Suicide ireland' research & societal response (pdf)

Theresa Lowry-Lehnen RGN, BSc (Hon’s) Specialist Clinical Practitioner (Nursing), Dip

Counselling, Dip Adv Psychotherapy, BSc (Hon’s) Clinical Science, PGCE (QTS) , H. Dip. Ed, MEd, Emotional Intelligence (Level 9) MHS Accredited.

Suicide Statistics - Ireland Average deaths by suicide in Ireland is 495.

The highest number of deaths by suicide (519) occurred in 2001.

Figures fell significantly from 2003- 2008 however;

Figures are expected to rise. (Central Statistics Office data for 2000 – 2008 ‘year of occurrence of death’ data)

Suicide Statistics - Ireland 424 suicides in 2008; (332 (78 %) male, while 92 (22 %)

female); a reduction of 36 compared with 460 in 2007 and 460 in 2006.

However the first quarter of 2009 saw an increase in suicides- 9.6 per 100,000 population compared to 6.8 per 100,000-same period in 2008. Suicide prevention experts say job losses and the recession may be linked to the increase.

There is growing concern re the increases in “undetermined” deaths - 119 in 2007 and 181 in 2008 (not included in suicide statistics).

HSE's National Office for Suicide Prevention (Sept 2009)

Suicide Statistics - Ireland

Suicide

Deliberate self

harm

Suicidal thoughts, hopelessness

poor mental health

N = 500 (approx)

A+E presentations =

11,000

DSH in the community =

estimated 70,000

N = 1 million

(estimated)

Suicide Statistics - Ireland Ireland - fourth highest rate of youth suicide in the EU

behind Lithuania, Finland and Estonia. The highest rates -Men aged-20 and 24 years. 10% of adolescents aged 13-19 in Ireland have a depressive

disorder. (NOSP 2009) Suicide is a 4 times more common in men than women. Men under 35 years account for 40% of all Irish suicides. Approx 8 suicides/week and 100 suicide attempts. Medical and farming professions are most at risk of

depression and suicide (CSO). Males represent 78% of suicides. Females 22%. 11,000 + cases of deliberate self-harm are seen in Irish

hospitals every year. In the community-DSH- estimated 70,000+. (NRDSH)

HSE's National Office for Suicide Prevention (Sept 2009)

Statistics-Suicide/Para-suicide Ireland Suicide Most common methods of

suicide -hanging, drowning. (2001- 2005) suicide by hanging

was the most common used method by males in all age groups and females in the younger age groups (CSO).

Poisoning and drowning were other methods used by females.(CSO)

A consistent trend has been that males are more likely to use violent methods while females use less lethal/ violent methods

(HSE 2006)

Para-suicide

Two main methods of para-suicide nationally are overdose and cutting.

More lethal methods such as hanging, drowning and firearms are rarely used in para-suicide.

In 2006 74% of all episodes of para-suicide involved overdose, with 41% of all cases involving alcohol.

Cutting accounted for 25% of men and 18% of females.

(HSE 2006)

Method of Suicide/Para-suicide

79%

2%15%

2%1%1%0%

Overdose

Alcohol

Poisoning

Hanging

Drowning

Cutting

Other

0%3%

4%

3%

24%3%

63%

Men Women

Alcohol was involved in 46% and 39%

of male and female episodes, respectively

© National Suicide Research Foundation, Ireland

Global Statistics Significant worldwide public health problem;

1 suicide/ minute

1 attempt /3 seconds

1,000,000 +/suicides worldwide /year.

Estimated - 10 to 20 million non-fatal attempts/year.

Global suicide rate is 16 : 100,000.

1.8% of worldwide deaths are suicides.

Global suicide rates -increased -60% in the past 45 years.

More people die from suicide than armed conflict.

www.who.org (2010)

Causative factors of Suicide (HSE 2006)

Sociological Psychological Biological

Changing family structure Mental well-being Genetics

Marital breakdown Personality Neurotransmitters- example- serotonin

Changing cultural values and religious practices

Psychosocial Psychiatric illness

Unemployment/ employment

Physical illness

Alcohol and substance misuse

Increased availability of methods of suicide

Risk Factors (HSE 2006)

Long term Factors

Short term/ precipitating factors

Socio-demographic Factors

Psychiatric illness Interpersonal problems Gender/ sex

Alcohol and substance misuse

Rejection Age

Previous suicide attempt Loss events Marital status

Family history of suicide Work Problems Occupation

Physical illness A humiliating life event Unemployment

Loss Access to means

Socio-Cultural Factors Gender: Four times as many women

attempt suicide as men: however, four times as many men actually succeed in their attempt.

