Suicide (health and wellbeing needs in South Tyneside)

Suicide is a public health concern. Nationally the number of people who take their own lives has been reducing in recent years. Nevertheless, in England, one person dies every two hours from suicide.[1]

Suicides are not inevitable; they are preventable.[2] Suicide is often the end point of a complex pattern of risk factors and distressing events, and the prevention of suicide has to address this complexity. There are many things that can be done in communities, outside hospital and care settings, to help those who think the only option is to end their own life.

Definition of suicide

A Coroner will only record a verdict of suicide if there is evidence beyond reasonable doubt that the injury was self-inflicted and that the deceased intended to take their own life. If the Coroner believes the evidence of suicide is not proven beyond reasonable doubt, or there is doubt about the deceased's intentions, then an open verdict will be recorded.

The ONS (Office for National Statistics) produces mortality data from death registrations. Where an open verdict is recorded these are generally coded by the ONS as deaths from injury or poisoning of undetermined intent. In presenting statistics about suicide, figures due to suicide are usually combined with those coded as due to injury of undetermined intent (Statistical Update on Suicide, January 2014, Department of Health).

In presenting this data, three year rolling averages are usually used to try to compensate to annual fluctuations due to small numbers.

• Suicide is an important public health issue. Suicide is a common cause of early life years lost, and has a devastating impact on families, communities and other survivors - economically and emotionally.
• The data shows that South Tyneside's suicide rates are not statistically dissimilar from the England average. There were fewer than 10 suicides per annum 2010 - 13.
• Only 1 in 3 people who complete suicide are known to mental health services.
• The Public Health Outcomes Framework requires public health departments within local authorities to report on suicide cases.
• Suicide prevention requires a partnership approach. There are many things that can be done in communities, outside hospital and care settings, to help those who think the only option is to end their own life.

The National Suicide Prevention Strategy was produced in September 2012 by the Department of Health and recognised that suicide is a major issue for society and a leading cause of years of life lost. The strategy outlines two main objectives

• to reduce the suicide rate in the general population in England 
• to provide better support for those bereaved or affected by suicide

A local South Tyneside suicide prevention action group has been examining a range of national guidance and local information, including the local suicide audit to understand more about the profile of individuals who have taken their own life in the borough.

There is good evidence about actions that can be taken at a local level to reduce the likelihood or opportunity for suicide, which the group has started to translate into an action plan.

The six key areas that are highlighted for action in the National Strategy and will also be taken forward locally by partners led by the Public Health team are:

1. Reduce the risk of suicide in key high risk groups including; young and middle aged men, people in the care of mental health services, people with a history of self-harm; people in contact with the criminal justice system and some specific occupational groups.

2. Tailor approaches to improve mental health in specific groups including; children and young people; survivors of abuse or violence; veterans; people living with long-term physical health conditions; people with untreated depression; people who are especially vulnerable due to social and economic circumstances; people who misuse drugs or alcohol; lesbian, gay, bisexual and transgender people, people from minority ethnic backgrounds, and asylum seekers.

3. Reduce access to the means of suicide; the national guidance suggests tackling: hanging and strangulation in psychiatric inpatient and criminal justice settings; self-poisoning; those in high-risk locations; and those on the rail and underground networks.

4. Provide better information and support to those bereaved or affected by suicide; it is important to: provide effective and timely support of the families bereaved or affected by suicide; have a place effective local response to the aftermath of a suicide and provided information and support for families friends and colleagues who are concerned about someone who may be at risk of suicide.

5. Support the media in delivering sensitive approaches to suicide and suicidal behaviour. The government wants to promote the responsible report of suicide in the press and to support the internet industry to remove content that encourage suicide and provide ready access to suicide prevention services.

6. Support research, data collection and monitoring. The government will continue to support high-quality research on suicide, suicide prevention and self-harm through the National Institute of health Research and the policy Research Programme. Work will also continue regarding data monitoring and National Framework Public Health indictors.

Many of these actions are not within the remit of the health or social services, but require very much a multi-agency approach e.g. criminal justice system (police, probation and prison), local authority (providing housing, reducing access to bridges etc.), coroner's office (information collection), third sector (e.g. debt advice, bereavement counselling or providing advice and support).

The action plan will be reviewed on a yearly basis.

Certain factors are known to be associated with increased risk of suicide.

