Written evidence from the Royal College of Psychiatrists-Revised (SPR0130)

The Royal College of Psychiatrists (RCPsych) is the professional medical body responsible for supporting psychiatrists throughout their careers, from training through to retirement, and in setting and raising standards of psychiatry in the United Kingdom.
 

The College aims to improve the outcomes of people with mental illness, and the mental health of individuals, their families and communities. In order to achieve this, the College sets standards and promotes excellence in psychiatry; leads, represents and supports psychiatrists; improves the scientific understanding of mental illness; works with and advocates for patients, carers and their organisations. Nationally and internationally, the College has a vital role in representing the expertise of the psychiatric profession to governments and other agencies. Our response was prepared by the College’s Patient Safety Group. We would be very happy to provide any further evidence the Committee needs either in writing or in person.

Summary

International evidence is clear that suicides are preventable with the introduction of national comprehensive suicide prevention strategies.

While Psychiatrists have an important role to play in helping reduce the number of suicides, we know that three-quarters of people who have died by suicide have not been in contact with specialist mental health services.  It is therefore important to take an early intervention approach to identify and provide empathetic support to people at risk of suicide.

There is evidence that it is possible to reduce the number of people who take their own lives, and this should include the following steps:

• Providing better support for people who self-harm, as half all suicides and two-thirds of young people who end their life by suicide, have previously harmed themselves.
• Not placing strong reliance on risk assessment tools that look at demographic groups, as they have been proven to not work in identifying risk. Instead, medical professionals should work with individuals using their own judgment, rooted in their clinical expertise.
• Professionals need to be trained to always take suicidal thoughts seriously and to respond to them with empathy and understanding.
• Resources need to be made available so that it is possible to work with anyone who presents to services, including primary care and Emergency Departments and other general medicine settings,  to support them to develop a Safety Plan to help keep them safe.
• All health and social care professionals should be aware of the Department of Health’s Information sharing and suicide prevention Consensus Statement and adapt their practice as necessary to work with families and friends in the ways this sets out[i].

1. Factors influencing the increase in suicide rates, with a focus on particularly at-risk groups

People with mental health problems being at increased risk of suicide

Some research has suggested that up to 90% of suicide deaths are likely to have occurred in conjunction with a mental illness.[ii]

The most comprehensive study of the factors influencing an increased rate of people with mental health conditions is the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness[iii].

It is however important to remember that three-quarters of patients who have died by suicide have not been in contact with mental health services at all. This suggests that while the vast majority of cases of suicide are linked to mental illness they are not being picked up or offered the important mental health treatment that could have saved their lives.

The information in the National Confidential Inquiry reports relate to the minority of people who have been in contact with secondary and specialist mental health services in the previous 12 months and have died by suicide.

Demographic factors linked to suicide rates

While suicide rates vary significantly amongst different demographic groups a recent BMJ review of suicide risk assessments found that demographic factors are unable to predict suicide risk accurately and should not be relied upon[iv]. A person may be at high risk of suicide even though not a member of a high-risk group. 

Conversely, not all members of high-risk groups are equally at risk of suicide.  Moreover, suicidal thoughts (and risk) can vary across a relatively short time period. The assessment of suicide risk by the clinician needs to be individually focused and carried out regularly.

2. The social and economic costs of suicide and attempted suicide

Few studies have focused upon the true economic cost of suicide, however available research indicates that the cost is huge. Canadian research has estimated that the direct costs (to Health Care, Police and Coroner Services, plus funeral costs) and indirect costs (loss of productivity in terms of employment, family responsibilities, childcare etc.) of each suicide are around £443,000[v].

This figure dramatically increases when intangible social costs such as grief, pain, suffering and lost life experiences for family and friends are included within calculations. New Zealand research estimated the cost of each suicide to be around £1.1 million[vi], with similar research based in Ireland putting the estimate higher at £1.4 million[vii]. Previous research suggested that about six people are significantly adversely affected by each death of someone by suicide. New research by Cerel and colleagues suggests that the figure is considerably higher, with far more people being adversely affected[viii] and that bereavement by suicide is itself a risk factor for suicide[ix].

Unfortunately, there are no figures for England and Wales, however research in Scotland placed the estimated cost of each suicide at around £1.1 million[x]. If we apply this figure to suicide rates in the UK, the UK annual cost of suicide is approximately £6.5 billion a year.

