Preventing suicide and self-harm

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Engagement paper on Future Strategy for Prevention of Suicide and Self Harm

The Scottish Government has set up a Working Group to consider future policy and action on prevention of suicide and self harm, in the context that the Choose Life strategy and action plan is approaching the end of its 10 year lifetime. The aim is to produce a new national strategy on suicide and self harm, to be published by the Scottish Government in late summer/early autumn 2013.

Suicide prevention

There were 772 deaths by suicide in Scotland in 2011 (death from intentional self harm and events of undetermined intent). This equates to an age-standardised rate of 14.5 suicides per 100,000 people and is a decrease compared to 2010, when there were 781 deaths by suicide and an age-standardised rate of 14.7 per 100,000 people. 

Based on three-year rolling averages there was a 17% per cent fall in suicide rates between 2000–2002, and 2009–2011.

For many years, Scotland has had a significantly higher rate of suicide than other constituent parts of the UK. From the 1970s to the early 2000s there was a steady rise in Scotland’s suicide rate, particularly in younger men. 


Choose Life [external site], published in 2002, is the Scottish Government’s 10-year national strategy and action plan to reduce suicide in Scotland by 20 per cent by 2013.

The strategy and action plan aims to ensure we take action nationally and locally to build skills, improve knowledge and awareness of 'what works' to prevent suicide, improve opportunities to prevent premature loss of life and provide hope and optimism for the future. It encourages partnership working and improved coordination between services.

In October 2010, following a review of Choose Life, the Scottish Government published a refreshed strategy for suicide prevention, with revised and refocused objectives. Download the Report of the National Suicide Prevention Group from the Scottish Government's website.

A designated National Implementation Team from NHS Health Scotland coordinates and supports development at the national level. Core functions include:

  • awareness raising and campaigning
  • working with the media
  • development and dissemination of information and knowledge
  • issuing guidance for, and supporting, local implementation.

Each of Scotland's 32 local authorities is working on locally identified priorities that contribute to the single outcome agreement. The monitoring of suicide prevention activities is usually carried out by a local Choose Life Steering Group. Many areas have a Choose Life Coordinator who oversees the implementation of these activities.

In general, local suicide prevention activities focus attention on:

  • educating and raising public awareness of suicide prevention
  • delivering prevention and intervention actions
  • providing practical help to those affected by suicide
  • achieving wide ownership of suicide prevention and involving a range of partners to ensure that suicide prevention is everyone's business.

As well as this, each NHS board in Scotland is responsible for ensuring that key groups of staff have undertaken appropriate suicide prevention training, and the Choose Life programme is supporting them to do this.

Desired outcomes

The desired outcome for suicide prevention is:

  • Reduce the rate of suicide in Scotland by 20 per cent by 2013.

The refreshed objectives for suicide prevention, published October 2010, are:

Objective 1: identify and intervene to reduce suicidal behaviour in high risk groups.

Objective 2: develop and implement a coordinated approach to reduce suicidal behaviour.

Objective 3: ensure interventions to reduce suicidal behaviour are informed by evidence from research and evaluated appropriately.

Objective 4: provide support to those affected by suicidal behaviour.

Objective 5: provide education and training about suicidal behaviour and promote awareness about the help available.

Objective 6: reduce availability and lethality of methods used in suicidal behaviour.

Current evidence

Suicide prevention

Choose Life and the then Scottish Executive commissioned two evidence reviews to inform suicide prevention work in Scotland:

  • a review of risk and protective factors for suicide
  • a review of effective interventions for suicide prevention.

The Risk and Protective Factors for Suicide and Suicidal Behaviour: A Literature Review [external site] identified a number of important points:

Risk factors: 

  • mental illness
  • attempted suicide
  • substance misuse
  • epilepsy
  • certain personality traits
  • unemployment
  • poverty
  • some limited evidence of impact of menstrual cycle, pregnancy and abortion.

    Protective factors:
  • coping skills
  • high reason for living
  • physical activity and health
  • family connectedness
  • supportive schools
  • health treatment
  • employment
  • exposure to suicidal behaviour (not via media)
  • social values 
  • religious participation (not for all).

