National Public Health Service for Wales

National Public Health Service for Wales Suicide prevention: Summary of the evidence

Suicide prevention:

Summary of the evidence

Version: 1 Date: February 2007 Status: Final draft Author: Sian Price Page: 1 of 64 Classification: National Public Health Service for Wales Suicide prevention: Summary of the evidence

Further information: [email protected]

© 2007 National Public Health Service for Wales Material contained in this document may be reproduced without prior permission provided it is done so accurately and is not used in a misleading context. Acknowledgement to the National Public Health Service for Wales to be stated.

TABLE OF CONTENTS

INTRODUCTION 4

LEVEL 1 PRIMARY PREVENTION – POPULATION LEVEL 6 INTERVENTIONS 1.1 General mental health promotion and suicide prevention 7 interventions 1.2 Specific mental health promotion programmes 11 1.3 Reducing access to means of suicide 16 1.4 Useful resources 17

LEVEL 2 EARLY IDENTIFICATION 18 2.1 Screening for suicide risk 19 2.2 Identification and management of depression 20 2.3 Management of drug and alcohol misuse 24 2.4 Management of mental illness 25 2.5 Preventing suicide in prisons and police custody 28 2.6 Physical illness 30 2.7 Useful resources 31

LEVEL 3 CRISIS INTERVENTION, MANAGING SUICIDAL BEHAVIOUR 34 3.1 Monitoring self harm 35 3.2 Interventions to reduce suicidal ideation 36 3.3 Assessment and short term management of people who self harm 37 3.4 Secondary prevention of self harm 41 3.5 The role of voluntary agencies 46 3.6 Useful resources 46

LEVEL 4 POSTVENTION 47 4.1 Reviewing completed suicides 48 4.2 Suicide of service users – Managing the impact on staff 50 4.3 Supporting those bereaved by suicide 51 4.4 Media portrayal of suicide 54 4.5 Monitoring suicide rates 57 4.6 Useful resources 58

CONCLUSION 60

APPENDICES I Risk factors associated with suicide 61 II Summary of recommendations from the British Isles Suicide 63 Researchers Group

INTRODUCTION Suicide and deliberate self harm have significant personal, social and economic consequences. Whilst there seems to be a broad consensus that many suicide deaths are preventable, there is no clear way to predict which individuals are likely to die from suicide and there is no research that demonstrates how suicide can be prevented in any individual1. Many studies have identified factors associated with an elevated risk of suicide but none of these allow a level of prediction that is clinically useful1. Despite this an understanding of the risk factors associated with suicide is useful targeting interventions at groups with an elevated risk of suicide. Suicide is a relatively rare event. Because of this and notwithstanding the ethical implications, very large numbers would be needed to conduct randomised controlled trials of interventions to prevent suicide. As a consequence much of the evidence around suicide prevention focuses on interventions designed to prevent repetition of self harm. Recently there has been a shift in focus in efforts to prevent suicide and a public health model has been adopted. This has meant a move away from concentrating on the treatment of high risk patients towards a more population based approach. This approach attempts to reduce the risk in the whole population by changing attitudes, knowledge, behaviours and norms that might predispose people to suicide. It also looks to address behaviours in society such as substance abuse that are known to be linked with suicide Using this model suicide prevention can be considered at four levels. These are; 1. Primary prevention, initiatives targeted at whole populations. These include general mental health promotion initiatives that aim to increase public and professional awareness, create a better understanding of mental illness, reduce stigma and encourage health seeking behaviour, specific mental health promotion initiatives targeted and primary prevention of mental ill health and substance abuse and measures to remove access to the means of suicide. 2. Early identification, this is also primary prevention but this level is more selective targeting interventions at groups who may be at a greater risk of suicide than the general population. This level includes the identification and management of depression, management of substance abuse and mental illness and suicide prevention in prisons. 3. Crisis intervention (secondary prevention). This level addresses interventions for those who have already demonstrated suicidal or self harming behaviour.

1 Goldney RD. Prediction of suicide and attempted suicide. In: Hawton K, Van Heeringen K editors. The international handbook of suicide and attempted suicide. Chichester: John Wiley; 2000.

4. Postvention (tertiary prevention). This level addresses the consequences of completed suicide. Interventions at this level may be targeted at specific individuals or at specific groups. This level includes helping those bereaved by suicide, the portrayal of suicide by the media and ‘learning the lessons’ from completed suicide. This document summarises the evidence for activities and interventions that may be of benefit in preventing suicide. The evidence is set out according to the four levels described above. The convention used in this document to indicate the type of evidence is;

Type 1 evidence: at least one good systematic review (including at least one randomised controlled trial)

Type II evidence: at least one good randomised controlled trial

Type III evidence: well designed interventional studies without randomisation

Type IV evidence: well designed observational studies

Type V evidence: expert opinion; influential reports and studies

Source: Barker J, Weightman A L, Lancaster J. Project for the enhancement of the Welsh Protocols for Health Gain: project methodology 2. Cardiff: Duthie Library;1997.

Where the type of evidence differs from this convention, details are given in the text. The examples provided in this document are not exhaustive. The intention is to highlight the type of interventions that might be effective and provide examples of these. In order to implement any of these interventions further information will be needed. The ‘Useful resources’ boxes provide links to some of the evidence summarised in the document and other sources of information.

The NPHS Vulnerable Adults team has undertaken the evidence review to contribute to the development of policy and practice within Wales .

LEVEL 1 – PRIMARY PREVENTION, POPULATION LEVEL INTERVENTIONS This section summarises the evidence for;  General mental health promotion or suicide prevention initiatives that influence public and professional awareness  Specific mental health promotion interventions targeted at preventing mental ill health and substance misuse  Reducing access to the means of suicide

1.1: GENERAL MENTAL HEALTH PROMOTION AND SUICIDE PREVENTION INTERVENTIONS General mental health promotion initiatives that influence public and professional awareness, aim to create better understanding of mental illness and suicide, reduce stigma and encourage health seeking behaviour. Topic Area National Campaigns may increase public and professional understanding of mental illness, reduce stigma and discrimination and promote ‘help seeking’ Supporting evidence 1.1.1 The Royal College of Physicians ‘Changing Type V evidence Minds Campaign’ ran for five years from 1998 to http://www.rcpsych.ac.uk/campaig 2003. The campaign targeted doctors, children ns/cminds/index.htm and young people, employers, the media and the general public. It aimed to increase public and Although a survey undertaken before the Campaign assessed professional understanding of mental health public attitudes no follow up problems and to reduce stigma and survey of its impact has been discrimination. A Tool Kit of materials was reported developed to help change minds and reduce stigma. These materials are now available on a website. A second website created by the Campaign provides in-depth articles about stigma by researchers, academics, mental health service users and carers. Following the official close of the Campaign the College has continued to develop the campaign website and distribute publications.

1.1.2 The Royal Collage of General Practitioners and Type IV evidence Royal College of Psychiatrists ran a ‘Defeat Depression’ Campaign from 1992 to 1996. It Rix S, Paykel E S, Lelliott P, Tylee A, Freeling P, Gask L, Hart D. aimed to educate GPs to recognise and treat Impact of a national campaign on depression to reduce the stigma associated with GP education: an evaluation of depression and encourage early seeking of the Defeat Depression Campaign. BJGP 1999; 49: 99-102. treatment by educating the public about the disorder and its treatment. To educate the public Paykel E S, Hart D, Priest RG. Changes in public attitudes to newspaper and magazine articles, radio and depression during the Defeat television programmes and other media activities Depression Campaign. Br J were used. Positive attitude change in the public Psychiatry 1998; 173:519-22. was achieved by the campaign. Surveys of public attitude were carried out by MORI in late 1991, early 1995 and mid 1997. These found significant positive change in attitudes regarding depression, reported experience of it, attitudes to antidepressants (and less consistently to treatment from GPs). Changes were in the order of 5 to 10%. Attitudes to depression and treatment by counselling were very favourable but antidepressants were seen as addictive and less effective.

Topic area Nationwide suicide prevention strategies with multiple objectives may be effective in reducing suicide Supporting evidence 1.1.3 The Finnish suicide project involved a national Type V evidence network, mass media communication and Upanne M, Hakanen J, Rautava regional planning of suicide prevention M. Can suicide be prevented? Specifically in involved three theme specific The suicide project in Finland programmes; 1992 – 1996: Goals, implementation and evaluation.  Proper care of suicide attempters Helsinki,:STAKES National  Support to survivors Research and Development Centre for Welfare and Health;  Project on depression “Keep your chin up” 1999. And a range of other initiatives and actions The Finnish suicide project ran from 1986 – 1996. It is the first  Regional development of schools crisis nationwide project to be management implemented and evaluated. The number of suicides in Finland  Co-operation with schools reduced by 9% between 1987 and  Collaboration with the church 1996.  Co-operation with the Finnish Defensive Forces  Support to young people  Collaboration with the police  Co-operation with the Ministry of Labour  Support during a recessions crisis o Development of occupational health services for the unemployed  Mutual help: male coping strategies  Addressing substance abuse  Treatment of depression  Development of a brochure on depression and alcohol  Early stage intervention by occupational health services  Substance abuse projects

Topic area The evidence supporting school curriculum based suicide prevention programmes for adolescents is equivocal and is insufficient to support the implementation of school curriculum based intervention programmes for adolescents Supporting evidence 1.1.4 Studies included in this review involved suicide Type III evidence education and general coping skills training. Systematic review Interventions ranged from a single 1 ½ hour including type III and IV session to 180 sessions of 55 minutes each studies. delivered over a 10 month period. Interventions were usually provided by school teachers with Ploeg J, Ciliska D, Brunton G, MacDonnell J, Apos O, Brien M A. additional training but school counsellors, social The effectiveness of school- workers, mental health specialists and school based curriculum suicide nurses were also used. prevention programs for adolescents. Ontario: Ministry of Health, Region of Hamilton- Five studies showed that interventions might Wentworth, Social and Public improve suicide related knowledge and attitudes Health Services Division; 1999.

and mental health indicators such as perceived The studies used in review were stress, anger and self-esteem. Some negative all based in Canada therefore the programme effects were also identified, findings may not apply to other especially for males. Some studies found that school/education systems programmes had detrimental effects on suicide related attitudes, hopelessness and coping.

Topic area Interventions that aim to change social norms about seeking help and incorporate training in suicide prevention may promote mental health and reduce risk of suicide Supporting evidence 1.1.5 The US Air Force suicide programme was Type IV evidence introduced in response to an increase in suicide Knox K L, Litts D A, Talcott G W, rates amongst Air Force personnel. The Catalano Feig J, Caine E D. Risk intervention aimed to remove the stigma of of suicide and related adverse seeking help for mental health or psychosocial outcomes after exposure to a suicide prevention programme in problems, enhance understanding of mental the US Air Force: cohort study. health and to change policies and social norms. BMJ 2003; 327: 1376. This study found that The initiatives included; implementation of the programme  Suicide awareness education and training was associated with a sustained included in squadron commander courses decline in the rate of suicide and other adverse outcomes such as  Suicide prevention incorporated into domestic violence .A 33% relative professional military education curriculum risk reduction was observed for suicide after the intervention.  Guidelines for commanders on use of Consideration needs to be given mental health services to improve referral to whether similar results would of active duty members for mental health be found in different populations. 84% of the population in this study evaluation, emphasis on mental health were male. In addition this was a professionals being seen by commanders multilayered intervention so it is not possible to know whether as partners in improving duty using separate or different performance combinations of elements of the  Strengthening preventative role of mental programme would be effective. health personnel  Community education and training for non-professionals in understanding suicide, intervention skills and referral procedures for people potentially at risk  Changes in policies to ensure individuals under investigation for legal problems are assessed for suicide risk  Establishment of critical incident stress management team to respond to traumatic events including completed suicides

1.2. SPECIFIC MENTAL HEALTH PROMOTION PROGRAMMES Specific mental health promotion interventions targeted at primary prevention of mental ill health and substance misuse. Topic area Interventions to improve mental health may have a role in preventing problems such as depression, anxiety, substance misuse and suicidal behaviour

Supporting evidence 1.2.1 The mental health briefing produced by the Systematic review of Health Education Board for Scotland for the studies of types II to IV Scottish Executive summarises the evidence of Mentality. Mental health effectiveness of interventions to improve the improvement: What works? A mental health of the following groups; briefing for the Scottish Executive. Edinburgh: Health Education  Early years Board for Scotland; 2001/2.  Young people: in school and community settings  Primary care  Workplace  Communities and neighbourhoods  Older people  People with mental health problems

1.2.2 A review of the effectiveness of mental health Review of evidence of promotion interventions undertaken by the Health types I to IV Education Authority addressed the question Tilford S, Delaney F, Vogels M What interventions have been shown to be Effectiveness of mental health effective in; promotion interventions: a review. London: Health Education  preventing specified mental disorders Authority; 1997. and related outcomes  promoting positive wellbeing  developing the major intermediate factors associated with mental health/prevention of mental disorder Findings in the report are summarised by life stage;  Childhood  Youth  Adulthood  Older age

1.2.3 This briefing paper is designed to support and Type V evidence strengthen mental health promotion practice. It provides a summary of effective mental health Friedli L. Making it effective: a guide to evidence based mental promotion interventions and discusses issues health promotion. Radical that are raised around the evidence base for mentalities. London: mentality; mental health promotion. It summarises findings 2003. from studies using a range of methodologies.