3. The measures necessary to tackle increasing suicide rates, and the barriers to doing so

3.1           The things others outside the NHS can do to tackle increasing suicide rates

A large proportion of those who have not had contact with specialist mental health services will often have been seen in primary care or at the general hospital. As long as suicide is seen as the preserve of specialist mental health services, opportunities for intervention will be missed.

A lack of awareness of the link between self-harm and suicide

One important societal change needed to deal with this issue would be a better understanding between the link between self harm and suicide. Although the function of self-harm is not to end one’s life, there is a proven link between self-harm and suicide. Almost half of the general population and two-thirds of young people who end their life by suicide, have previously harmed themselves[xi].

The UK has one of the highest rates of self-harm in Europe, at 400 patients per 100,000 of the population[xii] . These figures are however only for patients, sadly most acts of self-harm do not result in presentation for medical attention; so self-harm is largely a community problem with real-term figures unknown[xiii] .

Self-harm is more common in women and 16.7% of females will self harm at some point in their lives compared to a figure of 4.8% of men. There is a recent rise in the number of women who attend hospital following self-harm associated with alcohol and drug misuse[xiv]. This is often due to general changes in drinking patterns, which is worrying because people who self-harm can be more likely to do so after consuming alcohol.

We know however that early identification and intervention can minimise distress and reduce the likelihood of such a coping mechanism becoming well established and entrenched. It is therefore vitally important that anyone who self harms is supported to put together a Safety Plan (as described later in this document).

The role of educational establishments

The World Health Organisation has stated that suicide is “the second leading cause of death among 15-29 year olds globally in 2012”[xv]. It is therefore vital that educational establishments play a key role in helping to tackle suicide. 

One of the most important things educational establishments can do is help tackle the stigma around mental health. A Time to Change survey revealed that: of the 66% of student who describe themselves as having a mental health problem only 0.3 % of students declared a mental health disability on their application form. This was supported by a recent NUS survey that over half of students who experience mental health concerns do not seek support.

The NUS survey also showed that a third did not know how to access support and 40% stated anxiety about the support they would receive[xvi]. This shows that as well as tackling stigma more needs to be done to let students know about what services are available and reassure people about how they are going to be treated.

There are however some really impressive examples of good practice in universities. For example Worcester University and Wolverhampton University have adopted a ‘whole University approach’ to suicide prevention and some schools have embedded emotional resilience and/or resourcefulness training into their curriculum.

The role of the media in avoiding language that could lead to more suicides

The College of Psychiatrists has led and collaborated in a number of initiatives concerning the role of Social Media in suicide and suicide prevention. We work closely with national and international media outlets to model and promote safer reporting.  This includes College members who act as spokespeople engage journalists in modifying their language to help ensure that the Samaritans suicide reporting guidelines are adhered to.

3.2           How mental health services could be improved to tackle increased suicide rates

Importance of a thorough assessment and to ask about suicidal plans

As early intervention is so important when someone is in danger of ending their own life it is vital that people in contact with mental health services receive a thorough assessment.

Suicide risk is not always documented in routine clinical assessments, and although this may be an appropriate approach within some consultations, in others, it could result in inadequate mental health assessments[xvii].

Recent research from the National Confidential Inquiry (2015) highlighted deficits in assessment and management approaches. The case notes of patients known to health services who had died by suicide within a week of their last assessment, showed that:

• 14% had an inadequate Mental State Assessment (mental state assessments should always include suicide)
• 26% had an inadequate Risk Formulation
• 38% had an inadequate risk ‘Management Plan’

WHO World Mental Health Survey Initiative found that 29% people with suicidal thoughts went on to make a suicide attempt, usually within a year of onset of the thoughts.

If someone actually has a suicide plan there is a 56% probability that they will go on to have a suicide attempt, while only 15.4% of those patients who did not have a plan for suicide, subsequently went on to attempt suicide[xviii]. It is therefore key that mental health professionals ask specifically if their patients have a suicide plan.

The current approach to risk assessment and responding to those only identified as ‘high risk’ is fundamentally flawed and that the use of terms such as “low risk or “high risk” is unreliable, open to misinterpretation and potentially unsafe[xix]. The absence of risk factors does not mean the absence of any risk of suicide[xx]. For a variety of reasons (e.g. stigma, shame, fear or embarrassment) people may conceal or minimise their suicidal thoughts.

