Suicide rates, risks and prevention strategies

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Introduction
National initiatives on suicide prevention
England
Wales
Prediction of suicide risk
Representation of suicide by the media
Strategies to help
Suicide and mental distress
Risk
Care and services
Strategies to help
Suicide and substance misuse
Strategies to help
Suicide and deliberate self-harm
Strategies to help
Suicide and gender
Women
Men
Suicide in young people
Strategies to help
Suicide in older people
Strategies to help
Suicide, race and culture
Strategies to help
Suicide and sexuality
Strategies to help
Suicide in prisons
Strategies to help
Suicide in rural areas
Strategies to help
The effect of suicide on others
Support for those affected
Further reading
Useful contacts
References

Note: This factsheet is for professionals and students interested in the subject of suicide and suicide prevention strategies. Anyone concerned about a friend or relative who may be feeling suicidal should refer to Mind’s booklet, How to help someone who is suicidal. Anyone who is experiencing suicidal feelings should see How to cope with suicidal feelings, or, if in crisis, call Samaritans on 08457 90 90 90.

Introduction

The suicide rate in England and Wales has fallen in recent years and for the general population is now the lowest on record. [1] However, suicide is still the second most common cause of death in men aged 15–44 years, behind accidental death. There were a total of 4,336 suicides in England and Wales in 2005 (three-quarters of which were by men). [2] Thus, suicide continues to be a major public health issue, and particularly in those with mental distress. In light of this, the Government has established various strategies for reducing suicide rates, described in this factsheet.

The majority of people who die by suicide make contact with health professionals within a relatively short time before death. [3] For patients with mental ill health, relationships with health professionals appear to be particularly important; indeed, negative relationships have been cited as a key factor precipitating death by suicide (discussed in more detail below). Thus, health professionals can make a major contribution to reducing the number of deaths by suicide.

Further statistics relating to suicide can be found in Mind’s factsheet  Statistics 2: Suicide.

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National initiatives on suicide prevention

England
The 1992 White Paper The Health of the Nation [4]outlined the health strategy for England, and identified mental health as one of five key areas in which targets were set for improving people’s health. These targets included reducing the overall suicide rate by at least 15 per cent by 2000 and reducing suicides of people with severe mental illness by at least 33 per cent.

The 1999 White Paper Saving Lives: Our Healthier Nation [5] was an action plan to tackle poor health in general, and included a target to reduce the death rate from suicide and undetermined injury by at least 20 per cent by 2010. More specifically, this means that the aim is to reduce the annual rate of death from suicide from 9.2 deaths per 100,000 population in 1995–97 to 7.3 by 2009-11. The rate is currently about 8.5 deaths per 100,000. [6]

The Government has acknowledged that there is no single route to achieving these targets for reducing deaths by suicide, since the factors associated with suicide are many and varied. Factors include social circumstances, biological vulnerability, mental health problems, life events and access to means.

The National Suicide Prevention Strategy for England was published in 2002. [7] Elements of the strategy that relate to different groups of people are described below in relevant sections of this factsheet. Annual reports on progress are published by the National Institute for Mental Health in England (NIMHE). The target set in the National Suicide Prevention Strategy is still an important target for the Government and it is included in the National Standards, Local Action: Health and Social Care Standards and Planning Framework 2005/06–2007/08. [8]

Wales
The Welsh Assembly has not yet devised or implemented a national suicide prevention strategy for Wales. [9] However, the National Public Health Service for Wales has published a report on suicide prevention. It looks at:

• primary prevention, which includes:
  - mental health promotion and suicide prevention interventions
  - reducing access to means of suicide
• early identification, which includes:
  - screening for suicide risk
  - management of drug and alcohol misuse
  - management of mental illness
  - preventing suicides in prisons and police custody
• crisis intervention, which includes:
  - monitoring and assessment of self-harm
  - secondary prevention of self-harm
  - interventions to reduce suicidal ideation
• post-intervention, which includes:
  - reviewing completed suicides
  - managing impact on staff
  - supporting those bereaved by suicide
  - media portrayal of suicide.

The National Public Health Service for Wales’ proposed target is to reduce the suicide rate to 11.1 per 100,000 population by 2012. [10]  (The rate was 12.3 per 100,000 in 1995.)

The National Service Framework (NSF) for Mental Health in Wales has been developed following the publication of the Adult Mental Health Strategy for Wales. The standards outlined in the NSF are consistent with guidance from the National Institute for Health and Clinical Excellence (NICE).

