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Part 1
Understanding suicide and risk
1.1 Suicide statistics and UK policy
1.2 Definitions of suicide and related terms
1.3 Stigma and common myths about suicide
1.4 From thought to contemplation to preparation to action
1.5 Help-seeking and barriers to help-seeking
1.6 Suicide and mental health
Self-harm and suicide
Substance use and suicide
1.7 Risk assessment
The low-risk paradox
Risk scales
Psychosocial assessment
Follow-up and treatment planning
1.8 Risk and protective factors
Types of suicide risk factors
Static risk factors
Stable risk factors
Dynamic risk factors
Protective factors
1.9 Models of suicide
Shneidman’s cubic model (1972, 1987, 1993)
CBT
Cry of pain or entrapment model
Joiner’s interpersonal-psychological theory
The fluid vulnerability theory (FVT)
The integrated motivational-volitional model (IMV)
1.10 Intervening to help people at risk of suicide – who, where and when
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1.1 Suicide statistics and UK policy
Suicide accounts for an estimated 1.4% of all deaths worldwide (World Health Organisation, WHO 2014). On average, someone dies by suicide every 40 seconds somewhere in the world (Preventing Suicide: A Global Imperative 2014). Many more people die by suicide each year than in road traffic accidents, yet the funding for suicide prevention has been significantly lower in comparison to road accident prevention (Aleman & Denys 2014). Recent findings indicate that over 100 people are affected by every single suicide (Cerel et al 2019), with an increased likelihood of suicidal ideation, depression and anxiety for those closest to the individual (Cerel et al 2016).
In the United Kingdom, approximately 6,000 people die by suicide per year (Office for National Statistics, ONS 2018, 2019). According to the latest ONS statistics, the 2019 suicide rate for England and Wales was 11.0 deaths per 100,000 people (ONS 2020), the highest seen since 2000. Suicide and injury or poisoning of undetermined intent was the leading cause of death for both males and females aged 20–34 years in the United Kingdom between 2001 and 2018. Males had over three times the number of deaths from suicide compared with females for each year observed in this age group. Over the past decade, middle-aged men in their 40s and 50s have had the highest suicide rates of any age group or gender (ONS 2020). Despite significant efforts in public health initiatives to prevent suicide and the roll-out of crisis teams across the United Kingdom, there has been little variation in the rate of suicide since 2008 (Brown et al 2020).
Less than one third of people who end their life by suicide (28%) have accessed mental health services in the 12 months prior to death (Brown et al 2020). About one third of people who think about ending their life go on to attempt suicide, and 60% of these transitions occur within the first year after onset of suicidal thoughts (Nock et al 2008). It is estimated that for each adult who dies by suicide, there are likely to be 20–30 suicide attempts, though this varies widely according to age and gender. Suicide and suicide-related behaviours also cause considerable distress to those who lose a friend or family member through suicide. For all these reasons it is a major public health problem which requires an informed and compassionate response from anyone who can help.
Over the last decade important progress has been made to reduce suicide. In 2012, the UK government published its national suicide prevention strategy, which set out groups at higher risk and priority areas for action. In 2014, the WHO set the goal of a 10% reduction in suicide by 2020 through raising awareness, systematically mapping occurrences and developing nationally tailored suicide prevention strategies within the general population, and health services in particular (WHO 2014). The Five Year Forward View for Mental Health (Mental Health Task Force 2016) set a national ambition to reduce suicides by 10% by 2020/21. The National Strategy committed to tackling suicide in six key areas for action, with the scope of the strategy subsequently expanded (HMG 2017) to include addressing self-harm as a new key area:
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reducing the risk of suicide in high-risk groups;
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tailoring approaches to improve mental health in specific groups;
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reducing access to means of suicide;
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providing better information and support to those bereaved or affected by suicide;
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supporting the media in delivering sensitive approaches to suicide and suicidal behaviour;
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supporting research, data collection and monitoring; and
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reducing rates of self-harm as a key indicator of suicide risk.