A number of factors can determine how vulnerable a person is to suicidal thinking and behaviour. These include:

• life history - for example, having a traumatic experience during childhood, a history of sexual or physical abuse, or a history of parental neglect
• mental health - for example, developing a serious mental health condition, such as schizophrenia
• lifestyle - for example, misuse drugs or misuse alcohol
• employment - such as poor job security, low levels of job satisfaction or being unemployed
• relationships - being socially isolated, being a victim of bullying or having few close relationships

Factors such as: debt; lack of social capital; family breakdown and bereavement as well as the ability of services to identify and support people who may be at risk of developing mental health problems are also important factors to consider in suicide prevention.

Suicide rates in England

In the last 20 years the rates have generally declined with a very slight rise in the last few years. The latest available rate for England is 8.7 / 100,000 of the population (directly age standardised). The highest this rate has risen to in the last 20 years was 9.6 in 1998 - 2000 (where mortality is due to self harm and injury of undetermined intent).

In the UK, death by suicide is more common in men than women, the risk also varying by age. From 2001 to 2012 the highest risk for men in the UK was experienced by those aged 30 to 44 years, with those 45 to 59 being the next most at risk (with some evidence of a recent increase in the rate). For women this order was reversed. In men, fewest deaths by suicide tended to be seen in those aged 60 to 74 years, although in 2006 and 2010 the age group least at risk were the 15 to 29 year olds, which has been the case for females from 2001 to 2012 (ONS, 2104).

Suicide verdicts are not returned for children under 10 yrs and for children aged under 15yrs, deaths due to undetermined intent are not classified by the ONS as suicide (Statistical Update on Suicide, January 2014, Department of Health, p6)

Latest data suggests that hanging (including strangulation and suffocation) continues to be the most common method of suicide for men, but with women it is equally likely to be this or drug related poisoning.

Data shows that South Tyneside's suicide rates are not statistically dissimilar from the England average. The number of suicides in South Tyneside is small and can be expected to fluctuate each year; therefore it is difficult in these circumstances to identify any trends.

However a North East regional suicide prevention needs assessment and local suicide audits present more detailed information about completed suicides in South Tyneside from 2007 - 2013. The main points from the needs assessment and audits are highlighted below.

• 2007 - 2010 suicide audit: there were fewer than 10 suicides per annum
• 2011 - 2013 suicide audit: 43 deaths where 'self-harm was identified as a factor in death.'[1]
• Emergency hospital admissions for self-harm in South Tyneside are not statistically different from the England average.
• Most suicides take place at the deceased person's home.
• High rates of diagnosed depression prior to suicide (47% from 2011-13 audit, with coroners comments indicating that a further 9 individuals had undiagnosed depression)
• Males suicides outnumber female suicides (72% were male 2007 - 10 and 77% were male in 2011 - 13)
• Higher numbers of suicides in working age groups; but 38% were classed as unemployed and only 25% were in paid employment at time of death.
• 42% of suicides were by people living alone (however there was also 28% of unknown for living circumstances at time of death.)
• Hanging was the most common cause of death for men (51% of all suicides 2007 - 13)
• Asphyxia (33%) and falling from a height (33%) were the commonest methods of suicide amongst women.
• Contact with mental health services may be under-reported in Coroner's records (source: confidential SOTW suicides 2007 / 09 audit findings) but in 2007 / 09 three suicide victims were recorded as at risk by Mental Health Services. In 2011 - 13 eight of the deceased (19%) had documented contact with statutory mental health services within a year of their death.
• Most of those who completed suicide had been registered with a GP.
• Alcohol had been taken at the time of death in 36% of cases in 2007 / 08 and 35% of cases in 2011 - 13.
• Social media was mentioned in the documentation for 17% of suicide cases in 2011-13. The context in which social media was mentioned varied from conversations on social media forming part of the Coroner's investigation to bullying and harassment via social media. The cases involving social media were in individuals aged 36-58, with an average age of 50.

Go to the most recent local data on suicides

For further information: Public Health England has developed a suicide prevention profile on the fingertips website. The suicide prevention profile has been produced to develop an understanding at a local level and support an intelligence driven approach to suicide prevention. It collates and presents a range of publicly available data on suicide, associated prevalence, risk factors and service contact among groups at increased risk. It provides planners, providers and stakeholders with the means to profile their area and benchmark against similar populations.

[1] Note this uses a different methodology from the first audit. The wider inclusion criteria is designed to pick up as many cases as possible to give as good an insight as possible into suicide in South Tyneside.

