SUICIDE AND SEVERE SELF HARM PREVENTION IN PRIMARY CARE Dr Khalid Aziz Consultant Psychiatrist Barnet Dr Henry Andrews Consultant Psychiatrist Enfield Dr Leon Rozewicz Clinical Director Crisis & Emergency Resilience? • Everyone experiences stress and difficult circumstances during their life. • Most people can handle these tough times and may even be able to make something good from a difficult situation. • Resilience is the ability to bounce back after experiencing trauma or stress, to adapt to changing circumstances and respond positively to difficult situations. • It is the ability to learn and grow through the positive and the negative experiences of life, turning potentially traumatic experiences into constructive ones. • Being resilient involves engaging with friends and family for support, and using coping strategies and problem-solving skills effectively to work through difficulties. Contributory Factors - Individual Well-Being • Self Image: sense of self, including self-esteem secure identity, ability to cope, and mental health and wellbeing • Behavior: social skills including life skills, communication, flexibility, and caring • Spirit: sense of purpose, including motivation, purpose in life, spirituality, beliefs, and meaning • Heart: emotional stability, including emotional skills, humor, and empathy • Mind: problem solving skills, including planning, problem-solving, help-seeking, and critical and creativethinking. • Body: physical health, physical energy, and physical capacity A Person’s Reaction to Life Events - Main Factors 1. Individual Health and Well-Being - Sense of self, social skills, sense of purpose, emotional stability, problem-solving skills, and physical health. 2. Pre-Disposing or Individual Factors - Genes, gender and gender identity, personality, ethnicity/culture, socioeconomic background, and social/geographic inclusion or isolation. 3. Life History and Experience - Family history and context, previous physical and mental health, exposure to trauma, past social and cultural experiences, and history of coping. 4. Social and Community Support - Support and understanding from family, friends, local doctor, local community, school, level of connectedness, safe and secure support environments, and availability of sensitive professionals/carers and mental health practitioners. Myth vs. Fact Myth: People who talk about suicide don’t die by suicide. Fact: Many people who die by suicide have given definite warnings to family and friends of their intentions. Always take any comment about suicide seriously. Myth: Suicide happens without warning. Fact: Most suicidal people give many clues and warning signs regarding their suicidal intention. Myth vs. Fact Myth: People who are suicidal are fully intent on dying. Fact: Most suicidal people are undecided about living or dying – which is called suicidal ambivalence. A part of them wants to live; however, death seems like the only way out of their pain and suffering. They may allow themselves to “gamble with death,” leaving it up to other to save them. Myth: Males are more likely to be suicidal. Fact: Men die by suicide more often than women. However, women attempt suicide three times more often than men. Myth vs. Fact Myth: Asking a depressed person about suicide will push him/her to kill themselves.. Fact: Studies have shown that patients with depression have these ideas and talking about them does not increase the risk of them taking their own life. Myth: Improvement following a suicide attempt or crisis means that the risk is over. Fact: Most suicides occur within days or weeks of “improvement” when the individual has the energy and motivation to actually follow through with his/her suicidal thoughts. Myth vs. Fact Myth: Once a person attempts suicide the pain and shame will keep them from trying again. Fact: The most common psychiatric illness that ends in suicide is major depression, a recurring illness. Every time a patient gets depressed, the risk of suicide returns. Myth: Sometimes a bad event can push a person to suicide. Fact: Suicide also results from serious psychiatric disorders, not just a single event. Myth: Suicide occurs in great numbers around holidays in November and December. Fact: Highest rates of suicide are in April while the lowest rates are in December. Suicide - Definition • Suicide is a multi-determined phenomenon that occurs against a background of complex interacting biological, social, psychological and environmental risk and protective factors. • Despite the complexity of this phenomenon, suicide can be prevented. • “Ideation” – thinking about or planning for suicide Suicide - UK