and estimate risk of suicide may be beneficial in enhancing care givers skills and readiness to intervene.

Good Practice PointSilvola K, Sorenson Hoifodt T, Guttormsen T, Burkeland O. Applied suicide intervention skills training workshop. Tidsskr Nor Laegeforen 2003;123:2281-83.



2.5 PREVENTING SUICIDE IN PRISONS and POLICE CUSTODY

Topic areaMany individuals who enter custody share features with those from the general population who have an elevated risk of suicide and self harm. Policies and programmes that aim to minimise self harm and suicide might reduce this risk.

Supporting evidence2.5.1 The National Study of Prison Suicides 1999-2000

indicated the need for a number of changes in prison health care services, prison regime and environment.

Type V evidence Shaw J, Appleby L, Baker D. Safer prisons . A national study of prison suicides 1999-2000 by the National Confidential Inquiry into Suicides and Homicides by People with Mental Illness. London: Department of Health; 2003.Intervention studies are needed to show conclusively that implementation of the measures recommended in this report will prevent suicide.

2.5.2 The Royal College of Psychiatrists report ’Suicide in Prisons’, makes 26 recommendations for the attention of the prison health care service, psychiatrists and the Government. The report adopts a clinical approach to the prevention of suicide and treatment of suicidal thinking

Type V evidenceRoyal College of Physicians. Suicide in prisons. London: RCP; 2002.

2.5.3 Prison service order 2700 provides the prison service with instructions on identifying prisoners at risk of suicide and self-harm, on providing the care and support for these prisoners, and support for the staff caring for them. `

Type V evidenceHM Prison Service. Suicide and self harm prevention. Prison Service Order 2700. 2003

2.5.4 A comprehensive suicide prevention programme implemented throughout New York State was associated with a significant reduction in suicides over a 13 year period. Programme components were;

Policy and procedure guidelines to clarify roles of county jail, police department lockup and mental health agency personnel

Screening of detainees by trained jail/police officers

Supervision for inmates assessed as being at high –risk

Mental health observation housing – special cells and units offering varying levels of mental health and medical supervision

Scheduled mental health treatment Crisis intervention External hospitalisation for people with

serious mental illness Training for both jail and mental health staff Communication Investigation and monitoring of prisoner

deaths Staff debriefing

Good Practice Point: This study may represent type III evidence but insufficient information is provided to assess its quality.Cox J F, Morschauser P C (1997) A Solution to the problem of jail suicide. Crisis: Journal of Crisis Intervention and Suicide 1997; 18: 178-84.Differences in the criminal justice systems of the UK and the USA would need to be considered in deciding whether a similar programme might be effective in the UK.



Supporting evidence2.5.5 Suicide awareness training for prison staff may be

effective in improving reported attitudes and knowledge. This training is mandatory in the UK and is designed to assist prison staff in identifying and helping vulnerable prisoners. However long term studies would be needed to assess whether this training is effective in improving the identification of and assistance given to vulnerable prisoners and whether this has any impact on the suicide rate

Good Practice Point: Cutler J, Bailey J, Dexter P (1997) Suicide awareness training for prison staff: An evaluation. Issues in Criminal and Legal Psychology 1997; 28:65-9.This study may represent type III evidence but it is very small and insufficient information is provided to assess its quality

2.5.6 The World Health Organisation has published guidance for prison officers on preventing suicide. The document contains background information on suicide and identifies key activities that could be used as part of a suicide prevention programme.

Type V evidenceWorld Health Organisation. Preventing suicide. A resource for prison officers. Geneva: WHO; 2000.

2.5.7 Peer prevention initiatives may be a useful initiative for suicide prevention in prisons. One such programme in Canada has been evaluated. In this scheme the Samaritans are involved in the recruitment and training of inmate volunteers who wish to be involved in the peer suicide prevention service. Volunteers training includes;

The concept of befriending Effective and active listening Non-verbal communications The nature of mental illness Specific mental conditions including

schizophrenia, bipolar disorder, depression Suicide prevention and suicide intervention

Good Practice PointHall B, Gabor P. Peer suicide prevention in prison. Crisis 2004;25: 19-26.Qualitative evaluation demonstrated that this programme was generally perceived as worthwhile by both prison inmates and staff, however its impact on the occurrence of suicide and self harm is not reported



2.6 PHYSICAL ILLNESS

Topic areaPeople with physical illnesses, particularly cancer, neurological disorders, renal disease and chronic pain, are at greater risk of suicide than the general population. Policies & programmes that improve awareness, recognition and treatment of psychiatric illness, mental distress and suicidal ideation and behaviour in people with physical illness may reduce this risk.

Supporting evidence2.6.1 The Breast Cancer Centre and National Cancer

Control Initiative in Australia have published comprehensive clinical guidelines for the psychosocial care of adults with cancer.

Evidence based guideline containing evidence of types I to IV. National Breast Cancer Centre, National Cancer Control Initiative. Clinical practice guidelines for the psychosocial care of adults with cancer. Camperdown: National Breast Cancer Centre; 2003.

2.6.2 The Royal College of Psychiatrists and Royal College of Physicians have published guidance of the psychological care of medical patients. This contains recommendations to promote the psychological care of medical patients in general hospitals.

Type V evidenceReport of the joint working party of. the Royal College of Physicians, Royal College of Psychiatrists. The psychological care of medical patients. A practical guide. London: RCP,RCPsych; 2003.

2.6.3 The National Institute of Clinical Excellence has published guidance on improving supportive and palliative care for adults with cancer.

Evidence based guideline containing evidence of types I to V.National Institute for Clinical Excellence. Improving supportive and palliative care for adults with cancer. The manual. London: NICE; 2004.



2.7 USEFUL RESOURCES


http://www.ahrq.gov/clinic/3rduspstf/suicide/suiciderr.htmThe United States Preventative Services Task Force; screening for suicide risk; recommendations and Topic area.

http://www.ahrq.gov/clinic/3rduspstf/depression/depressrr.htm The United States Preventative Services Task Force; screening for depression; recommendations and Topic area.

http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=6524The Canadian Task Force on Preventative Health Care recommendations on screening for depression in primary care

http://www.nsc.nhs.uk/uk_nsc/uk_nsc_ind.htmUK National Screening Committee

http://www.nice.org.uk/pdf/cg023fullguideline.pdfNICE guideline on management of depression in primary and secondary care.

http://www.nice.org.uk/pdf/cg028fullguideline.pdfNICE guideline on the identification and management of depression in children and young people.

http://www.nice.org.uk/guidance/CG45/guidance/pdf/EnglishNICE guidance on Antenatal and postnatal mental health

http://www.sign.ac.uk/guidelines/fulltext/60/index.htmlSIGN guideline on postnatal depression and puerperal psychosis

http://www.sign.ac.uk/guidelines/fulltext/74/index.htmlSIGN guideline on the management of harmful drinking and alcohol dependence in primary care.