Age: The over 65’s and 15-30 age groups are at increased risk of suicide. Males under the age of 35 are most at risk. Among older people, suicide can occur as a consequence of increasing disability; 44% of one sample studied committed suicide to prevent being placed in a nursing home.

Marital Status: highest among divorcees, widowed and single people.

Substance abuse: About 60% of attempted suicides involve alcohol/ substance abuse.

Occupation: Highest rates among medical and farming professions

Unemployment (strong association between unemployment and suicide)

Access to means (example firearms)

(Bennett 2005)

(HSE 2006)

Socio-Cultural Factors Sexuality: 28% of homosexual or bisexual males but only 4%

of heterosexual male adolescents- considered or attempted suicide. For females the corresponding figures are 21% and 15%

Suicide among those who have recently been bereaved is also frequent.

Research also indicates that abuse in childhood is strongly linked with suicide.

(Bennett 2005)

Socio-cultural- Alcohol Estimated that 1: 10 Irish people are alcoholics.

Alcoholism in one person, directly affects the lives of at least 4-5 others.

Alcohol was involved in 46% of males and 39% of female episodes of suicide in 2008.

Consumption of alcohol in the Irish population has increased by 18% over the past 13 years, from 11.5 litres per adult in 1995 to 14.4 litres in 2008.

The recent national accounts from the Central Statistics Office show that expenditure on alcohol in Ireland is almost 10% per cent of total personal expenditure,

The recent EU-funded report claims that Ireland spends three times more than any other country on alcohol.

www.rutlandcentre.ie/alcohol(2010)

Suicide and Mental Illness Over 90 percent of people

who die by suicide have a psychological illness at the time of their death.

Untreated mental illness (including depression, bipolar disorder, schizophrenia, and others) is the cause for the vast majority of suicides.

Untreated depression is the number one cause for suicide.

(www.suicide.org 2010)

400,000+ Irish people currently experience depression (approx 1 in 10 of the population)

40,000+ Irish people currently experience Bi-Polar.

Severely depressed individuals usually lack the volition/energy to act on their feelings.

As depression begins to lift, individuals are more at risk/ inclined to commit suicide.

www. aware.ie (2009)

Statutory Sector /Voluntary Sector

General practitioner

Accident & Emergency

Psychological services

Adult psychiatric services

Child and Adolescent psychiatric services

Addiction counsellors

Samaritans

Grow

Mental Health Ireland

Aware

Schizophrenia Ireland

Alcoholics Anonymous

Rape crisis centre

Bodywhy’s

Bereavement counselling

Suicide Bereavement Support

Suicide in Ireland by age and gender

Average rates 2002-2006

Prevalence of DSH in 2008

Men:

180 / 100,000

(+11%)

Women:

223 / 100,000

(+4%)

All:

200 / 100,000

(+6%)

Regional Differences in DSH 2008 Males

Regional Differences in DSH 2008 Females

Overdose and DSH- 2008

Type of medication used in Overdose acts

Suicide - Hanging

Self-Cutting and DSH

Alcohol involvement in DSH

A Vision For Change (2006)

Report of The Expert Group on

Mental health Policy

Reach Out

National Strategy for

Action on Suicide Prevention

2005 - 2014

NOSP Annual Report 2009 The National Office for Suicide

Prevention 2009 Annual Report sets out progress against each of the Actions in Reach Out, the National Strategy for Action on Suicide Prevention, for the year 2009 and reflects the significant amount of work undertaken at local, regional and national level by community groups, voluntary organizations and statutory bodies in this sensitive and important

Review this document at http://www.nosp.ie/html/reports.html

Reach Out

National Strategy for Action on Suicide Prevention

2005 - 2014

Reach Out makes the point that social changes have impacted on the nature and extent of suicidal behaviour in Ireland.

Suicide rates doubled during the 1980s and 1990s. This was a time when society experienced considerable transition from an

agricultural rural economy to an urban service-orientated one. The church and rural norms were challenged. There have been considerable changes for young adults and older

people. Young men in rural areas can no longer assume that they have a

livelihood from farming. Fathers are isolated with the increasing number of single parent

families. Teenage girls struggle with media-induced expectations about their

physical appearance, and older people no longer have the support of an extended family network.