There maybe hidden vulnerable groups in South Tyneside where additional information is required and additional work would need to be carried out to assess these needs. These groups may include young carers, looked after children, people from ethnic minority backgrounds, LGBT and those people with long-term health conditions.

Forecasting suicides is complex, and it is difficult to incorporate significant influences such as economic conditions, therefore it not possible to give projected need or demand.

Suicide prevention is not the remit of one agency or organisation, but require very much a multi-agency approach e.g. criminal justice system (police, probation and prison), local authority (providing housing, reducing access to bridges etc.), coroner's office (information collection), third sector (e.g. debt advice, bereavement counselling or providing advice and support).

A review of suicide prevention strategies (Mann, J & Currier, D (2011), Evidence-based practice in suicidology: A source book, pp67 - 68) found the important areas to focus on are: education & awareness, screening, treatment, restricting access to means and media reporting of suicide. This review supports the approach outlined in the section on Strategic Priorities.

Frontline services

• Enable people to get support for worries; debt advice, welfare rights, employment advice, relationship breakdown, bereavement etc.
• Offer support and advice to keep physically and mentally active and maintain friendships so as to cope better with stress (e.g. 'five ways to wellbeing')

Education & awareness of individuals, staff and the community e.g.

• Improve mental health literacy, encourage discussion about mental health, and provide information about depression and services especially in 'male settings', or create specific interventions targeted at men such as 'Men's Sheds'
• Ensure frontline staff are suicide aware; offer training such as Applied Suicide Intervention Skills Training (ASIST) and Skills based training on risk management (STORM) or Mental Health First Aid
• Sign up to campaigns that challenge mental health stigma such as Time to Change, and the Campaign Against Living Miserably (CALM)

Primary care clinicians ask patients about thoughts of self harm or suicide where appropriate

• This would seem particularly important in South Tyneside, as outlined earlier a high % of those completing suicide had diagnosed depression.

Active and prompt treatment of mental health conditions e.g.

• Good access to primary mental health care
• Cognitive behavioural therapy for people experiencing suicidal thoughts
• 24 hour mental health crisis services
• Continued care for people who repeatedly self-harm
• Work with pharmacies to support good medicines management
• Safer prison cells and high quality assessment, care in custody and teamwork for prisoners at risk of self harm

Restrict access to means e.g.

• Structural intervention & signage, particularly at hot spots
• Limit availability of methods in prison cells and mental health hospitals (e.g. removing ligature points, reducing absconding from wards)

Following a suicide

• Conduct a multidisciplinary review
• Offer help and support for people bereaved by suicide

Ensure responsible media reporting of suicide - Samaritans Media Guidance

Postvention Postvention is defined as "activities developed by, with, or for suicide survivors, in order to facilitate recovery after suicide, and to prevent adverse outcomes including suicidal behaviour". Postvention policies and support need to be in place to reduce the likelihood of additional suicides or further suicidal behaviour.

Self-harm

A needs assessment to further explore and understand more about local issues around self-harm could support suicide prevention in South Tyneside.

Following an act of self-harm the rate of suicide increases to between 50 and 100 times the rate of suicide in the general population and men who self-harm are more than twice as likely to die by suicide as women. In addition the risk increases greatly with age for both men and women.

Self-harm can occur at any age but is most common in adolescence and young adulthood. Females are more likely to self-harm than males. It is estimated that in Great Britain between 4.6% and 6.6% of people have self-harmed (NICE, 2004). Self-harm is one of the top five causes of acute medical admission in the UK (NICE, 2004). However, even this might be an under-estimate. In a school survey, 13% of young people aged 15 or 16 reported having self-harmed at some time in their lives and 7% as having done so in the previous year.

Department of Health, 2012. Suicide prevention strategy for England, a cross cutting government strategy to save lives

Public Health England, 2014. Guidance for developing a local suicide prevention action plan.

NICE, 2004. Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care

NICE, 2011. Self-harm: longer-term management. NICE clinical guideline 133

NICE, 2011B. Common mental health disorders Identification and pathways to care. NICE clinical guideline 123

Department of Health (2008) Help is at hand: a resource for those bereaved by suicide and other traumatic, sudden death.

Many people who have had suicidal thoughts say they were so overwhelmed by negative feelings they felt they had no other option. However, with support and treatment they were able to allow the negative feelings to pass.  For confidential help and assistance, please visit NHS: Suicides. Alternatively, email (24 hours)  jo@samaritans.org or ring Samaritans (24 hours) 08457 90 90 90.