Scottish Government: Suicide Prevention Strategy 2013 - 2016

Our approach

The strategy focuses on suicide prevention activities in communities and in services. It is structured around five themes that contribute to the delivery of the National Outcome^[9] to enable people to live longer, healthier lives.

The World Health Organization has adopted a global target that suicides will be reduced by 10% by 2020.^[10] During the period of this strategy, we want to continue the downward trend in the rate of suicide in Scotland and make progress towards the WHO target.

A. Responding to people in distress

People who are in distress and who may be at risk of suicide, whether they are looking for help or as a consequence of their actions, will come into contact with a wide range of public and voluntary sector services. Often the first person they may see will be from one of the emergency services. Some people in distress will have a mental illness, but for many the distress may be temporary and linked to life events.

We will do better in engaging with their distress if we are compassionate and have a common understanding of what it means to respond in a person-centred and safe way. If we do that, the evidence tells us that people are more likely to engage with or stay connected to services or support that may help them over time.

The relationship between suicide and self-harm is complex. Many people who die by suicide will have a history of self-harm, but most people who self-harm will not go on to die by suicide. As such, self-harm is a clear risk factor for suicide, but it is also a phenomenon that we need to understand and address in its own right. On that basis, while we believe that many of the activities we will engage in to reduce suicide will have benefits for those who self-harm, the focus of this document is on prevention of suicide.

Commitment 1: We will take forward further work on self-harm as part of the publication of a document on responding to people in distress. This work will take into account feedback from the public engagement process which helped inform the development of this strategy (see Annex 2), the current work in Tayside in relation to Commitment 19 of the Mental Health Strategy and the Scottish Government's report Responding to Self-Harm in Scotland: Final Report.^[11]

While we have seen improvements in how services respond to people, too often we know that people who present in distress still feel stigmatised for their self-harm or intoxication and are referred elsewhere or have their physical condition addressed while their mental distress is ignored. We know that, in some cases, this is their last contact with services before they take their own lives. This needs to change. We require a continued focus on how to improve the collective way in which we respond to distress.

We need those who are the first point of contact to have the necessary information, skills and attitudes to make it more likely that their engagement is positive and supportive. This needs to be complemented by the general public health work of awareness-raising and training, so that people in the workplace, families, carers and friends of those who communicate suicidal thoughts know how to be supportive.

NHS Health Scotland already supports work to enhance skills in suicide intervention through the provision of coaching, mentoring and training. It ensures that trainers are supported to deliver training and it also monitors the quality of training delivered. The HEAT target to train 50% of frontline NHS staff in suicide prevention techniques was delivered in 2010 and will continue to be monitored. In addition, all probationer police officers in Scotland and all undergraduate mental health nurses now receive training in this area.

We know from extensive research evidence and from the pilot work in NHS Tayside in relation to Commitment 19 of the Mental Health Strategy^[12] that people in distress seek a more compassionate response, and as indicated above, the evidence is that people are more likely to achieve a positive outcome where they do receive such a response.

Commitment 2: NHS Health Scotland and NHS Education for Scotland will work together to develop and extend the current approach of workforce development activity to address a wider range of experience and in a wider range of contexts. In doing so we will consider how this support can be made available to families and communities. This work will also be linked to the work under Commitment 1 on distress.

In addition to addressing the workforce capability we also need to consider the current processes and pathways that determine the response that people receive when they present in distress. This work needs to cover the practicalities of what happens for people who present in A&E or who come into contact with the police when intoxicated. It needs to include, but extend beyond, protocols and agreements about what should happen in more serious cases, such as those that would be covered by Psychiatric Emergency Plans,^[13] and should build on the Commitment 19 work in NHS Tayside mentioned above.

Commitment 3: We will map existing arrangements for responding to people in distress in different environments and localities and will use this information to develop guidance which supports safety and person-centredness.

Commitment 4: For those presenting to A&E we will examine how existing local and national data sources, such as the Scottish Patients at Risk of Readmission and Admission (SPARRA), can be used to provide benefit to those at risk of suicide. We will also support improvement programmes that are aimed at linking available data sources to inform service responses for those at risk of suicide or repeat attendance, such as currently exist in NHS Greater Glasgow & Clyde and in Tayside.

B. Talking about suicide

How we talk about suicide is important. We know that talking openly about suicide in a responsible manner saves lives. We have adopted that approach through the Choose Life campaigns "Suicide: Don't hide it. Talk about it" and "Read Between the Lines".^[14] We will continue to campaign in this way during the period of this strategy.

