British Psychological Society response to the National Assembly for Wales Health Committee
Suicide Prevention
About the Society
The British Psychological Society, incorporated by Royal Charter, is the learned and professional body for psychologists in the United Kingdom. We are a registered charity with a total membership of just over 50,000.
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About this Response
The response was jointly led on behalf of the Society by:
Nigel Atter, British Psychological Society Policy Advisor
We hope you find our comments useful.
Alison Clarke Chair, BPS Professional Practice Board |
Dr Paul Hutchings CPsychol AFBPsS Chair, Welsh Branch |
British Psychological Society response to the National Assembly for Wales Health Committee
Suicide Prevention
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The extent of the problem of suicide in Wales and evidence for its causes - including numbers of people dying by suicide, trends and patterns in the incidence of suicide; vulnerability of particular groups; risk factors influencing suicidal behaviour.
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Comments:
Numbers of People Dying / Trends and Patterns Statistical data on the number of people dying by suicide is found in the Office of National Statistics, Suicides in Great Britain: 2016 registrations. For example,
‘The rate in Wales has fallen from 13.0 in 2015 to 11.8 per 100,000 people in 2016. The suicide rate in Wales is generally more erratic than in England, due mainly to having a smaller population, making any long- and short-term trends difficult to identify. Welsh males saw their lowest rate in 2008 at 15.1 and their highest in 2013 at 24.3 suicides per 100,000 males. Similarly to females in England, a large improvement was seen during the 1980s but there has been little change since’. (ONS, 2016 registrations).
Vulnerable groupsBruffaerts et al. (2011) found that roughly 60% of people with suicidal thoughts and behaviour do not receive treatment. For those who do, there are very few evidence-based treatments (such as prevention programmes, pharmacological interventions and psychological treatments) that are available. Thus it is important that there are tailored services to target specific groups, including: men, pregnant women and new mothers, people in the criminal justice system, children and young people, LGBT, people leaving the care of mental health services, and people who self-harm. Another challenge is that despite 75% of the world’s suicides occurring in low and middle income countries (Vijayakumar & Phillips, 2016), the vast majority of research and evidence is gathered in high income countries.
Self-harmSome recent encouraging evidence suggests that a very brief intervention based on implementation intentions (a volitional help sheet) may reduce repeated self-harm in patients admitted to hospital via emergency departments) (O’Connor et al 2017), however this was only helpful for those with a history of repeated self-harm. Results suggested that the help sheet might actually increase self-harm in those who had not previously been hospitalised for self-harm (i.e., it was their first ever hospital-treated episode), though this increase was not statistically significant. These findings now require replication.
The Psychological Risk and Protective FactorsIn addition to the established role of psychiatric disorders/mental health conditions in suicide risk (Turecki & Brent, 2015; Hawton, Saunders & O’Connor, 2012), personality and individual differences, cognitive factors, social factors and negative life events are all associated with suicide risk. The key psychological risk/protective factors for suicidal ideation and suicidal behaviour are indicated in the table below and the evidence for these factors is summarised in O’Connor & Nock, 2014.
In recent decades a number of theoretical models have been developed to describe the pathways to suicide (Joiner, 2005; Johnson et al., 2008; O’Connor, 2011; Klonsky & May, 2014). A commonalty across most of these models is that they are grounded within the ideation to action framework (Klonsky, 2014), namely that the factors leading to suicidal thinking are distinct from those that govern the transition from thinking about suicide to attempting suicide (O’Connor, 2011; O’Connor & Nock, 2014). One of these models, the integrated motivational-volitional (IMV) model of suicidal behaviour (IMV; O’Connor, 2011), maps the final common pathway to suicidal behaviour. In brief, the IMV model suggests that suicidal ideation emerges from feelings of defeat or humiliation from where there is no escape (O’Connor, 2011; O’Connor et al., 2013). Whether someone acts on their thoughts of suicide is governed by a range of factors, labelled volitional moderators (e.g., impulsivity, exposure to suicide, acquired capability, planning, access to the means of suicide), the presence of which increases the likelihood that suicide attempts/death by suicide will occur. For example, if someone has thoughts of suicide and is impulsive or knows someone close to them who has died by suicide, they are more likely to act on their thoughts of suicide. Theories such as the IMV model are important not only to advance our understanding of suicide risk but also because they form the basis for intervention development. However, the complexity of suicide risk should not be under-estimated.