Increasing socio-economic inequalities and social exclusion affecting a variety of groups residing in Ireland also increase suicide rates.

It is clear that this is not just a health problem, but a societal one.

Reach Out

National Strategy for Action on Suicide Prevention

2005 - 2014 Reach Out – 4 main approaches

The general population approach will promote positive mental health and bring about a positive attitude towards mental health, problem solving and coping in the general population

The targeted approach will reduce the risk of suicidal behaviour among high-risk groups and vulnerable people. These include those who commit deliberate self-harm, those at risk of or abusing alcohol and drugs, marginalised groups, prisoners, unemployed people, people who have experienced physical or sexual abuse, young men and older people.

The response to suicide will minimise distress felt by families, friends and the community following death, and ensure that individuals are not isolated or left vulnerable, so as to reduce the risk of related suicidal behaviour.

Information and research will be used to inform service development and provide information on where and how to get help.

(Begley et al. 2006) Reasons why young men are more likely to commit suicide

Social change- different types of pressure (mentally tougher) than in the past

Increased pressure to provide and succeed in education/work etc

Changes in the family- Divorce/ separation/ decrease in extended family/ Family life more stressful

Negative sense of community and over reliance on self.

Changing attitudes to religion

Over reliance –alcohol / drugs

Stigma attached to mental ill health

Attitude to seeking help (Anonymity/confidentiality)

Lack of knowledge/ accessibility / lack of knowledge of services- unsure -where to go to seek help.

Reluctance to see GP (Cost/ over reliance on medication/ confidentiality)

Difficulty in admitting problem.

Distrust of existing services.

Males choose more violent methods for taking their own life.

(Begley et al. 2006)

How society can make an effective response

Society needs to consider changes that have occurred in culture and society- family/ community / work and implement new procedures accordingly.

From a young age – boys should be encouraged to access support – family/ friends/ community services.

GP settings to incorporate mental health professionals.

Mental health nurse- in schools.

Youth focused services- such as Clockwork in Australia- service run by GP’s, nurses, psychologists, youth workers etc.

Begley et al. 2006


User friendly- one stop shop- which provides health information (especially for men)

Parenting courses

Skills based education programme for parents- how to cope in a crisis.

Consideration should be given to young men’s opinions and preferences when developing suicide/ bereavement services. Many have a strong religious/ pastoral element which may not be appropriate for many men.

Support for fathers who do not get to see their children.

Housing incentives

Awareness- leaflets/ programmes/ad’s.

Media- need to acknowledge- Impact of drugs and alcohol on mental health- highlighting positive coping strategies and damaging effects of negative behaviour (anger/ alcohol etc).

Begley et al. 2006


Education (PHSE) in schools- integrate mental health issues.

There are over 900 Gun clubs in the country- need to implement suicide prevention strategies.

Need to implement tighter restrictions to possessing a gun.

Gun safes- guns and ammunition kept separate.

Independent Dr’s as opposed to individuals own GP’s to determine medical (mental) fitness of applicants to hold a gun license.

Begley et al. 2006

“A Vision For Change” (2006) A Vision for Change (2006) details

a comprehensive model of mental health service provision for Ireland.

It proposes a holistic view of mental illness and recommends an integrated multidisciplinary approach to addressing the biological, psychological and social factors that contribute to mental health problems.

However the absence of meaningful progress in the implementation of Vision for Change remained an ongoing concern for the Mental Health Commission during 2008 and Amnesty International.

(MHC 2008 Annual report).

Since 2006-Government planned to raise some €700 million through the sale of lands used by psychiatric hospitals that are due for closure. By Feb 2010 this had not materialised and the implementation of ‘Vision for Change’ remained an ongoing concern.

March 2010- plans being implemented to close 14 Mental health institutions over the next 3 yrs. Monies from the sale to be used to treat patients in the community. Too little too late? (Value of lands/ property has greatly declined since 2008)

At the annual forum organised by the NOSP(Sept 2009), Minister of State for Mental Health John Maloney insisted funding for suicide prevention would continue. However in 2008 Gov. funds for suicide prevention were halved from 8,000,000 to 4,000,000 € per annum.