Recent years have seen the introduction and growth of various forms of "social media" and new technologies. Used positively, these can enable people to access information and support around prevention of suicide, such as those listed in Annex 1. At the same time, concerns have been expressed that people who are vulnerable to suicide can be exposed to inappropriate material through social media or through other internet sources. This is a challenging area but it needs to be part of our approach to reducing suicide in Scotland.

Commitment 5: We will work closely with NHS Health Scotland, see me^[15] and other agencies to develop and implement an engagement strategy to influence public perception about suicide and the stigma surrounding it and will use social media, in addition to other communication channels, to communicate key messages about suicide and its prevention.

We know that media reporting of suicide can increase the number of suicides in a locality. The quality and nature of that reporting can be a factor and we have worked with the National Union of Journalists (NUJ) to develop guidelines and deliver training on sensitive and appropriate reporting. We will continue to work with the NUJ and others to encourage the implementation of media guidelines and challenge inappropriate reporting when it occurs.

Finally, we will continue the work to reduce the stigma and discrimination of mental illness, primarily through the see me programme, which is funded by the Scottish Government and Comic Relief. We know that increasing the identification and treatment of mental illness is one of the factors in the success of reducing suicide in Scotland and we need to continue to build on that achievement.

C. Improving the NHS response to suicide

Analysis from the National Confidential Inquiry into Suicides and Homicides^[16] into the changing patterns and risk factors behind cases of suicide and homicide by people in contact with mental health services, has informed safety improvements for patients, prioritised attention to follow-up of patients after discharge from hospital, and supported the focus on action to tackle problem drinking and drug use. Healthcare Improvement Scotland^[17] leads on a range of improvement programmes, including the Scottish Patient Safety Programme for Mental Health (SPSP-MH) and the Suicide Reporting and Learning System (SRLS). Much work is already underway to improve quality and safety; we want to harness this work in the service of those at risk of suicide.

Commitment 6: We will work with Healthcare Improvement Scotland to support improvements for NHS Boards that focus on areas of practice which will make mental health services safer for people at risk of suicide, for example, transitions of care, risk management, observation implementation and medicines management. This will be delivered through the SRLS and SPSP-MH.

Data from the Scottish Suicide Information Database (ScotSID)^[18] indicate challenges that we need to look at further. Those who die by suicide tend to have had quite extensive contact across the range of health care services including GPs, A&E and acute hospitals, and there is a high correlation between serious self-harming and death by suicide. The ScotSID report also shows that, at the time of death, many people are receiving some form of medication used in the treatment of mental illness. Drawing on the National Confidential Inquiry, 30% of general population suicides were identified as having been in contact with mental health services in the 12 months before their death.

In addition to many chronic health conditions and morbidity highlighted in the Equally Well Report on Health Inequalities,^[19] suicide rates feature strongly in the most deprived populations in Scotland. The rate is three times higher in the most deprived 20% of the population compared to the least deprived 20%. Over the course of the Choose Life programme there has been a reduction of 20% in the deaths by suicide of males. Deaths by suicide for females have reduced by 10%. Despite this greater reduction in suicide among men, suicide is an overwhelmingly male behaviour.

The charts in this document^[20] highlight the areas of A&E, acute hospital admission and mental health prescriptions that present particular challenges within our current system and require a developmental approach towards improvement.

Chart 1 illustrates that of the 757 probable^[21] suicides in Scotland in 2010, more than one in five (21.5%) attended A&E at least once in the three months prior to death.

Chart 1

A&E Attendances	Number	Percentages
0	594	78.5
1	111	14.6
2	35	4.6
3	10	1.3
4+	7	0.9
Total	757	100

Source: ScotSID

In addition, combining the 2009 and 2010 totals for probable suicide (1,501), Chart 2 indicates that 890 (59%) had been inpatients in general hospitals in the five years before dying by suicide. Of those, almost one in four (24.5%) had a diagnosis of "Injury from intentional self-harm" and almost one in five (18%) had a diagnosis of "Unintentional injury (including assault by another person)", at discharge.

