Suicide Prevention
Samaritans Cymru response
Samaritans is a registered charity aimed at providing emotional support to anyone in emotional distress. In Wales, Samaritans work locally and nationally to raise awareness of their service and reach out into local communities to support people who are struggling to cope. They seek to use their expertise and experience to improve policy and practice and are active contributors to the development and implementation of Wales Suicide and Self Harm Prevention Action Plan ‘Talk to Me 2’.
1. The extent of the problem of suicide in Wales and evidence for its causes
1.1 Globally, over 800,000 people die by suicide each year.[1] In the United Kingdom and Ireland, more than 6000 people take their own lives each year and in Wales, between 300 and 350 people die by suicide each year. This is about 3 times the number killed in road accidents. In both England and Wales, suicide is the most common cause of death for men aged 20-49. Of the 322 suicides in Wales in 2016, 265 (82%) of these were by men.[2]In 2015, the age groups with the highest suicide rate per 100,000 in Wales were: 30-34 years, for all persons and 30-34 years for males. In reviewing trends over time, there has been a general increase in male suicide in Wales over the last 30 years, with a specific trend of increase since around 2008. Female suicide in Wales has decreased over same period, however, in line with the male trend, there has been a period of general increase since 2008.[3]
1.2 Whilst there is no single reason why people take their own lives, there are a wide range of risk factors and subsequent high-risk groups who are more likely to experience suicidal feelings or completed suicide. These groups include; young and middle-aged men; people in contact with mental health services, people living in areas of socio-economic deprivation; people with a history of self-harm; people experiencing loneliness and isolation, people in contact with the criminal justice system, including prisoners; people with a history of alcohol and substance misuse, asylum seekers and refugees, the Gypsy, Roma and Traveller community, specific occupational groups, such as doctors, nurses, veterinary workers, farmers and agricultural workers; friends and family bereaved by suicide, and lesbian, gay, bisexual, transgender and questioning (LGBTQ).
1.3 There must be a concerted and targeted effort from both public and voluntary bodies to identify and reduce the risk of suicide in high-risk groups. Whilst we must maintain an overall population approach to suicide prevention in Wales, it is important that there is cross-governmental and cross-sectoral knowledge of the risk factors for such a prevalent public health problem.
2. The social and economic impact of suicide.
2.1 Every suicide is a tragedy which has a devastating effect on families, friends, colleagues and the wider community. For each of the deaths by suicide in Wales each year, it has been suggested that an average of 6 people are deeply affected and family and friends who have been bereaved by suicide are 1.7 times more likely to attempt suicide.[4] The average cost of a suicide in the general population has been estimated as £1.67m per completed suicide.[5] This includes intangible costs (loss of life to the individual and the pain and suffering of relatives), as well as lost output (both waged and unwaged), police time and funerals.
2.2 We must provide better information and support to those bereaved or affected by suicide. Waiting lists for bereavement support are a major barrier to follow-up care in Wales. Resources such as ‘Help is at Hand Cymru’ must be more widely disseminated. The stigma around death by suicide can be isolating for the friends and families left behind with survivors of suicide loss experiencing very distinctive bereavement issues surrounding guilt, shame and rejection. We must promote talking as a form of help seeking and early intervention to reduce the stigma of bereavement by suicide.
3. The effectiveness of the Welsh Government’s approach to suicide prevention
3.1 As members of the National Advisory Group to Welsh Government on Suicide and Self-harm, we have contributed to the development and implementation of Talk to Me 2. We welcome the 3 C’s approach outlined in Talk to Me 2 (Cross-governmental, cross-sectoral and collaborative in design and delivery) and the identification of priority care providers, priority places and priority people. In terms of progress, we believe implementation is still an issue. In the Public Health Wales Midpoint review of the implementation of Talk to Me (2012), it was noted that implementation was difficult due to the ‘difficulty in setting up Regional Groups and a lack of high level support in many health boards and local authorities’ We believe the existence of such plans is vital for efforts to reduce suicide and self harm in Wales but this action plan needs a clear framework for implementation; one which recognizes the importance of acting locally.