Incidence • Third largest cause of death in Britain of premature mortality (after heart disease and cancer) (World Health Organization, 2000). • In 2007 there were still 7.9 suicides per 100 000 people - 4000 incidents/yr. • Younger people are more likely to die by suicide than older people. • Statistics show that in 16 to 24 year-olds, 5% have attempted suicide, compared with 2% of 65 to 74year-olds. However, the rate among people over 85 rises again Suicide - UK Incidence • Men are five times as likely to die by suicide as women. (WHO - Global Burden of Disease: 2004 Update report (World Health Organization, 2008) • Of people in the UK who die by suicide, only about 25% were in contact with mental health services in the 12 months before the suicide • Although it is generally acknowledged that most had a diagnosis of a mental disorder at the time of their death (Bertolote & Fleischmann, 2002). • In some studies, the rate of a diagnosed mental illness of those who have killed themselves has been found to be more than 80% (Arsenault-Lapierre et al, 2004; Fleischmann et al, 2005; McManus et al, 2009). Suicide - UK Incidence • Typical GP will see one suicide every five years on their list • One a year in a 10 000 group practice • No single assessment tool Risk Factors for Suicide: Socio-Demographic • Females more likely to attempt than males • Males more likely to die • Young and Old • Poverty, unemployment • Prisoners Risk Factors for Suicide: Family and Childhood • Parental depression, substance misuse, suicide • Parental divorce • Bullying Risk Factors for Suicide: Mental Health Problems • Impulsive, aggressive or socially withdrawn • Poor problem solving ability • Mood disorders; bipolar, psychotic depression • Substance/alcohol misuse • Schizophrenia • Recent discharge from psychiatric hospital Risk Factors for Suicide: Suicidal Behaviour • Access to means (guns, drugs, tablets) • History of suicide attempts • Specific plans Other Individual Suicide Risk Factors • Impulsivity - Contributes to suicidal behavior, especially in context of depression or bipolar disorder • Family History - Many mental disorders run in families, due to genetic factors • Prior Suicide Attempt Suicide Questions • How does the future look to you? What are your hopes? • Do you wish you could just not wake up in the morning? • Have you considered doing anything to harm yourself, or to take your own life? • Have you made actual plans to kill yourself? What are they? • What has stopped you from doing anything so far? Self Harm • An intentional act of self-poisoning or selfinjury irrespective of the type of motivation or degree of suicidal intent. • Includes suicide attempts as well as acts where little or no suicidal intent is involved • To reduce internal tension, • Distract themselves from intolerable situations • Form of interpersonal communication of distress or other difficult feelings • To punish themselves Problems of definition • Given the varying types of self-harm, the different contexts in which it occurs and the different motives and meaning for the individual concerned, defining self-harm is not straightforward. • The NICE guidelines (National Collaborating Centre for Mental Health, 2004) use the short and broad definition: • ‘Self-poisoning or self-injury, irrespective of the apparent purpose of the act.’ • The service users’ National Self-Harm Network (NSHN; 1998) presented an alternative description: • ‘Self-injury is frequently the least possible amount of damage and represents extreme self-restraint.’ Self Harm • Can sometimes be a bizarre form of selfpreservation. • Nevertheless it covers a wide spectrum of behaviour, with harmful physical effects • Person who repeatedly self-harms is at a higher risk of suicide. Self Harm • The UK has one of the highest self-harm rates in Europe, reported at about 400 per 100 000 people (Horrocks et al, 2002). • It has been estimated that there are 170 000 self-harm presentations at hospitals each year in England (Kapur et al, 1998) • Self-harm has been quoted as one of the five top causes of acute hospital admissions, but this greatly underestimates the problem since many people do not attend hospital. • As with suicide, younger people are more likely to selfharm than older individuals. Of those who present at hospitals, two-thirds of patients who self-harm are under 35 of whom two-thirds are female. Self Harm • Self-harm is poorly understood in society even among those who in their working lives as school teachers, pastors, social workers, housing officers, police, prison officers and even nurses and doctors encounter people who harm themselves. • People