Chart 2

General Acute Hospital Discharge
Main Diagnosis	Number	Percentages
Injury - intentional self-harm	218	24.5
Injury - unintentional	160	18
Other diagnosis	512	57.5
Total	890	100

Source: ScotSID

As Chart 3 below illustrates, of the 757 probable suicides in 2010, 424 (56%) had mental health prescriptions dispensed within 12 months prior to death. There is scope here to support clinical assessments and treatments that provide greater benefit and that link to use of psychological therapies and social prescribing.^[22] There is evidence to suggest that there are benefits in reviewing long-term use of mental health prescriptions.^[23]

Chart 3

Deaths by Individuals with Mental Health Prescriptions
Gender	Number	Percentages
Male	284	37
Female	140	19
Total	424	56

Source: ScotSID

Taking probable suicide figures for 2011 and 2012 together, almost three quarters (1,112, 72.5%) of those who died were male. The highest proportion of deaths for men and women occurred in the 35 to 54 age group (48%). We are concerned that there may be a number of people in their middle years living with depression and/or chronic conditions among this high proportion.

The evidence from ScotSID needs to be taken into account in how we develop and implement our strategy going forward. It suggests three particular programmes of work. The first is set out above (Commitment 4) and relates to how we respond to people when they present in A&E and other contexts in crisis. We will also link that work to the NHS work on unscheduled care.

In addition:

Commitment 7: We will work with the Royal College of General Practitioners and other relevant stakeholders to develop approaches to ensure more regular review of those on long-term drug treatment for mental illness, to ensure that patients receive the safest and most appropriate treatment.

Commitment 8: We will build on work already done in relation to Commitment 22 of the Mental Health Strategy^[24] to test ways of improving the detection and treatment of depression and anxiety in people with other long-term conditions.

D. Developing the evidence base

Suicide and its prevention require ongoing analysis and research. We have access to a range of valuable information on suicides - through ScotSID^[25] and the National Confidential Inquiry into Suicide and Homicide^[26] - from which we have identified areas for attention in this strategy; and there is a strong research community in Scotland which is internationally recognised. The work from ScotSID over the last couple of years has given us access to insights and areas for improvement that were simply not available to us previously either nationally or from the international evidence.

All NHS Boards' mental health services carry out individual suicide reviews that examine the circumstances of suicides of patients who were under their care - with the aim of making mental health services safer. Healthcare Improvement Scotland provides a unique resource through the Suicide Reporting and Learning System which analyses these reviews to promote learning and improvement strategies throughout Scotland.^[27] Recommendations from Fatal Accident Inquiries in relation to suicides, including the deaths on the Erskine Bridge,^[28] provide invaluable lessons on suicide prevention.

We want every aspect of suicide prevention to be informed by evidence or, if evidence is not available, at least to be underpinned by an evaluative framework that will yield knowledge on either what works or what does not work. The updated guidance from the Medical Research Council^[29] on developing and evaluating complex interventions provides helpful outline on methodologies and key questions to be taken into account in evaluating any work within health and social care settings.

Knowledge is vital to the work of improving engagement at first point of contact, throughout a person's journey through the health system and into the community. We want our knowledge sources to continue to be world-leading and to contribute substantially to our growing evidence base for suicide prevention.

Commitment 9: We will continue to fund the work of ScotSID and the Scottish element of the National Confidential Inquiry into Suicide and Homicide and we will also contribute to developing the national and international evidence base. In doing so we will work with statutory, voluntary sector and academic partners.

E. Supporting change and improvement

This strategy contains a range of elements covering health and other services, clinical and population interventions and the delivery of improvement through a range of approaches. No one agency has the capability to deliver across this agenda, but each element of the agenda requires support so that change will take place nationally and locally.

We will continue to have a National Programme for Suicide Prevention, hosted by NHS Health Scotland, that supports delivery of those parts of this strategy with a population health dimension - in particular, awareness raising, community activity, resource development and distribution, training and research. As part of its work with Community Planning Partnerships, Community Health Partnerships, Primary Care and voluntary agencies on health improvement and population health, NHS Health Scotland will support ways of improving the contribution to suicide prevention of local work in deprived areas, targeting men and women most at risk.

Commitment 10: NHS Health Scotland will continue to host the Choose Life National Programme for Suicide Prevention. This National Programme, in addition to the functions set out above, will continue to provide leadership and direction for local Choose Life co-ordinators and in respect of other health improvement aspects of suicide prevention.

Commitment 11: We will set up arrangements to monitor progress with implementation of all the commitments in this strategy. This will include an Implementation Board to be chaired by a Senior Manager from the Scottish Government.