3.2 Many of the top-level objectives in Talk to Me 2 are reliant on effective local partnership working through a cross-collaborative approach. For example, one of the main objectives is to improve awareness, knowledge and understanding of suicide and self harm amongst individuals who frequently come in to contact with people at risk of suicide and self harm and professionals in Wales. This objective is facilitated by frontline training in suicide awareness for public services. However, to achieve this, it is vital that local services, agencies and organisations work in a joined up and collaborative way to effectively manage and target their resources.
3.3 The most effective means of achieving this local and collaborative approach, is the creation and implementation of local suicide prevention plans and ensuring the engagement of Local Health Boards and local authorities in Regional Multi-Agency Suicide Prevention Fora. Local suicide prevention plans are developed and implemented by multi-agency groups and are critical to implementing the national suicide prevention strategies published by Welsh Government.
3.4 We are aware that there is inconsistency surrounding local forums and regional fora in Wales. Whilst there are some groups which champion the strategy and engage in multi-agency working, there are local authority areas in Wales who are not sufficiently engaged. Without a local suicide prevention plan, suicide prevention work is much less effective than it could be.
Through our own collaborative working, there are examples of good practice from public services in reducing access to the means of suicide. We provide a range of public services with Samaritans signs which they install in locations where they have identified a risk or have seen an increase in suicidal behaviour or suicide. We witness good partnership working between public services (such as Police and Fire and Rescue) but this does not necessarily mean they are linked up with local suicide prevention fora. This is for a range of reasons ranging from lack of awareness through to some groups being less focused on operational action.
Reducing Access to Means
3.5There is evidence to suggest that lives can be saved by the use of a variety of measures including: the installation of Samaritans signs; physical barriers; nets and telephone lines at high risk locations for suicide; and improved surveillance, such as CCTV, at possible, or known, high risk locations.[6] High risk locations could include: bridges, viaducts, high-rise buildings, multi-story car parks, cliffs and level crossings. Some services we work with identify the benefits of a preventative approach to reducing access to means at locations which are either known to be high-risk or have the potential to become so. In terms of fulfilling this trajectory, the main barrier is often budget and a lack of shared understanding throughout the sector. Whilst we work with many champions for mental health and suicide prevention, the placement of signs in particular can be a lengthy procedure in terms of budget and approval.
Suicide Prevention Training
3.6Alongside this, suicide prevention training should form a major part of local suicide prevention.There needs to be greater awareness surrounding the benefits of a preventative approach to suicide, including training of this kind. Training should be provided to frontline workers both in the public sector but also key frontline sectors who are more likely to meet vulnerable groups. Increased awareness of specialist training provided by organisations, including Samaritans and Mind, should also be highlighted. Suicide Prevention Training is particularly important for those identified as ‘Priority Care Providers’ in Talk to Me 2, such as Job Centre Staff, Emergency Health Staff and teachers.
3.7A good example of the benefits of suicide prevention training for workplaces and public services is our work with the rail industry in Wales. In 2010, Samaritans began working with Network Rail with the aim of preventing rail suicides and supporting those affected by them. The Rail Industry Suicide Prevention Programme (RISPP) is now a joint partnership between Samaritans, Network Rail and British Transport Police and the wider rail industry.
In Wales, our partnership with Network Rail and work with the wider rail industry focusses on seven key areas: Suicide prevention training, engaging the rail industry in suicide prevention and support activities, reaching out to those most at risk, supporting people affected by a traumatic incident, support at stations following a suicide, working with the media to encourage responsible reporting of rail suicides and working with police and health services. In Wales, the Network Rail suicide prevention team have developed a 12-point plan to push forward the agenda of suicide prevention. Its inclusion in the Wales Route joint suicide prevention plan, as well as adopting recommendations from Talk to me 2, ensures that they are making a difference for Wales and the Route. 1,400 frontline Arriva trains staff members in Wales have now completed a basic level of suicide prevention training, allowing them to act as a preventative force alongside their training for post-incident action.
4. Mental Health Services
4.1 1 in 3 people who die by suicide have been in contact with mental health services in the year before their death.[7] We believe that swift and timely access to psychological therapies can enable and improve recovery, and act as a form of early intervention which can reduce the need for secondary services. Despite the cross-party support and focus on access to psychological therapies in the Together for Children and Young People Programme (T4CYP), Together for Mental Health and the Mental Health (Wales) Measure, access to psychological therapies is still a problematic issue in Wales.
4.2 People’s mental health can deteriorate significantly during lengthy waiting times for psychological therapies, which can lead to suicidal feelings or suicide. As members of the Wales Alliance for Mental Health, we believe that an introduction of waiting time measures for psychological therapies across primary and secondary care is crucial. This data should be recorded and published to reduce waiting time
Post-hospital support
4.3 It is also crucial that health boards in Wales collect and publish data for post-hospital support for patients following admissions for self-harm or a mental health crisis. As of April 2017, there is only one health board in Wales that records how many people get timely follow up contact after they’ve been discharged. The lack of data for post-hospital support in Wales is a major concern. A survey of over 850 people with mental health problems about their experiences after leaving hospital in Wales showed those who weren’t followed up appropriately (after seven days or not at all) were twice as likely to attempt suicide and a third more likely to harm themselves compared to respondents who said they were followed up within seven days of being discharged.[8]
4.4 Research by the NSPCC found that 1,193 young people were admitted to A&E departments in Wales because of self-harm in 2015. That number has increased by 41 per cent in the past three years.[9]National suicide prevention strategies recognise that Accident & Emergency services have an important role in treating people who have self-harmed or have made a suicide attempt. At least half of people who die by suicide have a history of self-harm and one in four have attended hospital for self-harm in the preceding year.[10]Given the particularly high suicide risk of people who attend hospital and A&E after harming themselves it is essential that rapid follow-up care is always available. It’s essential that anyone having self-harmed is treated with respect, given a proper assessment and follow-up care.
Improvements to the accuracy and availability of suicide data.
4.5 We welcome some recent improvements to the availability of suicide data from agencies in the UK such as Office for National Statistics (ONS). Suicide data is now available more quickly and in more useful formats. However, there are still many challenges with suicide data across the UK and Republic of Ireland, which will hinder our understanding of suicide unless they are addressed.
4.6Ascertaining and recording numbers of attempted and completed suicides, and monitoring them, is an integral component in the development of suicide prevention. Local suicide audits are an effective way for public sector bodies to identify and respond to high risk groups in their areas, as well as reveal sites of concern. It is best practice for public sector organisations, including Health Boards, Local Authorities and the coroner, work to develop and undertake a suicide audit. Learning lessons from the response to a suicide to reduce the number of future suicides and better support bereaved families.
5. Innovative approaches to suicide prevention
Education – Investment in Prevention and Early Intervention
5.1 Many aspects of modern society impact negatively on the mental health and wellbeing of children and young people. The specialist Child and Adolescent Mental Health Services in Wales (CAMHS) is under more pressure than ever before. The last 4 years has seen a 100% increase in demand.[11]
5.2 We must embed a public health approach to mental health and suicide prevention by placing a primary focus on prevention rather than cure alone. Investment in prevention and early intervention can reduce human, social and economic costs. Emotional health programmes in schools should be viewed as a form of promotion, prevention and early intervention which could reduce pressure on CAMHS, reduce specific mental health problems and increase academic achievement.
5.3 To successfully implement and fulfil the potential of the new curriculum, we must provide emotional and mental health awareness training to teaching staff across all schools in Wales to increase confidence in teaching the subject. We must increase confidence in new teaching staff and ensure basic mental health literacy by embedding emotional and mental health awareness in Initial Teacher Training (ITT) and make sure the potential of the ‘Health and Wellbeing’ area of learning is fulfilled; The inclusion of emotional health and wellbeing on the curriculumshould be mandatory and not optional.
5.4 We have recently welcomed the announcement of a two-year Welsh Government trial which will allow pupils with mental health problems at more than 200 schools in Wales to access early help from onsite CAMHS practitioners. Whilst this kind of linking up between education and health services is essential, we would like to emphasise that our call for action continues to be placed further downstream and in the primary context of early intervention through building resilience; a skill that can mitigate suicide in the future. It is vital that we realise the potential of the new curriculum.
The Power of Community
5.5 Loneliness and isolation increases the likelihood of suicide and social connection is therefore a protective factor for suicide risk. One intervention which addresses loneliness and isolation is community and outreach group participation. In terms of achieving the protective factor of social connection, the theme or nature of community and outreach groups can be extensive and wide-ranging.
5.6 Organisations such as Men’s Sheds Cymru, which cite ‘social exclusion as a hidden but persistent problem in many communities’, aim to address the problem by creating community groups for men to pursue their interests, develop new ones, belong to a unique group, feel useful, fulfilled and a sense of belonging. Men’s Sheds is now established and growing in the United Kingdom but these type of organisations are supported and funded by the Third Sector and their sustainability needs to be safeguarded to protect those who are most vulnerable.
“It gives me a reason to get up in the morning and for two days a week I feel I’m gainfully employed. I feel good working with and helping chaps who often feel isolated in the community. I would need a very good reason not to come.” Bill, 67
5.7 It is vital that these types of community or social outreach groups are recognised for their health benefits; social connectedness tackles loneliness and isolation, and can work to reach those who are at the highest risk of being socially excluded and suicidal. This is particularly significant within the current Wales context, following the closure of Communities First and with the lack of a central strategy. Community groups should be given more focus as a form of prevention and early intervention for loneliness and isolation in Wales and policy solutions should be worked up to increase community participation.
Minimising the risk of the internet
5.8 The internet is often used by people who self-harm and/or attempt suicide to explore possible methods and read others’ personal accounts of suicidal feelings and behaviour. In a population survey of 21 year olds, of the 248 participants who had made suicide attempts (6% of the overall sample), almost three quarters reported suicide-related internet use at some point in their lives. One in five had accessed sites giving information on how to hurt or kill yourself, though most of these had also visited help-sites.[12]
5.9 This research which was undertaken by Samaritans and University of Bristol identified the internet may pose a particular threat to young people. A policy report launched in 2016 set out a range of implications and recommendations for the industry and providers of online help, both of which we believe should be circulated appropriately.
[1] World Health Organization (WHO). (2014). Preventing suicide: A global imperative. Retrieved from: http://www.who.int/mental_health/suicide-prevention/world_report_2014/en/
[2] ONS. (2016). Suicides in the United Kingdom, 2015 registrations. United Kingdom: Office for National Statistics
[3] Scowcroft, E. (2016). Suicide statistics report 2016: Including data for 2012-2014. Surrey: Samaritans.
[4] Pitman, A. L., Osborn, D. P., Rantell, K., & King, M. B. (2016). Bereavement by suicide as a risk factor for suicide attempt: A cross-sectional national UK-wide study of 3432 young bereaved adults.
[5]McDaid, D., Park, A., & Bonin, E. (2011). Population level suicide awareness training and intervention. In M. Knapp, D. McDaid & M. Parsonage (Eds.), Mental Health Promotion and Prevention: The Economic Case (26-28). London: Department of Health.
[7] National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). (2016). Making mental health care safer: Annual report and 20-year review. University of Manchester.
[8] Thousands left to cope alone after leaving mental health hospital - putting their lives at risk Mind Cymru (April 2017)
[10] How local authorities can prevent suicide, Samaritans (2017)
[11]National Assembly for Wales, Children, Young People and Education Committee. (2014). Inquiry into Child and Adolescent Mental Health Services (CAMHS)
[12] University of Bristol / Samaritans Policy Report (7/2016) Priorities for suicide prevention: balancing the risks and opportunities of internet use