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To cast a mental spell on suicide prevention

13 Sep 2013

More waves of the magic wand will be required to improve on recent gains in self-harm

Lloyd Mudiwa

and suicide prevention so as to bring mental health, for so long the ‘Cinderella’ of the health service, on a par with more ‘fashionable’ conditions, writes Lloyd Mudiwa.

In 2012 the National Registry of Deliberate Self-harm Ireland recorded 12,010 deliberate self-harm presentations to hospital. This is a 2 per cent reduction from 2011 and represents a decrease in the national levels of self-harm for the second year in a row (the decrease in 2010 was 4 per cent).

According to the National Office for Suicide Prevention (NOSP) Annual Report 2012, also launched last week along with the Self-harm Registry, based on Central Statistics Office (CSO) figures some 495 people died by suicide in 2010 (the latest figures available), down from 552 people the previous year.

A further 123 deaths were provisionally recorded as “undetermined”.

This rate is significantly higher than for any period over the past decade, and nearly double the 2009 figure of 74 suspect cases.

Caution must be urged as the rates are still provisional and may be subject to change, according to a disclaimer issued by the NOSP.

While these figures indicate that self-harm and suicide rates in Ireland may be stabilising, there is no room for complacency, especially given self-harm and suicide generally tend to affect the young and most vulnerable in our society.

Launching the two reports last week, in Hawkins House, Minister of State with responsibility for Mental Health Kathleen Lynch said while a provisional reduction in figures compared with previous years is welcome, rates remain too high.

Current data would suggest that the national suicide mortality rate has stabilised since 2009; however the rates among men aged 20-29 years, 40-49 years, and women aged 50-59 years remain high and continue to be of public health, Governmental and societal concern.

Also, the WHO collects international data on deaths by suicide, which allows for some comparison. While Ireland has the sixth-lowest rate of death by suicide in the EU, compared with the lowest rate of 3.9 in Greece and the highest of 34.0 in Lithuania, the comparison is less favourable for younger groups. Ireland rates fourth-highest in the EU for deaths by suicide for five-24 year-olds, at 13.9 per 100,000 population.

A worrying aspect in terms of self-harm acts is the hike in attempted hangings. Attempted hanging was involved in 7 per cent of all deliberate self-harm presentations (10 per cent for men and 3 per cent for women). At 776, the number of presentations involving attempted hanging has increased significantly, by 6 per cent from 2011 (n=734).

This is the greatest number of deliberate self-harm presentations involving hanging recorded by the Registry and is 75 per cent higher than the number recorded in 2007 (n=444).

The high risk of subsequent suicide among people using highly lethal methods of self-harm, is illustrated by the figures in the report.

In this context, there are indications that increasing rates of self-harm in men are likely to be followed or paralleled by increasing suicide rates among men.

This is put into context by the fact that next-care varied significantly by HSE hospitals groups.

The variation in recommended next-care is likely to be due to variation in the availability of resources and services but it also suggests that assessment and management procedures with respect to deliberate self-harm patients is likely to be variable and inconsistent across the country.

Considering the high risk of subsequent suicide among people using highly lethal methods of self-harm, suicide risk assessment combined with psychiatric and psychosocial assessment should be incorporated in the standard of care for self-harm patients presenting to hospital EDs.

As Minister Lynch said, it is “not acceptable” for a person who presents to an ED having self-harmed not to have a comprehensive risk and psychosocial psychiatric assessment and follow-up.

In 2012, the NOSP invested ?3.45 million in suicide prevention services and programmes across the voluntary and statutory sector, which was an increase of 17 per cent on 2011. That the HSE expects this to rise to over ?5 million this year, despite the turbulent economic situation, is a long overdue development in the obscure and neglected sector.

Its report also listed “key achievements”, including the development of a national online education programme on suicide prevention for GPs and evaluation of a self-harm training programme for frontline staff working in EDs.

The Second Report of the Suicide Support and Information System (SSIS), also launched at the event, records information on all cases of suicide identified in a pilot project in Cork City and County. Among the 307 cases recorded by the SSIS, differences were identified between subgroups of people who had died by suicide in terms of risk factors.

The importance of real-time information systems for self-harm and suicide — so that health services and communities can more quickly identify changes in risk factors and clusters of self-harm or suicide and plan services and appropriate responses accordingly — can never be overstated. For instance, in recent years, the Registry identified a significant increase in attempted suicidal drownings in Limerick, which was paralleled by an increase in fatal suicidal drownings.

Ongoing work is being undertaken by the NSRF to link the Registry data with suicide mortality data obtained through the Suicide Support and Information System in Cork and the CSO data. Linking the Registry self-harm data with the SSIS suicide mortality data revealed that self-harm patients were more than 42 times more likely to die by suicide than persons in the general population.

It is therefore recommended that deliberate self-harm data be linked with suicide mortality data at a national level in order to enhance insight into predictors of suicide risk.

Plans to implement the SSIS in Dublin with talks ongoing with the Dublin City Coroner Dr Brian Farrell are welcome, while an eventual nationwide roll-out of the programme would be encouraged and help to establish the true extent of the rate of suicides in Ireland.

After all, they say, ‘a problem clearly stated is a problem half solved’. Ever wondered what happens to Cinderella after the ball?

13 September 2013

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