The complexity of suicide risk Biopsychosocial models attempt to integrate the understanding of biological, psychological and sociocultural factors associated with an increased risk of suicidal behaviour and death by suicide. They recognise that these behaviours cannot be understood from any one perspective alone. Instead suicidality is best explained as a complex interplay between risk factors across domains. As an illustration, consider the association between unemployment and suicide. Exposure to high rates of unemployment can affect an individual’s feelings of hopelessness or entrapment – to increase risk of suicidality. However, not everyone who is unemployed will feel suicidal. Risk factors are likely to interact with one another in complex ways to determine vulnerability. It is valuable to consider the contribution of biological, psychological and social factors at every point in the suicidal process. Psychological processes can be described as the biological and social factors which act to increase the risk that a person will end their life. However, even at this point, environmental factors such as the availability of means of suicide, and psychological factors, such as an individual’s propensity to select between these means, will influence the likelihood of death. Thus understanding the complex interplay between the various biological, psychological and social risk factors that contribute to risk of suicidality is critical to the development of comprehensive and effective suicide prevention and treatment approaches.
Risk assessment Although risk factors that increase the propensity to engage in suicidal behaviour have been identified, suicide remains a rare event and most risk factors have little positive predictive value in determining likelihood of eventual death by suicide (Turecki & Brent, 2015; Hawton, Saunders & O’Connor, 2012; Franklin et al., 2017). Likewise, as reviewed by Bolton, Gunnell & Turecki (2015) although a number of risk assessment scales for suicide exist none to date provide enough robust evidence to justify their routine use in clinical settings and the vast majority are limited by their reliance on patient self-report (Quinlivan et al., 2017; Chan et al., 2016). Novel, evidence based, methods of suicide risk assessment are being developed, but these are still at an early stage. The National Institute for Health and Care Excellence supports the importance of conducting an assessment of patient risk and needs, but does not support the use of specific risk assessment tools (https://www.nice.org.uk/donotdo/do-not-use-risk-assessment-tools-and-scales-to-predict-future-suicide-or-repetition-of-selfharm). All individuals who present to hospital following self-harm should receive a caring assessment, which takes into account individual, social, and behavioural influences. Such an assessment should address an individual’s clinical history and current condition, their previous suicidal behaviour as well as their current suicidal thoughts and plans. It should also address their social context, help them to keep themselves safe when in crisis and support them in obtaining ongoing clinical treatment, as required. A compassionate psychosocial assessment plays an important role in establishing a positive therapeutic relationship between a clinician and patient in distress. It is important to ask about suicide in a direct but sensitive manner. Although clinicians can be concerned about exploring suicidal thoughts, there is no evidence to suggest that talking about suicidal thoughts and plans increases risk of suicidal ideation or self-harm, and some evidence that it is beneficial for those at higher risk (Dazzi et al., 2014).
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The social and economic impact of suicide.
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2. |
Comments:
Postvention: Providing support after suicideThere has been increased recognition of the importance of supporting vulnerable populations, such as bereaved families and friends, following suicides (WHO, 2014). The research demonstrates that people who are exposed to suicide deaths are at increased risk of complicated grief, traumatic grief and PTSD (Melhelm et al., 2004). Furthermore, the relatives and friends of the deceased may be particularly vulnerable to suicidal thoughts and behaviour (Joiner, 2005). Psychologists have a key role in providing support and interventions to those affected by the death and psychological models may be applied to understand how individuals manage grief and adjustment following a death by suicide.
There is emerging evidence supporting beneficial effects of a number of interventions, including counselling postvention for survivors and outreach at the scene of suicide (Szumilas & Kutcher, 2011). In addition, evidence-based guidelines for responding to suicide in a secondary school setting have been published recently (Cox et al, 2016). However, further research is required into the effectiveness of postvention services and interventions on reducing suicide and attempted suicide/self-harm.
Suicide deaths
are often incredibly traumatic, the method of death is frequently
violent and survivors are often plagued with the
“re-experiencing” symptoms of trauma, such as
flashbacks, nightmares and intrusive thoughts. These can occur even
if the survivor did not witness the death scene. Re-experiencing,
when accompanied with avoidance and hypervigilance symptoms, is
characteristic of PTSD, and therefore counsellors need to be
equipped to recognise and manage these symptoms or refer the person
for trauma-focused cognitive therapy or another recognised PTSD
treatment (NICE, 2005).