Topic area Alcohol dependence is recognised as a risk factor for suicide and there is some evidence that early drinking experiences are linked to later alcohol dependence. Primary prevention of alcohol misuse in young people may reduce suicide risk in later life. Supporting evidence 1.2.4 The Strengthening Families programme and Systematic review including culturally focused skills training may be evidence of types II and III effective in primary prevention of alcohol misuse in young people Foxcroft DR, Ireland D, Lowe G, Breen R. Primary prevention of alcohol use in young people. The Cochrane Database of Systematic Reviews 2002, Issue 3.

These interventions may be effective over the longer term but require further evaluation

Topic area Alcohol dependence is recognised as a risk factor for suicide. Interventions that are effective in reducing alcohol misuse may be effective in preventing suicide Supporting evidence 1.2.5 This briefing paper summarises the evidence Review of systematic for effective interventions to prevent and reviews, meta-analyses reduce alcohol misuse. It summarises the and non-systematic evidence to support interventions to reduce reviews containing hazardous drinking delivered in a range of evidence of types I to V healthcare settings and interventions to reduce Mulvihill C, Taylor L, Waller S alcohol impaired driving Naidoo B, Thom B. Prevention and reduction of alcohol misuse. London: Health Development Agency; 2005. Topic area Drug misuse is a recognised risk factor for suicide. Prevention of drug use in young people may be effective in reducing suicide. Supporting evidence 1.2.6 This evidence briefing summarises evidence on Review of systematic prevention and/or reduction of drug use among reviews, meta-analyses young people. It addresses; and non-systematic  School based interventions reviews containing  Police officer, teacher, peer and parent evidence of types I to V led approaches Canning U, Milward L, Raj T, Warm D. Drug use prevention among young people: a review of reviews. London: Health Development Agency; 2004.

Topic area People who experience poor social environments or severe adverse life events may be particularly vulnerable to mental health problems. Interventions to alleviate the impact of these may prevent development of mental health problems in the longer term. Supporting evidence 1.2.7 This review considers interventions for; Type 1 evidence  Children living in poverty Mental health promotion in high  Children with behavioural difficulties risk groups. Effective Health Care  Children experiencing divorce and Bulletin 1997; 3 (3). bereavement  Adults undergoing divorce or separation  Adults experiencing unemployment  Depression in pregnancy  Bereavement  Long-term carers of people who are highly dependent The review concluded; High quality pre-school education and support visits for new parent can improve mental health in children and parents in disadvantaged communities School-based interventions and parent training programmes for children showing behavioural problems can improve conduct and mental well being Mental health problems in children of separating parents can be reduced by providing cognitive skills training and emotional support Social support and problem solving or cognitive – behavioural training in the unemployed can improve mental health and employment outcomes Mental health problems often experienced by long-term carers can be prevented by respite care and some forms of psycho-social support Counselling, by itself, has not been shown to produce sustained benefit in a variety of groups at risk The primary health care team has an important role in identifying and co-ordinating the management of people at high risk. Structured multi-sectoral co-ordination of strategies targeting those most likely to benefit are needed

Topic area Patterns of emotional, cognitive and social functioning established early in a child’s life will influence their later development and in particular their mental health. Parenting programmes may have a role to play in improving the emotional and behavioural adjustment of children Supporting evidence 1.2.8 There is some evidence to support the use of Type 1 evidence group based parenting programmes to Barlow J, Parsons J. Group-based improve the emotional and behavioural parent-training programmes for adjustment of children under 3 years. improving emotional and behavioural adjustment in 0-3 year old children. The Cochrane Database of Systematic Reviews 2003, Issue 2.

The evidence as to whether results are maintained over time is equivocal. Further input may be required at a later stage in development; further research on this aspect is required.

Topic area The origins of many mental health problems may lie in infancy and childhood. There is evidence that maternal psychological health may have a significant impact on the mother-infant relationship and this may have consequences for the long and short- term psychological health of the child. Supporting evidence 1.2.9 Parenting programmes using five theoretical Type 1 evidence approaches were shown to be effective in Barlow J, Coren E, Stewart-Brown improving a range of aspects of maternal SSB. Parent-training programmes psychosocial functioning (These included for improving maternal psychosocial measures of maternal anxiety, depression and health. The Cochrane Database of Systematic Reviews 2003, Issue 4. self-esteem). The programme categories were;  Behavioural Overall the results of the review were positive but some studies  Cognitive-behavioural showed no effect. Further research  Multi-modal is needed to assess which factors of these contribute to successful  Behavioural-humanistic outcomes.  Rational-emotive All the programmes reviewed were successful in producing positive change in maternal psychosocial health

Topic area There is a recognised link between depression and suicide. Depression is common and has a significant impact on the functioning of young people who develop it. There is some evidence that psychological depression prevention programmes are effective in preventing depression in young people. Supporting evidence 1.2.10 Psychological depression prevention Type 1 evidence programmes were shown to be effective in Merry S, McDowell H, Hetrick S, Bir J, short - term reduction of depressive symptoms Muller N. Psychological and/or and diagnosis of depressive illness. educational interventions for the prevention of depression in children and adolescents. The Cochrane Database of Systematic Reviews 2004, Issue 2.

There were methodological problems with the studies included in the review and there were very few studies of educational interventions. The results are described as encouraging but the authors recommend that further research is undertaken to confirm these results before depression prevention programmes are introduced

Topic area Many factors in the workplace can affect the mental health of employees. Understanding and addressing these factors is complex but may have a range of benefits Supporting evidence 1.2.11 The Toolkit for Mental Health in the Type V evidence Workplace has been developed to help Hughes S. A toolkit for mental health organisations address some of the issues promotion in the workplace. Trent around mental health at work and to provide Mental Health in the Workplace Project. a framework for action London: mentality; 2002.

1.3. REDUCING ACCESS TO MEANS OF SUICIDE Interventions that have an impact on the environment and reduce access to the means to commit suicide Topic area There is evidence to support the effectiveness of providing safety barriers to prevent suicide by jumping, for example, from bridges Supporting evidence 1.3.1 This case study describes how in 1996 suicide Type IV evidence safety barriers were removed from a central Beautrais A L. Effectiveness of city bridge after having been in place for 60 barriers at suicide jumping sites: a years. Removal of the barriers was followed case study. Aust N Z Psychiatry 2001; by a substantial increase in suicides by 35:557-62. jumping from the site. In the period 1992 – 1995 there were three suicides, from 1997- 2000 there were fifteen. Following the removal of the barriers the rate of suicides by jumping in the city did not change but the pattern changed significantly with more suicides from the bridge in question and fewer at other sites.

1.3.2 The pattern of suicides in the Bristol area is Type III evidence affected by the presence of the Clifton Nowers M, Gunnell D. Suicide from Suspension Bridge. A study demonstrated that the Clifton Suspension Bridge. J suicide by jumping in this area is significantly Epidemiol Community Health more common that in England and Wales as a 1996;50:30-2. whole. The Clifton Suspension Bridge (at the time of the study) did not have safety barriers designed to prevent suicide.

Topic area There is evidence that suggests reducing pack sizes of paracetamol and aspirin sold over the counter may reduce suicide deaths by poisoning. Supporting evidence 1.3.3 Legislation on the packaging of paracetamol Type IV evidence and salicylates was introduced in September Hawton K, Townsend E, Deeks J, 1998; this restricted the number of tablets that Appleby L, Gunnell D, Bennewith O, could be sold in one transaction. This Cooper J. Effects of legislation legislation is associated with a decline in restricting pack sizes of paracetamol and salicylate in the United Kingdom: mortality and morbidity from self poisoning before and after study. BMJ 2001; with these drugs. 322:1203 – 07.

Topic area Using blister packs rather than loose preparations may reduce suicide from self poisoning Supporting evidence 1.3.4 In a study of eighty patients admitted to Type IV evidence hospital after paracetamol overdose 69% of those who had taken 25 or more tablets had Hawton K, Ware C, Mistry H, Hewitt J, Kingsbury S, Roberts D, Weitzel H. used a lose preparation rather than a blister Paracetamol self-poisoning. pack (odds ratio = 3.0, 95% CI 1.12 to 9.95, P Characteristics, prevention and harm = 0.028). reduction. Br J Psychiatry 1996; 168: 43-8.

1. 4 USEFUL RESOURCES

These are web links to some of the resources and documents referred to in the text and other useful sources of information

www.changingminds.co.uk www.stigma.org/everyfamily Websites for the ‘Changing Minds’ campaign

http://www3.interscience.wiley.com/cgi-bin/mrwhome/106568753/HOME The Cochrane Library

http://www.hebs.com/researchcentre/cr/crscripts/FTReportTocM.cfm? TxtTCode=1395&Nav=1&sc=specialist&SA=WW Mental Health Improvement: What works? A briefing for the Scottish Executive

http://www.hda-online.org.uk/Documents/effective_mentalhealth.pdf Effectiveness of mental health promotion: a review. Health Education Authority

http://www.mentality.org.uk/services/resources/toolkit.htm Link to order “Mental Health in the workplace toolkit”

http://www.stakes.fi/verkkojulk/pdf/mu161.pdf Evaluation and report of the Finnish Suicide Prevention Project

http://www.york.ac.uk/inst/crd/ehc33.pdf Effective Health Care Bulletin. Mental health promotion in high risk groups

http://www.hda.nhs.uk/Documents/drug_use_prevention.pdf Health Development Agency evidence briefing. Drug use prevention among young people: a review of reviews

http://kc.nimhe.org.uk/upload/NationalFramework1.pdf Making it possible: Improving Mental Health and Well-being in England. National Institute for Mental Health in England

http://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr.pdf World Health Organisation report. Prevention of mental disorders: effective interventions and policy options: a summary report

www.york.ac.uk/inst/crd/pdf/4ment.pdf A National Contract for Mental Health.

www.york.ac.uk/inst/crd/pdf/5Educ.pdf Summarises findings of systematic reviews including health promotion programmes. Evidence from systematic reviews of research relevant to implementing the ‘wider public health’ agenda. Centre for Reviews and Dissemination. August 2000

http://www.show.scot.nhs.uk/publicationsindex.htm Link to ‘Equal Minds’ National programme for improving mental health and well-being in Scotland

Version: 1 Date: February 2007 Status: Final draft Author: Sian Price Page: 18 of 64 Classification: National Public Health Service for Wales Suicide Prevention: Summary of evidence

LEVEL 2: EARLY IDENTIFICATION This section is concerned with primary prevention of suicide and self harm and considers interventions targeted at groups who may be at greater risk of suicide than the general population. Interventions at this level aim to identify at risk groups and address the factors that put them at risk of suicide. A table of risk factors associated with suicide is included at appendix I. This section summarises the available evidence for;  Screening for suicide risk  Identification and management of depression  Management of drug and alcohol misuse  Management of mental illness  Preventing suicide in prisons and police custody  Suicide prevention in people with physical illness

Version: 1 Date:February 2007 Status: Draft Author: Sian Price Page: 19 of 64 Classification: National Public Health Service for Wales Suicide Prevention: Summary of evidence

2.1. SCREENING FOR SUICIDE RISK Topic area Suicide risk is assessed along a continuum ranging from suicidal ideation alone (relatively less risk) to suicidal ideation with a plan (relatively greater risk). Mood and other mental disorders, co-morbid substance abuse, a history of deliberate self-harm and suicide attempts are among the factors associated with an increased risk of suicide. There is however, no research that enables suicide or suicidal behaviour to be accurately predicted in individuals. Supporting evidence 2.1.1 The United States Preventative Services Task Evidence based guideline Force (USPSTF) has concluded that there is based on systematic literature review -only 1 study providing limited insufficient evidence to recommend for or against evidence was identified. routine screening by primary care clinicians to Gaynes B N, West S L, Ford C A, detect suicide risk in the general population. Frame P, Klein J, Lohr K N. Screening for suicide risk: recommendation and topic area. Ann Intern Med 2004; 140: 820-1.

2.1.2 A 10 year prospective study of patients who had Type IV evidence been admitted to hospital with suicidal thinking Beck A T, Steer R A, Kovacs M, Garrison B. Hopelessness and found that a score of 10 or more on the Beck Eventual Suicide: A 10-Year Hopelessness Scale correctly identified 91% of Prospective Study of Patients eventual suicides. However the number of true Hospitalized With Suicidal Ideation. Am J Psychiatry 1985; 142: 559-63. positives (that is individuals who scored 10 or more and eventually died by suicide) was 10 but there were 76 false positives. The high proportion of false positive limits the clinical usefulness of the scale.