http://www.ahrq.gov/clinic/3rduspstf/alcohol/alcomisrs.htmUS Preventative Services Task Force recommendations on screening and counseling interventions in primary care to reduce alcohol misuse

http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4123297&chk=lLGV84DOH guidance on developing alcohol misuse interventions

www.doh.gov.uk/drugdep.htmDOH Guidelines Drug Misuse and Dependence – Guidelines on Clinical management available

http://www.rcgp.org.uk/drug/docs/cocaine.pdfRoyal College of GPs guidance on working with crack and cocaine users


http://www.rcgp.org.uk/drug/docs/cocaine.pdf

http://www.doh.gov.uk/drugdep.htm

http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4123297&chk=lLGV84



http://www.ahrq.gov/clinic/3rduspstf/alcohol/alcomisrs.htm

http://www.sign.ac.uk/guidelines/fulltext/74/index.html

http://www.sign.ac.uk/guidelines/fulltext/60/index.html

http://www.nice.org.uk/guidance/CG45/guidance/pdf/English

http://www.nice.org.uk/pdf/cg028fullguideline.pdf

http://www.nice.org.uk/pdf/cg023fullguideline.pdf

http://www.nsc.nhs.uk/uk_nsc/uk_nsc_ind.htm

http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=6524

http://www.ahrq.gov/clinic/3rduspstf/depression/depressrr.htm

http://www.ahrq.gov/clinic/3rduspstf/suicide/suiciderr.htm


http://www.bap.org.uk/consensus/BAP_Guidelines.pdfBritish Association for Psychopharmacology guidelines on management of substance abuse, addiction and comorbidity

http://www.update-software.com/abstracts/AB005031.htmCochrane Review on psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification

http://www.update-software.com/abstracts/AB004147.htmCochrane review psychosocial combined with agonist versus agonist treatments alone for treatment of opioid dependence

http://www.update-software.com/abstracts/AB000270.htmCochrane review of community mental health teams for people with severe mental illnesses and disordered personality

http://www.medicine.manchester.ac.uk/suicideprevention/nci/Useful/avoidable_deaths_full_report.pdf‘Avoidable Deaths’. Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, 2006

www.doh.gov.uk/mentalhealth/safetyfirstSafety First. Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, 2001

http://hebw.cf.ac.uk/mhnsf/intro.htmHealth Evidence Bulletin (Wales) Mental Health National Service Framework edition

http://www.wales.gov.uk/subihealth/content/keypubs/pdf/adult-mental-nsf-e.pdfAdult Mental Health Services. A National Framework for Wales. Cardiff: Welsh Assembly Government, April 2002.

www.livingworks.netLink to LivingWorks Education website for information on ASIST and other suicide prevention training

http://www.dh.gov.uk/assetRoot/04/03/43/01/04034301.pdf‘Safer Prisons’ National Study of Prison Suicides 1999-2000 by the National Confidential Inquiry into Suicides and Homicides by People with Mental Illness

http://www.rcpsych.ac.uk/publications/cr/council/cr99.pdfThe Royal College of Psychiatrists report ‘Suicide in Prisons’

http://pso.hmprisonservice.gov.uk/PSO_2700_suicide_and_self_harm_prevention.docHM Prison Service – Suicide and self harm prevention

http://www.nhmrc.gov.au/publications/_files/cp90.pdfhttp://www.nhmrc.gov.au/publications/_files/cp90.pdfNational Breast Cancer Centre and National Cancer Control Initiative (Australia) clinical practice guidelines for the psychosocial care of adults with cancer


http://www.nhmrc.gov.au/publications/_files/cp90.pdf

http://www.nhmrc.gov.au/publications/_files/cp90.pdf

http://pso.hmprisonservice.gov.uk/PSO_2700_suicide_and_self_harm_prevention.doc

http://pso.hmprisonservice.gov.uk/PSO_2700_suicide_and_self_harm_prevention.doc

http://www.rcpsych.ac.uk/publications/cr/council/cr99.pdf

http://www.dh.gov.uk/assetRoot/04/03/43/01/04034301.pdf

http://www.livingworks.net/

http://www.wales.gov.uk/subihealth/content/keypubs/pdf/adult-mental-nsf-e.pdf

http://hebw.cf.ac.uk/mhnsf/intro.htm

http://www.doh.gov.uk/mentalhealth/safetyfirst

http://www.medicine.manchester.ac.uk/suicideprevention/nci/Useful/avoidable_deaths_full_report.pdf


http://www.update-software.com/abstracts/AB000270.htm



http://www.bap.org.uk/consensus/BAP_Guidelines.pdf


http://www.rcplondon.ac.uk/pubs/wp_pcomp.pdfRoyal College of Physicians/Royal College of Psychiatrists document ‘The psychological care of medical patients’

http://www.nice.org.uk/pdf/csgspmanual.pdfImproving Supportive and Palliative Care for Adults with Cancer. National Institute for Clinical Excellence.


http://www.nice.org.uk/pdf/csgspmanual.pdf

http://www.rcplondon.ac.uk/pubs/wp_pcomp.pdf


LEVEL 3: CRISIS INTERVENTION, MANAGING SUICIDAL BEHAVIOUR

TERMS USED IN THIS SECTIONThe terms ‘attempted suicide’, ‘para-suicide’, ‘deliberate self-harm’ and ‘self injurous behaviour’ are all used to refer to behaviours that result in self-inflicted injury or poisoning. This document uses the term ‘self-harm’ to refer to all such behaviour regardless of its purpose or intent. Currently this seems to be the preferred term and is used on the basis that there is an increasing acceptance that many forms of self-harming behaviour are likely to occur along a continuum that ranges from suicidal ideation to completed suicide3.

The term suicidal behaviour is used to refer to completed suicide, thoughts about suicide (suicidal ideation) and self harm.

This document summarises the available evidence for; Monitoring self harm Interventions to reduce suicidal ideation Assessment and short term management of people who self harm Secondary prevention of self harm The role of voluntary agencies

3 Van Heeringen K, Hawton K, Williams JMG. Pathways to suicide: an integrative approach. In: Hawton K. van Heeringen K, editors. The international handbook of suicide and attempted suicide. Chichester:Wiley;2002.Version: 1 Date:February 2007 Status: DraftAuthor: Sian Price Page: 35 of 64 Classification:


3.1 MONITORING SELF HARM

Monitoring self harm may help identify means of suicide prevention. Self harm is a significant risk factor for suicide. Trends in self harm have implications for clinical services and may reflect levels of psychopathology in the community4. Understanding the links between non fatal self harm and completed suicide will support research and the development of clinical services. Accurate monitoring of health service contacts for self harm would support this and help ensure that those who self harm receive appropriate health care.

Topic areaClinical databases of hospital attendances for self harm have proved useful in identifying trends in self harm

Supporting evidence3.1.1 This paper describes the process involved in

setting up a clinical database of hospital attendances for self harm and includes a checklist of issues that should be considered.

Type V evidenceHorrocks J, House A, Owens D Establishing a clinical database for hospital attendances because of self-harm. Psychiatric Bulletin 2004; 28: 137-39.

3.1.2 A study in Oxford demonstrated that over an 11 year period (1985 -1995) there was a substantial increase in rates of self harm, in particular there was a marked rise amongst young men. This rise had implications for both general medical and psychiatric services

Type IV evidenceHawton K, Fagg J, Simkin S, Bale E, Bond A. Trends in deliberate self-harm in Oxford, 1985-1995. Implications for clinical services and the prevention of suicide. Br J Psychiatry, 1997;171: 556-60.

3.1.3 A subsequent study in Oxford (1990 - 2000) highlighted a decline in paracetamol overdoses towards the end of the study period. It is argued that this is a consequence of the reduction in paracetamol pack sizes.

The study also found a rise in antidepressant overdoses, especially SSRIs and an increase in the use of alcohol.

These changes in patient characteristics have implications for service provision.

Type IV evidenceHawton K, Harriss L, Hall S, Simkin S, Bale E, Bond A. Deliberate self-harm in Oxford, 1990-2000: a time of change in patient characteristics. Psychol Med 2003; 33: 987-95.

4 Hawton K, Harriss L, Hall S, Simkin S, Bale E, Bond A (2003) Deliberate self-harm in Oxford, 1990-2000: a time of change in patient characteristics. Psychol Med 2003;33:987-95.Version: 1 Date:February 2007 Status: DraftAuthor: Sian Price Page: 36 of 64 Classification:


3. 2 INTERVENTIONS TO REDUCE SUICIDAL IDEATION

Suicidal ideation is recognised as a risk factor for completed suicide1

Topic areaInterventions that reduce suicidal thoughts may help to reduce the risk of an individual self harming or dying from suicide.