The Suicide Crisis Assessment Nurse (SCAN) (Dublin & Wexford)

The Suicide Crisis Assessment Nurse (SCAN) –launched- March 2007 by the Cluain Mhuire Service in Blackrock, Co. Dublin, provides a fast-track priority referral system from primary care for people experiencing a suicidal crisis. It is operated by one nurse five days a week from 9a.m. to 5p.m.

In August (2009) the Wexford service, (consists of three nursing posts), was rolled out across the county.

Referrals to the service are made by the GP who calls the nurse, and the patient needing help will be seen within hours, or the same day.

‘Minding the gap’ – SCAN nurse link role in maintaining contact with patients until they engage with ‘next care’ services.

Next care’ pathway[Mental Health Services; Counselling: Social Networks/Vol Groups]

www.hse.ie (2010)

Suicide Crisis Assessment Nurse (SCAN) Wex: GP’s = circa 45 practices Dublin: GP’s = circa 67 practices

Population = circa 132,000 Population = 183,000

- New Ross - Blackrock - Wexford Town - Dunlaoighre - Rosslare - Shankill - Enniscorthy - Dundrum - Gorey - Kilmacud -Arklow - Mt Merrion Network & partnership approach with 90% of

locality GP’s. Ongoing analysis and evaluation of the service –

consulting GP’s, Mental Health Colleagues & Service Users.

crisis referrals in the 65 days pre and post implimentation

Response

Audit

No. Cases

(65 days)

Assessed

Same day

Delayed

assessment

Not seen Documented

assessment

Pre SCAN

13 8 5

(mean > 2days)

1 60%

SCAN

16 11 2

(mean < 1 day)

3 100%

Period Pre-SCAN 65 Days SCAN first 65 days

Adverse event

(requiring medical adm.)

2 0

Number of bed days resulting

from admissions following

assessments

172

16

Cost to CMHT budget 60,185 Euro 5,599 Euro

Projected annual cost 337,030 Euro 31,354 Euro

Effect of introduction of SCAN service On patient care and CMHT

Mainstreaming SCAN: The Challenge

Dublin:

Training 3 Community Psychiatric Nurses to deliver the Primary Care Suicide Crisis Assessment Nurse model

Wexford:

Provision of a 7 day Wexford General Hospital liaison nursing service and a 5 day County wide Primary Care Suicide Crisis Assessment Nurse Service.

Nationally:

Sharing know-how with other community psychiatric services

Incorporating SCAN skills into advanced nurse practitioner training

Informing service planners of benefits to patients and cost savings

However both Chluain Mhuire and the Wexford service only have enough funding from the NOSP until March 2010

Wexford SHIP Self Harm Intervention Programme

Commenced -June 2004- a joint initiative between the HSE South East Area’s Adult Counselling Service and its Suicide Resource Office.

Individuals at risk of suicide or self harm are eligible to self refer or be referred by a health professional

Weekday office hours (Tel 053 74050)

Provides short term counselling contracts up to 12 sessions duration

Lower age threshold : 16 years

Statistics- Wexford SHIP 2009: 83 referrals

2008: 120 referrals;

2007: 102 referrals;

2006 : 116 referrals)

Source of referrals

0

10

20

30

40

50

60

A&

E

GP

Menta

l H

oth

er

pare

nt

SC

AN

Vol agen

self r

ef

Source

Nu

mb

er

of

clien

ts

Self referrals: where did they hear

about the service

0

5

10

15

20

25

A.&

E

.

Dept

Com

har

Frie

nd

G.P

.

Mental H

R/R

SC

AN

Sib

ling

Vol A

gen

Agency

HSE –South Regional Suicide Resource Office Bereavement Counselling Service for Sudden

Traumatic Death Counselling Hrs per County

Wexford 68%

Waterford 17%

Tipperary 3%

Carlow 8% Kilkenny

4%

Wexford

Waterford

Tipperary

Carlow

Kilkenny

280.5

137.5

54

29.5 28

0

50

100

150

200

250

300

Wexford Waterford SouthTipperary

Carlow Kilkenny

Role of Triage - Suicide

Often-Point of first contact If the triage clinician suspects risk of suicide, or deliberate self harm-regardless

of chief complaint- Ask questions—save a life. Ask patient direct questions and/or get information from family

members/friend if present How the questions are asked affects the likelihood of getting a truthful response.