2.1.3 A 7 year prospective study of psychiatric Type IV evidence outpatients showed that a score of 9 or above on Beck A T, Brown G, Berchick R J, Stewart B L, Steer R A. Relationship the Beck Hopelessness scale correctly identified between hopelessness and ultimate 16 of the 17 patients who died by suicide during suicide: a replication with psychiatric the follow up period. However the group with this outpatients. Am J Psychiatry 1990; 147:190-95. score included 1145 individuals who did not die by suicide. Using the Beck Depression Score and a cut-off score of 23 or above identified a group of 743, 13 of whom died by suicide during the follow up period. The high number of false positives identified by these scales limits their clinical application.

2.2 IDENTIFICATION AND MANAGEMENT OF DEPRESSION Topic area Depression is a well recognised risk factor for suicide. Screening adults in primary care might improve identification and treatment of depression thus reducing the risk of suicide. Supporting evidence 2.2.1 The United States Preventative Services Task Type I evidence Force (USPSTF) recommends screening adults Pignone M P, Gaynes B N, Rushton J L, Mills Burchell C, Orleans C T, for depression in clinical practices with systems Mulrow C D, Lohr K N. Screening for in place to ensure accurate diagnosis, effective depression in adults: a summary of the treatment and follow up. They found good evidence for the U.S. Preventative Services Task Force. Ann Intern Med evidence that this improves the accurate 2002; 136: 765-76. identification of depressed patients in primary The overall quality of evidence was graded as ‘fair’ meaning that the care settings and that treatment of these patients evidence was sufficient to determine decreases morbidity. effects on health outcomes but the strength of evidence was limited by the The USPSTF concluded that there is insufficient number, quality or consistency of the evidence to recommend for or against routine individual studies. screening of children or adolescents for depression. 2.2.2 The Canadian Task Force on Preventative Type I evidence Health Care makes the following Macmillan H L, Patterson J S, Wathen C N and the Canadian Task Force on recommendations; Preventative Health Care. Screening for depression in primary care: There is fair evidence that screening adults in the recommendations statement from the general population for depression in primary care Canadian Task Force on Preventative Health Care. Canadian Medical settings that have integrated programmes for Association Journal 2005; 172: 33-5. feedback and treatment. There is insufficient evidence to recommend for or against screening adults in the general population for depression in primary care settings where effective follow up and treatment are not available. There is insufficient evidence to recommend for or against routine screening for depression among children or adolescents in primary care settings. 2.2.3 In the United Kingdom the policy of the National Type V evidence Screening Committee (as of May 2005 due for The evidence upon which this recommendation was made is unclear. review in May 2006) is that routine screening of National Screening Committee Policy. the population or subsets of the population for Depression screening. 2006. depression is not recommended. http://rms.nelh.nhs.uk/screening/viewR esource.asp? categoryID=1337&uri=http %3A//libraries.nelh.nhs.uk/common/res ources/%3Fid%3D60968

Topic area Education should improve the ability of primary care practitioners to identify and manage depression; however the evidence for this is equivocal. Supporting evidence 2.2.4 A randomised controlled trial was used in 60 Type II evidence primary care practices in an English health Thompson C, Kinmonth A L, Stevens L, Peveler R C, Stevens A, Ostler K J, district to assess the effectiveness of an Pickering R M, Baker N G, Henson A, educational programme based on a clinical Preece J, Cooper D, Campbell M J. practice guideline for improving the recognition Effects of a clinical-practice guideline and practice-based education on and outcome of depression. detection and outcome of depression in primary care: Hampshire Depression Although the programme was well received it did Project randomised controlled trial. not lead to improvements in recognition of, or Lancet 2005; 355: 185-91. patient’s recovery from, depression. 2.2.5 In Sweden an educational programme for GPs Type III evidence on the symptoms, diagnosis, prevention and Rutz W, Walinder J, Eberhard G, Holmberg G, von Knorring A L, Wistedt treatment of depression was associated with a B, Aberg-Wistedt A. An educational decrease in the number of suicides (and a program on depressive disorders for decrease in the number of suicides of individuals general practitioners on Gotland: background and evaluation. Acta unknown to either GPs or psychiatrists), a Psychiatry Scand 1989; 79: 19-26 decrease in the use of inpatient care for depressive disorders, an increase in the prescription of antidepressants and a decrease in the prescription of major tranquilisers, sedatives and hypnotics. Rutz W, von Knorring L, Walinder J. Three years after the project ended inpatient care Long-term effects of an educational for depressive disorders had increased, the program for general practitioners given by the Swedish Committee for the prescription of antidepressants had stabilised Prevention and Treatment of and the suicide rate had returned almost to Depression. Acta Psychiat Scand baseline. These results suggest that the 1992; 85: 83-8. education programme had an effect on the detection and management of depression in the short term. Further research would be necessary to assess whether regular repetition of an educational programme would have long term effects.

Topic area Effective treatment of depression in primary and secondary care may reduce the occurrence of suicide and self harm Supporting evidence 2.2.6 The National Institute for Clinical Excellence has Evidence based guideline issued guidance on the management of includes evidence of types I to IV and good practice points. depression. This covers the treatment and National Institute for Clinical Excellence management of depression as defined by ICD- Depression. Management of 10, this encompasses; depression in primary and secondary care. London: NICE; 2004.  Mild depression  Moderate depression  Severe depression  Severe depression with psychotic symptoms 2.2.7 The National Institute for Clinical Excellence has Evidence based guideline issued guidance on the identification and includes evidence of types I to IV and good practice points. management of depression in children and young National Institute of Clinical Excellence people in primary, community and secondary Depression in children and young care people. Identification and management in primary, community and secondary care. London: NICE; 2005.

Topic area Suicide is the leading cause of maternal death in the UK2. Early identification and treatment of postnatal depression may reduce the risk of maternal suicide. The evidence supporting the accuracy of screening for postnatal depression is equivocal Supporting evidence 2.2.8 In the United Kingdom the National Screening Type V evidence Committees policy on screening for postnatal http://libraries.nelh.nhs.uk/screening/view Resource.asp? depression is that the available evidence does searchText=Postnatal+depression&searc not support the use of screening tools. The hZone=%2Fscreening %2FsearchResponse.asp&uri=http Committee recommends that the Edinburgh %3A//libraries.nelh.nhs.uk/common/resou postnatal depression scale should not be used rces/%3Fid%3D60978 This policy was adopted on the basis of as a screening tool but could be used as a the evidence supporting the NICE checklist as part of the mood assessment for Routine Antenatal Care postnatal mothers when used in conjunction Guideline. National Institute for Clinical Evidence/National Collaborating Centre with professional judgement and a clinical for Women’s and Children’s Health. interview Antenatal Care: Routine care for the healthy pregnant woman. London: RCOG; 2003. 2.2.9 The Scottish Intercollegiate Guidelines Network Evidence based guideline has issued guidelines on postnatal depression containing evidence of Types I to IV and good practice points and puerperal psychosis. These address; Scottish Intercollegiate Guidelines  Diagnosis, screening and prevention Network. Postnatal depression and puerperal psychosis. Edinburgh:  Management SIGN; 2002.  Prescribing issues in pregnancy and lactation These guidelines recommend that that the Edinburgh postnatal depression scale (EPDS) should be offered to women as part of a screening programme for postnatal depression. The guidelines state that the EPDS is not a diagnostic tool and that diagnosis of postnatal depression requires clinical evaluation. The guideline developers found some evidence that, in research settings, combining the EPDS with the General Health Questionnaire may be more effective than using either tool alone.

2.2.10 The National Institute for Health and Clinical Evidence based guideline Excellence guidance on antenatal and includes evidence of types I to IV and good practice points. postnatal mental health makes National Institute for Health and Clinical recommendations for the prediction, detection Excellence. Antenatal and postnatal and treatment of mental disorders in women mental health. Clinical Management and Service guidance .NICE clinical during pregnancy and the postnatal period. guideline 45. London: NICE; 2007.

2 Royal College of Obstetricians and Gynaecologists. Why mothers die 2000-2002. The sixth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. London: RCOG; 2004.

2.3 MANAGEMENT OF DRUG AND ALCOHOL MISUSE Topic area People with drug and alcohol problems are at greater risk of suicide and self-harm than the general population. Effective management of these problems may reduce this risk although currently there is little direct evidence of this Supporting evidence 2.3.1 There is evidence that alcohol problems are Type I evidence more prevalent in people with depression than Sullivan L E, Fiellin D A, O’Connor P G The prevalence and impact of in the general population and this group may alcohol problems in major depression: be at greater risk of suicide than those with A systematic review. American J Med depression alone. The evidence concerning the 2005; 118: 330-41. This review identified a limited number effect of alcohol on the course of depression is of studies of variable quality. Most equivocal although it is associated with a worse studies addressed those with severe depression course, an increased risk of relapse alcohol problems in inpatient care. and less likelihood of recovery; however antidepressants can be effective in this group. 2.3.2 Guidelines for the management of harmful Evidence based guideline drinking and alcohol dependence in primary includes evidence of types I to V and good practice points. care have been developed by the Scottish Scottish Intercollegiate Guidelines Intercollegiate Guidelines Network. They Network. The management of harmful address; drinking and alcohol dependence in primary care. Edinburgh: SIGN; 2003.  Detection and assessment  Brief interventions for hazardous and harmful drinking  Detoxification  Referral and follow up  Advising families  Information for discussion with patients and carers 2.3.3 The Department of Health has published Good Practice Guidance guidelines to support organisations in Includes evidence of types II to V. Department of Health. Alcohol misuse developing and implementing programmes that interventions guidance on developing can improve the care of hazardous, harmful a local programme of improvement. and dependent drinkers. London: DOH; 2005. 2.3.4 The Department of Health, Scottish Office Type V evidence Department of Health, Welsh Office and Department of Health, Scottish Office Department of Health, Welsh Office, Department of Health and Social Services, Department of Health and Social Northern Ireland have published clinical Services, Northern Ireland (1999) guidelines on managing drug misuse and Drug misuse and dependence – guidelines on clinical management. dependence. These guidelines are primarily for London: Stationery Office; 1999. members of the medical profession 2.3.5 The British Association for Evidence based guideline Psychopharmacology has developed includes evidence of types I to IV. Lingford-Hughes A R, Welch S, Nutt D guidelines for the treatment of substance J. Evidence-based guidelines for the misuse, addiction and comorbidity with pharmacological management of psychiatric disorders. The primary focus of substance misuse, addiction and comorbidity: recommendations from these guidelines is on pharmacological the British Association for management Psychopharmacology. J Psychopharmacol 2004; 18: 293-335.

2.4 MANAGEMENT OF MENTAL ILLNESS People with a mental illness are at greater risk of suicide and suicidal behaviour than the general population. Effective identification and management of mental illness may reduce this risk. Topic area The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness makes recommendations on clinical practice and policy that may reduce the risk of suicide by people under mental health care. Supporting evidence 2.4.1 The most recent report ‘Avoidable Deaths’ Type V evidence makes the following recommendations. Avoidable Deaths. Five year report of the National Inquiry into Suicide and Homicide by Mental health services should take steps People with Mental Illness. London: Department to; of Health; 2006.  Reduce absconding from in-patient units  Strengthen transition from ward to community  Ensure that high risk patients receive enhanced CPA, backed up by peer review in the highest risk cases  Respond robustly when care plans breakdown  Accept that prevention is possible in many cases, particularly for inpatient suicides  Strengthen observation procedures on the wards  Further improve the physical environment on wards  Develop services for dual diagnosis patients  Give greater emphasis to risk management in older people’s services

Supporting evidence 2.4.2 The 2001 report ‘Safety First’ identified the Type V evidence following common antecedents to suicide in Safety First. Five year report of the National Inquiry into Suicide and patients with recent contact with mental health Homicide by People with Mental services; Illness. London: Department of Health;  Adverse life events – 44% 2001.  Suicidal ideation – 29%  Disengagement – 27%  Deliberate self harm - 25%  Non-compliance with treatment - 19%  Increased alcohol misuse - 18%  Bereavement - 5%  Clear evidence of relapse – 27%

Topic area Studies suggest that continuity of contact following discharge from psychiatric inpatient care may reduce the risk of suicide Supporting evidence 2.4.3 A case-control study of suicides in recent Type IV evidence inpatients found that discontinuity of care from a King EA, Baldwin DS, Sinclair JMA, Baker NG, Campbell MJ, Thompson significant professional was associated with an C. The Wessex Recent In-Patient increased risk of suicide. The highest risk of Suicide Study 1. Case-control study of suicide occurred immediately after leaving 234 recently discharged psychiatric patient suicides. Br J Psychiatry 2001; hospital. The authors suggest that flexible 178: 531-36. community support should be made available at this stage in an effort to reduce this risk. 2.4.4 Reductions in care were found to be strongly Type IV evidence associated with suicide in people discharged from Appleby L, Dennehey JA, Thomas CS, Faragher EB, Lewis G (1999) inpatient psychiatric care. In a case-control study Aftercare and clinical characteristics of of 149 people those who died from suicide were people with mental illness who commit more likely to have had their care reduced at their suicide: a case-control study. Lancet 1999; 353: 1397-1400. final appointment before death (odds ratio 3.7 95% CI 1.8 – 7.6). The authors argue that maintaining care beyond the point of clinical recovery is important in protecting those who are at high risk of suicide.