Moreover, suicidal thoughts (and risk) can vary across a relatively short time period. The assessment of suicide risk by the clinician needs to be individually focused and carried out regularly

The importance of positive attitudes amongst mental health professionals

Negative attitudes and “malignant alienation” (including therapeutic nihilism of professionals towards challenging patients) may intrude on the therapeutic relationship and actually contribute to a suicide[xxi].

Conversely, a more positive and understanding approach helps build a therapeutic alliance between suicidal patients and their therapists, which can be a protective factor against suicide[xxii].

Suicidal patients undergoing constant observation reported positive feelings towards their observers, if they found them friendly and willing to help. Patients reported a reduction in their suicidal thoughts if the observers were perceived as optimistic and gave emotional support. Conversely, the patients’ distress was exacerbated by experiencing a lack of empathy or validation of their feelings

How mental health professionals can identify risk and mitigate them

Practitioners need to identify “risks” not to predict suicide, but to fully understand the person’s individual experience in order to intervene using a bio-psycho-social model to mitigate or decrease the risks now and in the future. Given that it is not possible to predict future suicide attempts with any accuracy, focusing on identified risk factors could provide a false sense of security.

Additionally, the expectation that risk must be controlled, and preferably eliminated, might paradoxically increase suicide risk rather than reduce it as it might make individuals less likely to disclose their suicidal intent and cause professionals to be reluctant to identify patients at risk of suicide for fear that they are unable to “manage suicide risk”.

The idea of “suicide mitigation” might be a helpful approach[xxiii]. Suicide mitigation starts from the assumption that the expression of suicidal thoughts always needs to be taken seriously and met with empathy and understanding. This involves a compassionate and collaborative engagement, assessment and intervention with the co-production of a Safety Plan in addition to the usual treatment and care plan. Increasing hopefulness, resilience, reasons for living and reducing access to means have been shown to reduce suicide risk.

The importance of Safety Plans

A Safety Plan is an agreed set of activities, strategies, people and organisations to contact for support if someone becomes suicidal or if their suicidal thoughts get worse. They are also useful if someone is concerned that they might self-harm. 

A Safety Plan should be co-produced with the patient, who will identify most of the elements; if the patient is unable to articulate their wishes or when the risk is high, however, the clinician may have to take a more directive role.

The Royal College of Psychiatrists believe that every person who is having suicidal thoughts or has started self-harming needs a Safety Plan. These plans need to include explicit reference to removal of means of suicide or self harm and need to set out actions which are proportionate, timely and clinically meaningful.

3.3 How other health services can play their part in reducing suicide rates             

As described in the second annual report of the cross-government suicide prevention strategy, Preventing suicide in England: two years on, Emergency Departments and General Practitioners are at the front line of suicide prevention.

Patients are commonly assessed or admitted to Emergency Departments and medical wards following self-harm. Non-fatal self-harm (with or without suicidal intent) is one of the most common reasons for presentation to an ED and acute hospital admission. Hawton et al (2007) estimate that there are more than 200,000 hospital attendances following self-harm in England every year.

Once a person has self-harmed, the likelihood that he or she will die by suicide increases 50 to 100 times[xxiv], compared to someone who has never self-harmed. 20% of people who attend hospital after self-harming repeat within a year (many return to the same hospital)[xxv].

Up to one in 50 patients who attend hospital after self-harm will die by suicide within one year and one in 15 within nine years [xxvi]. More than 50% of people who die by suicide have self-harmed (15% within previous year)[xxvii]. People who self-harm also have a higher mortality from all-cause mortality (not just suicide)[xxviii].

How GPs and other medical professionals can best help people who have self-harmed

NICE Guidelines recommend that all patients should receive a psycho-social assessment following self-harm; this intervention can in itself reduce repetition of the behaviour. In the general hospital staff can minimise the risk of early self-discharge through compassionate engagement with patients who attend following self-harm.

General hospital staff need to be able to engage compassionately with people who self-harm, undertake triage assessments and refer as appropriate to secondary mental health care services. They should also be trained to be able to co-produce a basic immediate Safety Plan with the patient.

