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Suicide and self-harm

Ireland’s rate of suicide has fallen in recent years. This is a very welcome development, especially following the period of economic turmoil that we experienced between 2008 and 2013.

Suicide is intentional self-killing and it features in every society for which there is recorded history. Self-harm is the intentional infliction of non-fatal harm on oneself and includes a wide variety of methods such as overdosing and self-cutting.

Globally, over 800,000 people die due to suicide every year and for every suicide there are many more people who engage in self-harm. In 2015, there were 11,189 presentations to hospitals in Ireland with non-fatal self-harm, according to the National Self-Harm Registry Ireland (www.nsrf.ie). This is the same as the rate in 2002, six years prior to Ireland’s economic recession. Two in every three episodes of self-harm involve taking an overdose; one in every three involves alcohol; and one-quarter involve self-cutting.

In 2015, 452 people died by suicide in Ireland, according to the National Office for Suicide Prevention (www.nosp.ie), a 19 per cent reduction since 2011, despite likely population growth. Consistent with previous years, the 2015 suicide rate in men (16.4 per 100,000 population per year) was substantially higher than that in women (3.2 per 100,000 population per year). However, Ireland’s overall suicide rate is relatively low by European standards, although it is well above average for younger adults.

Can self-harm and suicide be predicted? Key risk factors for non-fatal self-harm include female gender, younger age, poor social support, major life events, poverty, being unemployed, being divorced, mental illness and previous deliberate self-harm. Key risk factors for suicide include male gender, poor social support, major life events, chronic painful illness, family history of suicide, mental illness and previous deliberate self-harm. For both self-harm and suicide, availability of means is also significant (eg, easy availability of tablets to take overdoses).

Suicide is associated with major depression (long-term risk of suicide: 10-15 per cent), bipolar affective disorder (10-20 per cent), schizophrenia (10 per cent) and alcohol dependence syndrome (15 per cent). In addition, individuals who engage in self-harm have a 30-fold increased risk of completed suicide over the following four years.

Despite these associations, the majority of people with these risk factors will not die by suicide, because the increases in risk associated with these risk factors are small and, despite its tragedy and implications, suicide is (from a mathematical viewpoint) a statistically rare event, with fewer than 500 suicides per year in a population of 4.7 million. As a result, it is impossible to predict suicide at the level of the individual. This is true even for people who have thoughts of suicide, because the proportion of people with suicidal thoughts who go on to complete suicide is less than one-in-200.

So, if risk is impossible to predict accurately at individual level, what can be done to prevent suicide and to keep Ireland’s rate going down?

First, open discussion and exploration of risk factors are still very useful for guiding treatment and providing support to people who present with suicidal crises (although accurate prediction remains impossible). Relieving distress and promoting tolerance of difficult emotions are priorities.

Treatment of mental illness is vital and the College of Psychiatrists of Ireland emphasises that ‘effective treatment of depression is an important means of reducing suicide rates’. Good treatment of depression in primary care (by GPs and their teams) is essential, as is treatment of substance abuse, including alcohol. Other, more specific treatments for mental disorders might also help reduce suicidal behaviours for certain people: lithium for bipolar disorder, clozapine for schizophrenia and dialectical behaviour therapy for emotionally unstable personality disorder.

From a public health perspective, public education and measures to limit access to means of self-harm are very important and effective. Regulations governing paracetamol sales are an excellent example as they greatly reduce harm resulting from paracetamol overdose in Ireland and elsewhere. Placing barriers at known suicide locations (eg, certain bridges) is another very effective method for deterring self-harm and suicide. Research shows that a great number of people who are deterred or delayed in this fashion will re-consider their suicidal thoughts and very many will not proceed to find other means of self-harm.

In 2015, a new national suicide prevention strategy was launched, titled Connecting for Life: Ireland’s National Strategy to Reduce Suicide, 2015-2020. The strategy involves preventive and awareness-raising work with the population as a whole, supportive work with local communities, and targeted approaches for priority groups. The strategy proposes high-quality standards of practice across service delivery areas and – most importantly – an underpinning evaluation and research framework. In parallel, the budget for the National Office for Suicide Prevention increased from €3.7 million in 2010 to €11.5 million in 2016.

Approaches rooted outside of core mental health services will be vital in this process: Addressing alcohol problems and other addictions, reducing homelessness, reforming the criminal justice system and improving access to social care. Education in schools is also proven to be effective in reducing self-harm.

These are important issues that matter to everyone. Everyone knows a family affected by suicide. One-in-four people will develop a mental illness at some point in life. There is no ‘them’; there is only ‘us’.

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