Use a tactful, non-judgmental, non-condescending approach. Example; 1. Do you feel you are at risk/threat to yourself or somebody else? 2. Are you currently thinking about ending your life? 3. Have you ever thought that life was not worth living? 4. Have you ever thought about ending your life? 5. Have you ever attempted suicide? When suicidal ideation is present the triage clinician must ask about: 1) Frequency, intensity, and duration of thoughts; 2) Existence of a plan and whether preparatory steps have been taken; and 3) Intent

(Suicide Risk: A Guide for Evaluation and Triage-at /www.sprc.org/library/SuicideRiskGuide8.pdf)

High risk patients/ Interventions Include those who have: Made a serious or nearly lethal

suicide attempt Persistent suicide ideation or

intermittent ideation with intent and/or planning

Psychosis, including command hallucinations

Recent onset of major psychiatric illnesses, especially MDD (Clinical Depression)

Been recently discharged from a psychiatric unit

History of acts/threats of aggression or impulsivity


Emergency services (Ambulance/ Gardai)

Emergency evaluation by Dr.

Psychiatric/psychological evaluation ASAP

Ensure family/friend to monitor while waiting professional review

Maintain contact with the patient until help arrives.


Resources Samaritans

4-5 Usher's Court Usher's Quay Dublin 8 Office: 24 Hour Telephone Helpline:

www.samaritans.org [email protected](24 Hour Email Helpline)

01-6710071 1850 609090

Text-phones (For the deaf and hard of hearing) 1850 60 90 91

Barnardos Christchurch Square Dublin 8. Office: Callsave:

www.barnardos.ie [email protected] 01-4549699 or 1850 222 300

Aware 72, Lower Leeson Street

Dublin 2. Office: 01-6617211 Helpline: 1890 303 302 (7 days from 10am - 10pm)

www.aware.ie [email protected]

Living Links- National Committee Office 5 Lower Sarsfield Street, Nenagh, Co. Tipperary. Phone: 067 43999 or 087 4122052 Email; [email protected] Web:; www.livinglinks.ie

Mental Health Ireland Mensana House 6 Adelaide Street Dun Laoighre Co. Dublin. Office:

www.mentalhealthireland.ie [email protected] Tel;01-2841166

Console All Hallows College Drumcondra Dublin 9 Office: Helpline:

www.console.ie [email protected] 01-8574300 1800 201 890

Providing support to those bereaved by suicide

Grow Ormonde Home

Barrack Street Kilkenny

www.grow.ie [email protected] 1890 474 474

.

Documents/ Government Publications A Vision for Change (2006); Report of the expert group on mental

health policy, Government publication office, Dublin.

Begley et al (2006) ‘The Male Perspective: Young men’s outlook on life’, Bord Slainte, Suicide prevention Office, Midwestern Health board.

HSE (2006) Towards Understanding; A suicide Information Booklet, Regional Suicide Resource Office, Waterford.

Mental Health Commission (2008), Annual report; including the report of the Inspector of Mental Health Services, Government publication office, Dublin.

National office for suicide prevention (2008) Annual Report

Reach Out (2005-2014) National Strategy for Action on Suicide Prevention, Government publication office, Dublin.

The Quality Framework (2007) Mental Health Services in Ireland, Government publication office, Dublin.

‘Human understanding is the most effective

weapon against suicide’

Dr Edwin Shneidman

References A Vision for Change (2006); Report of the expert group on mental health policy,

Government publication office, Dublin.

Bennett, P (2005) Abnormal Clinical Psychology; An Introductory Textbook (Second edition).

Maidenhead: Open University Press

HSE (2006) Towards Understanding; A suicide Information Booklet, Regional Suicide Resource Office, Waterford.

National Centre for Health Statistics; (CSO)Deaths: Injuries (2002-2008), Government publication office, Dublin.

National office for suicide prevention (2009) Annual Report, Government publication office, Dublin.

Reach Out (2005-2014) National Strategy for Action on Suicide Prevention, Government publication office, Dublin.

Suicide Risk: A Guide for Evaluation and Triage-at /www.sprc.org/library/SuicideRiskGuide8.pdf

www.aware.ie

www.hse.ie

www.rutlandcentre.ie

www.suicideireland.com

www.suicide.org

www.who.org