Intervention saves lives
The link between self-harm and suicide means hospitals have an important role to play in prevention. My column from the Medical Independent on 26 September 2013. Minister of State with Responsibility for Mental Health Ms Kathleen Lynch and the new HSE National Director for Mental Health, Mr Stephen Mulvany launched the new political term with three significant publications on suicide prevention on 5 September. Two new research publications from the National Suicide Research Foundation (NSRF) provide some grounds for optimism.
Ireland has led the world by being the first country to have a deliberate self-harm register. This register collects detailed information on anyone who presents to a hospital emergency department (ED) who has self-harmed. Now 10 years old, a clear enough picture is emerging. In 2012, just there were just more than 12,000 presentations to EDs representing 9,483 individuals. A very small number of people are responsible for 8 per cent of those presenting to EDs as multiple repeated presentations. As repeated deliberate self-harm (DSH) is a strong predictor of death by suicide, responding to DSH is a crucial area for prevention and intervention work.
The numbers of deliberate self harm presentations have fallen slightly year on year since 2010. However, figures for 2012 are 12 per cent higher than pre-economic crisis numbers in 2007. What we are seeing is a small decline and levelling out, but figures are still way too high and higher than five years ago. While 80 per cent of deaths by suicide are male, females have always made up a greater proportion of people who deliberately selfharm.
However, the latest years of the register show increasing numbers of men who have deliberately self-harmed. In all cases, two-thirds of those presenting had overdosed, 38 per cent of cases involved alcohol, which is related to the timing of self-harm presentations with higher numbers around midnight, on Sundays, Mondays and bank holidays.
The research found significant variation in the care provided, with up to 20 per cent leaving hospital before receiving the recommended care in the North East. The South fared best with six per cent leaving without care. At the launch, Minister Lynch emphasised the importance of comprehensive assessment and treatment for people who present having self-harmed, but admitted that it was not currently guaranteed.
Dr Ian Daly, HSE Clinical Lead for Mental Health assured that such comprehensive and consistent assessment and care in EDs would be in place by year end. A report from the Suicide Support and Information System (SSIS) details the essential support for people bereaved by suicide and, crucially, the collection of much more detailed information on people who have died by suicide in the Cork region. By following up all coroners reports on suicides as well as some open verdicts, and talking to families bereaved, as well as GPs and health professionals, a wealth of information has been collected.
The 307 cases reflect national suicide figures, 80 per cent of deaths by suicide being male. Just 40 per cent of those who died by suicide were in employment; 33 per cent were unemployed. Forty per cent had worked in construction, 13 per cent in agriculture, 9 per cent in sales/business and 6 per cent in healthcare. This demonstrates a strong link between the economic crisis and suicide. The SSIS also found that over two-thirds of those who had died by suicide had a known history of self-harm. Alcohol was involved in 60 per cent of deaths, 40 per cent of them had a psychiatric diagnosis, the majority of whom experienced depression. These research reports quite clearly show the varied and complex factors influencing people who selfharm and die by suicide. Whether it is young men, older men, women, a psychiatric history, the use drugs and alcohol, employment versus unemployment, a history of self-harm, each requires a different type of intervention and care response.
Speaking on 5 September, Mr Gerry Raleigh, Director of the National Office of Suicide Prevention said that his office had sufficient funds (it underspent by €2 million from the the 2012 budget of €7 million). However, given that the mental health budget has been disproportionately cut in six austerity budgets, that adult community mental health teams are staffed at a fraction of what they are meant to be, that EDs are under-resourced to meet the needs of people in mental distress, the virtual absence of the mental health promotion and primary care services for those with mental health difficulties, this statement may come back to haunt him.
Figures of deaths by suicide and deliberate self-harm may be stabilising. Preventing both requires a cross society response, but given the critical link between self-harm and death by suicide, health services have a vital role to play. There is no room for complacency.