In 2018, the National Institute for Health and Care Excellence (NICE 2018) published guidelines on how to prevent suicides in community and custodial settings. The National Suicide Prevention Alliance (NSPA) is the leading England-wide, cross-sector coalition of public, private and voluntary organisations for suicide prevention and is continuing to grow in its reach and membership. The responsibility for the strategic suicide prevention planning in England lies with the Local Authority Public Health Teams, working in partnership https://www.local.gov.uk/sites/default/files/documents/1.37_Suicide%20prevention%20WEB.pdf.
Nearly every local area in England now has a multi-agency suicide prevention plan in place. As we move towards Integrated Care Systems, all local health systems are expected to develop cross-organisational five-year plans to be implemented from August 2019 detailing how they will deliver the Long-Term Plan. This includes a continued focus on multi-agency work to prevent and reduce suicide (DOH 2012; NICE 2018). Priorities are:
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delivering our ambition for zero suicide amongst mental health inpatients and improving safety across mental health wards and extending this to whole community approaches;
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addressing the highest risk groups including middle-aged men and other vulnerable groups such as people with autism and learning disabilities, and people who have experienced trauma by sexual assault and abuse;
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tackling the societal drivers of suicide such as debt, gambling addiction and substance misuse and the impact of harmful suicide and self-harm content online;
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addressing increasing suicides and self-harming in young people; and
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improving support for those bereaved by suicide.
One aim of suicide prevention is to improve detection of suicide risk in general practice. Luoma et al (2002) found 77% on average had had contact with a general practitioner (GP) in the previous 12 months, and 45% in the month prior to their death by suicide. In England, Pearson et al (2009) found that 91% of people who ended their life had consulted their GP at least once in the year before death, with an average of seven consultations, almost double the general population rate (Galway et al 2007). A case-control study of suicides in England over a ten-year period concluded that suicide risk is associated with increasing frequency of GP consultations, particularly in the three months prior to suicide. These patients had consulted their GP more than 24 times in the year before ending their life (National Confidential Inquiry into Suicide and Safety in Mental Health, NCISH 2014). Despite widespread and frequent contact, many suicidal patients are missed by GPs (Leavey and Hawkins 2017).
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1.2 Definitions of suicide and related terms
ASSISTED SUICIDE, also known as assisted dying, is suicide undertaken with the help of another person (often a physician) by providing the individual with the means to end their life or by providing advice on how to do it.
ATTEMPTED SUICIDE OR SUICIDE ATTEMPT is an attempt to take one’s life that does not end in death but may result in self-injury or the non-fatal attempt to inflict self-harm with the intent to die.
PARASUICIDE refers to any suicidal behaviour or self-harm where there is no result in death. It is a non-fatal act in which a person deliberately causes injury to him- or herself or ingests excess prescribed medication.
POSITIVE RISK-TAKING OR POSITIVE RISK MANAGEMENT is identifying the potential risks involved and developing plans and actions that reflect the positive potentials and stated priorities of the service user. It involves using available resources and support to achieve desired outcomes and minimise potentially harmful outcomes. It requires an agreement of goals, or a clear explanation of any differences of opinion regarding the goals or courses (Southern Health NHS Trust 2012). Its purpose is for individuals to take control of their lives and make choices – either positive or negative – and learning from the consequences of those choices – again positive or negative. In practice this requires a balance between the interests of the individual and societal pressures to control risk (Felton et al 2017).
POSTVENTION is a term that was first coined by Shneidman (1972), which he used to describe “appropriate and helpful acts that come after a dire event”. A postvention is an intervention conducted after a suicide, to support those bereaved (family, friends, professionals and peers) who may be at increased risk of suicide themselves and may develop complicated grief reactions.
REASONS FOR LIVING (RFL) and REASONS FOR DYING (RFD) are important individual reasons for staying alive (e.g. family) or wanting to die (e.g. hopelessness) and reflect the internal motivational conflict of the suicidal mind (Jobes & Mann 1999).
RISK is the likelihood, imminence and severity of a negative event occurring such as violence, self-harm or self-neglect (Department of Health, DOH 2007). It is the likelihood of an event happening with potentially harmful or beneficial outcomes for self and others. Risk behaviours include suicide, self-harm, neglect, aggression and violence (Southern Health NHS Trust 2012).
RISK ASSESSMENT: A risk assessment is a detailed clinical assessment that includes the evaluation of a wide range of biological, social and psychological factors that are relevant to the individual and future risks, including suicide and self-harm (...