    The Risk and Protective Factors for Suicide and Suicidal Behaviour: A Literature Review [external site] suggested that suicide prevention activity should:
  • tackle societal and structural risk determinants that result in social injustices that lead to social and health inequalities which the evidence links to inequalities in suicide risk
  • enhance individual and psychosocial protective factors in the general population (and those who are more vulnerable) to help prevent them from becoming future members of suicide risk groups where possible, e.g. the mentally ill, prisoners, the unemployed, those in poverty
  • focus on developing family and community connectedness
  • challenge and identify ways to remove cultural values and beliefs that unfairly expose certain groups to elevated suicidal risk, such as those who are sexually abused, lesbian, gay, bisexual, and transgender communities and prisoners.
  • target interventions to particular suicide risk groups, taking into account the highly distinct and individual risk and protective combinations to which people are exposed
  • identify mechanisms that reduce the exposure of individuals and communities to multiple risk factors
  • identify mechanisms that increase the exposure of individuals and communities to multiple protective factors.

Effectiveness of Interventions to Prevent Suicide and Suicidal Behaviour: A Systematic Review [external site] found that although the evidence base was focused on pharmacological interventions, some broader approaches showed positive outcomes:

  • restriction of access to means and ongoing informal contact with individuals at high risk
  • treatment with intensive cognitive/behavioural therapies, such as Dialectical Behaviour Therapy (DBT) and Cognitive Behaviour Therapy (CBT)
  • provision of intermediate care within the prison setting

Choose Life initiatives are also supported by an established programme of research and evaluation activity. The initiatives include:

Case studies

Suicide prevention

Below you will find an example of how the seven original national objectives from Choose Life (2002) are being turned into local actions in Edinburgh:

  • local actions are identified in relation to early intervention and prevention across a range of actions identified above in relation to key risk groups
  • improved local information, awareness raising and training is planned on suicide, self-harm, and mental health and wellbeing
  • improved information about local services that can provide appropriate support and responses for professionals, community and voluntary groups, carers, and people experiencing difficulties is also planned.

Responding to immediate crisis

Objective: To provide support and services to people at risk and people in crisis; to provide an immediate crisis response and to help reduce the severity of any immediate problems.

  • Locally, the Choose Life Steering Group links to the Edinburgh Crisis Centre run by Penumbra, which ensures that the needs of people experiencing a range of mental health crises are addressed either directly through this service or by other appropriate services.
  • Links will be made to the Mental Health Assessment Team, the Emergency Social Work Service, community mental health teams (CMHTs) offering crisis and emergency response services.
  • Information derived from Quality Improvement Scotland and its Suicide Review Groups and other inquiries and Critical Incident Reviews will be used to assist in the identification of risk factors and ensure the implementation of recommendations across a range of agencies.
  • Professionals will be trained to identify and manage young people and others in the community who may present a significant risk of self harm and suicide. Consideration will be given to joint protocols and referral pathways.

Longer-term work to provide hope and support recovery

Objective: To provide on-going support and services to enable people to recover and deal with the issues that may be contributing to their suicidal behaviour.

  • A range of service responses is proposed in relation to the development or extension of support services available in Edinburgh. Some of the funding available through Choose Life will be used to commission such services.
  • The need for a range of protocols is identified within the actions in the key risk groups and their development will be promoted and supported.

Coping with suicidal behaviour and completed suicide

Objective: To provide effective support to those who are affected by suicidal behaviour or a completed suicide.

  • Cruse Bereavement Care, an organisation which has worked extensively with people affected by suicidal behaviour, is represented on the Choose Life Steering Group.
  • The Edinburgh Carers Council is also represented on the Steering Group and it is keen to develop information and awareness-raising for carers of people with mental health problems.

Promoting greater public awareness and encouraging people to seek help early

Objective: To ensure greater public awareness of positive mental health and well-being, suicidal behaviour, potential problems and risks amongst all age groups; to encourage people to seek help early.

  • Local actions are proposed throughout the key groups sections with regard to raising greater public awareness about positive mental health.
  • The provision of training, awareness-raising and information is proposed in schools, primary care and for key risk groups and carers.

Supporting the media

Objective: To ensure that any depiction or reporting by any section of the media of a completed suicide or suicidal behaviour is undertaken sensitively and appropriately and with due respect for confidentiality.

  • Work is required on this area locally and the Edinburgh Choose Life Steering Group will link with the National Implementation Team on media matters.

