fatal deliberate self-harm (suicide, completed suicide)

and

non-fatal deliberate self-harm (DSH, parasuicide, attempted suicide)

are separate phenomena which overlap to some degree. Both medical and social factors are involved in their aetiology, prevention and management.

SUICIDE can be dined as an act of self-harm, undertaken with conscious self-destructive intent, with a fatal outcome.

Frequency There are between 4000 and 5000 suicides in England and Wales per year; about 10 per 100 000 population, and around 1% of all deaths. Official statistics have tended to underestimate the true rate because only cases with proven evidence of intent, such as a suicide note, were given suicide verdicts by the coroner. Some deaths given ìaccidentî or ìundeterminedî verdicts in the past were probably suicides. However, coroners may have become more ready to give suicide verdicts in recent years when the evidence points in that direction.

Methods Methods which are most easily available are most likely to be used, and media publicity about a suicide is often followed by other deaths using the same method. Methods can be thought of as violent (for example hanging or jumping) and non-violent (drugs and other forms of poison). Males and mentally disordered persons tend towards violent methods, females towards non-violent.

Hanging/strangling/suffocation and gassing by car exhaust fumes (carbon monoxide) are now the most common methods taken overall, although poisoning (often by medicinal drugs) remains the commonest method in women. Other methods include drowning, shooting, cutting, jumping and burning.

Epidemiology

• Temporal trend Numbers of suicides in the UK and some other countries have declined somewhat in recent years 1, partly due to the detoxifying of the household gas supply (natural rather than coal gas) and motor vehicle exhaust fumes (introduction of catalytic converters). Attempts have been made to relate this to contemporaneous increases in antidepressant prescribing rates 2, but this is impossible to prove.
• Age: the rate increases with age, but suicide in young men (age 15ñ24) has recently become more frequent.
• Sex: more than twice as common in men.
• Marital status: divorced people have the highest rates, followed by the widowed and single, and married the lowest.
• Social class: highest rates at both extremes of the social scale.
• Occupation: high-risk groups include doctors, vets, pharmacists and farmers.
• Residential circumstances: inner city areas with a mobile population have high rates. Psychiatric inpatients, those recently discharged from such hospitals, and prisoners are all at high risk.
• Nationality: there are large differences between the suicide rates of different countries. These are partly real, due for example to religious and cultural variation, but some apparent differences result from differing methods of ascertainment. High rates are found in Greenland, Hungary, Austria, Denmark, Japan, Germany and Eastern Europe. Low rates are found in Eire, Italy, Spain, Greece and the Netherlands.
• National circumstances: suicide rates fall in wartime. High suicide rates are found in association with economic depression, unemployment, and high divorce rates.

Causes

• Psychiatric disorder: present immediately before death in up to 90% of cases, as indicated by the ìpsychological autopsyî technique of interviewing those who knew the dead person. Depressive illness, often inadequately treated, is the commonest diagnosis, especially in older people. Alcohol and drug misuse are also common, especially in the young. Personality disorder often co-exists. ìRationalî suicide, by mentally normal people in hopeless situations, is rare in Western societies.

• Stressful circumstances, including life events such as bereavement, and long-term social difficulties such as unemployment.

• Social isolation, in those who live alone and/or lack confiding relationships.

• Physical illness: raised suicide rates are found in association with certain physical conditions, including epilepsy, other neurological disorders, peptic ulcer, renal failure on dialysis, and AIDS.

• Neurochemistry: deficiency of 5-HT has been linked to suicidal behaviour in some studies.

The French sociologist Emile Durkheim, whose influential book Le Suicide was published in 1894, distinguished three types: ìanomicî related to a disorganized society, ìegoisticî among people isolated from their social group, and ìaltruisticî for the benefit of others.

More recent research suggests that the psychological state of hopelessness is a key precursor of suicide.

Prevention Some preventive strategies aim to improve the management of individuals at high risk, others to reduce factors associated with suicidality in society as a whole. Reduction of suicide rates, both for the general population and for psychiatric patients, is among the targets in the governmentís ìHealth of the Nationî strategy.

A recent systematic review 3 indicates that ìphysician education in depression recognition and treatment and restricting access to lethal methods reduce suicide rates.î However, it is important to remember that not only depression but all mental disorders (apart possibly from learning disability and dementia) carry an increased risk of suicide 4.