who harm themselves are subject to stigma and hostility. Self Harm - who is affected? • All ages and from all social and cultural backgrounds. • Some groups are especially vulnerable because of life experiences, personal or social circumstances, physical factors or a combination of these elements. • There is a higher incidence of self-harm among: ‐ ‐ ‐ ‐ ‐ prisoners, asylum seekers, veterans from the armed forces, People bereaved by suicide, some cultural minority groups and people from sexual minorities. Self Harm - Forms/Methods • Can take many forms. • The most common form of self–injury is: ‐ Cutting (with a variety of implements and degrees of severity). ‐ Cutting is more repetitive than other forms of self harm, and that it may not be as predominantly a female activity as is commonly thought (Lilley et al, 2008). • Other forms: ‐ ‐ ‐ ‐ ‐ ‐ ‐ Overdose/Self Poisoning Burning Hanging Strangulation Scratching Banging or hitting body parts, and Mutilation of parts of the body or interfering with wound healing Self Harm • Manifestation of emotional distress. • Indicates something is wrong rather than a primary disorder. • Person’s contributory circumstances are individual. Commonly includes: ‐ ‐ ‐ ‐ ‐ Difficult personal circumstances Death or other trauma in the family Past trauma (including abuse, neglect or loss) Social or economic deprivation Mental disorder. Self Harm • May often be associated with the misuse of drugs or alcohol. • Rate of self-harm; more in women and girls than men and boys • Completed suicide is more prevalent among men and boys. Self Poisoning • Self-poisoning is the intentional use of: ‐ More than prescribed or recommended doses of any drug sometimes labelled ‘indirect selfharm’ ‐ Includes poisoning by non-ingestible substances ‐ Overdoses of recreational drugs and severe alcohol intoxication where this seems to be intended as an act of self-harm. ‐ People may switch methods of harming themselves over time. Self Harm - Other • Eating disorders • Physical risk-taking • Sexual risk-taking • Self-neglect • One could consider self-neglect as another form of self-harm • When people who repeatedly harm themselves through cutting or taking overdoses are helped to overcome these behaviours, eating disorders or other selfdamaging problems may emerge. Self Harm-Anxieties • Families and friends may be frustrated and distressed by the actions of the person who self-harms • Professionals can have similar responses. • When the person needs humane care and understanding they may also encounter hostility, disengagement or bewilderment. • More negative attitudes amongst some “non specialist “ services Motives chosen by young people to explain reason for self-injury ( Royal College Of Psychiatrists Report CR158) Motive Self-cutting, % (n/N) Self-poisoning, % (n/N) Escape from a terrible state of mind 73.3 (140/191) 72.6 (53/73) Punishment 45.0 (85/189) 38.5 (25/65) Death 40.2 (74/184) 66.7 (50/75) Demonstration of desperation 37.6 (71/189) 43.9 (29/66) Wanted to find out if someone loved them 27.8 (52/188) 41.2 (28/66) Attention seeking 21.7 (39/180) 28.8 (19/66) Wanted to frighten someone 18.6 (35/188) 24.6 (16/65) Wanted to get back at someone 12.5 (23/184) 17.2 (11/64) Self Harm-Assessment • Requires a bio-psycho-social approach to assess: ‐ Their problems ‐ Their needs ‐ The risks of further harm to this individual ‐ To provides a person-centre management plan. Intervention Three basic steps: 1. Show you care 2. Ask about Self Harm/Suicide intentions or previous attempts. 3. Offer/Get/Encourage to get help Psychological Therapies • Engaging service users in assessing appropriate interventions & Evidence-based therapies: • Problem-solving therapy • Cognitive Behavioural therapy (CBT) • Dialectical Behaviour Therapy (DBT) • It is important that psychiatrists and other mental health professionals do not restrict their thinking about prevention and intervention to those things that can be done in the clinic, but engage with and in the local community in addressing self-harm and suicide. RCPSYCH CR58 Acknowledgements • Living Is For Everyone. Fact sheet 6: Resilience, vulnerability, and suicide prevention. www.livingisforeveryone.com • International Association on Suicide Preventionwww.iasp.info • Clayton, J. Suicide Prevention: Saving Lives One Community at a Time. American Foundation for Suicide Prevention. www.afsp.org • Self-harm, suicide and risk: helping people who selfharm, Final report of a working group College Report CR158 June 2010, Royal College of Psychiatrists London • Dr Leon Rozewicz, Clinical Director, Crisis & Emergency Services, BEH MHT NHS Trust.