Supporting evidence3.2.1 Brief psychodynamic – interpersonal therapy may

be effective in reducing suicidal ideation. Patients who presented to an accident and emergency department following deliberate self-poisoning were given four sessions of psychodynamic interpersonal therapy by a nurse therapist in their own home. Six months post treatment the psychotherapy group had significantly greater reduction in suicidal ideation and a significant reduction in repetition of self harm than those who received treatment as usual. Those with less severe depression, no prior history of self harm and who had not taken alcohol with the overdose were most likely to benefit

Type II evidenceGuthrie E, Kapur N, Mackway-Jones K, Chew-Graham C, Moorey J, Mendel E, Marino-Francis F, Sanderson S, Turpin C, Boddy G. Predictors of outcome following brief psychodynamic-interpersonal therapy for deliberate self-poisoning. Aust N Z J Psychiatry 2003;37:532-36.

The inclusion criteria used in this study may have meant that those most at risk of repetition of suicidal behaviour were excluded, only half those eligible for inclusion agreed to participate.



3.3 ASSESSMENT AND SHORT TERM MANAGEMENT OF PEOPLE WHO SELF HARM

Repetition of self harm is a major risk factor for suicide.

Topic areaSuicidal intent at the time of self harm is associated with risk of future suicide but currently there is no method identifying the individuals who self harm and are at greatest risk of completing suicide

Supporting evidence3.3.1 A study that evaluated the predictive value of the

Beck Suicidal Intent scale found that it cannot usefully predict which patients will die from suicide.

2489 patients were included in the study with a mean follow up of 5.2 years

Type IV evidenceHarriss L, Hawton K. Suicidal intent in deliberate self-harm and the risk of suicide: The predictive power of the Suicide Intent Scale. J Affect Disord 2005;86:225-33.

Topic areaThose whose index episode of self harm uses a method of high lethality and those who have an escalating severity of self poisoning are at greater risk of death from suicide. Enhanced treatment and monitoring of those who repeat self harm, use more lethal methods or escalate severity of self poisoning may reduce the risk of subsequent suicide.

Supporting evidence3.3.2 Long term follow up showed that those who

repeated self harm were at significantly greater risk of suicide than those who had a single episode; this risk was greater in female than males. Suicide risk was further increased in females with multiple repeat episodes of self harm. Length of follow up from initial episode of self harm ranged from 3 to 12 years.

Type IV evidenceZahl DL, Hawton K. Repetition of deliberate self-harm and subsequent suicide risk: long-term follow-up study of 11 583 patients. Br J Psychiatry 2004;185:70-5.

3.3.3 A study of 3690 individuals admitted to Christchurch Hospital in New Zealand following deliberate self harm showed that over a 10 year follow up period those whose index episode of self harm used a method of high lethality (carbon monoxide poisoning, hanging, gunshot, jumping, drowning, motor vehicle accident or burning) had a significantly greater risk of death from suicide than those who use less lethal methods (overdose/poisoning, cutting/stabbing)

Type IV evidenceGibb SJ, Beautrais AL, Fergusson DM. Mortality and further suicidal behaviour after an index attempt: a 10 year study. Aust N Z J Psychiatry 2005; 39:95-100.



Supporting evidence3.3.4 A study in Australia identified several variables

associated with an increased risk of suicide in individuals who present with an increasing severity of self poisoning. These variables were increase in dose ingested, decrease in coma score and an increase in drug or alcohol misuse. The best predictor of completed suicide was combining an increase of 70 or more in the number of tablets ingested with a decrease in Glasgow coma score of 2 or more.

Type IV evidenceCarter G, Reith DM, Whyte IM, McPherson M. Repeated self-poisoning: increasing severity of self-harm as a predictor of subsequent suicide. Br J Psychiatry 2005;186:253-57.

Topic areaPsychosocial and psychiatric assessment of people who self harm may help to reduce the likelihood of repetition

Supporting evidence3.3.5 Patients treated in a general hospital who

received a psychosocial assessment after self poisoning were less likely to self poison again within 12 weeks than those were not assessed.

Patients who had certain risk factors for repetition of self harm (such as previous self poisoning, psychiatric history and substance abuse) were more likely to receive a psychosocial assessment.

Type IV evidenceKapur N, House A, Dodgson K, May C, Creed F. Effect of general hospital management on repeat episodes of deliberate self poisoning: cohort study. BMJ 2002;325:866-67.

3.3.6 Patients who self harm and are discharged directly from the accident and emergency department without a psychiatric assessment are more likely to repeat self harm in the following year than those who are assessed before discharge.

Patients who were not assessed were more likely to have a past history of self harm, be in the 20-34 year age group and to have presented difficult behaviour in the accident and emergency department. Those who presented between 5pm and 9am were less likely to be assessed than those presenting between 9am and 5pm

Type IV evidenceHickey L, Hawton K, Fagg J, Weitzel H. Deliberate self-harm patients who leave the accident and emergency department without a psychiatric assessment. A neglected population at risk of suicide. J Psychosom Res 2001;50:87-93.

3.3.7 Patients who discharge themselves from the accident and emergency department before completion of an initial assessment are more likely to repeat self harm in the following year than those who complete initial assessment

Type IV evidenceCrawford MJ, Wessely S. Does initial management affect the rate of repetition of deliberate self harm? Cohort study. BMJ 1998;317:985.



Topic areaThe quality of psychosocial can be improved by training and audit

Supporting evidence3.3.8 The STORM (Skills Training on Risk

Management) Project, a district wide programme on the assessment and management of suicide risk, was effective in improving the skills of accident and emergency, primary care and mental health staff. However a before and after analysis of suicide rates showed that there was no significant improvement following the intervention.

Good practice pointAppleby L, Morriss R, Gask L, Roland M, Lewis B, Perry A, Battersby L, Colbert N, Green G, Amos T, Davies L, Faragher B. An educational intervention for front-line health professionals in the assessment and management of suicidal patients (The STORM Project) Psychol Med 2000;30:805-12.

Type III evidenceMorriss R, Gask L, Webb R, Dixon C, Appleby L. The effects on suicide rates of an educational intervention for front-line health professionals with suicidal patients (the STORM Project). Psychol Med 2005;35:957-60.

3.3.9 A one hour teaching session improved the quality of psychosocial assessment performed by junior doctors and nurses working in the accident and emergency department. Before the intervention 13% of records were judged to be adequate, following the intervention this went up to 46%.

Type III evidenceCrawford MJ, Turnbull G, Wessely S. Deliberate self harm assessment by accident and emergency staff – an intervention study. Journal of Accident and Emergency Medicine 1998;15:18-22.

3.3.10 Clinical audit can be effective in improving the quality of psychosocial assessment of adults presenting to accident and emergency department s with deliberate self harm.

Following an initial audit using the Royal College of Psychiatrists standards for service provision5 medical staff were encouraged to use a pre-printed checklist for risk assessment and all new senior house officers were required to attend a training seminar conducted by a senior lecturer in psychiatry.

A subsequent audit showed that a higher proportion of patients were assessed by a mental health specialist and that the quality of information recorded had improved significantly.

Good practice pointDennis M, Evans A, Wakefield P, Chakrabarti S. The psychosocial assessment of deliberate self harm: using clinical audit to improve the quality of the service. Emergency Medical Journal 2001;18:448-50.

3.3.11 A small study in Wales showed no significant differences in outcome between psychosocial assessments carried out by a trained mental health nurse and those completed by senior house officers in psychiatry.

Good practice pointGriffin G, Bisson JI. Introducing a nurse-led deliberate self-harm assessment service. Psychiatric Bulletin 2001;25:212-14.

5 Royal College of Psychiatrists. The general hospital management of adult deliberate self-harm. A consensus statement on standards for service provision. London:RCP;1994Version: 1 Date:February 2007 Status: DraftAuthor: Sian Price Page: 40 of 64 Classification:


Topic areaShort term management of self harm includes treatment of self-poisoning and self injury, and psychosocial and risk assessment.