Topic area People with a mental illness are at greater risk of suicide and suicidal behaviour than the general population. Effective identification and management of mental illness may reduce this risk. Supporting evidence 2.4.5 Community mental health team management is Type I evidence more effective than standard care (usually hospital Coid J, Simmonds S, Joseph P, Marriot S, Tyrer P. Community outpatient care) for people with severe mental Mental health teams (CMHTs) for illness in terms of promoting greater acceptance of people with severe mental illnesses treatment and reducing inpatient admissions and and disordered personality. The Cochrane Database of Systematic deaths by suicide. Reviews, 1998, Issue 4. 2.4.6 Long-term treatment with clozapine may reduce the Type I evidence risk of suicide and suicidal behaviour in people with Hennen J, Baldessarini R J (2005) Suicidal risk during treatment with schizophrenia. clozapine: a meta-analysis. Schizophr Res 2005; 73: 139-45. This review found a 3 fold reduction in the risk of suicidal behaviours in those who were treated long-term with clozapine however the authors stated that well designed studies are rare and that the only RCT did not find a reduced risk of completed suicide. 2.4.7 Long-term treatment with lithium may reduce the Type I evidence risk of suicide and suicidal behaviour in people with Tondo L, Hennen J, Baldessarini R J. Lower suicide risk with long-term a major affective illness lithium treatment in major affective illness: a meta-analysis. Acta Psychiatr Scand 2001; 104: 163- 72.

Cipriani A, Pretty H, Hawton K, Geddes J R (2005) Lithium in the prevention of suicidal behaviour and all-cause mortality in patients with mood disorders: A systematic review of randomized trials. Am J Psychiatr 2005;162: 1805 - 19.

Topic area Suicide prevention training for carers of people with mental illness may reduce the likelihood of self harm and suicide Supporting evidence 2.4.8 ASIST (Applied Suicide Intervention Skills Training) Good Practice Point a two-day intensive, interactive and practice- Silvola K, Sorenson Hoifodt T, Guttormsen T, Burkeland O. dominated workshop designed to help care givers Applied suicide intervention skills recognise and estimate risk of suicide may be training workshop. Tidsskr Nor beneficial in enhancing care givers skills and Laegeforen 2003;123:2281-83. readiness to intervene.

2.5 PREVENTING SUICIDE IN PRISONS and POLICE CUSTODY Topic area Many individuals who enter custody share features with those from the general population who have an elevated risk of suicide and self harm. Policies and programmes that aim to minimise self harm and suicide might reduce this risk. Supporting evidence 2.5.1 The National Study of Prison Suicides 1999-2000 Type V evidence indicated the need for a number of changes in Shaw J, Appleby L, Baker D. Safer prisons . A national study of prison prison health care services, prison regime and suicides 1999-2000 by the National environment. Confidential Inquiry into Suicides and Homicides by People with Mental Illness. London: Department of Health; 2003. Intervention studies are needed to show conclusively that implementation of the measures recommended in this report will prevent suicide. 2.5.2 The Royal College of Psychiatrists report ’Suicide Type V evidence in Prisons’, makes 26 recommendations for the Royal College of Physicians. Suicide attention of the prison health care service, in prisons. London: RCP; 2002. psychiatrists and the Government. The report adopts a clinical approach to the prevention of suicide and treatment of suicidal thinking 2.5.3 Prison service order 2700 provides the prison Type V evidence service with instructions on identifying prisoners at HM Prison Service. Suicide and self harm prevention. Prison Service risk of suicide and self-harm, on providing the care Order 2700. 2003 and support for these prisoners, and support for the staff caring for them. ` 2.5.4 A comprehensive suicide prevention programme Good Practice Point: implemented throughout New York State was This study may represent type III associated with a significant reduction in suicides evidence but insufficient information is provided to assess its quality. over a 13 year period. Programme components Cox J F, Morschauser P C (1997) A were; Solution to the problem of jail suicide. Crisis: Journal of Crisis  Policy and procedure guidelines to clarify Intervention and Suicide 1997; 18: roles of county jail, police department 178-84. lockup and mental health agency personnel Differences in the criminal justice systems of the UK and the USA  Screening of detainees by trained jail/police would need to be considered in officers deciding whether a similar programme might be effective in the  Supervision for inmates assessed as being UK. at high –risk  Mental health observation housing – special cells and units offering varying levels of mental health and medical supervision  Scheduled mental health treatment  Crisis intervention  External hospitalisation for people with serious mental illness  Training for both jail and mental health staff  Communication  Investigation and monitoring of prisoner deaths  Staff debriefing

Supporting evidence 2.5.5 Suicide awareness training for prison staff may be Good Practice Point: effective in improving reported attitudes and Cutler J, Bailey J, Dexter P (1997) Suicide awareness training for knowledge. This training is mandatory in the UK prison staff: An evaluation. Issues in and is designed to assist prison staff in identifying Criminal and Legal Psychology and helping vulnerable prisoners. However long 1997; 28:65-9. This study may represent type III term studies would be needed to assess whether evidence but it is very small and this training is effective in improving the insufficient information is provided to identification of and assistance given to vulnerable assess its quality prisoners and whether this has any impact on the suicide rate 2.5.6 The World Health Organisation has published Type V evidence guidance for prison officers on preventing suicide. World Health Organisation. Preventing suicide. A resource for The document contains background information on prison officers. Geneva: WHO; 2000. suicide and identifies key activities that could be used as part of a suicide prevention programme. 2.5.7 Peer prevention initiatives may be a useful initiative Good Practice Point for suicide prevention in prisons. One such Hall B, Gabor P. Peer suicide prevention in prison. Crisis 2004;25: programme in Canada has been evaluated. In this 19-26. scheme the Samaritans are involved in the Qualitative evaluation demonstrated recruitment and training of inmate volunteers who that this programme was generally perceived as worthwhile by both wish to be involved in the peer suicide prevention prison inmates and staff, however its service. Volunteers training includes; impact on the occurrence of suicide  The concept of befriending and self harm is not reported  Effective and active listening  Non-verbal communications  The nature of mental illness  Specific mental conditions including schizophrenia, bipolar disorder, depression  Suicide prevention and suicide intervention

2.6 PHYSICAL ILLNESS Topic area People with physical illnesses, particularly cancer, neurological disorders, renal disease and chronic pain, are at greater risk of suicide than the general population. Policies & programmes that improve awareness, recognition and treatment of psychiatric illness, mental distress and suicidal ideation and behaviour in people with physical illness may reduce this risk. Supporting evidence 2.6.1 The Breast Cancer Centre and National Cancer Evidence based guideline Control Initiative in Australia have published containing evidence of types I to IV. National Breast Cancer Centre, comprehensive clinical guidelines for the National Cancer Control Initiative. psychosocial care of adults with cancer. Clinical practice guidelines for the psychosocial care of adults with cancer. Camperdown: National Breast Cancer Centre; 2003. 2.6.2 The Royal College of Psychiatrists and Royal Type V evidence College of Physicians have published guidance of Report of the joint working party of. the Royal College of Physicians, Royal the psychological care of medical patients. This College of Psychiatrists. The contains recommendations to promote the psychological care of medical psychological care of medical patients in general patients. A practical guide. London: RCP,RCPsych; 2003. hospitals. 2.6.3 The National Institute of Clinical Excellence has Evidence based guideline published guidance on improving supportive and containing evidence of types I to V. National Institute for Clinical palliative care for adults with cancer. Excellence. Improving supportive and palliative care for adults with cancer. The manual. London: NICE; 2004.

2.7 USEFUL RESOURCES

http://www.ahrq.gov/clinic/3rduspstf/suicide/suiciderr.htm The United States Preventative Services Task Force; screening for suicide risk; recommendations and Topic area.

http://www.ahrq.gov/clinic/3rduspstf/depression/depressrr.htm The United States Preventative Services Task Force; screening for depression; recommendations and Topic area.

http://www.guideline.gov/summary/summary.aspx?view_id=1&doc_id=6524 The Canadian Task Force on Preventative Health Care recommendations on screening for depression in primary care

http://www.nsc.nhs.uk/uk_nsc/uk_nsc_ind.htm UK National Screening Committee

http://www.nice.org.uk/pdf/cg023fullguideline.pdf NICE guideline on management of depression in primary and secondary care.

http://www.nice.org.uk/pdf/cg028fullguideline.pdf NICE guideline on the identification and management of depression in children and young people.

http://www.nice.org.uk/guidance/CG45/guidance/pdf/English NICE guidance on Antenatal and postnatal mental health

http://www.sign.ac.uk/guidelines/fulltext/60/index.html SIGN guideline on postnatal depression and puerperal psychosis

http://www.sign.ac.uk/guidelines/fulltext/74/index.html SIGN guideline on the management of harmful drinking and alcohol dependence in primary care.

http://www.ahrq.gov/clinic/3rduspstf/alcohol/alcomisrs.htm US Preventative Services Task Force recommendations on screening and counseling interventions in primary care to reduce alcohol misuse

http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAnd Guidance/PublicationsPolicyAndGuidanceArticle/fs/en? CONTENT_ID=4123297&chk=lLGV84 DOH guidance on developing alcohol misuse interventions

www.doh.gov.uk/drugdep.htm DOH Guidelines Drug Misuse and Dependence – Guidelines on Clinical management available

http://www.rcgp.org.uk/drug/docs/cocaine.pdf Royal College of GPs guidance on working with crack and cocaine users

http://www.bap.org.uk/consensus/BAP_Guidelines.pdf British Association for Psychopharmacology guidelines on management of substance abuse, addiction and comorbidity

http://www.update-software.com/abstracts/AB005031.htm Cochrane Review on psychosocial and pharmacological treatments versus pharmacological treatments for opioid detoxification

http://www.update-software.com/abstracts/AB004147.htm Cochrane review psychosocial combined with agonist versus agonist treatments alone for treatment of opioid dependence

http://www.update-software.com/abstracts/AB000270.htm Cochrane review of community mental health teams for people with severe mental illnesses and disordered personality

http://www.medicine.manchester.ac.uk/suicideprevention/nci/Useful/avoidable_deat hs_full_report.pdf ‘Avoidable Deaths’. Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, 2006

www.doh.gov.uk/mentalhealth/safetyfirst Safety First. Five-Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, 2001

http://hebw.cf.ac.uk/mhnsf/intro.htm Health Evidence Bulletin (Wales) Mental Health National Service Framework edition

http://www.wales.gov.uk/subihealth/content/keypubs/pdf/adult-mental-nsf-e.pdf Adult Mental Health Services. A National Framework for Wales. Cardiff: Welsh Assembly Government, April 2002.

www.livingworks.net Link to LivingWorks Education website for information on ASIST and other suicide prevention training

http://www.dh.gov.uk/assetRoot/04/03/43/01/04034301.pdf ‘Safer Prisons’ National Study of Prison Suicides 1999-2000 by the National Confidential Inquiry into Suicides and Homicides by People with Mental Illness

http://www.rcpsych.ac.uk/publications/cr/council/cr99.pdf The Royal College of Psychiatrists report ‘Suicide in Prisons’

http://pso.hmprisonservice.gov.uk/PSO_2700_suicide_and_self_harm_prevention. doc HM Prison Service – Suicide and self harm prevention

http://www.nhmrc.gov.au/publications/_files/cp90.pdf http://www.nhmrc.gov.au/publications/_files/cp90.pdf National Breast Cancer Centre and National Cancer Control Initiative (Australia) clinical practice guidelines for the psychosocial care of adults with cancer

http://www.rcplondon.ac.uk/pubs/wp_pcomp.pdf Royal College of Physicians/Royal College of Psychiatrists document ‘The psychological care of medical patients’

http://www.nice.org.uk/pdf/csgspmanual.pdf Improving Supportive and Palliative Care for Adults with Cancer. National Institute for Clinical Excellence.