• Medical care of the mentally ill: many suicides have been in contact with GPs or psychiatrists shortly before death, raising the possibility that better medical management might have prevented the fatal act. Psychiatric patients who have voiced suicidal thoughts, have a past history of suicide attempts, or possess the sociodemographic factors listed above should be considered at high risk.

• Counselling services, such as the confidential telephone helplines for despairing and suicidal people run by the Samaritan organisation.

• Restricting availability of methods, such as catalytic converters for cars; controls on sales and possession of medicines, guns and poisons. Restricting the amount of analgesic, which can be bought without prescription, seems to have reduced suicide rates in the UK 5.

• physical considerations such as making psychiatric wards as safe as possible (for example by removing potential ligature points, from which a patient might hang himself) and preventing public access to bridges or clifftops from which others have jumped to their deaths.

• Educational programmes, for example to improve the recognition and management of potentially suicidal patients in general practice, or to dissuade young people from suicidal behaviour.

The Aftermath of Suicide: effects on those involved Bereavement counselling and practical help may be required in the immediate aftermath of the death, which will almost always be a very difficult time for relatives.

In the longer term, the relatives of those who died by suicide are at high risk of psychiatric illness and social problems and many take years to adjust, if ever they do, to a death which frequently seems like an act of aggression as well as of self-destruction. Others however ultimately find their lives made easier, for example if the dead person had been affected for many years by a severe and intractable personality disorder, mental illness or drug/alcohol misuse.

Sometimes, suicide can even seem to be an act with a violent aspect, perhaps directed towards those left behind. The family can sometimes seem almost to be ìvictimsî of suicide.

Suicide can also exact a toll on, for example, train drivers, who can expect occasionally to be in the unenviable position of applying the brakes as they sight a person on the tracks ahead, knowing that it is physically impossible to stop in time. They even have their own slang expression (ìone underî) for these events. Mental health problems and medicolegal considerations are frequent.

The professionals involved often react with distress and guilt, understandable but not always justified. A certain number of suicides are bound to occur in psychiatric practice, and it is not possible to predict exactly which individuals are going to kill themselves, or when. After a suicide has taken place, review of the case may well suggest some way that management could have been improved; this should be used as a constructive opportunity to improve future standards of practice in the unit concerned, rather than a collective ìguilt-tripî or, still worse, a search for a scapegoat.


The Aftermath of Suicide: Learning lessons Some suicides, for example those resulting from an acute severe depressive illness which could almost certainly have been cured, are major tragedies. In other cases, for example those associated with chronic intractable mental or physical illness, the argument for prevention may be less strong. However, recent proposals for legalizing ìmedically assistedî suicide have aroused much professional and public controversy, and are unlikely to be accepted in the foreseeable future.

The key initiative here is the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness 6, which is a continuing national survey. Between 1996ñ2000, there were 4859 cases of suicide in England and Wales who had been in recent contact with mental health services.

ì.. 1100 (23%) had been discharged from psychiatric in-patient care less than 3 months before death. Post-discharge suicide was most frequent in the first 2 weeks after leaving hospital; the highest number occurred on the first dayÖî

ì..Deaths of young patients were characterised by jumping from a height or in front of a vehicle, schizophrenia, personality disorder, unemployment and substance misuse. In older patients, drowning, depression, living alone, physical illness, recent bereavement and suicide pacts were more common.î 6.

Hence, there should be a documented risk assessment before discharge from inpatient care, and follow-up of those on the enhanced tier of the Care Programme Approach within 7 days. All this should be straightforward in patients with a clear-cut mental illness such as schizophrenia. There is more difficulty in deciding what is appropriate for other patients who have contact with mental health services, for example ìyoung people with personality disorder, unemployment and substance misuseî, none of which are readily treatable by medical means.

NON-FATAL DELIBERATE SELF-HARM (DSH, PARASUICIDE, ATTEMPTED SUICIDE)

Definition and terminology Non-fatal deliberate self-harm (DSH) is deliberate overdose or self-injury without a fatal outcome. Most such acts are not determined attempts at self-killing, and therefore the previous terms parasuicide and attempted suicide are less frequently employed. The term deliberate self-harm has become preferred, because it is neutral and gives a clear description.

Accidental injuries and acts intended to cause pleasure are excluded from the definition of DSH. Factitious disorder involves a form of self-injury, for example, self-injection with pus to produce fever. The intended outcome is to deceive health-care professionals into thinking that person is unwell, and therefore needs care. However in this case, the self-injury is clearly only a part of the picture and thus factitious disorder is regarded as separate from simple DSH.