Supporting evidence3.3.12 The National Institute for Clinical Excellence has

commissioned guidelines on the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. The guideline is for all people aged 8 years and over.The guideline addresses

Service user experience of services Consent The medical and surgical care of people

who have self harmed Psychosocial assessment after hospital

attendance for self-harm Psychological, pharmacological and

psychosocial interventions for the management of self- harm

Evidence based guideline includes evidence of types I to IV and good practice points. National Institute for Clinical Excellence. Self-harm: the short- term physical and psychological management and secondary prevention of self-harm in primary and secondary care. London: NICE; 2004.

3.3.13 The New Zealand Guidelines Group has issued evidence based guidelines on the assessment and management of people at risk of suicide. These include;

Assessment in emergency departments and by mental health services including assessment of risk

Crisis/initial management Assessment and crisis management in

specific populations including the elderly and children

Evidence based guideline includes evidence of types I to IV and good practice points. New Zealand Guidelines Group. The assessment and management of people at risk of suicide. Wellington: New Zealand Ministry of Health/New Zealand Guidelines Group; 2003.



3.4. SECONDARY PREVENTION OF SELF HARM

Secondary prevention of self harm is important in reducing the likelihood of completed suicide

Topic areaPsychosocial interventions may be helpful in reducing repetition of self harm in children, adolescents and young people

Supporting evidence3.4.1 Dialectical behavioural therapy (DBT) may be

of benefit in preventing suicidal behaviour during inpatient admission in acute care child and adolescent units. However at 1 year follow up there was no difference between those receiving DBT and the treatment as usual group in self harm, suicidal ideation and symptoms of depression

Type II evidenceKatz LY, Cox BJ, Gunasekara S, Miller AL. Feasibility of dialectical behaviour therapy for suicidal inpatient adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 2004;43:276-82.

This was a small pilot study with only 62 participants, 8 of these were not followed up at 1 year.

3.4.2 Group therapy may be effective in preventing repeated self harm in the short term in adolescents. A pilot study in Manchester found that developmental group psychotherapy designed specifically for adolescents who harm themselves was more effective than routine care in preventing repetition of self harm in the seven months following the intervention. The treatment was not more effective than routine care in improving depression

Type II evidenceWood A, Trainor G, Rothwell J, Moore A, Harrington R/. Randomized trial of group therapy for repeated deliberate self-harm in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 2001;40:1246-53.

The results of this study should be treated with caution as it a pilot study with a total on 31 participants in each arm.

3.4.3 Multisystemic therapy (MST), an intensive family and community based treatment, may be effective in preventing repetition of self harm in young people.

A study in the USA compared the effect of MST with that of psychiatric hospitalisation in a group of young people who had been approved for admission to hospital as a result of suicidal ideation, self harm, psychosis or threat of harm to self or others.

MST was significantly more effective than hospitalisation in reducing self harm in the 16 months following recruitment to the study

Type II evidenceHuey SJ, Henggeler SW, Rowland MD, Halliday-Boykins CA, Cunningham PB, Pickrel SG, Edwards J. Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies. Journal of the American Academy of Child and Adolescent Psychiatry 2004;43:183-90.

Consideration needs to be given to whether the results of this study would be generalisable to the UK because of the characteristics of the sample used and the differences between the health systems of the USA and the UK.



Supporting evidence3.4.4 Telephone counselling services might be

effective in improving mental state and reducing suicidal ideation in adolescents.

An evaluation of the effectiveness of telephone counselling services set up as part of Australia’s National Youth Suicide Prevention Strategy found that significant decreases in suicidality and significant improvement in mental state were found during the course of counselling sessions.

Type III evidenceKing R, Nurcombe B, Bickman L, Hides L, Reid W. Telephone counselling for adolescent suicide prevention. Changes in suicidality and mental state from beginning to end of a counselling session. Suicide Life Threat Behav 2003;33:400-11.

Topic areaPsychosocial interventions may be useful in preventing repetition of self harm

Supporting evidence3.4.5 A systematic review of psychosocial interventions

following self harm found that cognitive behavioural therapies had a beneficial effect on repetition of self harm, but there was uncertainty around the size of the effect

Type I evidenceVan der Sande R, Buskens E, Allart E, van der Graaf Y, van Engeland H. Psychosocial intervention following suicide attempt: a systematic review of treatment interventions. Acta Psychiatr Scand 1997;96:43-50.

This review may be subject to bias because it included only studies published in English

3.4.6 A systematic review of psychosocial interventions for self harm concluded that there is considerable uncertainty around which psychosocial treatments are most effective in preventing repetition of deliberate self harm.

Reduced repetition was found with problem solving therapy and provision of emergency cards but these were not statistically significant.

Significantly reduced repetition was found with dialectical behaviour therapy when compared with standard aftercare for women who were multiple repeaters of self harm.

Type I evidenceHawton K, Townsend E, Arensman E, Gunnell D, Hazell P, House A, van Heeringen K. Psychosocial and pharmacological treatments for deliberate self harm. The Cochrane Database of Systematic Reviews, 1999, Issue 4.

3.4.7 A meta-analysis of randomised controlled trials of problem solving therapy found that for deliberate self harm patients it significantly improved scores for depression and hopelessness when compared with treatment as usual. Significantly more patients in the treatment groups reported improvement in their problems

Type I evidenceTownsend E, Hawton K, Altman DG, Arensman E, Gunnell D, Hazell P, House A, Van Heeringen K. The efficacy of problem-solving treatments after deliberate self-harm: meta-analysis of randomized controlled trials with respect to depression, hopelessness and improvement in problems. Psychol Med 2001;31:979-88.



Supporting evidence3.4.8 Brief psychodynamic – interpersonal therapy may

be effective in reducing repetition of self harm. Patients who presented to an accident and emergency department following deliberate self-poisoning were given four sessions of psychodynamic interpersonal therapy by a nurse therapist in their own home. Six months post treatment the psychotherapy group had a significant reduction in repetition of self harm when compared with those who received treatment as usual.

Type II evidenceGuthrie E, Kapur N, Mackway-Jones K, Chew-Graham C, Moorey J, Mendel E, Marino -Francis F, Sanderson S, Turpin C, Boddy G. Randomised controlled trial of brief psychological intervention after deliberate self poisoning. BMJ 2001; 323:135-8.The inclusion criteria used in this study may have meant that those most at risk of repetition of suicidal behaviour were excluded, only half those eligible for inclusion agreed to participate.

3.4.9 Brief manual assisted cognitive therapy was not more effective than treatment as usual in preventing repetition of self harm but an economic evaluation suggested that it was superior to treatment as usual when cost and effectiveness were combined.

The patients included in this study had presented with recurrent deliberate self harm and were followed up for 1 year. Patients in the treatment group received a booklet based on cognitive behavioural therapy and were offered up to five plus two booster sessions of cognitive behaviour therapy from a therapist in the first 3 months of the study.

Type II evidenceTyrer P, Thompson S, Shmidt U, Jones V, Knapp M, Davidson K, Catalan J, Airlie J, Baxter S, Byford S, Byrne G, Cameron S, Caplan R, Cooper S, Ferguson B, Freeman C, Frost S, Godley J, Greenshields J, Henderson J, Holden N, Keech P, Kim L, Logan K, Manley C, MacLeod A, Murphy R, Patience L, Ramsey L, De Munroz S, Scott J, Seivewright H, Sivakumar K, Tata P, Thornton S, Ukoumunne OC, Wessely S. Randomised controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study. Psychol Med 2003; 33:969-76.

3.4.10 In a small study in the USA 10 sessions of cognitive therapy were found to be effective in preventing repetition of deliberate self harm. When compared to usual care the group receiving cognitive therapy were significantly less likely to repeat self harm in the 18 months following intervention

Type II evidenceBrown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, Bech AT. Cognitive therapy for the prevention of suicide attempts. JAMA 2005;294:563-70.

Generalisation of this study to the UK may be limited. The majority of the sample were African Americans and it is recognised that this group have a lower rate of completed suicide than whites. The authors note that the small number of changes in episodes of self harm in the follow up period may affect the studies significance, and a large number of participants (25% of intervention group) were lost to follow up at 12 months



Topic areaImplementation of intensive in-patient followed by a community intervention programme for all those who self harm is not justified by the available evidence.