LEVEL 3: CRISIS INTERVENTION, MANAGING SUICIDAL BEHAVIOUR TERMS USED IN THIS SECTION The terms ‘attempted suicide’, ‘para-suicide’, ‘deliberate self-harm’ and ‘self injurous behaviour’ are all used to refer to behaviours that result in self- inflicted injury or poisoning. This document uses the term ‘self-harm’ to refer to all such behaviour regardless of its purpose or intent. Currently this seems to be the preferred term and is used on the basis that there is an increasing acceptance that many forms of self-harming behaviour are likely to occur along a continuum that ranges from suicidal ideation to completed suicide3. The term suicidal behaviour is used to refer to completed suicide, thoughts about suicide (suicidal ideation) and self harm. This document summarises the available evidence for;  Monitoring self harm  Interventions to reduce suicidal ideation  Assessment and short term management of people who self harm  Secondary prevention of self harm  The role of voluntary agencies

3 Van Heeringen K, Hawton K, Williams JMG. Pathways to suicide: an integrative approach. In: Hawton K. van Heeringen K, editors. The international handbook of suicide and attempted suicide. Chichester:Wiley;2002. Version: 1 Date:February 2007 Status: Draft Author: Sian Price Page: 35 of 64 Classification: National Public Health Service for Wales Suicide Prevention: Summary of evidence

3.1 MONITORING SELF HARM Monitoring self harm may help identify means of suicide prevention. Self harm is a significant risk factor for suicide. Trends in self harm have implications for clinical services and may reflect levels of psychopathology in the community4. Understanding the links between non fatal self harm and completed suicide will support research and the development of clinical services. Accurate monitoring of health service contacts for self harm would support this and help ensure that those who self harm receive appropriate health care. Topic area Clinical databases of hospital attendances for self harm have proved useful in identifying trends in self harm Supporting evidence 3.1.1 This paper describes the process involved in Type V evidence setting up a clinical database of hospital Horrocks J, House A, Owens D Establishing a clinical database for attendances for self harm and includes a hospital attendances because of self- checklist of issues that should be considered. harm. Psychiatric Bulletin 2004; 28: 137-39. 3.1.2 A study in Oxford demonstrated that over an 11 Type IV evidence year period (1985 -1995) there was a substantial Hawton K, Fagg J, Simkin S, Bale E, Bond A. Trends in deliberate self-harm increase in rates of self harm, in particular there in Oxford, 1985-1995. Implications for was a marked rise amongst young men. This rise clinical services and the prevention of had implications for both general medical and suicide. Br J Psychiatry, 1997;171: 556-60. psychiatric services 3.1.3 A subsequent study in Oxford (1990 - 2000) Type IV evidence highlighted a decline in paracetamol overdoses Hawton K, Harriss L, Hall S, Simkin S, Bale E, Bond A. Deliberate self-harm in towards the end of the study period. It is argued Oxford, 1990-2000: a time of change in that this is a consequence of the reduction in patient characteristics. Psychol Med paracetamol pack sizes. 2003; 33: 987-95. The study also found a rise in antidepressant overdoses, especially SSRIs and an increase in the use of alcohol. These changes in patient characteristics have implications for service provision.

4 Hawton K, Harriss L, Hall S, Simkin S, Bale E, Bond A (2003) Deliberate self-harm in Oxford, 1990-2000: a time of change in patient characteristics. Psychol Med 2003;33:987-95. Version: 1 Date:February 2007 Status: Draft Author: Sian Price Page: 36 of 64 Classification: National Public Health Service for Wales Suicide Prevention: Summary of evidence

3. 2 INTERVENTIONS TO REDUCE SUICIDAL IDEATION Suicidal ideation is recognised as a risk factor for completed suicide1 Topic area Interventions that reduce suicidal thoughts may help to reduce the risk of an individual self harming or dying from suicide. Supporting evidence 3.2.1 Brief psychodynamic – interpersonal therapy may Type II evidence be effective in reducing suicidal ideation. Patients Guthrie E, Kapur N, Mackway-Jones K, Chew-Graham C, Moorey J, Mendel E, who presented to an accident and emergency Marino-Francis F, Sanderson S, Turpin department following deliberate self-poisoning C, Boddy G. Predictors of outcome were given four sessions of psychodynamic following brief psychodynamic- interpersonal therapy for deliberate interpersonal therapy by a nurse therapist in their self-poisoning. Aust N Z J Psychiatry own home. Six months post treatment the 2003;37:532-36.

psychotherapy group had significantly greater The inclusion criteria used in this study reduction in suicidal ideation and a significant may have meant that those most at risk reduction in repetition of self harm than those of repetition of suicidal behaviour were excluded, only half those eligible for who received treatment as usual. Those with less inclusion agreed to participate. severe depression, no prior history of self harm and who had not taken alcohol with the overdose were most likely to benefit

3.3 ASSESSMENT AND SHORT TERM MANAGEMENT OF PEOPLE WHO SELF HARM Repetition of self harm is a major risk factor for suicide. Topic area Suicidal intent at the time of self harm is associated with risk of future suicide but currently there is no method identifying the individuals who self harm and are at greatest risk of completing suicide Supporting evidence 3.3.1 A study that evaluated the predictive value of the Type IV evidence Beck Suicidal Intent scale found that it cannot Harriss L, Hawton K. Suicidal intent in deliberate self-harm and the risk of usefully predict which patients will die from suicide: The predictive power of the suicide. Suicide Intent Scale. J Affect Disord 2005;86:225-33. 2489 patients were included in the study with a mean follow up of 5.2 years

Topic area Those whose index episode of self harm uses a method of high lethality and those who have an escalating severity of self poisoning are at greater risk of death from suicide. Enhanced treatment and monitoring of those who repeat self harm, use more lethal methods or escalate severity of self poisoning may reduce the risk of subsequent suicide. Supporting evidence 3.3.2 Long term follow up showed that those who Type IV evidence repeated self harm were at significantly greater Zahl DL, Hawton K. Repetition of deliberate self-harm and subsequent risk of suicide than those who had a single suicide risk: long-term follow-up study episode; this risk was greater in female than of 11 583 patients. Br J Psychiatry males. Suicide risk was further increased in 2004;185:70-5. females with multiple repeat episodes of self harm. Length of follow up from initial episode of self harm ranged from 3 to 12 years. 3.3.3 A study of 3690 individuals admitted to Type IV evidence Christchurch Hospital in New Zealand following Gibb SJ, Beautrais AL, Fergusson DM. Mortality and further suicidal behaviour deliberate self harm showed that over a 10 year after an index attempt: a 10 year study. follow up period those whose index episode of Aust N Z J Psychiatry 2005; 39:95-100. self harm used a method of high lethality (carbon monoxide poisoning, hanging, gunshot, jumping, drowning, motor vehicle accident or burning) had a significantly greater risk of death from suicide than those who use less lethal methods (overdose/poisoning, cutting/stabbing)

Supporting evidence 3.3.4 A study in Australia identified several variables Type IV evidence associated with an increased risk of suicide in Carter G, Reith DM, Whyte IM, McPherson M. Repeated self- individuals who present with an increasing poisoning: increasing severity of self- severity of self poisoning. These variables were harm as a predictor of subsequent increase in dose ingested, decrease in coma suicide. Br J Psychiatry 2005;186:253- 57. score and an increase in drug or alcohol misuse. The best predictor of completed suicide was combining an increase of 70 or more in the number of tablets ingested with a decrease in Glasgow coma score of 2 or more.

Topic area Psychosocial and psychiatric assessment of people who self harm may help to reduce the likelihood of repetition Supporting evidence 3.3.5 Patients treated in a general hospital who Type IV evidence received a psychosocial assessment after self Kapur N, House A, Dodgson K, May C, Creed F. Effect of general hospital poisoning were less likely to self poison again management on repeat episodes of within 12 weeks than those were not assessed. deliberate self poisoning: cohort study. BMJ 2002;325:866-67. Patients who had certain risk factors for repetition of self harm (such as previous self poisoning, psychiatric history and substance abuse) were more likely to receive a psychosocial assessment. 3.3.6 Patients who self harm and are discharged Type IV evidence directly from the accident and emergency Hickey L, Hawton K, Fagg J, Weitzel H. Deliberate self-harm patients who department without a psychiatric assessment are leave the accident and emergency more likely to repeat self harm in the following department without a psychiatric year than those who are assessed before assessment. A neglected population at risk of suicide. J Psychosom Res discharge. 2001;50:87-93. Patients who were not assessed were more likely to have a past history of self harm, be in the 20- 34 year age group and to have presented difficult behaviour in the accident and emergency department. Those who presented between 5pm and 9am were less likely to be assessed than those presenting between 9am and 5pm

3.3.7 Patients who discharge themselves from the Type IV evidence accident and emergency department before Crawford MJ, Wessely S. Does initial management affect the rate of completion of an initial assessment are more repetition of deliberate self harm? likely to repeat self harm in the following year Cohort study. BMJ 1998;317:985. than those who complete initial assessment

Topic area The quality of psychosocial can be improved by training and audit Supporting evidence 3.3.8 The STORM (Skills Training on Risk Good practice point Management) Project, a district wide Appleby L, Morriss R, Gask L, Roland M, Lewis B, Perry A, Battersby L, Colbert N, programme on the assessment and Green G, Amos T, Davies L, Faragher B. management of suicide risk, was effective in An educational intervention for front-line improving the skills of accident and health professionals in the assessment and management of suicidal patients (The emergency, primary care and mental health STORM Project) Psychol Med staff. However a before and after analysis of 2000;30:805-12. suicide rates showed that there was no Type III evidence significant improvement following the Morriss R, Gask L, Webb R, Dixon C, intervention. Appleby L. The effects on suicide rates of an educational intervention for front-line health professionals with suicidal patients (the STORM Project). Psychol Med 2005;35:957-60. 3.3.9 A one hour teaching session improved the Type III evidence quality of psychosocial assessment Crawford MJ, Turnbull G, Wessely S. Deliberate self harm assessment by performed by junior doctors and nurses accident and emergency staff – an working in the accident and emergency intervention study. Journal of Accident department. Before the intervention 13% of and Emergency Medicine 1998;15:18-22. records were judged to be adequate, following the intervention this went up to 46%.

3.3.10 Clinical audit can be effective in improving the Good practice point quality of psychosocial assessment of adults Dennis M, Evans A, Wakefield P, Chakrabarti S. The psychosocial presenting to accident and emergency assessment of deliberate self harm: using department s with deliberate self harm. clinical audit to improve the quality of the service. Emergency Medical Journal Following an initial audit using the Royal 2001;18:448-50. College of Psychiatrists standards for service provision5 medical staff were encouraged to use a pre-printed checklist for risk assessment and all new senior house officers were required to attend a training seminar conducted by a senior lecturer in psychiatry. A subsequent audit showed that a higher proportion of patients were assessed by a mental health specialist and that the quality of information recorded had improved significantly. 3.3.11 A small study in Wales showed no significant Good practice point differences in outcome between psychosocial Griffin G, Bisson JI. Introducing a nurse- led deliberate self-harm assessment assessments carried out by a trained mental service. Psychiatric Bulletin 2001;25:212- health nurse and those completed by senior 14. house officers in psychiatry.

5 Royal College of Psychiatrists. The general hospital management of adult deliberate self- harm. A consensus statement on standards for service provision. London:RCP;1994 Version: 1 Date:February 2007 Status: Draft Author: Sian Price Page: 40 of 64 Classification: National Public Health Service for Wales Suicide Prevention: Summary of evidence

Topic area Short term management of self harm includes treatment of self-poisoning and self injury, and psychosocial and risk assessment. Supporting evidence 3.3.12 The National Institute for Clinical Excellence has Evidence based guideline commissioned guidelines on the short-term includes evidence of types I to IV and good practice points. National Institute physical and psychological management and for Clinical Excellence. Self-harm: the secondary prevention of self-harm in primary and short- term physical and psychological secondary care. The guideline is for all people management and secondary prevention of self-harm in primary and aged 8 years and over. secondary care. London: NICE; 2004. The guideline addresses  Service user experience of services  Consent  The medical and surgical care of people who have self harmed  Psychosocial assessment after hospital attendance for self-harm  Psychological, pharmacological and psychosocial interventions for the management of self- harm 3.3.13 The New Zealand Guidelines Group has issued Evidence based guideline evidence based guidelines on the assessment includes evidence of types I to IV and good practice points. New Zealand and management of people at risk of suicide. Guidelines Group. The assessment These include; and management of people at risk of suicide. Wellington: New Zealand  Assessment in emergency departments Ministry of Health/New Zealand and by mental health services including Guidelines Group; 2003. assessment of risk  Crisis/initial management  Assessment and crisis management in specific populations including the elderly and children

3.4. SECONDARY PREVENTION OF SELF HARM Secondary prevention of self harm is important in reducing the likelihood of completed suicide Topic area Psychosocial interventions may be helpful in reducing repetition of self harm in children, adolescents and young people Supporting evidence 3.4.1 Dialectical behavioural therapy (DBT) may be Type II evidence of benefit in preventing suicidal behaviour Katz LY, Cox BJ, Gunasekara S, Miller AL. Feasibility of dialectical behaviour during inpatient admission in acute care child therapy for suicidal inpatient adolescents. and adolescent units. However at 1 year follow Journal of the American Academy of Child up there was no difference between those and Adolescent Psychiatry 2004;43:276- 82. receiving DBT and the treatment as usual group in self harm, suicidal ideation and This was a small pilot study with only 62 symptoms of depression participants, 8 of these were not followed up at 1 year. 3.4.2 Group therapy may be effective in preventing Type II evidence repeated self harm in the short term in Wood A, Trainor G, Rothwell J, Moore A, Harrington R/. Randomized trial of group adolescents. A pilot study in Manchester found therapy for repeated deliberate self-harm that developmental group psychotherapy in adolescents. Journal of the American designed specifically for adolescents who harm Academy of Child and Adolescent Psychiatry 2001;40:1246-53. themselves was more effective than routine care in preventing repetition of self harm in the The results of this study should be treated with caution as it a pilot study with a total seven months following the intervention. The on 31 participants in each arm. treatment was not more effective than routine care in improving depression 3.4.3 Multisystemic therapy (MST), an intensive Type II evidence family and community based treatment, may be Huey SJ, Henggeler SW, Rowland MD, Halliday-Boykins CA, Cunningham PB, effective in preventing repetition of self harm in Pickrel SG, Edwards J. Multisystemic young people. therapy effects on attempted suicide by youths presenting psychiatric A study in the USA compared the effect of MST emergencies. Journal of the American Academy of Child and Adolescent with that of psychiatric hospitalisation in a Psychiatry 2004;43:183-90. group of young people who had been approved Consideration needs to be given to for admission to hospital as a result of suicidal whether the results of this study would be ideation, self harm, psychosis or threat of harm generalisable to the UK because of the to self or others. characteristics of the sample used and the differences between the health systems of MST was significantly more effective than the USA and the UK. hospitalisation in reducing self harm in the 16 months following recruitment to the study

Supporting evidence 3.4.4 Telephone counselling services might be Type III evidence effective in improving mental state and King R, Nurcombe B, Bickman L, Hides L, Reid W. Telephone counselling for reducing suicidal ideation in adolescents. adolescent suicide prevention. Changes in suicidality and mental state from An evaluation of the effectiveness of telephone beginning to end of a counselling session. counselling services set up as part of Suicide Life Threat Behav 2003;33:400- 11. Australia’s National Youth Suicide Prevention Strategy found that significant decreases in suicidality and significant improvement in mental state were found during the course of counselling sessions.