Suicide prevention is a priority for services in Wales and will be addressed using relevant NICE guidance and the recommendations of the Safety First report. [11]

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Prediction of suicide risk

Key indicators that someone may be at risk of suicide include:

• recent bereavement or other loss
• recent break-up of a close relationship
• a major disappointment (such as failed exams or a missed job promotion)
• a major change in circumstances (such as retirement, redundancy or children leaving home)
• physical or mental illness
• substance misuse
• deliberate self-harm, particularly in women
• previous attempts
• loss of a close friend or relative by suicide.

People are at particular risk if they have made a previous suicide attempt, if there is a history of suicide in their family, or if they have begun tidying up their affairs (for example, by making a will or taking out insurance). Suicidal thoughts are a key element of depression, and people who have symptoms of depression are therefore at particular risk, especially if they express a sense of hopelessness about the future or see no point in life.

A history of past suicide attempts is the most accurate predictor of future risk attempts. [12] It has been estimated that 10–15 per cent of people in contact with healthcare services as a result of a first suicide attempt eventually die by suicide, [13] the risk being highest during the first year after an attempt.

Further information is given in Mind’s booklet, How to help someone who is suicidal.

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Representation of suicide by the media

One study showed that, following a storyline involving a drug overdose in the TV medical drama Casualty, presentations for self-poisoning increased by 17 per cent in the week after the broadcast and by 9 per cent in the second week. Thirty-two patients who presented in the week after broadcast and were interviewed had seen the episode. Of these, 20 per cent said it had influenced their decision to take an overdose, and 17 per cent said it had influenced their choice of drug. [14]

This study underlines the need for extreme caution in portraying suicidal behaviour on television, and in particular about giving details of the method used.

Strategies to help
Both Samaritans and the Mediawise Trust have developed guidelines for the media. Key points include:

• placing responsible articles on suicide prevention in the media
• reducing sensationalism and positive tone about suicide
• including facts about suicide
• avoiding reference to the means of suicide
• improving population awareness of the potential benefits of seeking help in times of crisis by promoting portrayal in the media of suicidal people seeking help and gaining benefit
• influencing the training of journalists to ensure that they report issues about mental illness and suicidal behaviour in an informed and sensitive manner.

The Department of Health’s ‘Mind Out for Mental Health’ campaign includes specific activities targeting suicide reduction:

• incorporating guidance on the representation of suicide into workshops held with students at journalism colleges
• discussion sessions between leaders in mental health and journalists
• a series of roadshows at which frontline journalists discuss responsible reporting
• a feature on suicide in media journals.

NIMHE and the Care Services Improvement Partnership (CSIP) liaise with media groups and voluntary and other organisations to promote guidelines on media reporting (see ‘Useful contacts’). Their Communications and Knowledge Services Team offers support for work on communications, anti-stigma and discrimination (called the Shift initiative). Information on how to report on suicide is available online at Shift’s website (www.shift.org.uk), which includes guidelines from various organisations around the world working with mental health issues. [15]

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Suicide and mental distress

Risk
Research indicates that virtually all mental illnesses and some medical disorders, for example heart disease, cancer, visual impairment and neurological disorders, are associated with an increased risk of suicide. [16], [17] Suicidal thoughts and actions – both past and present – increase the risk still further. Functional mental disorders such as schizophrenia and depression are associated with the highest risk overall; substance misuse and organic disorders are associated with a lesser degree of risk. [18] On average, people with recurrent depression have a 15–20 per cent increased risk of suicide; people living with schizophrenia have a 10–15 per cent increased risk. These figures may be underestimates however, as many who die by suicide may have been experiencing undiagnosed depressive illness.

Depression
The Mental Health Foundation estimates that 70 per cent of recorded suicides are by people experiencing depression, [19] often undiagnosed.

Depression is often accompanied by thoughts of suicide; indeed suicidal ideation is an important element in the diagnosis of depression. The deeper the depression, the more likely a person is to experience suicidal ideation. However, suicidal acts become more likely when a person is coming out of a depressive episode and energy levels and motivation become stronger.

Schizophrenia
A study by the World Health Organization (WHO) found that suicide was the leading cause of death in those with a diagnosis of schizophrenia. [20]

Although depression is generally recognised as a factor contributing to suicide in people with schizophrenia, research suggests that the seriousness of suicidal intent is related less to the degree of depression than with one particular aspect of depression – hopelessness about the future. [21] Among people with a diagnosis of schizophrenia, despite the occasional dramatic psychotic suicide, the greatest risk for suicide occurs during non-psychotic depressed phases of the illness. [22]

Care and services
The One in ten report published by the National Schizophrenia Fellowship (now Rethink) analysed 589 cases of suicide between 1991 and 1999, the majority of which occurred after individuals were allowed to leave the ward unsupervised. About a third of suicides by people with a mental illness diagnosis occur while they are still inpatients.

The Safety First report suggests that 40 per cent of suicides by people with mental health problems occur while they are psychiatric inpatients or shortly after discharge, and that a quarter of patients who die by suicide have been in contact with mental health services in the year before their death; 23 per cent of people who killed themselves did so within 3 months of being discharged from hospital. [23]

In its Safety First report, The National Confidential Inquiry reported that 17 per cent of suicides were preventable if better care and services had been available, and concluded that a significant proportion of suicides by people with mental health problems could be prevented. [24] Louis Appleby also identified negative staff–patient relationships as a key factor linked to suicide by psychiatric patients, particularly if they result in premature discharge. [25]

One study has shown that people with mental health problems continue to be at high risk of suicide for a considerable time after they appear well. [26] The study looked at a 30-month sample of people in the Greater Manchester area who had received an inquest verdict of suicide or an open verdict (149 cases). Those who took their own lives were more likely to have had their care reduced at their final appointment with a health worker because they were deemed to be improving or doing well. This included a reduction in supervision and a reduction in drug dosage (most of which were initiated by the patient). The study also found that only a third of those who died had an identifiable key worker – a key factor in the Care Programme Approach introduced in 1991 for vulnerable patients. The study concluded that people with mental health problems remain at high risk of suicide for some time after they appear well. The study suggests that care should not be reduced for up to a year after a person at high risk of suicide is thought to have improved, as this is the period when they are at greatest risk.

The Manchester study also found that suicide was associated with a history of deliberate self-harm (usually overdose) and suicidal thoughts during aftercare. Forty per cent of the cases had a diagnosis of a major affective disorder such as depression, 24 per cent had a diagnosis of alcoholism, 23 per cent had a diagnosis of schizophrenia, 5 per cent were diagnosed with personality disorder and 5 per cent were dependent on drugs.

Strategies to help
The National Suicide Prevention Strategy for England has recommended the following action plan to reduce suicides amongst people in contact with psychiatric services:

• staff training in the management of risk, 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
• prompt access to services for people in crisis and their families
• assertive outreach teams to prevent loss of contact with vulnerable and high-risk patients
• atypical antipsychotic medication to be available for all patients with severe mental illness who are non-compliant with ‘typical’ drugs because of side effects
• local strategies for dual diagnosis covering training on the management of substance misuse services, and staff with specific responsibility to develop the local service
• all likely ligature points in wards to be removed or covered
• follow-up within seven days of discharge from hospital for anyone with severe mental illness or a history of self-harm in the previous three months
• patients with a history of self-harm in the last three months to receive supplies of medication covering no more than two weeks
• local arrangements for information sharing with criminal justice agencies
• policy ensuring post-incident multidisciplinary case review and information to be given to families of involved patients.

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Suicide and substance misuse

Substance misuse has long been recognised as a risk factor for suicide and suicide attempts. Alcohol and drugs affect thinking and reasoning ability, and can act as depressants. They can decrease inhibitions, increasing the likelihood of a depressed person making a suicide attempt.

A 1999 report by the Department of Health found that, among suicides outside of a hospital setting, 38 per cent had a history of alcohol misuse, and 26 per cent had a history of drug misuse. [27]  Estimates suggest that about 15 per cent of people who misuse alcohol may eventually kill themselves. [28] Among people who misuse drugs, the risk of suicide is 20 times that of the general population. [29]

Research suggests that men are nine times more likely than women to misuse alcohol, and men diagnosed with alcoholism are six times as likely to die by suicide as men in the general population. Although women are less likely than men to misuse alcohol, those who do are at a much greater risk of suicide than men, with a suicide rate twenty times that of the general population. [30]

Alcohol and drugs are thought to be of particular significance in suicides that appear to be impulsive, and are particularly implicated in suicides of young men. Drug misuse is thought to be a factor in the increase in young male suicides.

Strategies to help
The National Suicide Prevention Strategy for England has been working closely with NIMHE’s Substance Misuse Programme to improve the clinical management of alcohol and drug misuse, particularly among young men. This includes:

• the development of a risk-assessment training package to be used in a range of settings, including substance misuse services
• a dual diagnosis programme that aims to help those who experience both mental health problems and substance misuse. [31] 

In the Alcohol Harm Reduction Strategy for England, [32] the Government acknowledges that access to help must be offered in several different settings in order to reach those in need of support. Access points for training and support will therefore be offered through general practice, hospital emergency departments, inpatient and outpatient services, and mental health services. The service is also aimed at people who misuse drugs, as 25 per cent of drug users also misuse alcohol. [33]

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Suicide and deliberate self-harm

The term ‘deliberate self-harm’ covers all acts of self-harm, self-injury or attempted suicide. Although acts of deliberate self-harm and suicide attempts do not necessarily involve an intention to die, there is a strong association between deliberate self-harm, attempted suicide and subsequent death by suicide. A British study found that women who have a history of deliberate self-harm are 15 times more likely to die by suicide compared with other women. The risk is particularly high during the six months following deliberate self-harm. [34] All incidents of self-harm should therefore be treated with extreme care. [35]

Strategies to help

National Instititute for Health and Clinical Excellence
The NICE clinical guideline Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care makes a number of recommendations, outlined below.

Treatment

• People who have self-harmed should be offered treatment for the physical consequences of self-harm, regardless of their willingness to accept psychosocial assessment or psychiatric treatment.
• Adequate anaesthesia and/or analgesia should be offered to people who have self-injured throughout the process of suturing or other painful treatments.
• Staff should provide full information about the treatment options, and make all efforts necessary to ensure that someone who has self-harmed can give, and has the opportunity to give, meaningful and informed consent before any and each procedure (for example, taking the person to hospital by ambulance) or before treatment is initiated.

Assessment of needs

• All people who have self-harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.

Assessment of risk

• All people who have self-harmed should be assessed for risk. This assessment should include identification of the main clinical and demographic features known to be associated with risk of further self-harm and/or suicide, and identification of the key psychological characteristics associated with risk, in particular depression, hopelessness and continuing suicidal intent.

Psychological, psychosocial and pharmacological interventions

• Anyone who has self-harmed should undergo a psychosocial assessment. Decisions about referral for further treatment and help should be based on a comprehensive psychiatric, psychological and social assessment, including an assessment of risk, and should not be determined solely on the basis of having self-harmed.

National Suicide Prevention Strategy for England

Key messages within the National Suicide Prevention Strategy for England include the development of standards for service provision in the following areas:

• emergency departments
• inpatient wards
• child and adolescent psychiatry.

The NSPSE has also helped establish three centres for the monitoring of deliberate self-harm. Through this monitoring it will be possible to estimate the number of suicides in the year following deliberate self-harm. The work is co-ordinated by the Centre for Suicide Research at Oxford University.

Other strategies

• NIMHE has worked with local services to establish procedures and services for people presenting at hospital emergency departments with deliberate self-harm, with the aim of assessing risk of suicide, mental health needs and substance misuse.
• A risk-assessment package has been published by the Department of Health (available from NIMHE’s website – www.nimhe.csip.org.uk). It is aimed at frontline clinical staff, the prison service, primary care, substance misuse services and college counselling services. [36] 

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Suicide and gender

For several years, Britain and the USA were the only countries that had diverging trends in male and female suicide rates. Between 1971 and 1998, the suicide rate for women in England and Wales almost halved, while the rate for men almost doubled. [37] This trend has changed in recent years, however, and the number of suicides by men is decreasing, as is the total number of suicides in England and Wales. [38] Nevertheless, men are still far more vulnerable than women to death by suicide: suicides by men still account for 75 per cent of all suicides in the UK. Suicide rates are higher in men than in women across all age groups. In the 25–44-year age range, men are 3.5 times more likely than women to take their own lives, while men aged 45 years and over are more than twice as likely to die by suicide as women in the same age range. [39]

Amongst young people (15–19 years old) girls are more likely to attempt suicide, but boys are much more likely to die as a result of a suicide attempt.

Women

The precipitating life events for women who attempt suicide tend to be losses or crises in significant social or family relationships. As with men, suicide is more common among women who are single or recently separated, divorced or widowed. However, women are more likely than men to have stronger social supports, to feel that their relationships are deterrents to suicide, and to seek psychiatric and other medical intervention. [40] As described above, women who have a history of deliberate self-harm are at increased risk of suicide, particularly during the six months after deliberate self-harm. [41]

Men

Men are traditionally more reluctant than women to talk about problems or express their feelings. They are less likely to go to their GP with psychological problems and are more likely to present with physical problems, which may not be recognised as a manifestation of mental distress.

The breakdown of traditional gender roles and the concept of the ‘new man’ have left many men feeling uncertain as to what is expected of them, particularly in terms of significant relationships. Research suggests that marriage is a protective factor against suicide by men, and that half of the increase in young male suicides may reflect the greater proportion of young men who are unmarried. [42]

Men have been particularly affected by the disappearance of traditional manufacturing jobs. Men in unskilled employment are twice as likely to kill themselves compared with other men in the general population. [43] This risk of suicide in unemployed men is two to three times higher than in the general population, and although no direct link has been shown between unemployment and young male suicide, there may be an indirect link from the effects of unemployment, such as poverty.

Factors such as race, age and substance misuse also contribute to gender differences in suicide rates.

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Suicide in young people

Suicide accounts for almost 23 per cent of all deaths of people aged 15–24 years, and is the second most common cause of death in young people after accidental death. [44] It has been estimated that 7–14 per cent of adolescents will self-harm at some time in their life, [45] and as many as 20–45 per cent of older adolescents say they have had suicidal thoughts. [46]

There appears to be a reluctance to acknowledge suicidal feelings in the very young, and this reluctance infiltrates youth suicide statistics. For every suicide recorded in the 1980s among 10–14 year olds in the UK, three other children were deemed to have died from ‘undetermined’ causes or ‘accidental’ drug overdoses. [47] In most cases of suicide there is a tendency towards minimising, denying and mythologising suicide, but particularly so in children and adolescents. [48]

Academic pressure, family break-up and relationship problems are all causes of mounting stress and anxiety for young people. Young people who have been physically or sexually abused are often at increased risk of suicide or deliberate self-harm. Substance misuse is thought to be a significant factor in youth suicide. Research in the USA suggests that one in three adolescents is intoxicated at the time of a suicide attempt.

The Suicide in Avon study [49] found that 80 per cent of young men who had died by suicide had had no contact with their GP, psychiatrist or other support agency in the four weeks before death. The study found that a quarter of young male suicides were related to interpersonal stresses in the 72 hours before death, implying that many of these suicides were impulsive.

Research has shown that young people who die by suicide are more likely than their peers to have had a friend or relative who has died through suicide. [50], [51] Kate Hill has described the aftermath of a suicide as a dangerous time for those in close proximity, suggesting that they may identify with the victim and so already be vulnerable, the emotional furore following the death possibly loosening internal restraints against self-destruction. [52]

Strategies to help

NIMHE is working closely with schools, colleges and universities to develop a health promotion strategy that:

• promotes the mental health of students
• supports the development of internal counselling services
• extends risk assessment training into college counselling services.

Work has been commissioned through the Department for children, schools and families (formerly the Department for Education and Skills) to map current national initiatives to promote mental health in schools and to identify further opportunities, such as the National Curriculum on citizenship and the National Health Schools Standard.

Mental health promotion pilots that target young men have been run in Camden (north London), Manchester and Bedfordshire. They found that it is not appropriate to develop generic health promotion that is aimed at all young men, as young men differ greatly depending on factors such as cultural background, social disadvantage and employment/unemployment. Experience from these pilots will be implemented in other parts of the country. The pilots also indicate that alternative terms to ‘mental health’ should be used, such as stress management or wellbeing. [53]

The National Suicide Prevention Strategy for England recommends that the prevention of suicide in young men should be aided by:

• improved risk management skills in frontline clinical staff
• measures to reduce alcohol and substance misuse
• availability of support at times of crisis
• promoting the recognition of suicide risk in primary care
• supporting the management of depression in primary care.

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Suicide in older people

Although suicide rates in older people of both sexes have fallen considerably since the 1950s, they are still high, particularly in older men. Suicide in older people is strongly associated with depression, physical pain or illness, living alone and feelings of hopelessness and guilt. Community surveys suggest that 10–20 per cent of older people may be experiencing depression, but only a fraction of these are known to their GP or psychiatric services. [54]

Most older people who commit suicide live in the community, and most have had no contact with old-age psychiatry services. One study found that community old-age psychiatry services were seeing fewer than 25 per cent of older people with depression who later went on to kill themselves, and most of these people had not seen their family doctor within the month before suicide. [55]

Strategies to help

The National Service Framework for Older People [56] seeks to promote good mental health in older people and to treat and support those with dementia and depression by:

• ensuring access to integrated mental health services
• effective diagnosis
• treatment and support for them and their carers.

NIMHE is working with leaders of services for older people and primary care to identify ways of enhancing the assessment and clinical management of depression in older people, particularly in those with physical illness. NIMHE is also consulting with voluntary service providers on the resourcing and development of services for vulnerable older people. Regional collaborations for older people and mental health organisations have been established in some parts of the country. NIMHE will consult with these organisations on actions to be taken on suicide prevention.

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Suicide, race and culture

Race and cultural background can be major influences on suicidal behaviour. For example, one study found that the suicide rate in women aged 16–24 years was three times higher in women of Asian origin than in white British women. [57] Asian women’s groups have linked this high suicide rate to cultural pressures, conservative parental values and traditions such as arranged marriages that may clash with the wishes and expectations of young women. [58] Asian men appear to be far less vulnerable to suicide than young men from white British backgrounds.

Within the Hindu faith, there appears to be a general taboo against suicide, particularly among men; however, the idea of ‘altruistic’ suicide is acceptable, and there is a historic tradition associated with bereaved women, particularly widows, ending their life by suicide.

Patterns of self-harm and suicide continue to be different for white people and people from minority ethnic groups. [59] Suicide rates are higher among women than men of Chinese origin, which is in line with reports of suicide in China. [60]

Strategies to help

Black and minority ethnic groups are not specifically targeted in the National Suicide Prevention Strategy for England. However, after consultation with black and minority ethnic groups, the Mental Health Act Commission has identified a number of themes that might help to develop better support for people from these communities who experience mental health problems. The themes are listed and explored further in Celebrating our Cultures: Guidelines for Mental Health Promotion with Black and Minority Ethnic Communities published by NIMHE in 2004. [61] The guidelines highlight the importance of:

• the need to consult with and act upon the views, perceptions and priorities of black and minority ethnic communities
• the stigma attached to mental illness within these communities
• the need to recognise the religious, linguistic and cultural needs of black and minority ethnic communities
• the need to foster and develop partnerships with the black and minority ethnic voluntary sector.

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Suicide and sexuality

A British survey of 4000 lesbian, gay and bisexual (LGB) people found that 34 per cent of men and 24 per cent of women had experienced violence because of their sexuality; 32 per cent had been harassed and 73 per cent had been called names because of their sexuality in the past 5 years. [62]

Many LGB people question their sexual orientation in adolescence, and many experience rejection from family and friends when they disclose their sexual orientation. [63] Many young LGB also experience attacks and bullying in school. [64] Many LGB people say they get negative responses from mental health professionals when they disclose their sexual orientation. In one survey, one-third of gay men, a quarter of bisexual men and more than 40 per cent of lesbians said they had had negative or mixed responses from mental health professionals. [65]

LGB people are considered to be at high risk of suicide. The causes are thought to be linked to their negative experiences relating to their sexuality. However, it is difficult to establish the true risk of suicide for this group, as sexual orientation is not recorded when death is registered. NIHME has therefore commissioned research to identify the risk factors for this group. [66]

Strategies to help

The National Suicide Prevention Strategy for England does not specifically target LGB people, although it does describe the promotion of the mental health of socially excluded groups in general terms.

Further information is provided in Mind’s Lesbians, gay men, bisexuals and mental health factsheet.

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Suicide in prisons

In 2002, 85 men and 9 women died by suicide in prison in England and Wales. [67] Prison suicides increased by 40 per cent during the 1990s and the number in 2002 was the highest in the last 10 years. This rate is more than 12 times the total male suicide rate. [68] In 2005–06, the number of self-inflicted deaths in prison had gone down to 70. [69]

Within the prison population as a whole, young prisoners, particularly those under 21 years of age, who make up a third of the remand population, are considered to be most at risk. In 1995, 20 per cent of prison suicides were by people under 21, the majority of who were male. [70]

The most comprehensive study ever into suicide and self-harm in prison, published in 1993, identified a range of characteristics and background factors associated with a risk of suicide and self-harm by prisoners. [71] Many prisoners had experienced multiple deprivations before their imprisonment, and to this was added the stresses resulting from custody and a range of situational problems. Although all prisoners may be vulnerable at certain times, three particularly vulnerable groups were identified: younger ‘poor copers’, those with mental health problems, and adult male serious offenders. Approximately one-third of prisoners who died by suicide had mental health problems, although the report indicated that coping problems and situational factors were more significant than psychiatric explanations.

In the late 1980s Judge Tumin, then Chief Inspector of Prisons, was commissioned by the Home Secretary to review the Prison Service’s policy on suicide and self-harm. In this 1990 report, Judge Tumin wrote that current prison service policy failed to communicate the social dimension to self-harm and self-inflicted death. It did not stress sufficiently the significance of the environment in which prisoners and staff were expected to live and work, or the importance of constructive activities in helping inmates to cope with anxiety and stress. Above all, it failed to give weight to the need to sustain people while in custody and to the importance of relationships between inmates and between staff and inmates in providing support. [72]

Strategies to help

As a result of this review, the Prison Service developed a new policy: Caring for the Suicidal in Custody. [73] The key elements of the policy are:

• new suicide screening, care plans and staged risk management systems
• implementation of intervention strategies for repeated deliberate self-harm
• improved health screening on reception into custody to assist in the detection of mental disorder, vulnerability to suicide, self-harm and substance misuse
• prisoners who have been trained by Samaritans to listen to be accessible at all times for prisoners in distress
• primary care – creating a safe environment, and helping prisoners to cope with custody
• special care – identifying and supporting prisoners in crisis and treating them with dignity
• aftercare – caring for the needs of those affected by suicide and self-harm
• community responsibility – involving the whole prison community in the awareness and care of the suicidal.

Working with the prison service, NIMHE is continuing to:

• investigate ways of improving information sharing into and across the criminal justice system about people known to be at risk of suicide
• commission internal and external research which might help to establish the factors that make prisoners vulnerable to suicide and self-harm
• establish the most effective interventions to reduce rates of suicide and self-harm in prisons
• provide training around mental health issues for prison staff.

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Suicide in rural areas

Although statistics indicate that mental illness and suicide may be more common in urban than rural areas, these statistics should be interpreted with caution. Studies indicate that people in rural areas are less likely to disclose or seek help for symptoms of mental distress and are therefore less likely to be identified as needing help, and fewer services are available in rural areas. [74]

Suicide rates are higher among vets and farmers than in the general population, probably because they have access to means of suicide, such as guns and medication/drugs. [75]

Strategies to help

Helplines have been provided for farmers by the National Union of Farmers, the Rural Stress Information Network, the Farmers’ Crisis Network, Rural Minds and Samaritans.

The Department of Health and NIMHE have supported the Rural Stress Action Plan. [76] Key aims of the plan are to deliver support to those experiencing stress in rural communities and to develop regional support networks and a rural initiative fund. NIMHE will work with Rural Minds and through the Rural Stress Action Plan to share successful local support initiatives for farmers and their families. This will include reviewing the dissemination of helpline numbers, and exploring the further development of teleconferencing facilities for farmers. NIMHE will also liaise with professional organisations to explore how occupational health services can be made more readily available.

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The effect of suicide on others

Bereavement following suicide has certain features that may prolong the grieving process. Survivors (the friends and family who have been affected by suicide) may get stuck in an endless and fruitless search for a definitive answer as to why the suicide occurred, or they may believe that they were somehow responsible for the death and may punish themselves by continuing to grieve. Anger and guilt are common reactions to bereavement, but are often more intense and long-lasting among survivors of suicide.

Alison Wertheimer writes of the experiences of people bereaved by suicide in A special scar, and explains that all survivors – but particularly those who either witness the suicide or, more commonly, find the body – are likely to be affected by the experience for many years; especially if the victim died in a violent way. Survivors may struggle to understand why someone has taken their own life.

Support for those affected

Faced with bereavement, many people can rely on support from a variety of people, including family, friends and colleagues. However, those faced with bereavement due to suicide may find that they have less social support because suicide is not considered to be a socially acceptable way to die under any circumstances. People do not know how to react to suicide, or how to comfort someone who has been bereaved by suicide. [77]

People who felt close to or who identified with someone who has died by suicide are thought to be at increased risk of self-destructive behaviour during the grieving process (discussed above). [78] Young people are considered to be particularly vulnerable if they have been close to someone who has died by suicide. [79]

A number of organisations provide support to people bereaved by suicide, including children and young people. (See Useful contacts below.)

As part of its consultation process, NIMHE has highlighted the specific needs of people bereaved by suicide. In liaison with support organisations, NIMHE has developed a support pack for people in contact with bereaved families, such as GPs, the police and religious leaders. The pack ‘Help is at Hand’, is available from various organisations, including the Department of Health (see Further reading below).

Further information can be found in Mind’s booklet Understanding bereavement.

Further reading

Factsheets available from Mind
Crisis services factsheet
Statistics 2: suicide

Booklets available from Mind
About self-harm: a guide for young people
How to cope with suicidal feelings
How to help someone who is feeling suicidal
Understanding bereavement
Understanding depression
Understanding schizophrenia
Understanding self-harm

Other publications
J. Mark G. Williams 2002, Suicide and attempted suicide, Penguin Books
Kay Redfield Jamison 2001, Night falls fast: Understanding suicide, Picador

Available from Department of Health
Help is at Hand: a resource for people bereaved by suicide and other sudden, traumatic death, DH Publications Orderline: PO Box 777, London SE1 6XH Tel: 0870 155 54 55  This guide contains information about procedures such as the coroner's inquest, suggestions for how to cope and details of sources of support, with contact details of helping organisations and pointers to useful reading material. The booklet also provides information for healthcare and other professionals who come into contact with bereaved people, to assist them in providing help and to suggest how they themselves may find support if they need it.

Useful contacts

Care Services Improvement Partnership (CSIP)
tel: 0113 254 5127
web: www.csip.org.uk

Centre for Suicide Research
tel: 01865 226 258
email: csr@psych.ox.ac.uk
web: http://cebmh.warne.ox.ac.uk/csr/linksbereaved.html
Website provides useful ‘research’ and ‘publications’ sections.

Cruse – Bereavement Care
tel: 020 8939 9530
email: info@crusebereavementcare.org.uk
web: www.crusebereavementcare.org.uk 
Cruse Bereavement Care’s aims are to promote the well-being of bereaved people and to enable anyone bereaved by death to understand their grief and cope with their loss. Offers information, advice, education and training services.

Cruse Cymru
tel: 029 2088 6913
email: cruse.cymru@care4free.net

Farm Crisis Network
tel: 01788 510 866
web: www.farmcrisisnetwork.org.uk 
Information about mental health problems affecting the rural community.

The MediaWise Trust
tel: 0117 939 9333
web: www.mediawise.org.uk
Advice, information, research and training on media ethics

Mental Health Foundation (MHF)
tel: 020 7803 1101
web: www.mhf.org.uk
Carries out research, and campaigns and works to improve services for anyone affected by mental health problems.

National Institute for Health and Clinical Excellence (NICE)
web: www.nice.org.uk 
Guidelines on the treatment of mental health problems, including self-harm and depression.

National Institute for Mental Health in England (NIMHE)
web: www.nimhe.csip.org.uk 
NIMHE is part of CSIP and is responsible for supporting the implementation of positive change in mental health and mental health services in England.

PAPYRUS
tel: 01282 432 555
email: admin@papyrus-uk.org
web: www.papyrus-uk.org 
PAPYRUS is a voluntary organisation committed to the prevention of young suicide and the promotion of mental health and emotional wellbeing. It provides resources and support for those dealing with suicide, depression or emotional distress – particularly teenagers and young adults.

Rethink
web: www.rethink.org
Research, campaigning and support services for those with severe mental illness.

Rural Minds
email: Ruralminds@mind.org.uk

Ruralnet UK
tel: 0845 1300 411
email: enquiries@ruralnetuk.org 
website: www.ruralnet.org.uk 
A subscription network service that facilitates communication between like-minded rural advocates and is used by individuals and groups in rural communities across the UK.

Winston’s Wish
tel: 01242 515 157
helpline: 08452 03 04 05
email: info@winstonswish.org.uk
web: www.winstonswish.org.uk 
Winston's Wish is a charity that helps bereaved children and young people rebuild their lives after a family death, offering practical support and guidance to families, professionals and anyone concerned about a grieving child.

References

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Originally written by George Stewart, Mind Information Officer, May 1999.
Last updated by Inger Hatloy, November 2007.