Supporting evidence3.4.11 A controlled study in the Netherlands found that

brief admission to a special crisis-intervention unit and problem-solving aftercare was no more effective than treatment as usual in preventing repetition of self harm in the 12 months following intervention. There were no differences between the control and intervention groups in scores for psychological well being and hopelessness at 3, 6, and 12 months

Type II evidenceVan der Sande R, Van Rooijen L, Buskens E, Allart E, Hawton K, Van der Graaf Y, Van Engeland H. Intensive inpatient and community intervention versus routine care after attempted suicide: A randomised controlled intervention study. Br J Psychiatry 1997;171:35-41.

Topic areaCrisis cards are unlikely to be effective in preventing recurrence of self harm.

Supporting evidence3.4.12 Patients randomised to receive a card offering a

24 hour crisis telephone consultation with an on-call psychiatrist for up to six months after an index episode of self harm were as likely to repeat self harm in the 12 months following the index episode as those who did not receive a card.

Type II evidenceEvans J, Evans M, Morgan G, Hayward A, Gunnell D. Crisis card following self-harm: 12-month follow-up of a randomised controlled trial. Br J Psychiatry 2005;187:186-87.

Topic areaInviting people who have self harmed to consult their GP does not appear to be effective in preventing repetition of self harm

Supporting evidence3.4.13 An intervention in which GPs sent a letter to

people who had self harmed inviting them to consult combined with guidelines on the assessment and management of deliberate self harm for GPs to use in these consultations did not result reduce the incidence of self harm in the 12 months following the index episode

Type II evidenceBennewith O, Stocks N, Gunnell D, Peters TJ, Evans MO, Sharp DJ. General practice based intervention to prevent repeat episodes of deliberate self harm: cluster randomised controlled trial. BMJ 2002;324:1254-157.



Topic areaIt may be possible to improve compliance with referral to after care in people who have self harmed3.4.14 A study in Belgium investigated the benefit of

home visits by community nurses in increasing compliance with referral to out patient after care amongst people who had been admitted to a hospital accident and emergency department following self harm. The intervention significantly improved compliance with referral in the intervention group. Although there was a decrease in repetition of self harm between the intervention and control groups this did not reach significance

Supporting evidenceType III evidenceVan Heeringen K, Jannes S, Buylaert W, Henderick H, De Bacquer D, Van Remoortel J. The management of non-compliance with referral to out-patient after-care among attempted suicide patients: A controlled intervention study. Psychol Med 1995;25:963-70.

This study may not be directly generalisable to the UK because if differences between the roles of community nurses in the UK and Belgium

Topic areaPharmacological interventions may be of benefit in preventing repetition of self harm.

Supporting evidence3.4.15 A systematic review of pharmacological

treatments for deliberate self harm found that depot flupenthixol significantly reduced rates of repetition of deliberate self harm when compared with placebo

Type I evidenceHawton K, Townsend E, Arensman E, Gunnell D, Hazell P, House A, van Heeringen K. Psychosocial and pharmacological treatments for deliberate self harm. The Cochrane Database of Systematic Reviews 1999, Issue 4.

Topic areaMajor depression may be inadequately treated both before and after episodes of self harm

Supporting evidence3.4.16 A small study in Finland investigated a group of

43 patients with unipolar DSM-III-R major depression and found that in the month before an episode of self harm only 7 were receiving anti-depressants in adequate doses and 7 were receiving weekly psychotherapy.1 month following self harm, 7 were receiving antidepressants in adequate doses and 9 were receiving weekly psychotherapy

Type IV evidenceSuominen KH, Isometsa ET, Henriksson MM, Ostamo AI, Lonnqvist JK. Inadequate treatment for major depression both before and after attempted suicide. Am J Psychiatry 1998;155:1778-80.



3.5. THE ROLE OF VOLUNTARY AGENCIES

Topic areaLay volunteers, such as The Samaritans have a role in crisis intervention

Supporting evidence3.5.1 A review of studies of suicide prevention

centres, including several studies examining the effectiveness of the Samaritans in the UK , identified 14 studies of which 7 reported a preventative effect

Type IV evidenceLester D. The effectiveness of suicide prevention centres: a review. Suicide Life Threat Behav 1997;27:304-10.

This review did not contain sufficient information to assess its quality

3.5.2 Signs displaying the Samaritans’ national number were erected in car parks in the New Forest (in southern England). During the three year intervention period the number of car park suicides fell significantly, no significant changes were found in comparable forest districts.

Type III evidenceKing E, Frost N. The New Forest Suicide Prevention Initiative (NFSPI). Crisis 2005;26:25-33.


These are web inks to some of the resources and documents referred to in the text.

http://www.medicine.manchester.ac.uk/storm/trainingLink for STORM training –University of Manchester

http://www.bps.org.uk/downloadfile.cfm?file_uuid=C11587F1-7E96-C67F-DD13-357E1AA3B75D&ext=pdfLink to full NICE guideline ‘The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care’

http://www.samaritans.org.uk/know/about/about.shtmThe Samaritans website

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001764/frame.htmlCochrane review on Psychological and Pharmacological treatments for deliberate self harm

http://www.nzgg.org.nz/guidelines/0005/Suicide_Fulltext.pdf#page=57New Zealand guidelines on The Assessment and Management of People at Risk of Suicide


http://www.nzgg.org.nz/guidelines/0005/Suicide_Fulltext.pdf#page=57

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001764/frame.html

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001764/frame.html

http://www.samaritans.org.uk/know/about/about.shtm

http://www.bps.org.uk/downloadfile.cfm?file_uuid=C11587F1-7E96-C67F-DD13-357E1AA3B75D&ext=pdf

http://www.bps.org.uk/downloadfile.cfm?file_uuid=C11587F1-7E96-C67F-DD13-357E1AA3B75D&ext=pdf

http://www.medicine.manchester.ac.uk/storm/training


LEVEL 4: POSTVENTION

The term ‘postvention’, probably first used by Shneidman in 19726, is used to describe ‘appropriate and helpful acts that come after a dire event’.

The approach at level 4 differs from levels 1 to 3 in that it is concerned with the aftermath of suicide. It addresses some of the issues around helping those bereaved by suicide, learning lessons from completed suicide and media reporting of suicide.

6 Shneidman ES. Foreword. In Cain AC, editor. Survivors of suicide. Springfield: Charles C Thomas; 1972. p ix-xi.Version: 1 Date:February 2007 Status: DraftAuthor: Sian Price Page: 48 of 64 Classification:


4.1: REVIEWING COMPLETED SUCIDES

RationaleReviewing suicide of people known to mental health services and those in the community who have not been in contact with mental health services may enable lessons to be learned that could contribute to suicide prevention.

Topic AreaThe National Confidential Inquiry into Suicide and Homicide by people with Mental Illness7 reviews suicides of people in contact with mental health services and makes recommendations for service practice and development that can be used to inform local suicide prevention strategies.

Supporting evidence

4.1.1 The National Institute for Mental Health in England has produced a toolkit that allows services to assess whether they are addressing the Inquiry recommendations. The audit involves a retrospective examination of the notes and records of people who have completed suicide or who have been considered to be at significant risk of suicide.

Type IV evidenceNational Institute for Mental Health in England. Preventing suicide – A toolkit for mental health services. Leeds: NIMHE; 2003.

Topic AreaPsychological autopsy is a valuable method of reviewing completed suicide. It uses structured interviews with family members, friends and health care workers. Information is also collected from healthcare records and forensic examination. Use of case control designs enables an estimation of the role of specific risk factors.8

Supporting evidence

4.1.2 This review of methodological issues around psychological autopsy is designed to assist those considering using this method and those who need to assess reports of psychological autopsy studies.

Good Practice PointHawton K, Appleby L, Platt S, Foster T, Cooper J, Malmberg A, Simkin S. The psychological autopsy approach to studying suicide: a review of methodological issues. J Affect Disord 1998;50:269-76.