Topic area Psychosocial interventions may be useful in preventing repetition of self harm Supporting evidence 3.4.5 A systematic review of psychosocial interventions Type I evidence following self harm found that cognitive Van der Sande R, Buskens E, Allart E, van der Graaf Y, van Engeland H. behavioural therapies had a beneficial effect on Psychosocial intervention following repetition of self harm, but there was uncertainty suicide attempt: a systematic review of around the size of the effect treatment interventions. Acta Psychiatr Scand 1997;96:43-50.

This review may be subject to bias because it included only studies published in English 3.4.6 A systematic review of psychosocial interventions Type I evidence for self harm concluded that there is considerable Hawton K, Townsend E, Arensman E, Gunnell D, Hazell P, House A, van uncertainty around which psychosocial Heeringen K. Psychosocial and treatments are most effective in preventing pharmacological treatments for repetition of deliberate self harm. deliberate self harm. The Cochrane Database of Systematic Reviews, 1999, Issue 4. Reduced repetition was found with problem solving therapy and provision of emergency cards but these were not statistically significant. Significantly reduced repetition was found with dialectical behaviour therapy when compared with standard aftercare for women who were multiple repeaters of self harm. 3.4.7 A meta-analysis of randomised controlled trials of Type I evidence problem solving therapy found that for deliberate Townsend E, Hawton K, Altman DG, Arensman E, Gunnell D, Hazell P, self harm patients it significantly improved scores House A, Van Heeringen K. The for depression and hopelessness when efficacy of problem-solving treatments compared with treatment as usual. Significantly after deliberate self-harm: meta- analysis of randomized controlled trials more patients in the treatment groups reported with respect to depression, improvement in their problems hopelessness and improvement in problems. Psychol Med 2001;31:979- 88.

Supporting evidence 3.4.8 Brief psychodynamic – interpersonal therapy may Type II evidence be effective in reducing repetition of self harm. Guthrie E, Kapur N, Mackway-Jones K, Chew-Graham C, Moorey J, Mendel E, Patients who presented to an accident and Marino -Francis F, Sanderson S, emergency department following deliberate self- Turpin C, Boddy G. Randomised poisoning were given four sessions of controlled trial of brief psychological intervention after deliberate self psychodynamic interpersonal therapy by a nurse poisoning. BMJ 2001; 323:135-8. therapist in their own home. Six months post The inclusion criteria used in this study may have meant that those most at risk treatment the psychotherapy group had a of repetition of suicidal behaviour were significant reduction in repetition of self harm excluded, only half those eligible for when compared with those who received inclusion agreed to participate. treatment as usual. 3.4.9 Brief manual assisted cognitive therapy was not Type II evidence more effective than treatment as usual in Tyrer P, Thompson S, Shmidt U, Jones V, Knapp M, Davidson K, Catalan J, preventing repetition of self harm but an Airlie J, Baxter S, Byford S, Byrne G, economic evaluation suggested that it was Cameron S, Caplan R, Cooper S, superior to treatment as usual when cost and Ferguson B, Freeman C, Frost S, Godley J, Greenshields J, Henderson effectiveness were combined. J, Holden N, Keech P, Kim L, Logan K, Manley C, MacLeod A, Murphy R, The patients included in this study had presented Patience L, Ramsey L, De Munroz S, Scott J, Seivewright H, Sivakumar K, with recurrent deliberate self harm and were Tata P, Thornton S, Ukoumunne OC, followed up for 1 year. Patients in the treatment Wessely S. Randomised controlled trial group received a booklet based on cognitive of brief cognitive behaviour therapy versus treatment as usual in recurrent behavioural therapy and were offered up to five deliberate self-harm: the POPMACT plus two booster sessions of cognitive behaviour study. Psychol Med 2003; 33:969-76. therapy from a therapist in the first 3 months of the study. 3.4.10 In a small study in the USA 10 sessions of Type II evidence cognitive therapy were found to be effective in Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, Bech AT. preventing repetition of deliberate self harm. Cognitive therapy for the prevention of When compared to usual care the group suicide attempts. JAMA 2005;294:563- receiving cognitive therapy were significantly less 70. likely to repeat self harm in the 18 months Generalisation of this study to the UK following intervention may be limited. The majority of the sample were African Americans and it is recognised that this group have a lower rate of completed suicide than whites. The authors note that the small number of changes in episodes of self harm in the follow up period may affect the studies significance, and a large number of participants (25% of intervention group) were lost to follow up at 12 months

Topic area Implementation of intensive in-patient followed by a community intervention programme for all those who self harm is not justified by the available evidence. Supporting evidence 3.4.11 A controlled study in the Netherlands found that Type II evidence brief admission to a special crisis-intervention Van der Sande R, Van Rooijen L, Buskens E, Allart E, Hawton K, Van der unit and problem-solving aftercare was no more Graaf Y, Van Engeland H. Intensive effective than treatment as usual in preventing inpatient and community intervention repetition of self harm in the 12 months following versus routine care after attempted suicide: A randomised controlled intervention. There were no differences between intervention study. Br J Psychiatry the control and intervention groups in scores for 1997;171:35-41. psychological well being and hopelessness at 3, 6, and 12 months

Topic area Crisis cards are unlikely to be effective in preventing recurrence of self harm. Supporting evidence 3.4.12 Patients randomised to receive a card offering a Type II evidence 24 hour crisis telephone consultation with an on- Evans J, Evans M, Morgan G, Hayward A, Gunnell D. Crisis card following self- call psychiatrist for up to six months after an harm: 12-month follow-up of a index episode of self harm were as likely to randomised controlled trial. Br J repeat self harm in the 12 months following the Psychiatry 2005;187:186-87. index episode as those who did not receive a card.

Topic area Inviting people who have self harmed to consult their GP does not appear to be effective in preventing repetition of self harm Supporting evidence 3.4.13 An intervention in which GPs sent a letter to Type II evidence people who had self harmed inviting them to Bennewith O, Stocks N, Gunnell D, Peters TJ, Evans MO, Sharp DJ. consult combined with guidelines on the General practice based intervention to assessment and management of deliberate self prevent repeat episodes of deliberate harm for GPs to use in these consultations did self harm: cluster randomised controlled trial. BMJ 2002;324:1254- not result reduce the incidence of self harm in the 157. 12 months following the index episode

Topic area It may be possible to improve compliance with referral to after care in people who have self harmed 3.4.14 A study in Belgium investigated the benefit of Supporting evidence home visits by community nurses in increasing Type III evidence compliance with referral to out patient after care Van Heeringen K, Jannes S, Buylaert W, Henderick H, De Bacquer D, Van amongst people who had been admitted to a Remoortel J. The management of non- hospital accident and emergency department compliance with referral to out-patient following self harm. The intervention significantly after-care among attempted suicide patients: A controlled intervention improved compliance with referral in the study. Psychol Med 1995;25:963-70. intervention group. Although there was a This study may not be directly decrease in repetition of self harm between the generalisable to the UK because if intervention and control groups this did not reach differences between the roles of significance community nurses in the UK and Belgium

Topic area Pharmacological interventions may be of benefit in preventing repetition of self harm. Supporting evidence 3.4.15 A systematic review of pharmacological Type I evidence treatments for deliberate self harm found that Hawton K, Townsend E, Arensman E, Gunnell D, Hazell P, House A, van depot flupenthixol significantly reduced rates of Heeringen K. Psychosocial and repetition of deliberate self harm when compared pharmacological treatments for with placebo deliberate self harm. The Cochrane Database of Systematic Reviews 1999, Issue 4.

Topic area Major depression may be inadequately treated both before and after episodes of self harm Supporting evidence 3.4.16 A small study in Finland investigated a group of Type IV evidence 43 patients with unipolar DSM-III-R major Suominen KH, Isometsa ET, Henriksson MM, Ostamo AI, Lonnqvist depression and found that in the month before an JK. Inadequate treatment for major episode of self harm only 7 were receiving anti- depression both before and after depressants in adequate doses and 7 were attempted suicide. Am J Psychiatry 1998;155:1778-80. receiving weekly psychotherapy.1 month following self harm, 7 were receiving antidepressants in adequate doses and 9 were receiving weekly psychotherapy

3.5. THE ROLE OF VOLUNTARY AGENCIES

Topic area Lay volunteers, such as The Samaritans have a role in crisis intervention

Supporting evidence 3.5.1 A review of studies of suicide prevention Type IV evidence centres, including several studies examining Lester D. The effectiveness of suicide prevention centres: a review. Suicide Life the effectiveness of the Samaritans in the UK , Threat Behav 1997;27:304-10. identified 14 studies of which 7 reported a preventative effect This review did not contain sufficient information to assess its quality 3.5.2 Signs displaying the Samaritans’ national Type III evidence number were erected in car parks in the New King E, Frost N. The New Forest Suicide Prevention Initiative (NFSPI). Crisis Forest (in southern England). During the three 2005;26:25-33. year intervention period the number of car park suicides fell significantly, no significant changes were found in comparable forest districts.

These are web inks to some of the resources and documents referred to in the text.

http://www.medicine.manchester.ac.uk/storm/training Link for STORM training –University of Manchester

http://www.bps.org.uk/downloadfile.cfm?file_uuid=C11587F1-7E96-C67F-DD13- 357E1AA3B75D&ext=pdf Link to full NICE guideline ‘The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care’

http://www.samaritans.org.uk/know/about/about.shtm The Samaritans website

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001764/frame .html Cochrane review on Psychological and Pharmacological treatments for deliberate self harm

http://www.nzgg.org.nz/guidelines/0005/Suicide_Fulltext.pdf#page=57New Zealand guidelines on The Assessment and Management of People at Risk of Suicide

LEVEL 4: POSTVENTION The term ‘postvention’, probably first used by Shneidman in 1972 6, is used to describe ‘appropriate and helpful acts that come after a dire event’. The approach at level 4 differs from levels 1 to 3 in that it is concerned with the aftermath of suicide. It addresses some of the issues around helping those bereaved by suicide, learning lessons from completed suicide and media reporting of suicide.

6 Shneidman ES. Foreword. In Cain AC, editor. Survivors of suicide. Springfield: Charles C Thomas; 1972. p ix-xi. Version: 1 Date:February 2007 Status: Draft Author: Sian Price Page: 48 of 64 Classification: National Public Health Service for Wales Suicide Prevention: Summary of evidence

4.1: REVIEWING COMPLETED SUCIDES Rationale Reviewing suicide of people known to mental health services and those in the community who have not been in contact with mental health services may enable lessons to be learned that could contribute to suicide prevention. Topic Area The National Confidential Inquiry into Suicide and Homicide by people with Mental Illness7 reviews suicides of people in contact with mental health services and makes recommendations for service practice and development that can be used to inform local suicide prevention strategies. Supporting evidence 4.1.1 The National Institute for Mental Health in Type IV evidence England has produced a toolkit that allows National Institute for Mental Health in England. Preventing services to assess whether they are addressing suicide – A toolkit for mental the Inquiry recommendations. The audit involves health services. Leeds: NIMHE; a retrospective examination of the notes and 2003. records of people who have completed suicide or who have been considered to be at significant risk of suicide.

Topic Area Psychological autopsy is a valuable method of reviewing completed suicide. It uses structured interviews with family members, friends and health care workers. Information is also collected from healthcare records and forensic examination. Use of case control designs enables an estimation of the role of specific risk factors.8 Supporting evidence 4.1.2 This review of methodological issues around Good Practice Point psychological autopsy is designed to assist those Hawton K, Appleby L, Platt S, Foster T, Cooper J, Malmberg A, considering using this method and those who Simkin S. The psychological need to assess reports of psychological autopsy autopsy approach to studying studies. suicide: a review of methodological issues. J Affect Disord 1998;50:269-76.