Knowing what works

To improve the quality, collection and availability of information on issues relating to suicide and suicidal behaviour and on effective interventions to ensure the better design and implementation of responses and services and use of resources.

  • This is a national programme objective which will be informed by local actions.​

Self-harm

Self-harm can be defined as ‘self poisoning or self-injury, irrespective of the apparent purpose of the act' and describes a wide range of things that people do to themselves in a deliberate and usually hidden way, which are damaging. See The Site [external site] for more information. It includes cutting, burning, scalding, banging heads and other body parts against walls, and hair-pulling, biting, and swallowing or inserting objects as well as self-poisoning.

Although the true extent of self-harm is unknown, we know that, in Scotland, in 2009-10, there were 12,741 acute hospital stays where a diagnosis of self-harm was recorded.

Evidence suggests that young people are more likely to self-harm than adults, although people who self harm come from all age groups and backgrounds. There are reports of very young children receiving help for self-harm. Consequently, the Scottish Youth Parliament has identified self-harm as a key priority for action in Scotland. Older people who self-harm have an increased risk of suicide. See the Choose Life website [external site] for more information.

In Scotland there is a considerable amount of activity relating to prevention of self-harm, but there are widespread differences across local areas in definitions of what constitutes ‘high risk’ suicidal behaviour and in the range of activities which have been developed to address the problem.

Self-harm is often used as a coping mechanism, and many young people who self-harm lack confidence, are extremely sensitive and have low self-esteem.

There is a wide range of factors that might contribute to self-harming, including feeling isolated, relationships, poor body image, academic pressures, powerlessness, alcohol misuse, fear of losing control, and abuse, among many others.

We currently lack a clear picture of the extent of activity across Scotland in relation to training, services, research and guidelines.

In Towards a Mentally Flourishing Scotland, the Scottish Government committed to improving the knowledge and understanding of self-harm in Scotland and to preparing an appropriate response. The Government said that it would work with partners to:

  • agree a definition of self-harm and develop a non-stigmatising language and description of self-harm
  • increase awareness of self-harm and its determinants
  • map and assess existing training provision and projects across Scotland
  • increase our understanding of effective methods of prevention and offer guidance to those delivering both general and specific services
  • develop local and national information.

A National Self Harm Working Group was established in August 2009 to take these tasks forward and to map out the next stage of activity in developing services and health improvement approaches. The Group’s work, including the consultation, resulted in the publication of the refreshed paper, Responding to Self-Harm in Scotland Final Report: Mapping Out the Next Stage of Activity in Developing Services and Health Improvement Approaches.

Summary reports from the Scottish Government’s written consultation and the NHS Health Scotland/Choose Life consultation with key professional groups and with people with lived experience of self-harm can be found on the Choose Life website.

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Desired Outcomes

The desired outcome for self-harm prevention is:

  • to reduce the incidence of self-harm
  • agree a definition of self-harm and develop a non-stigmatising language and description of self-harm
  • increase awareness of self harm and its determinants
  • map and assess existing training provision and projects across Scotland
  • increase our understanding of effective methods of prevention and offer guidance to those delivering both general and specific services
  • develop local and national information.

Current Evidence

Self-harm According to Truth Hurts: National Inquiry into Self-harm among Young People [external site] while much can be done to address self-harm within wider strategies for mental health improvement, an effective response to young people who self-harm requires that self-harm is understood, and responded to as a specific issue.

The report asserts that a comprehensive approach to self-harm requires both a broad, generic focus on improving mental wellbeing and behaviour-specific information, training and intervention.

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Recommendations

NICE Self-harm recommendations for EnglandNICE clinical practice guideline number 16: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care [external site] make a number of key priorities for implementation (NICE Guidelines are applicable in England):

  • people who have self-harmed should be treated with the same respect, care and privacy as any patient
  • staff should have appropriate training
  • activated charcoal should be immediately available to ambulance and emergency department staff
  • preliminary psychosocial assessment at triage
  • physical treatment, with appropriate analgesia/anaesthesia, should be given, regardless of willingness to accept psychosocial assessment or psychiatric treatment
  • a full assessment of need should be offered
  • an assessment of risk should be carried out
  • decisions about referral for further psychological, psychosocial and pharmacological interventions should be based on comprehensive psychiatric, psychological and social assessment, and should not be determined solely on the basis of having self-harmed.

 

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