7 Department of Health. Avoidable Deaths: Five year report of the National Confidential Inquiry into suicide and homicide by people with mental illness. London: DOH; 2006. Available:http://www.medicine.manchester.ac.uk/suicideprevention/nci/Useful/avoidable_deaths_full_report.pdf

8 Isometsa ET. Psychological autopsy studies – a review. Eur Psychiatry 2001;16:379-85.Version: 1 Date:February 2007 Status: DraftAuthor: Sian Price Page: 49 of 64 Classification:




Topic AreaRoot cause analysis is a structured approach to investigating adverse events. It is the approach advocated by the National Patient Safety Agency.

Supporting evidence

4.1.3 This paper reviews the benefits and limitations of root cause analysis in the investigation of serious untoward events in mental health services. It concludes that the method is not proven as a means of reducing serious untoward events but suggests that the method might be more consistent and less threatening and demoralising for staff than other approaches.

Good Practice PointNeal LA, Watson D, Hicks T, Porter M, Hill D. Root cause analysis applied to the investigation of serious untoward incidents in mental health services Psychiatric Bulletin 2004;28:75-7.

Topic AreaApproximately three-quarters of people who die from suicide are not in contact with mental health services at the time of their death. These suicides are not routinely examined but review of these cases may be useful in informing suicide prevention initiatives.

Supporting evidence

4.1.4 A case controlled psychological autopsy study of people not in contact with mental health services at the time of their suicide found that nearly a third of cases (32%) had no current mental illness, although past contact with mental health services was a clear predictive factor for suicide. This finding highlights the need for population based strategies and suggests that despite their apparent recovery, those with a past history of mental illness may remain at risk of suicide.

Type IV evidenceOwens C, Booth N, Briscoe M, Lawrence C, Lloyd K. Suicide outside the care of mental health Services. A case-controlled psychological autopsy study. Crisis 2003;24:113-21.



4.2 SUICIDE OF SERVICE USERS – MANAGING THE IMPACT ON STAFF

RationaleSuicide by service users may have a significant emotional and professional impact on staff. Training and support for staff may help to reduce this impact

Supporting evidence4.2.1 This paper sets out the action that should be

taken in the event of a patient suicide. It covers communication, formal obligations, support for staff and education/review.

Good Practice PointHodelet N, Hughson M. What to do when a patient commits suicide. Psychiatric Bulletin 2001;25:43-5.

4.2.2 A questionnaire survey of 247 psychiatrists found that around a third of those who had experienced a patient suicide suffered adverse emotional consequences (low mood, irritability, poor sleep) and 15% considered early retirement. Colleagues, family and friends were considered to be the best sources of help and critical incident reviews were seen as useful.

Good Practice PointAlexander DA, Klein S, Gray NM, Dewar IG, Eagles JM. Suicide by patients: questionnaire study on its effects on consultant psychiatrists. BMJ 2000;320:1571-4.

4.2.3 In small questionnaire survey of community mental health team members 66% reported that patient suicide had some or great impact on their personal life (for example sleep disturbance, poor concentration, preoccupation with work) and 73% reported some or great impact on their professional life (for example self doubt, anxiety, distancing from clients). 40% reported that these adverse effects lasted longer than 1 month.

Peer support, incident reviews, dedicated staff meeting and support form senior colleagues were all reported as being helpful in dealing with adverse effects.

Good Practice PointLinke S, Wojciak J, Day S. The impact of suicide on community mental health teams: findings and recommendations. Psychiatric Bulletin 2002;26:50-2.

4.2.4 This paper, based on the development of a crisis resolution team, sets out a framework for supporting staff through major incidents such as service user suicide.

Good Practice PointWalmsley P. Patient suicide and its effect on staff. Nursing Management 2003;10:24-6.



4. 3. SUPPORTING THOSE BEREAVED BY SUICIDE

RationaleRecent studies suggest that bereavement after suicide is not necessarily more severe than bereavement following other types of death but that it gives rise to certain issues that make coping with a loss from suicide particularly difficult9.

Supporting evidence4.3.1 This review argues that bereavement following

suicide is distinct from other bereavement in three ways;

The thematic content of griefo Suicide violates the norm of self-

preservation, those bereaved by suicide have problems in understanding the motives and the frame of mind of those who have died

o Those bereaved through suicide show higher levels of blame, guilt and responsibility for the death

o Those bereaved through suicide have heightened feelings of rejection and abandonment

Social processeso Those bereaved by suicide may be

viewed by others as more psychologically disturbed, less likeable, more blameworthy, more in need of professional mental health care and more likely to remain sad and depressed longer

The impact suicide has on familieso Suicide may adversely affect family

functioning and may contribute to the development of mental illness in surviving family members

o Suicide bereavement may increase the risk of suicidal behaviour and completion in surviving family members

Literature ReviewJordan JR. Is suicide bereavement different? A reassessment of the literature. Suicide Life Threat Behav 2001:31:91-102.

4.3.2 Older people bereaved through suicide scored higher on measures of stigmatisation, shame and sense of rejection than controls bereaved through natural causes. In addition nearly 40% found media reporting of coroners’ inquests and inquest procedures significant sources of distress.

Type IV evidenceHarwood D, Hawton K, Hope T, Jacoby R. The grief experiences and needs of bereaved relatives and friends of older people dying through suicide: a descriptive and case-control study. J Affect Disorder 2002;72:185-94.

4.3.3 A case control study in the USA found that adolescents who had lost friends through suicide were more likely than controls to experience post traumatic stress disorder and depression. Follow up was over three years

Type IV evidenceBrent D A, Moritz G, Bridge J, Perper J, Canobbio R. Long-term impact of exposure to suicide: A three-year controlled follow up. Journal of the American Academy of Child and Adolescent Psychiatry 1996;35:646-53.

Supporting evidence

9 Hawton K, Simkin S. Helping people bereaved by suicide. BMJ 2003;327:177-78.Version: 1 Date:February 2007 Status: DraftAuthor: Sian Price Page: 52 of 64 Classification:


4.3.4 Bereavement interventions that may be useful following suicide include;At the site of suicide;

Instruct the family that, for forensic purposes, nothing should be touched

Explain resuscitation and official procedures Arrange opportunity for the family to spend

time with the body, preferably alone, after the investigation

Debrief the resuscitation team Arrange professional cleaning services Debrief with a colleague

First 24 hoursInformation

Tell others the true cause of death, including children

Viewing or photographs of the body Public funeral

Follow-upInformation

Models of suicide, including the neurotransmitter model

Causes of mental illness and risk for survivors Limitations of prediction of suicide Lifestyle education and grief survival strategies

Counselling Assess mental state Rationalise unrealistic negative feelings The ‘why’ may never be solved Mark achievements Raise self-esteem

Specific agencies Medical practitioners

o Information on the dying processo Interpretation of the post mortem reporto Mental state and psychosocial

assessmento Physical review, e.g. blood pressure

checko Medical certificates

Coroner’s officeo Return of suicide noteso Information on how death occurredo Post mortem report

Support group Minister of religion

Review Three months At issue of post mortem report Anniversaries

Literature Review/ Good Practice PointsClark SE, Goldney R. The impact of suicide on relatives and friends. In: Hawton K, Van Heeringen K, editors. The international handbook of suicide and attempted suicide. Chichester: Wiley, 2000: p467-84.



Supporting evidence4.3.5 Active postvention programmes such as LOSS (Local

Outreach to Suicide Survivors Program) may be beneficial in encouraging those bereaved by suicide to seek help and support. LOSS team members are staff from a crisis intervention centre and people who have themselves been bereaved by suicide, all team members receive specials training. Attendance of LOSS team members at suicide scenes has reduced the expression of inappropriate attitudes by the emergency services. LOSS team members are also able to provide support for emergency service first responders. LOSS team members may also attend funeral services, support death notification and work as peer facilitators for suicide survivors support groups.