Organisational Postvention
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The effectiveness of the Welsh Government’s approach to suicide prevention - including the suicide prevention strategy Talk to me 2 and its impact at the local, regional and national levels; the effectiveness of multi-agency approaches to suicide prevention; public awareness campaigns; reducing access to the means of suicide.
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Comments:
The Society has no comment to make.
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The contribution of the range of public services to suicide prevention, and mental health services in particular.
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Comments:
Public Information Campaigns There is emerging evidence for increasing awareness via public information campaigns to improve the care for people diagnosed with depression and simultaneously address awareness and skills in early identification of suicide risk among healthcare and community-based professionals (Szekely et al, 2013; Hegerl et al, 2013), with proven synergistic effects of simultaneously implementing evidence-based interventions (Harris et al, 2016).
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The contribution of local communities and civil society to suicide prevention.
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5. |
Comments:
Prevention“Early identification and effective management are key to ensuring that people receive the care they need.” (WHO, 2014 p.9) There are two important aspects to prevention: as noted above: (i) understanding the factors associated with suicidal thinking/ideation with a view to reducing distress and (ii) reducing the likelihood that an individual makes a suicide attempt or dies by suicide. It is important to understand the psychological processes underlying each aspect as interventions must be tailored to each; for example, intervention at the suicide ideation stage would be specifically targeted at preventing progression to suicidal attempt. National suicide prevention strategies tend to adopt a dual track approach of implementing large-scale public health interventions, such as restricting access to lethal means of suicide as well as intervening with those at high risk (see WHO, 2014). High risk groups may include those who have self-harmed in the past; they are important group to target given the established relationship between self-harm and future death by suicide.
Restricting access to meansRestricting access to means involves implementation of measures to reduce availability of and access to frequently used means of suicide, e.g. drugs, fire arms, enhancing safety of bridges etc. Internationally, there is consistent evidence that restricting access to lethal means is associated with a decrease in suicide and that substitution to other methods is limited (Zalsman et al, 2016).
Education
Responsible Media ReportingThe importance of responsible media reporting of suicide in print, broadcast, internet, and social media is underlined by Niederkrotenthaler et al. (2014). The role of mass media has been shown to be effective in reducing stigma and increasing help seeking behaviour. There are also indications of promising results based on multi-level suicide prevention programmes (Niederkrotenthaler et al., 2014). A systematic review covering 30 studies on social media sites for suicide prevention (Robinson et al, 2016) showed that social media platforms can reach large numbers of individuals and may allow others to intervene following expression of suicidal behaviour. However, reported challenges include lack of control over user behaviour, possibility of suicide contagion, limitations in accurately assessing suicide risk, and issues relating to privacy and confidentiality.
Intervention - How effective are psychosocial interventions?
Preventing
repeat self-harm is a crucial part of suicide prevention efforts
since, as noted earlier, many who die by suicide have previously
engaged in such behaviour (NCIS, 2016). The gold-standard method
for assessing the effectiveness of interventions is a randomised
controlled trial (RCT).
Under 18s
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Other relevant Welsh Government strategies and initiatives - for example Together for Mental Health, data collection, policies relating to community resilience and safety.
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Comments:
The Society has no comment to make.
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Innovative approaches to suicide prevention.
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Comments:
Electronic mental health interventionsElectronic mental health (e-mental health) interventions represent a promising means of increasing the capacity for patients’ self-management of depression (Arensman et al., 2015). Using the Internet to deliver treatment for affective disorders has been shown to be an effective option for reaching patients who were not able to receive face-to-face treatment due to geographical or other situational barriers (Vallury et al, 2015) or to augment face-to-face therapy (Hoifodt et al, 2013).
Electronic mental health interventions for mental health problems and mood disorders in particular have increased rapidly over the past decade. In recent years, an increasing number of e-mental health interventions have been delivered in the form of apps that are delivered via smartphones (Dogan et al, 2017). Available research underlines the value of smartphone-based approaches for gathering long-term objective data to predict changes in clinical states. However, the current evidence base does not provide conclusive information on the effectiveness and the risks of these approaches. Methodological limitations in this area include small sample sizes, variations in the number of observations or monitoring duration, lack of RCTs, and heterogeneity of methods (Dogan et al, 2017).
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References
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