7 Department of Health. Avoidable Deaths: Five year report of the National Confidential Inquiry into suicide and homicide by people with mental illness. London: DOH; 2006. Available:http://www.medicine.manchester.ac.uk/suicideprevention/nci/Useful/avoidable_deat hs_full_report.pdf

8 Isometsa ET. Psychological autopsy studies – a review. Eur Psychiatry 2001;16:379-85. Version: 1 Date:February 2007 Status: Draft Author: Sian Price Page: 49 of 64 Classification: National Public Health Service for Wales Suicide Prevention: Summary of evidence

Topic Area Root cause analysis is a structured approach to investigating adverse events. It is the approach advocated by the National Patient Safety Agency. Supporting evidence 4.1.3 This paper reviews the benefits and limitations of Good Practice Point root cause analysis in the investigation of serious Neal LA, Watson D, Hicks T, Porter M, Hill D. Root cause untoward events in mental health services. It analysis applied to the concludes that the method is not proven as a investigation of serious untoward means of reducing serious untoward events but incidents in mental health services Psychiatric Bulletin 2004;28:75-7. suggests that the method might be more consistent and less threatening and demoralising for staff than other approaches.

Topic Area Approximately three-quarters of people who die from suicide are not in contact with mental health services at the time of their death. These suicides are not routinely examined but review of these cases may be useful in informing suicide prevention initiatives. Supporting evidence 4.1.4 A case controlled psychological autopsy study of Type IV evidence people not in contact with mental health services Owens C, Booth N, Briscoe M, Lawrence C, Lloyd K. Suicide at the time of their suicide found that nearly a outside the care of mental health third of cases (32%) had no current mental Services. A case-controlled illness, although past contact with mental health psychological autopsy study. Crisis 2003;24:113-21. services was a clear predictive factor for suicide. This finding highlights the need for population based strategies and suggests that despite their apparent recovery, those with a past history of mental illness may remain at risk of suicide.

4.2 SUICIDE OF SERVICE USERS – MANAGING THE IMPACT ON STAFF Rationale Suicide by service users may have a significant emotional and professional impact on staff. Training and support for staff may help to reduce this impact Supporting evidence 4.2.1 This paper sets out the action that should be Good Practice Point taken in the event of a patient suicide. It covers Hodelet N, Hughson M. What to do when a patient commits communication, formal obligations, support for suicide. Psychiatric Bulletin staff and education/review. 2001;25:43-5. 4.2.2 A questionnaire survey of 247 psychiatrists found Good Practice Point that around a third of those who had experienced Alexander DA, Klein S, Gray NM, Dewar IG, Eagles JM. Suicide by a patient suicide suffered adverse emotional patients: questionnaire study on consequences (low mood, irritability, poor sleep) its effects on consultant and 15% considered early retirement. psychiatrists. BMJ 2000;320:1571-4. Colleagues, family and friends were considered to be the best sources of help and critical incident reviews were seen as useful. 4.2.3 In small questionnaire survey of community Good Practice Point mental health team members 66% reported that Linke S, Wojciak J, Day S. The impact of suicide on community patient suicide had some or great impact on their mental health teams: findings and personal life (for example sleep disturbance, poor recommendations. Psychiatric concentration, preoccupation with work) and 73% Bulletin 2002;26:50-2. reported some or great impact on their professional life (for example self doubt, anxiety, distancing from clients). 40% reported that these adverse effects lasted longer than 1 month. Peer support, incident reviews, dedicated staff meeting and support form senior colleagues were all reported as being helpful in dealing with adverse effects. 4.2.4 This paper, based on the development of a crisis Good Practice Point resolution team, sets out a framework for Walmsley P. Patient suicide and its effect on staff. Nursing supporting staff through major incidents such as Management 2003;10:24-6. service user suicide.

4. 3. SUPPORTING THOSE BEREAVED BY SUICIDE Rationale Recent studies suggest that bereavement after suicide is not necessarily more severe than bereavement following other types of death but that it gives rise to certain issues that make coping with a loss from suicide particularly difficult9. Supporting evidence 4.3.1 This review argues that bereavement following Literature Review suicide is distinct from other bereavement in Jordan JR. Is suicide bereavement different? A three ways; reassessment of the literature.  The thematic content of grief Suicide Life Threat Behav o Suicide violates the norm of self- 2001:31:91-102. preservation, those bereaved by suicide have problems in understanding the motives and the frame of mind of those who have died o Those bereaved through suicide show higher levels of blame, guilt and responsibility for the death o Those bereaved through suicide have heightened feelings of rejection and abandonment  Social processes o Those bereaved by suicide may be viewed by others as more psychologically disturbed, less likeable, more blameworthy, more in need of professional mental health care and more likely to remain sad and depressed longer  The impact suicide has on families o Suicide may adversely affect family functioning and may contribute to the development of mental illness in surviving family members o Suicide bereavement may increase the risk of suicidal behaviour and completion in surviving family members

4.3.2 Older people bereaved through suicide scored Type IV evidence higher on measures of stigmatisation, shame and Harwood D, Hawton K, Hope T, Jacoby R. The grief experiences sense of rejection than controls bereaved and needs of bereaved relatives through natural causes. In addition nearly 40% and friends of older people dying found media reporting of coroners’ inquests and through suicide: a descriptive and case-control study. J Affect inquest procedures significant sources of Disorder 2002;72:185-94. distress. 4.3.3 A case control study in the USA found that Type IV evidence adolescents who had lost friends through suicide Brent D A, Moritz G, Bridge J, Perper J, Canobbio R. Long-term were more likely than controls to experience post impact of exposure to suicide: A traumatic stress disorder and depression. Follow three-year controlled follow up. up was over three years Journal of the American Academy of Child and Adolescent Psychiatry 1996;35:646-53.

Supporting evidence

9 Hawton K, Simkin S. Helping people bereaved by suicide. BMJ 2003;327:177-78. Version: 1 Date:February 2007 Status: Draft Author: Sian Price Page: 52 of 64 Classification: National Public Health Service for Wales Suicide Prevention: Summary of evidence

4.3.4 Bereavement interventions that may be useful Literature Review/ Good following suicide include; Practice Points At the site of suicide; Clark SE, Goldney R. The impact of suicide on relatives and friends. In:  Instruct the family that, for forensic purposes, Hawton K, Van Heeringen K, editors. The nothing should be touched international handbook of suicide and  Explain resuscitation and official procedures attempted suicide. Chichester: Wiley,  Arrange opportunity for the family to spend 2000: p467-84. time with the body, preferably alone, after the investigation  Debrief the resuscitation team  Arrange professional cleaning services  Debrief with a colleague First 24 hours Information  Tell others the true cause of death, including children  Viewing or photographs of the body  Public funeral Follow-up Information  Models of suicide, including the neurotransmitter model  Causes of mental illness and risk for survivors  Limitations of prediction of suicide  Lifestyle education and grief survival strategies Counselling  Assess mental state  Rationalise unrealistic negative feelings  The ‘why’ may never be solved  Mark achievements  Raise self-esteem Specific agencies  Medical practitioners o Information on the dying process o Interpretation of the post mortem report o Mental state and psychosocial assessment o Physical review, e.g. blood pressure check o Medical certificates  Coroner’s office o Return of suicide notes o Information on how death occurred o Post mortem report  Support group  Minister of religion Review  Three months  At issue of post mortem report  Anniversaries

Supporting evidence 4.3.5 Active postvention programmes such as LOSS (Local Good Practice Point Outreach to Suicide Survivors Program) may be beneficial in Campbell FR, Cataldies L, McIntosh J, Millet K. An active encouraging those bereaved by suicide to seek help and postvention program Crisis support. LOSS team members are staff from a crisis 2004;25:30-2. intervention centre and people who have themselves been bereaved by suicide, all team members receive specials training. Attendance of LOSS team members at suicide scenes has reduced the expression of inappropriate attitudes by the emergency services. LOSS team members are also able to provide support for emergency service first responders. LOSS team members may also attend funeral services, support death notification and work as peer facilitators for suicide survivors support groups. 4.3.6 Surveys of relatives’ experience of coroners’ inquests of Survey suicides have shown that these can cause considerable Barraclough BM, Shepherd DM. 10 The immediate and enduring distress. In response to such surveys The Broderick Report effects of the inquest on published in the 1970s made recommendations that would relatives of suicides. Br J relieve some of this distress; however these Psychiatry 1977;131:400-4. recommendations were never implemented. 4.3.7 A recent in depth qualitative study of the effect of suicide Survey/Good Practice inquests on bereaved relatives found that little had improved Points since the 1970s. Relatives were disturbed by the judicial Biddle L. Public hazards or private tragedies? An atmosphere, media activity, the invasion of their privacy and exploratory study of the effect of giving evidence. This was compounded by lack of preparation coroners’ procedures on those and communication before the inquest. The inquest adversely bereaved by suicide. Soc Sci Med 2003;56:1033-45. affected grieving by exacerbating shame, guilt and anger and was not helpful in allowing relatives to reach a meaningful and acceptable account of the death. In response to this study the British Suicide Researchers Group have made a series of recommendations on how the inquest process might be improved. A summary of these recommendations is attached at appendix II. A draft bill published on 12 June 2006 proposed coroner reform for England and Wales. A draft charter for bereaved people who come into contact with the coroner service is included in the bill (www.dca.gov.uk/legist/coroners_draft_charter_bereaved.pdf). If implemented the charter will meet some of the British Suicide Researchers Group recommendations.

10 Home Office. Report of the Committee on Death Certification and Coroners. (The Broderick Committee). London: HMSO; 1971 Version: 1 Date:February 2007 Status: Draft Author: Sian Price Page: 54 of 64 Classification: National Public Health Service for Wales Suicide Prevention: Summary of evidence

4.4. MEDIA PORTRAYAL OF SUICIDE Topic area Whether or not reporting and portrayal of suicide in the media lead to imitation by vulnerable individuals has long been debated. The current consensus is that there is evidence of such an effect11 Supporting evidence 4.4.1 A recent quantitative review of suicide Literature review reporting in the media based on non-fictional Stack S. Suicide in the media: A quantitative review of studies based stories found that; on nonfictional stories. Suicide Life  Studies measuring the effect of Threat Behav 2005;35:121-33.

reporting the suicide of an This study did not provide sufficient entertainment or political celebrity were information to allow an assessment of 5.27 times more likely to report its quality. Where odds ratios were used confidence intervals were not imitation than stories reporting on non- reported. celebrities  Studies that focused on stories that used negative definitions of suicide were 99% less likely to report imitation  Studies on television reporting of suicides were 79% more likely to report imitation than other studies Studies on female suicide were 4.89 times more likely to report imitation than other studies 4.4.2 A narrative review of reporting of suicide in Type IV evidence non-fictional media concluded that there is an Pirkis J, Blood R W. Suicide and the media Part I: Reportage in association between portrayal of suicide and nonfictional media. Crisis 2001;22: actual suicide. The authors concluded that this 146-54. association was causal on the basis that the association satisfied criteria of consistency, strength, temporality, specificity and coherence. 4.4.3 A narrative review of reporting of suicide in Type IV evidence fictional media concluded that the evidence for Pirkis J, Blood R W. Suicide and the media Part II: Portrayal in fictional an association is moderate at best. media. Crisis 2001;22:155-62.

4.4.4 A recent study in Hong Kong in response to Type IV evidence the emergence of a new method of suicide Chan KPM, Yip PSF, Au J, Lee DTS. Charcoal-burning suicide in post- (charcoal burning) found that media reports transition Hong Kong. Br J Psychiatry were pivotal in bringing this method to the 2005;186:67-73. attention of a specific group of vulnerable people. The authors argued that media reporting conveyed an implicit message that charcoal burning is an easy, painless and effective means of ending one’s life. Survivors who were interviewed reported that they learnt of and were reminded of the method through newspaper reports.