Good Practice PointCampbell FR, Cataldies L, McIntosh J, Millet K. An active postvention program Crisis 2004;25:30-2.

4.3.6 Surveys of relatives’ experience of coroners’ inquests of suicides have shown that these can cause considerable distress. In response to such surveys The Broderick Report10 published in the 1970s made recommendations that would relieve some of this distress; however these recommendations were never implemented.

SurveyBarraclough BM, Shepherd DM. The immediate and enduring effects of the inquest on relatives of suicides. Br J Psychiatry 1977;131:400-4.

4.3.7 A recent in depth qualitative study of the effect of suicide inquests on bereaved relatives found that little had improved since the 1970s. Relatives were disturbed by the judicial atmosphere, media activity, the invasion of their privacy and giving evidence. This was compounded by lack of preparation and communication before the inquest. The inquest adversely affected grieving by exacerbating shame, guilt and anger and was not helpful in allowing relatives to reach a meaningful and acceptable account of the death.

In response to this study the British Suicide Researchers Group have made a series of recommendations on how the inquest process might be improved. A summary of these recommendations is attached at appendix II.

A draft bill published on 12 June 2006 proposed coroner reform for England and Wales. A draft charter for bereaved people who come into contact with the coroner service is included in the bill (www.dca.gov.uk/legist/coroners_draft_charter_bereaved.pdf). If implemented the charter will meet some of the British Suicide Researchers Group recommendations.

Survey/Good Practice PointsBiddle L. Public hazards or private tragedies? An exploratory study of the effect of coroners’ procedures on those bereaved by suicide. Soc Sci Med 2003;56:1033-45.

10 Home Office. Report of the Committee on Death Certification and Coroners. (The Broderick Committee). London: HMSO; 1971Version: 1 Date:February 2007 Status: DraftAuthor: Sian Price Page: 54 of 64 Classification:

http://www.dca.gov.uk/legist/coroners_draft_charter_bereaved.pdf


4.4. MEDIA PORTRAYAL OF SUICIDE

Topic areaWhether or not reporting and portrayal of suicide in the media lead to imitation by vulnerable individuals has long been debated. The current consensus is that there is evidence of such an effect11

Supporting evidence4.4.1 A recent quantitative review of suicide

reporting in the media based on non-fictional stories found that;

Studies measuring the effect of reporting the suicide of an entertainment or political celebrity were 5.27 times more likely to report imitation than stories reporting on non-celebrities

Studies that focused on stories that used negative definitions of suicide were 99% less likely to report imitation

Studies on television reporting of suicides were 79% more likely to report imitation than other studies

Studies on female suicide were 4.89 times more likely to report imitation than other studies

Literature reviewStack S. Suicide in the media: A quantitative review of studies based on nonfictional stories. Suicide Life Threat Behav 2005;35:121-33.

This study did not provide sufficient information to allow an assessment of its quality. Where odds ratios were used confidence intervals were not reported.

4.4.2 A narrative review of reporting of suicide in non-fictional media concluded that there is an association between portrayal of suicide and actual suicide. The authors concluded that this association was causal on the basis that the association satisfied criteria of consistency, strength, temporality, specificity and coherence.

Type IV evidencePirkis J, Blood R W. Suicide and the media Part I: Reportage in nonfictional media. Crisis 2001;22: 146-54.

4.4.3 A narrative review of reporting of suicide in fictional media concluded that the evidence for an association is moderate at best.

Type IV evidencePirkis J, Blood R W. Suicide and the media Part II: Portrayal in fictional media. Crisis 2001;22:155-62.

4.4.4 A recent study in Hong Kong in response to the emergence of a new method of suicide (charcoal burning) found that media reports were pivotal in bringing this method to the attention of a specific group of vulnerable people. The authors argued that media reporting conveyed an implicit message that charcoal burning is an easy, painless and effective means of ending one’s life. Survivors who were interviewed reported that they learnt of and were reminded of the method through newspaper reports.

Type IV evidenceChan KPM, Yip PSF, Au J, Lee DTS. Charcoal-burning suicide in post-transition Hong Kong. Br J Psychiatry 2005;186:67-73.

Supporting evidence11 Hawton K, Williams K. Influences of the media on suicide. BMJ 2002;325:1374-75.Version: 1 Date:February 2007 Status: DraftAuthor: Sian Price Page: 55 of 64 Classification:


4.4.5 A recent prospective study in Australia found that;

39% of media items were followed by an increase in male suicides

31% by an increase in female suicides

Items were more likely to be associated with an increases in both male and female suicides if

o They occurred in the context of multiple other reports on suicide

o They were broadcast on television

They were about completed suicide

Type IV evidencePirkis JE, Burgess PM, Francis C, Blood RW, Jolley DJ. The relationship between media reporting of suicide and actual suicide in Australia. Soc Sci Med 2006;62:2874-86.



Topic areaInitiatives to improve media reporting of suicides may have an impact on imitation

Supporting evidence4.4.6 In Austria media guidelines and a media

campaign were launched in response to a sharp increase in suicide rates associated with the introduction of a subway system in Vienna. As a consequence there was a marked change in the nature of media reporting and this was associated with an 80% fall in the number of subway related suicides and suicide attempts.

Type IV evidenceEtzersdorfer E, Sonneck G. Preventing suicide by influencing mass-media reporting. The Viennese experience 1980-1996. Archives of Suicide Research 1998;4:67-74.

4.4.7 In Switzerland the introduction of media guidelines on reporting of suicide resulting in an improvement in the quality of reporting although the number of articles on suicide increased. The authors concluded that the most effective means of influencing the media was personal contact with the editor of a tabloid newspaper.

Type IV evidenceMichel K, Frey C, Wyss K, Valach L. An exercise in improving suicide reporting in print media. Crisis 2000;21: 71-9.

4.4.8 The Media Wise Trust provides guidance for journalists (written by journalists) on portraying suicide in the media and has developed training modules for media professionals on this topic.

Good Practice PointThe Media Wise Trust. The media and suicide. Guidance for journalists from journalists. 2003. Available .http://www.mediawise.org.uk/files/uploaded/The%20Media%20and%20Suicide%20.pdf[Accessed 6 Jul 2006]

4.4.9 The World Health Organisation has published a resource for media professionals on suicide prevention. These outline the impact of media reporting of suicide, list sources of information and provide guidelines on reporting suicide.

Good Practice PointWorld Health Organisation. Preventing suicide. A resource for media professionals. Geneva: WHO; 2000.

4.4.10 The American Foundation for Suicide Prevention has published recommendations for the media on reporting suicide. These cover suicide contagion, interviewing surviving relatives and friends and make recommendations for appropriate language.

Good Practice PointCenters for Disease Control and Prevention, National Institute of Mental Health, Office of the Surgeon General, Substance Abuse and Mental Health Services Administration, American Foundation for Suicide Prevention, American Association of Suicidology, Annenberg Policy Center (2001) Reporting on suicide: Recommendations for the media. Available www.afsp.org/education/recommnedations/5/1.htm[Accessed 6 Apr 2006]


http://www.afsp.org/education/recommnedations/5/1.htm

http://www.afsp.org/education/recommnedations/5/1.htm

http://www.mediawise.org.uk/files/uploaded/The%20Media%20and%20Suicide%20.pdf




4.5. MONITORING SUICIDE RATES

Topic areaSuicide is a significant cause of premature mortality. Targets for suicide reduction are usually based on a reduction in the age-standardised overall population suicide rate. A favourable trend in this rate may mask an adverse trend in rates for young people.

Supporting evidence4.5.1 Analysis of routine mortality and census data

for England and Wales shows that although age-standardised suicide rates fell by 18% (95% confidence interval 15-21) between 1981 and 1998, the potential years of life lost before the age of 65 increased by 5% (95% confidence interval 4-6). Measures of potential years of life lost (PYLL) are a better approach to quantifying the effect of premature mortality for health outcomes, such as suicide, that have a high prevalence in young people.

National suicide reduction targets should focus on PYLL as well as overall suicide rates.

Type IV evidenceGunnell D, Middleton N. National suicide rates as an indicator of the effect of suicide on premature mortality. Lancet 2003;362:961-62.





http://kc.nimhe.org.uk/upload/SuicidePreventionToolkitweb.pdfLink to NIMHE suicide prevention toolkit

http://www.npsa.nhs.uk/health/resources/root_cause_analysis/conditionsLink to National Patient Safety Agency root cause analysis toolkit

www.tcf.org.ukThe Compassionate Friends (Shadow of Suicide) (for parents who have lost a child, and siblings)

www.crusebereavementcare.org.ukCRUSE Bereavement Care;

www.papyrus-uk.orgPAPYRUS (committed to prevention of youth suicide) will help bereaved parents and carers make contact with sources of support

www.uk-sobs.org.ukSurvivors of Bereavement by Suicide (SOBS)

www.winstonswish.org.ukWinston’s Wish supports bereaved children and their families

http://www.mindframe-media.info/index.php Link to home page of Australian resource for media professionals, downloads available include guidelines for reporting suicide

www.presswise.org.ukThe MediaWise Trust

http://cebmh.warne.ox.ac.uk/csr/linksmedia.htmlUniversity of Oxford Centre for Suicide Research links to the Media and suicidal behaviour

http://www.who.int/mental_health/media/en/426.pdfLink to WHO resource for media professionals on preventing suicide

www.afsp.orgAmerican Foundation for Suicide Prevention

www.suicidology.org American Association of Suicidology (AAS), USA

www.suicideprevention.caCanadian Association for Suicide Prevention (CASP), Canada

[email protected] Association for Suicide Prevention (IASP), USA

www.spanusa.orgSuicide Prevention Advocacy Network (SPAN), USA


http://www.spanusa.org/

mailto:[email protected]

http://www.suicideprevention.ca/

http://www.suicidology.org/

http://www.afsp.org/

http://www.who.int/mental_health/media/en/426.pdf

http://cebmh.warne.ox.ac.uk/csr/linksmedia.html

http://www.presswise.org.uk/

http://www.mindframe-media.info/index.php

http://www.winstonswish.org.uk/

http://www.uk-sobs.org.uk/

http://www.papyrus-uk.org/

http://www.crusebereavementcare.org.uk/

http://www.tcf.org.uk/

http://www.npsa.nhs.uk/health/resources/root_cause_analysis/conditions

http://kc.nimhe.org.uk/upload/SuicidePreventionToolkitweb.pdf


www.suicidepreventionaust.orgSuicide Prevention Australia (SPA), Australia

http://www.suicideinfo.ca/ Centre for Suicide Prevention (CSP)Suicide Information and Education Collection (SIEC), Canadawww.griffith.edu.au/school/psy/aisrapAustralian Institute for Suicide Research and Prevention (AISRP), Australia

www.sprc.orgSuicide prevention centre, USA

www.med.uio.no/ipsy/ssff/hoveden-gelsk.htmSuicide Research and Prevention Unit, Norway


http://www.med.uio.no/ipsy/ssff/hoveden-gelsk.htm

http://www.sprc.org/

http://www.griffith.edu.au/school/psy/aisrap

http://www.suicideinfo.ca/

http://www.suicidepreventionaust.org/


CONCLUSIONSuicide and deliberate self harm have significant personal, social and economic consequences. There is no clear way to predict which individuals are likely to die from suicide and there is no research that demonstrates how suicide can be prevented in any one individual. Adoption of the four level model described in the introduction, underpinned by the evidence set out in this document would support a move away from concentration on people with mental illness considered to be at ‘high risk’ of suicide towards a more population based prevention approach. This approach attempts to reduce the risk of suicide in the whole population by changing attitudes, knowledge, behaviours and norms that may predispose people to suicide. The model facilitates a strategic approach to suicide prevention as clear organisation responsibilities can be assigned at each of the levels.



Appendix I

RISK FACTORS ASSOCIATED WITH SUICIDE

FACTOR ESTIMATED INCREASED RISK

Male gender1 X 3Age

Men 15-44years2 X 4Current or ex psychiatric patients3 X 104 weeks following discharge from psychiatric hospital4

X100-200

Prisoners (male and female)5 X 5-10Self-harm6a In first year following self harm6b

X 30X 66

Socioeconomic deprivation7 Not knownSubstance misuse

Drug misuse8a

Heroin8b

Alcohol8c

Prescription drugs8d

Prescription drugs and alcohol8e

Prescription and illicit drugs8f

X 20X 14X 6X 20X 16X 44

Schizophrenia9

Previous depressive disorder Previous suicide attempts Drug misuse Agitation or motor restlessness Fear of mental disintegration Poor adherence to treatment Recent loss

X 3X 4X 3X 2.5X 12X 4X 4

Major depression10 X 20Bipolar disorder11 X 15Dysthymia12 X 15Anorexia nervosa13 X 23Anxiety disorders14 X 6 -10Personality disorder15 X 7Physical illness16

Cancer Neurological disorders Renal disease Chronic pain

X1.5 – 4Not knownNot knownNot known

For men being divorced or separated17 X 2Unemployment18 X 2 -3Family history of suicide19 Not known



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Appendix IISummary of recommendations from the British Isles Suicide Researchers Group12

Level Area RecommendationPrimary recommendation

Allow coroners to dispense with public suicide inquest

In non-complex cases where there is no dispute over facts and with family agreement, coroners allowed the discretion to process suicides without a public hearing

Secondaryrecommendations

Standards of practice

Existing guidelines should be updated and operationalised as standards of acceptable practice. These to be made public and reviewed

Training Coroners and coroner’s officers to receive training on aspects of bereavement, questioning techniques and dealing with the media.

Before the inquest Pre-inquest briefing

The relatives of the deceased should be briefed face-to-face by court representative/welfare officer with the purpose of:

Providing full information and preparation for all aspects of the procedureOutlining the rights of the bereavedRedressing unrealistic expectations at the outsetEstablishing a point of contact for the inquiryMaking the inquest multifunctional by allowing the bereaved to state questions they would like answered and relaying these to the coroner if appropriate

Written information

Briefing supported by written information to address difficulties the bereaved experience in processing and retaining information

Re-definition of the coroner’s officer role

Coroner’s officer role officially widened to encompass information and support giving to relatives to include the proposed briefing and also dissemination of information regarding specific help-sources for those bereaved by suicide. Role to be professionalized and formalised through bereavement training.

Timescales for completion

Excluding exceptional cases, inquests to be held within 4 months. Where this is not attainable, reasons for the delay to be explained to relatives

Scheduling the date

Coroner’s office to liaise with relatives regarding inquest date. Relatives not to be informed by ‘summons’

Suicide notes Addressee to be provided with copy of the note. Where no addressee is stated, the note to be given to the next of kin at the coroner’s discretion.

During the inquest Reduced formality

Inquests to be conducted in comfortable, sensitive surroundings with a minimum formality

Press restrictions Media prohibited at relative’s request where no function of public broadcast can be justified

Restrictions on graphic evidence

Coroners to restrict graphic details heard by relatives to a minimum. Wherever detailed reporting of post-mortem findings are necessary, coroners to allow relatives the opportunity to leave the courtroom

Relieving relatives of the witness role

Coroners where able to relieve relatives who have given statements from public formal questioning/giving evidence under oath

After the inquest De-briefing Relatives provided with an opportunity to discuss what has taken place and ask questions

Complaints procedure

A formal, established and accessible complaints procedure made available to relatives who are unhappy with the inquest process (including pre-inquest procedure)

Return of suicide notes

Originals to be returned automatically

12 Biddle L. Public hazards or private tragedies? An exploratory study of the effect of coroners’ procedures on those bereaved by suicide. Soc Sci Med 2003;56:1033-45.Version: 1 Date:February 2007 Status: DraftAuthor: Sian Price Page: 64 of 64 Classification: