For many people suicide is hard to broach, cloaked in silence and difficult to understand or make sense of. There’s no easy way wither or writing about it. While perceptions and attitudes towards mental illness are gradually changing suicide all too often remains taboo. What is the scale of this avoidable loss of life, how can we reach people at risk of suicide (and support their family, friends and communities) and do rural areas present particular challenges or opportunities for suicide prevention? I offer three points.
In December 2017 the Office for National Statistics (ONS) published its latest statistical bulletin on suicides in the UK. This records registered deaths from suicide by age, sex, area of usual residence and method. In the UK, in 2016, 5,962 suicides were registered – three-quarters of suicides were amongst men, in persons aged 40-44 years of age (with this age group having a suicide rate of 15.3% per 100,000 population) and the most common method hanging. The bulletin highlights a 3.6% reduction in registered suicides between 2015 and 2016; with registrations in England falling a significant amount, Wales and Northern Ireland falling slightly and Scotland increasing by a small amount. According to Emyr John at ONS “the fall in suicide rates from 2015 to 2016 is the largest decrease in 20 years. It fell for both males and females in the UK…It’s interesting to note that between 1981 and 2016, the male suicide rate among the 75 and over group has more than halved.”
It is thought these figures under-represent the true loss of life because of the ‘standard of proof’ required to register suicide. Part 1 of the Coroners and Justice Act 2009 places a duty on a coroner to investigate a death where they are made aware that the body is within that coroner’s area and they have reason to suspect that the deceased died a violent or unnatural death; that the cause of the death is unknown; and/or the deceased died while in custody or state detention. Where an inquest is held the outcome are known as ‘conclusions’ and may be short form or narrative and include one or more of the following type: accident or misadventure, alcohol/drug related, industrial disease, lawful/unlawful killing, natural causes, open, road traffic collision, stillbirth or suicide. From these conclusion types the standard of proof required for unlawful killing and suicide is the criminal standard of proof ‘beyond reasonable doubt.’ For all other types of conclusion the standard of proof is the civil standard of proof ‘on the balance of probabilities.’
The standard of proof has raised debates around whether coroners are reluctant to reach a verdict of suicide and/or whether the current arrangements mask the true number of suicides. Analysis from Bournemouth University, for example, suggested if coroners used the civil standard of proof (rather than criminal proof) there would be a 30-50% increase in recorded suicides. Professor Colin Pritchard, who led the study, describes how “when a death occurs, coroners have to decide whether the death was suicide – which could be hurtful to the family – or whether it was an accident or give an open verdict because they could not decide which. It is then categorised by the World Health Organisation (WHO) stats as an Undetermined Death (UnD) and it is amongst UnD that under-reported suicides are more likely…the UK had a disproportionately higher UnD in every age band than any other country.” In its final report the Health Committee noted its disappointment that in the third progress report on the suicide prevention strategy no reference made to changing the standard of proof.
In addition to overall figures we do know that some groups more at risk than others. Maternal suicide, for example, is the third largest cause of direct maternal deaths occurring during or within 42 days of the end of pregnancy. However, it remains the leading cause of direct deaths occurring during pregnancy or up to a year after the end of pregnancy, with 1 in 7 women who die in the period between 6 weeks and one year after pregnancy dying from suicide. Figurescompiled by the Ministry of Justice show 119 people killed themselves in prisons in England and Wales in 2016 – an increase of 29 people (32%) on the previous year. In 2017 the Samaritans published a report setting out why socioeconomic disadvantage is a key risk factor for suicidal behaviour – revealing suicide rates to be two to three times higher in the most deprived neighbourhoods compared to the most affluent. In 2017 ONS published data on suicides by occupation – this revealed males in the lowest-skilled occupations had a 44% higher risk of suicide than men as a whole (with the risk among labourers three times higher) and for women the risk of suicide was found to be 24% higher among professionals. Male and female carers both had a higher risk of suicide than average.
In England, it is difficult to get statistics differentiating those at risk from suicide living in rural areas compared to that of urban areas. In March 2017 the Local Government Association (LGA) and Public Health England (PHE) published a report on health and wellbeing in rural areas. This described how the risk of suicide and undetermined injury may be higher in farming communities due to various factors related to isolation and ease of access to the means of suicide such as guns and poisons. The map on page 32 of the report shows higher suicide rates in areas that are rural and sparsely populated; although some deprived urban areas also have higher than average rates. PHE also publishes a Suicide Prevention Profile – this provides publically available data on suicide, risk factors and service contact by Local Authority or Clinical Commissioning Group geography. In January 2018 ONS provided raw data on farmer suicides in England and Wales between 2000 and 2017.
In other countries more data is available on the scale of the loss of life in rural areas. In the United States, for example, data compiled by the Centers for Disease Control and Prevention (CDC) found rural counties consistently had higher suicide rates than metropolitan counties. Between 2001 and 2015 suicide rates for rural counties was 17.32% per 100,000 people compared to 11.92% in large metropolitan counties. Over the same period the suicide rate increased by more than 20%. States with the highest suicide rates include Alaska, Montana and Wyoming and those with the lowest rates New Jersey and New York. The University of Washington found people who die by suicide are frequently experiencing undiagnosed, undertreated or untreated depression. Research from Mental Health America suggests the availability of treatment may be an issue in rural states – with Alabama having one mental health worker for every 1,200 people compared to one health worker per 420 people in New York. Studies have also shown that rural dwellers have more guns than their urban counterparts – with 51% keeping a gun at home in rural areas compared to 25% in urban areas. 86% of suicide attempts using guns end in death, compared to just 2% of attempts using drugs.
Suicide can affect anyone and while we should not concentrate on the numbers, having timely and accurate data – particularly for rural areas – could enable us to respond more quickly (which initiatives are working well and less well? Where are the gaps?)
In September 2012 the Coalition Government published ‘preventing suicide in England: a cross-departmental outcomes strategy to save lives.’ This sought to reduce the suicide rate in the general population and provide better support for those bereaved or affected by suicide. It contained six areas for action: (1) reduce the risk of suicide in key high-risk groups, (2) tailor approaches to improve mental health in specific groups, (3) reduce access to the means of suicide, (4) provide better information and support to those bereaved or affected by suicide, (5) support the media in delivering sensitive approaches to suicide and suicidal behaviour and (6) support research, data collection and monitoring. Since then, three strategy updates have been provided: in 2014 (which included a focus on what local areas could do to reduce suicide), in 2015 (which highlighted an increase in self-inflicted deaths of prisoners and increases in suicides among young people); and in 2017 (which follows the Health Committee’s inquiry and sets out how the Government intends to strengthen its response). Suicide prevention strategies are also published in Scotland, Wales and Northern Ireland.
The Five Year Forward View for Mental Health, issued in February 2016 by the Independent Mental Health Taskforce, set out a number of objectives for the whole health system in England on suicide prevention. This includes a commitment to reducing the number of people taking their own lives by 10% by 2020-2021 compared to 2016-2017 levels and improving the seven day crisis response service across the NHS. In July 2016 an implementation plan was published. This lays out a blueprint for the view’s delivery over the coming years to 2020-2021. Under suicide prevention this includes a commitment for all Clinical Commissioning Groups (CCGs) to work with local partners to develop and deliver suicide prevention plans. These local plans are intended to focus on evidence-based preventative interventions that target high-risk locations and high-risk groups in ways that draw upon localised real time data. Government has committed £25 million to help CCGs and their partners implement their activities and actions from 2018-2019.
Since 2012 with the establishment of Health and Wellbeing Boards (HWB) Local Authorities have been responsible for developing local suicide action plans. According to the Local Government Association (LGA), by the end of 2016 95% of areas had plans in place or were in the process of drawing them up. The LGA produced a suicide prevention guide for Councils – this includes a set of good practice case studies from Lincolnshire, Cheshire and Merseyside, Warwickshire and Torbay.
The task of Local Authorities now, and the Government’s ask, is to take practical steps to reduce suicides.
In a health context, an approach known as ‘zero suicide’ has emerged. The concept can be traced back to Detroit which in 2001 became the first place to adopt the idea of becoming a ‘zero suicide city.’ Poverty and high unemployment were contributing to high rates of depression and high rates of suicide. Here mental health professionals began to focus on preventative care – tackling the stigma around mental illness and using identifiers to highlight cases of crisis or potential crisis. Patients attending health clinics are now routinely screened for depression and mental health issues and those identified as being ‘at risk’ can be referred to a mental health specialist. A central recording system means patients are traceable and information coordinated among health and non-medical practitioners. By 2005 the suicide rate among the patient population had fallen by 75% and by 2008 had been eliminated altogether.
In the UK, learning from the United States has informed four zero suicide pilot initiatives covering the East of England (Bedfordshire, Cambridgeshire & Peterborough), Merseyside and the South West (e.g. Somerset, Cornwall, Devon, Dorset, Gloucestershire, Wiltshire). In November 2017, the Zero Suicide Alliance was launched at the House of Commons; a collaboration of NHS Trusts, businesses, organisations and individuals committed to suicide prevention, it aims to raise awareness of and promote free suicide prevention training which is accessible to all. In January 2018 the Secretary of State for Health and Care, Jeremy Hunt, outlined plans for mental health trusts to draw up detailed plans to achieve zero suicides, starting with those in inpatient settings. It is intended organisations will learn from the pilot schemes – improving suicide risk assessment, improving staff training and improving access to crisis care around the clock.
The zero suicide approach is underpinned by the belief that suicide is preventable and that it is not inevitable for people in crisis. However, the Health Committee in its inquiry flagged that though Local Authorities have suicide prevention plans there is currently little or no information about the quality of plans – and the assurance process to monitor their implementation currently lacking. Where the resources to deliver will actually come from (and whether the £25 million allocated by Government in 2018-2019 is enough) have also been highlighted.
The Health Committee’s inquiry recommended that to reach out to those in distress we need to offer non-traditional routes to help people who are unlikely to access mainstream services. If early intervention is important, and supporting people in non-clinical settings is important (including people who are not in contact with any health services), what does this look like in a rural setting?
Back in 2016, NHS Health Scotland published a planning tool and a guide to suicide prevention in rural areas. While no single pattern emerges in rural areas these documents highlight particular risk factors in rural areas (e.g. isolation, declining incomes, the stigma associated with mental health, culture of self-reliance, poor service provision, availability of lethal means and occupational groups such as farmers, vets and doctors); an approach to reviewing [rural proofing] interventions within a suicide prevention strategy; and focussing on what is missing from current interventions.
At a national level charities such as ‘MIND’ - which seeks to address the challenges and stigma faced by those living in rural communities as part of its core activities - through to Farming Help(which runs a helpline and provides other support services for the farming community) provide support. At a more local level there are a plethora of examples of good practice. There are groups that provide mutual support and advocacy – HUG represents the interests of users of mental health services across the Highlands of Scotland and ‘You Are Not Alone’ (YANA) provides a confidential helpline for those feeling isolated, depressed or unable to cope. In some rural areas mental health services are provided using custom-built vehicles (e.g. Doris, the Vale of Clwyd Mind’s mobile outreach vehicle); and/or or using existing community venues (e.g. nurse and farmer health checks at auction mart; and Reading Well. Some Rural Community Councils (RCCs) provide Suicide Awareness Training for frontline workers in areas such as care, family support, housing, children’s centres schools, police, social workers, diocese, probation and youth offending, foster carers, job centres and the general public – for example: Derbyshire, Leicestershire and RutlandIn the United States, the Suicide Prevention Research Centre recommends educating primary health and care providers on how to assess and manage suicide risk (including reducing access to lethal means among vulnerable individuals) and using telepsychiatry and mobile crisis teams to support individuals at risk. The Rural Heath Information Hub holds a repository of suicide prevention rural project examples. The Winston Churchill Memorial Trust has a suicide prevention, intervention and postvention award category – with fellows funded in 2014 and 2018 spending time in the United States and Canada where extensive amounts of work in the field have already been done and support structures have been put in place.
For some of us, sharing our personal experiences of bereavement or suicidal crisis takes enormous courage. Suicide leaves families, friends and communities distraught. Many people find it difficult to talk about suicide and it is difficult to write about. But rather than walking away I believe we need to talk about suicide and suicide prevention in ways that help those that are suffering and those that so desperately want to help them.
If you are concerned about someone who may be suicidal or are at risk yourself the following helplines are available 24 hours a day unless otherwise stated: Samaritans 116 123; Campaign Against Living Miserably (CALM) for men 5pm to midnight 0800 585858; Papyrus for people under 35 weekdays 10.00am-10.00pm weekends 2.00pm-10.00pm 0800 0684141 or text 07786 209697; Childline for young people under 19 0800 1111 the number won’t show up on your phone bill; or the Silver Line for older people 0800 4708090. If you have lost a loved one support is available from Cruse 0808 8081677.
Jessica is a researcher/project manager at Rose Regeneration; an economic development business working with communities, Government and business to help them achieve their full potential. Her current work includes supporting a Lottery programme to help people into paid work; research for the NHS on rural workforce issues and a project looking to deliver higher level technical education and skills in rural areas. In her spare time Jessica volunteers for a farming charity which aims to prevent things from getting to the desperate stage. She can be contacted by email email@example.com telephone 01522 521211. Website: http://roseregeneration.co.uk/ Blog: http://ruralwords.co.uk/ Twitter: @RoseRegen
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