Some particular steps that all primary care providers could consider to better support attempts to reduce suicide are:

• Promote a shared language, approach and understanding to suicide prevention;
• Understand the importance of a thorough and effective clinical assessment
• Be able to safely and effectively assess, triage and refer as appropriate
• The need for a change in culture to one of “primary prevention” i.e.  – opportunistic assessments as not all patients who are at risk of suicide present to GPs with a presenting complaint of “feeling suicidal”
• All GPs should have these skills to be able to co-produce a safety plan with every patient who is experiencing suicidal thoughts or following self-harm;
• GPs should be able to help patients build wellbeing, resilience and resourcefulness;
• Promoting appropriate help seeking and self-care;
• Need to know when it’s appropriate to seek help from Statutory and third sector services and how to signpost people to the appropriate service for their needs.

The importance of involving family and friends in suicide prevention plans

Clinicians can gain useful and important information from third parties, such as family, friends or first responders, in addition to any objective evidence, particularly if someone has self-harmed or attempted suicide. Even where a person wishes particular information not to be shared, this does not prevent practitioners from listening to the views of family and friends, or prevent them from providing general information such as how to access services in a crisis.

The Royal College of Psychiatrists would strongly advocate all health and social care professionals should be aware of the Information sharing and suicide prevention Consensus Statement and adapt their practice as necessary to work with families and friends in the ways this sets out, as we are aware of cases where this has not been followed[xxix].

(Note: The term ‘family and friends’ is used here to refer to the person or people with whom the individual has a close emotional relationship).

Examples of good practice

To support them do this the College of Emergency Medicine (2013) has published a Mental Health Toolkit which includes evidence of best practice and the Royal College of General Practitioners Mental Health Training group has suggested that suicide prevention training should be mandatory for GPs every two years.

Public Health England and Health Education England (2016) are also publishing a list of all nationally available training, which should help medical professionals get the skills they need to help prevent self-harming leading to suicide.

Some good local examples are Warwickshire Public Health service and Northampton and Corby CCGs who have adopted a whole-county approach to training GPs on suicide prevention.

The College would also suggest that the Toolkit “Tooling up and gearing up mental health in primary care” may be helpful[xxx].

4. Learning lessons from international research

The focus of this submission is suicide prevention in the England, but we consider it helpful to place this in a global context. The World Health Organisation report ’ Preventing Suicide, a global imperative’ (2014)[xxxi] provides an excellent summary of the global epidemiology of suicide, and  includes an analysis of risk and protective factors for suicide. The Key message is that it is clear both that suicides are preventable, and that national comprehensive multi-sectoral suicide prevention strategies are needed to prevent them. These include:

• Restricting access to the means for suicide. An effective strategy for preventing suicides and suicide attempts is to restrict access to the most common means, including pesticides, firearms and certain medications.
• Suicide prevention should be a core component of healthcare services. Early identification and effective management of mental disorders and substance misuse are key to ensuring that people receive the care they need.
• Communities play a critical role in suicide prevention through providing social support to vulnerable individuals, engaging in their follow-up care, tackling stigma and supporting those bereaved by suicide.

We recommend that the Health Select Committee reviews this document as part of its work on suicide prevention.

5. Resources for people at risk of suicide

Royal College of Psychiatrists resources: practical, compassionate advice and links to all main UK crisis support organisations. All three are available at  http://www.connectingwithpeople.org/ucancope 

Feeling on the edge helping you get through it - for people in distress attending the Emergency Department following self harm or with suicidal thoughts http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/feelingontheedge.aspx

Feeling overwhelmed and staying safe - for anybody struggling to cope when bad things happen in their life and includes advice on how to make a ‘Safety Plan’ http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/feelingoverwhelmed.aspx

U Can Cope - designed to help people develop resilience and cope with any current/future difficulties in their life. Just as helpful for adults

http://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/youngpeople/ucancope.aspx

RCPsych Self-harm leaflet:

http://www.rcpsych.ac.uk/healthadvice/problemsdisorders/self-harm.aspx

Staying safe if you’re not sure life’s worth living has practical, compassionate advice and links for people in distress http://www.connectingwithpeople.org/StayingSafe

The U Can Cope film (22 minutes long) inspirational stories of three people for whom life had become unbearable but who found a way through with support http://www.connectingwithpeople.org/ucancope

September 2016

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