Frequency Exact frequency is impossible to determine because milder cases may not be referred to hospital, or even present to health services at all. Community surveys indicate a lifetime prevalence of up to 5% for DSH.

A major epidemic occurred during the 1960s and 1970s, when self-poisoning became the commonest reason for a young person to be admitted to a medical ward. Rates have declined since that time, though still more than 140,000 people present with DSH to hospital in England and Wales each year 7.

Non-fatal deliberate self-harm is at least 10 times more common than completed suicide, though there is some evidence that rates of DSH and suicide move in tandem.

Methods About 90% are self-poisonings, often by painkillers bought without prescription such as paracetamol, and/or prescribed psychotropic drugs; they are often accompanied by alcohol. Others are by more violent methods, such as self-cutting, or burning, for example by cigarette ends.

Epidemiology

• Age: highest in the late teens and early twenties.
• Sex: twice as common in women.
• Social conditions: highest rates are in social classes IV and V, and in inner city areas with a high incidence of social problems.

Motives Up to 10% of episodes of DSH are serious suicide attempts, which failed. In other cases the reported motivation is to escape from an intolerable situation or state of mind, an appeal for help, or an attempt to influence another person. Some patients cannot explain their motivation.

Motivation is frequently multiple, mixed and complex and changeable. Patients often say that they wanted to die when they did the act, but that this co-existed with other motives and feelings, such as need to get out of an impossible situation.

Causes

• Life events and social difficulties: about 70% of acts follow a distressing event, usually involving disharmony with another person. Long-term social problems, for example family or economic difficulties, are common.

• Psychiatric disorder: It is clear that there is a high prevalence of mental disorder amongst DSH patients, but it is difficult to generalize. All types of mental disorder are seen, including psychosis occasionally. Symptoms of low mood are common (over 50% of cases), but most do not have a pervasive clinical depressive illness at follow up. Personality disorder and substance misuse are also common (perhaps 25% plus).

Assessment Before a valid psychosocial assessment can be carried out, the patient must have had time to recover from the immediate effects of the self-harm, for example drowsiness or confusion after an overdose. Three aspects require special attention:

• Whether there was serious suicidal intent, as indicated by:

• Whether psychiatric illness requiring treatment is present.

• Whether social problems are present.

It is not feasible, or necessary, for all cases to be assessed by a psychiatrist. Junior medical staff, nurses and social workers in the general hospital can be trained to identify those patients needing psychiatric referral. Standardised rating scales are available to aid the interview assessment.

Although many acts of DSH do not appear ìseriousî on assessment, patients who have done an act of DSH nevertheless have a continuing elevated suicide risk. Accordingly, assessment will particularly focus on risk factors for suicide, which include male sex, living alone, previous deliberate self-harm, the presence of chronic mental or physical disease and substance misuse.

Management Over 50% are judged to need psychiatric and/or social work follow-up as outpatients, but a high proportion fail to keep follow-up appointments. From 10 to 20% of cases are judged to need psychiatric hospital admission because of psychiatric illness and/or continuing suicidal intentions.

Acute dilemmas may arise in the general hospital when self-harm patients are brought in but refuse medical treatments such as stomach washout, or suture of lacerations. The Mental Health Act 1983 does not cover administration of medical treatment (as opposed to psychiatric treatment) against the patientís will, however in a life-threatening emergency it is permitted to give this under common law. The chosen course of action should be justified in the case-notes, and full explanations to patients and/or relatives given.

Repeated DSH is a frequent feature of borderline personality disorder; every hospital or community mental health team will have a small number of regular attenders with the presentation. Often, the behaviour can get worse, if the patient is repeatedly admitted to hospital. Sometimes, management by behavioural means is appropriate; for example, the patient can agree a written contract that if they self harm, they will be admitted to the hospital overnight and discharged the next day.

Prognosis About 20% repeat deliberate self-harm in the subsequent year, and around 1% die by suicide in the subsequent year (nearly a 100-fold increase over the general population suicide rate). Up to 10% die by suicide eventually.

Prevention Primary preventive strategies are similar to those described above for completed suicide.

Psychiatric treatment, social work and counselling have been evaluated for secondary prevention in people who have already carried out an attempt. Although these interventions do help to reduce psychosocial problems, they have not been shown to reduce the repetition rate for deliberate self-harm.