Supporting evidence 11 Hawton K, Williams K. Influences of the media on suicide. BMJ 2002;325:1374-75. Version: 1 Date:February 2007 Status: Draft Author: Sian Price Page: 55 of 64 Classification: National Public Health Service for Wales Suicide Prevention: Summary of evidence

4.4.5 A recent prospective study in Australia found Type IV evidence that; Pirkis JE, Burgess PM, Francis C, Blood RW, Jolley DJ. The relationship  39% of media items were followed by between media reporting of suicide and an increase in male suicides actual suicide in Australia. Soc Sci  31% by an increase in female Med 2006;62:2874-86. suicides  Items were more likely to be associated with an increases in both male and female suicides if o They occurred in the context of multiple other reports on suicide o They were broadcast on television They were about completed suicide

Topic area Initiatives to improve media reporting of suicides may have an impact on imitation Supporting evidence 4.4.6 In Austria media guidelines and a media Type IV evidence campaign were launched in response to a Etzersdorfer E, Sonneck G. Preventing suicide by influencing mass-media sharp increase in suicide rates associated reporting. The Viennese experience with the introduction of a subway system in 1980-1996. Archives of Suicide Vienna. As a consequence there was a Research 1998;4:67-74. marked change in the nature of media reporting and this was associated with an 80% fall in the number of subway related suicides and suicide attempts. 4.4.7 In Switzerland the introduction of media Type IV evidence guidelines on reporting of suicide resulting in Michel K, Frey C, Wyss K, Valach L. An exercise in improving suicide an improvement in the quality of reporting reporting in print media. Crisis 2000;21: although the number of articles on suicide 71-9. increased. The authors concluded that the most effective means of influencing the media was personal contact with the editor of a tabloid newspaper. 4.4.8 The Media Wise Trust provides guidance for Good Practice Point journalists (written by journalists) on The Media Wise Trust. The media and suicide. Guidance for journalists from portraying suicide in the media and has journalists. 2003. developed training modules for media Available professionals on this topic. .http://www.mediawise.org.uk/files/uplo aded/The%20Media%20and %20Suicide%20.pdf [Accessed 6 Jul 2006] 4.4.9 The World Health Organisation has published Good Practice Point a resource for media professionals on suicide World Health Organisation. Preventing suicide. A resource for media prevention. These outline the impact of media professionals. Geneva: WHO; 2000. reporting of suicide, list sources of information and provide guidelines on reporting suicide. 4.4.10 The American Foundation for Suicide Good Practice Point Prevention has published recommendations Centers for Disease Control and Prevention, National Institute of Mental for the media on reporting suicide. These Health, Office of the Surgeon General, cover suicide contagion, interviewing Substance Abuse and Mental Health surviving relatives and friends and make Services Administration, American Foundation for Suicide Prevention, recommendations for appropriate language. American Association of Suicidology, Annenberg Policy Center (2001) Reporting on suicide: Recommendations for the media. Available www.afsp.org/education/recommnedati ons/5/1.htm [Accessed 6 Apr 2006]

4.5. MONITORING SUICIDE RATES Topic area Suicide is a significant cause of premature mortality. Targets for suicide reduction are usually based on a reduction in the age-standardised overall population suicide rate. A favourable trend in this rate may mask an adverse trend in rates for young people. Supporting evidence 4.5.1 Analysis of routine mortality and census data Type IV evidence for England and Wales shows that although Gunnell D, Middleton N. National suicide rates as an indicator of the age-standardised suicide rates fell by 18% effect of suicide on premature (95% confidence interval 15-21) between 1981 mortality. Lancet 2003;362:961-62. and 1998, the potential years of life lost before the age of 65 increased by 5% (95% confidence interval 4-6). Measures of potential years of life lost (PYLL) are a better approach to quantifying the effect of premature mortality for health outcomes, such as suicide, that have a high prevalence in young people. National suicide reduction targets should focus on PYLL as well as overall suicide rates.

http://kc.nimhe.org.uk/upload/SuicidePreventionToolkitweb.pdf Link to NIMHE suicide prevention toolkit

http://www.npsa.nhs.uk/health/resources/root_cause_analysis/conditions Link to National Patient Safety Agency root cause analysis toolkit

www.tcf.org.uk The Compassionate Friends (Shadow of Suicide) (for parents who have lost a child, and siblings)

www.crusebereavementcare.org.uk CRUSE Bereavement Care;

www.papyrus-uk.org PAPYRUS (committed to prevention of youth suicide) will help bereaved parents and carers make contact with sources of support

www.uk-sobs.org.uk Survivors of Bereavement by Suicide (SOBS)

www.winstonswish.org.uk Winston’s Wish supports bereaved children and their families

http://www.mindframe-media.info/index.php Link to home page of Australian resource for media professionals, downloads available include guidelines for reporting suicide

www.presswise.org.uk The MediaWise Trust

http://cebmh.warne.ox.ac.uk/csr/linksmedia.html University of Oxford Centre for Suicide Research links to the Media and suicidal behaviour

http://www.who.int/mental_health/media/en/426.pdf Link to WHO resource for media professionals on preventing suicide

www.afsp.org American Foundation for Suicide Prevention

www.suicidology.org American Association of Suicidology (AAS), USA

www.suicideprevention.ca Canadian Association for Suicide Prevention (CASP), Canada

[email protected] International Association for Suicide Prevention (IASP), USA

www.spanusa.org

Suicide Prevention Advocacy Network (SPAN), USA www.suicidepreventionaust.org Suicide Prevention Australia (SPA), Australia

http://www.suicideinfo.ca/ Centre for Suicide Prevention (CSP) Suicide Information and Education Collection (SIEC), Canada www.griffith.edu.au/school/psy/aisrap Australian Institute for Suicide Research and Prevention (AISRP), Australia

www.sprc.org Suicide prevention centre, USA

www.med.uio.no/ipsy/ssff/hoveden-gelsk.htm Suicide Research and Prevention Unit, Norway

CONCLUSION Suicide and deliberate self harm have significant personal, social and economic consequences. There is no clear way to predict which individuals are likely to die from suicide and there is no research that demonstrates how suicide can be prevented in any one individual. Adoption of the four level model described in the introduction, underpinned by the evidence set out in this document would support a move away from concentration on people with mental illness considered to be at ‘high risk’ of suicide towards a more population based prevention approach. This approach attempts to reduce the risk of suicide in the whole population by changing attitudes, knowledge, behaviours and norms that may predispose people to suicide. The model facilitates a strategic approach to suicide prevention as clear organisation responsibilities can be assigned at each of the levels.

Appendix I

RISK FACTORS ASSOCIATED WITH SUICIDE

FACTOR ESTIMATED INCREASED RISK Male gender1 X 3 Age  Men 15-44years2 X 4 Current or ex psychiatric patients3 X 10 4 weeks following discharge from psychiatric X100-200 hospital4 Prisoners (male and female)5 X 5-10 Self-harm6a X 30 In first year following self harm6b X 66 Socioeconomic deprivation7 Not known Substance misuse  Drug misuse8a X 20  Heroin8b X 14  Alcohol8c X 6  Prescription drugs8d X 20  Prescription drugs and alcohol8e X 16  Prescription and illicit drugs8f X 44 Schizophrenia9  Previous depressive disorder X 3  Previous suicide attempts X 4  Drug misuse X 3  Agitation or motor restlessness X 2.5  Fear of mental disintegration X 12  Poor adherence to treatment X 4 X 4  Recent loss Major depression10 X 20 Bipolar disorder11 X 15 Dysthymia12 X 15 Anorexia nervosa13 X 23 Anxiety disorders14 X 6 -10 Personality disorder15 X 7 Physical illness16  Cancer X1.5 – 4  Neurological disorders Not known  Renal disease Not known  Chronic pain Not known For men being divorced or separated17 X 2 Unemployment18 X 2 -3 Family history of suicide19 Not known

REFERENCES

1. Data for Wales for 2003, source HealthShow 2006 2. Data for Wales for 2003, source HealthShow 2006 3. Appleby L. Suicide in psychiatric patients: risk and prevention. Br J Psychiatry 1992; 161:749-58 4 Goldacre M, Seagrott V, Hawton K. Suicide after discharge from psychiatric inpatient care. Lancet 1993; 342:283-86 5 Charlton J, Kelly s, Dunnell K, Evans B, Jenkins R. Suicide deaths in England and Wales. Population Trends 1992; 69: 10-16 Dooley E. Prison suicides in England and Wales, 1972-87. Br J Psychiatry 1990; 156:40-5 Dyer O. Suicide among women prisoners at a record high. BMJ 2003; 327:122 6a Cooper J, Kapur N, Webb R, Lawler M, Guthrie E, Mackway Jones K, Appleby L. Suicide after deliberate self harm. Am J Psychiatry 2005;162: 297-303 Gibbs SJ, Beautrais AL, Fergusson DM. Mortality and further suicidal behaviour after an index suicide attempt: A 10-year study. Aust N Z J Psychiatry 2005 39: 95-100 6b Hawton K, Zahl D, Weatherall R. Suicide following deliberate self harm: long-term follow-up of patients who presented to a general hospital. Br J Psychiatry 2003;182:537-42 7 Gunnell DJ, Peters TJ, Kammerling RM, Brooks J. Relation between parasuicide, suicide, psychiatric admissions and socioeconomic deprivation. BMJ 1995; 311:226-30 8a. Harris EC, Barraclough B. Suicide as an outcome of mental disorders. Br J Psychiatry 1997; 170: 205-28 8b. Darke S, Ross J. Suicide among heroin users: Rates, risk factors & methods. Addiction 2002; 97: 1383-94 8c,d,e,f Harris EC, Barraclough B. Suicide as an outcome of mental disorders. Br J Psychiatry 1997;170:205-28 9. Hawton K, Sutton L, Haw C, Sinclair J, Deeks JJ. Schizophrenia and suicide: systematic review of risk factors. Br J Psychiatry 2005;187: 9-20. 10. Harris EC, Barraclough B. Suicide as an outcome of mental disorders. Br J Psychiatry 1997;170:205-28 11. Harris EC, Barraclough B. Suicide as an outcome of mental disorders. Br J Psychiatry 1997;170:205-28, 12. Harris EC, Barraclough B. Suicide as an outcome of mental disorders. Br J Psychiatry 1997;170:205-28 13. Harris EC, Barraclough B. Suicide as an outcome of mental disorders. Br J Psychiatry 1997;170:205-28 14. Harris EC, Barraclough B. Suicide as an outcome of mental disorders. Br J Psychiatry 1997;170:205-28 15. Harris EC, Barraclough B. Suicide as an outcome of mental disorders. Br J Psychiatry 1997;170:205-28 16. Stenager EN, Stenager E. Physical illness and suicidal behaviour. In: Hawton K, van Heeringen K, editors. The international handbook of suicide and attempted suicide. Chichester:Wiley: 2002. 17. Kposowa AJ. Marital status and suicide in the National Longitudinal Mortality Study. J Epidemiol Community Health 2000;54:254-61 18. Blakely TA, Collings SCD, Atkinson J. Unemployment and suicide. Evidence for a causal association? J Epidemiol Community Health 2003; 57:594-600 19. Roy A, Nielsen D, Rylander G, Sarchiapone M. The genetics of suicidal behaviour. In: Hawton K, van Heeringen K, editors. The international handbook of suicide and attempted suicide. Chichester:Wiley;2002.

Appendix II Summary of recommendations from the British Isles Suicide Researchers Group12 Level Area Recommendation Primary Allow coroners to In non-complex cases where there is no dispute over facts recommendation dispense with and with family agreement, coroners allowed the discretion to public suicide process suicides without a public hearing inquest Secondary Standards of Existing guidelines should be updated and operationalised as recommendations practice standards of acceptable practice. These to be made public and reviewed Training Coroners and coroner’s officers to receive training on aspects of bereavement, questioning techniques and dealing with the media. Before the inquest Pre-inquest The relatives of the deceased should be briefed face-to-face briefing by court representative/welfare officer with the purpose of: Providing full information and preparation for all aspects of the procedure Outlining the rights of the bereaved Redressing unrealistic expectations at the outset Establishing a point of contact for the inquiry Making the inquest multifunctional by allowing the bereaved to state questions they would like answered and relaying these to the coroner if appropriate Written Briefing supported by written information to address difficulties information the bereaved experience in processing and retaining information Re-definition of Coroner’s officer role officially widened to encompass the coroner’s information and support giving to relatives to include the officer role proposed briefing and also dissemination of information regarding specific help-sources for those bereaved by suicide. Role to be professionalized and formalised through bereavement training. Timescales for Excluding exceptional cases, inquests to be held within 4 completion months. Where this is not attainable, reasons for the delay to be explained to relatives Scheduling the Coroner’s office to liaise with relatives regarding inquest date. date Relatives not to be informed by ‘summons’ Suicide notes Addressee to be provided with copy of the note. Where no addressee is stated, the note to be given to the next of kin at the coroner’s discretion. During the inquest Reduced Inquests to be conducted in comfortable, sensitive formality surroundings with a minimum formality Press restrictions Media prohibited at relative’s request where no function of public broadcast can be justified Restrictions on Coroners to restrict graphic details heard by relatives to a graphic evidence minimum. Wherever detailed reporting of post-mortem findings are necessary, coroners to allow relatives the opportunity to leave the courtroom Relieving Coroners where able to relieve relatives who have given relatives of the statements from public formal questioning/giving evidence witness role under oath After the inquest De-briefing Relatives provided with an opportunity to discuss what has taken place and ask questions Complaints A formal, established and accessible complaints procedure procedure made available to relatives who are unhappy with the inquest process (including pre-inquest procedure) Return of suicide Originals to be returned automatically notes

12 Biddle L. Public hazards or private tragedies? An exploratory study of the effect of coroners’ procedures on those bereaved by suicide. Soc Sci Med 2003;56:1033-45. Version: 1 Date:February 2007 Status: Draft Author: Sian Price Page: 64 of 64 Classification: