Survival plan

On average, somebody commits suicide every two hours in England.
The government’s Our Healthier Nation white
paper,¹ set a target of reducing the death rate from
suicide by at least a fifth by 2010. And last week, as part of the
plan to achieve this, the government published a suicide prevention
strategy for England (news, page 6, 19 September).² In
Scotland, the National Framework for the Reduction of Suicide and
Self-Harm is due to be published in November.

The English strategy forms part of the government’s plan
to improve mental health services and its implementation will be
led by the new National Institute for Mental Health in England,
based within the Department of Health. According to the government,
the strategy will not be a one-off document, “but an ongoing,
co-ordinated set of activities evolving over several years”.

The strategy comprises six goals:

• To reduce risk in key high-risk groups.
• To promote mental well-being in the wider population.
• To reduce the availability and lethality of suicide
  methods.
• To improve the reporting of suicidal behaviour in the
  media.
• To promote research on suicide and suicide prevention.
• To improve monitoring of progress towards the target for
  reducing suicide.

A welcome addition to the strategy is the inclusion of less well
known groups of people at risk of suicide, such as those

from ethnic minorities, particularly Asian women. Other groups
that professionals wish to see attention switched to include gay
men and lesbians, women who experience domestic abuse and
unemployed young men.

However, evidence shows that the most common risk factors for
suicide are being male, living alone, unemployment, alcohol or drug
misuse, and mental illness. Suicide is the main cause of premature
death in people with mental illness. About 1,200 people in contact
or recently in contact with mental health services commit suicide
each year.

Action is already under way to cut this figure. Under the
National Service Framework for Mental Health, local mental health
services must have a suicide audit system. The NHS Plan introduced
new clinical teams providing assertive outreach, early intervention
and crisis resolution. And local mental health services are
developing written care plans for people on enhanced care programme
approach to address their employment, housing and benefits
needs.

Action that local mental health services are expected to
implement in the future are set out in a 12-point checklist in the
strategy, which includes:

• Staff training in risk management every three years.
• All patients with severe mental illness and a history of
  self-harm or violence to receive the most intensive level of care
  under the care programme approach.
• Individual care plans to specify action to be taken if a
  patient is non-compliant or fails to attend.
• Assertive outreach teams to prevent loss of contact with
  vulnerable and high-risk patients.
• Local strategies for dual diagnosis covering training on the
  management of substance misuse, joint working with substance misuse
  services and staff with specific responsibility to develop the
  local service.
• Follow-up within seven days of discharge from hospital for
  everyone with severe mental illness or a history of self-harm in
  the previous three months.

Although the emphasis on risk assessment training for staff is
welcomed by Alison Cobb, policy officer at mental health charity
Mind, she is concerned that it may take the attention too far away
from identifying the underlying causes and gaining access to
services. “It’s good if staff have better tools and knowledge
in risk assessment, but it’s not just about that, but turning
that focus onto appropriate support so they can develop support
networks, as well as responding where there has been an actual
suicide risk identified.”

A mentally ill person’s darkest hour can be when they have
been discharged from hospital. It is a huge step to go from 24-hour
care to being at home, says Cobb. She is concerned that the
checklist advocates follow-up contact within seven days of
discharge, and says that it should be within the first couple of
days as that is the most vulnerable time.

“It shows that there will be a continuity of support and that
people are interested and concerned,” she says.

For this to happen, front-line staff need to be well supported
so they do not feel isolated in making decisions or that they do
not have the resources to make time to spend with people after they
have been discharged from hospital. “It’s not something that
front-line staff should be carrying on their own, it’s
important that there’s attention and action at all levels,
not just the front line,” says Cobb.

The suicide prevention strategy is a step forward in helping
reduce the stigma of mental illness, says Graham Thornicroft,
professor of community psychiatry and head of the health service
research department at the Institute of Psychiatry. A major task
now is to develop a better understanding among the public of the
features of depression and how people can access help quickly when
they need it.

“Too often, social withdrawal may be seen as laziness, for
example among young people, and produce blame from family and
friends rather than understanding that can lead to assessment and
treatment,” Thornicroft says.

The lack of understanding by professionals and non-professionals
about the role alcohol plays in mental well-being is one of two
issues that are crucial in preventing suicide, says Eric Appleby,
director of Alcohol Concern and a member of the strategy’s
reference group.

The other is the problem around dual diagnosis, when people fall
between alcohol services and mental health services. “We need to
speed up the process of managing dual diagnosis. Progress in
finding the best way of managing this has been painfully slow. More
effort needs to be put into running pilots, disseminating what we
know and getting commissioners to commission the services to tackle
that.”

As a depressant, alcohol plays a major role in mental illness.
And depressed young men, for whom suicide is the most common cause
of death at about 1,300 a year, often drink more than others,
leading some to attempt suicide.

This is where voluntary organisations have a vital role to play
in the suicide prevention strategy, says Appleby. Voluntary rather
than statutory service providers are often the first port of call
for users and are often best placed to act before alcohol damages a
young person’s mental health.

And as many people with alcohol or mental health problems often
have a combination of issues, non-specialist voluntary
organisations such as the Citizens Advice Bureaux should also be on
the lookout for warning signs, says Appleby. “They will see people
at a low point. If they give the right messages and information
when they see these people, hopefully it can prevent things
spiralling out of control.”

So, will the strategy deliver? Much depends on how hard the
government pushes it. Meanwhile, Cobb sounds a note of caution.
Mind is concerned that the draft mental health bill will deter
people from seeking help from mental health services because of
fears around compulsory treatment. “We wouldn’t see the draft
mental health bill as a suicide prevention strategy,” she says.

In light of this, the government might find that two key
policies aimed at improving people’s well-being would be
cancelling each other out.

¹ Department of Health,
Saving Lives: Our Healthier Nation, The Stationery Office,
1999

² DoH, National Suicide
Prevention Strategy for England, DoH, 2002