Mental health problems are a significant risk factor for suicide. Most diagnosed mental illnesses are associated with an increased suicide risk. Suicide prevention is often only seen as an issue for mental health services. However, the Report of the National Confidential Inquiry into Suicide and Homicide with Mental Illness (Appleby et al 1999) suggest only one in four people who took their own lives (about 1,000 each year) had been in contact with specialist mental health services in the year before their death. More recent data suggests this is approximately one-third (NCISH 2018; NICE 2019). Arsenault-Lapierre et al (2004) carried out a systematic review of a sample of people who died by suicide and found 87.3% had a history of psychiatric disorders. They also found that men and women who end their life by suicide have a different psychiatric profile and that the relative proportion of psychiatric disorders in people who die by suicide tends to vary according to geographical region.

Clinical depression is a strong predictor of suicide and attempted suicide (Cheng et al 2000; Harwitz 8c Ravizza 2000). Although considerable research has been carried out into the relationship between depression and suicide, depression is too general a category to have clinically meaningful predictive value (Westermeyer et al 1991). Other mental health conditions also have a high risk of suicide such as Emotionally Unstable Personality Disorder (EUPD) (Soloff et al 2000), psychosis (Westermeyer et al 1991) and gender identity disorder (di Ceglie 2000), irrespective of co-existing rates of depression (Soloff et al 2000). Patients most at risk are those with a combination of risk factors, such as people with high-risk mental health problems (major depression, EUPD and/or substance misuse) who then experience loss (Cheng et al 2000). Self-harm and substance misuse have both been identified as significant risk factors for suicide (see below). EUPD is the diagnosis with the highest risk of suicide, followed by depression, bipolar disorder, opioid use and schizophrenia (Chesney et al 2014). One study found that 73% of patients with borderline personality disorder (EUPD) have attempted suicide, with the average patient having 3.4 attempts (Soloff et al 2000). Anorexia nervosa has the highest standardised mortality rate of any psychiatric disorder and approximately one in five patients dies from suicide, not starvation (Arcelus et al 2011).

Although suicidal behaviour is strongly associated with mental disorders, there is no simple linear relationship between the two. Leboyer and colleagues (2005) noted that suicidal thoughts and behaviour may constitute an isolated psychological phenomenon, partially independent from other expressions of psychopathology (Ahrens 8c Linden 1996; Ahrens et al 2000). The vast majority of people with mental disorders do not attempt suicide (O’Connor 8c Nock 2014).Thus, psychiatric disorders as risk factors for suicidal behaviour have only limited predictive power (Nock et al 2010). Further, there is minimal evidence that treating mental illness reduces suicidality. Whilst medication has undoubtedly helped many people who suffer with mental health problems, there is extensive evidence that targeting and treating mental disorders has little or mixed impact on suicidal risk (Cuijpers et al 2013; Braun et al 2016; Jakobsen et al 2017). Despite the widespread use of medication, there is fairly limited data (based on randomised controlled trials [RCTs]) about the efficacy of medicine in reducing suicidality (Zalsman et al 2016).

Given that suicidality does not exclusively arise in the context of preexisting mental health problems, an additional challenge for suicide prevention is appropriate provision for those with non-mental-health- related needs (Windfuhr 8c Kapur 2011). Individuals with suicidality present with a variety of needs that are not exclusively mental-health- based, including societal, community, relationship and individual risk factors (Turecki 8c Brent 2016).

Self-harm and suicide

Self-harm is the single biggest indicator of suicide risk, with around half of people dying by suicide having a history of self-harm at some point in their life (Foster et al 1997). Following an act of self-harm, the rate of suicide increases to between 50 and 100 times the rate of suicide in the general population (Owens et al 2002; Hawton et al 2003) within the year following self-harm (Chan et al 2016). Different studies find differing rates for this association for men and women (Hawton et al 2003; Cooper et al 2005). Hawton et al found the risk increases greatly with age for both men and women. A large study by Klonsky et al (2013) also found NSSI (and suicidal ideation) was a very robust predictor of suicide attempts. They suggest NSSI may be a uniquely important risk factor for suicide because it is associated with both increased desire and capability for suicide.

The relationship between self-harm and suicide is complex. Mental health staff often under-rate suicide risk in patients who self-harm repeatedly. People may indeed self-harm repeatedly but not attempt suicide. Only a small percentage of people who self-harm attempt suicide (Carroll et al 2014). A person who self-harms does not typically intend to die by suicide but does so for a variety of reasons and with a variety of intentions, not always with suicidal intent. Self-harm may be viewed as lying on a continuum of suicidal behaviour, with death by suicide at the extreme end of the continuum (Stanley et al 1992; Kapur et al 2013).There is growing evidence of a distinction between NS SI, suicidal ideation and suicide attempts (Mars et al 2019). In 2018 in the United Kingdom, as in previous years, the most common method of suicide for both males and females was hanging, suffocation or strangulation (all grouped together), and, second, poisoning - usually drug overdose (ONS 2019). These differ from the most common forms of non-fatal self-harm (cutting or burning). However, many individuals engage in both behaviours (Jacobson et al 2008; Klonskv et al 2013). Repeatedly injuring oneself intentionally, causing pain, bleeding or scars, is clearly likely to erode the natural aversion to pain and avoidance of harm that helps prevent us acting on suicidal thoughts or urges. For this reason, any self-harm is targeted as a potentiality life- threatening behaviour in dialectical behaviour therapy (DBT) (Linehan 1993). Self-harm may result in an accidental death or escalate and result in death. A suicide mitigation approach recognises that self-harm increases the likelihood of future suicide, which is why every episode of self-harm needs to be taken seriously. Early identification and intervention can minimise distress and reduce the likelihood of such a coping mechanism becoming established and entrenched.

A thorough risk assessment is important for any individual who presents to services with self-harm (NICE 2011). It is important to identify if the self-harm ever requires medical intervention (which indicates escalated risk) or if the person could end their life incrementally, for example moving from minor cutting to cutting an artery or self-harming when under the influence of drugs and alcohol. The National Confidential Inquiry into Suicide and Safety in Mental Health (2018) highlighted that recent self-harm is increasingly common as an antecedent of suicide in people with mental health problems but may not be given sufficient weight at assessment. The enquiry concluded that protocols for managing self-harm in patients who are under mental health care should highlight the shortterm risk (NICE 2019).

To conclude, self-harm (which includes intentional self-poisoning or self-injury) is common, often repeated and associated with suicide. This highlights the importance of early intervention after an episode of self-harm in suicide prevention. Cooper et al (2005) suggest treatment should include attention to physical illness, alcohol problems and living circumstances. In 2010, the Royal College of Psychiatry report on Self-harm, Suicide and Risk recommended the provision of evidence-based psychological therapies for people who self-harm, which sadly, ten years later, many services still lack. In a Cochrane review of treatment for self-harm, Hawton et al (2016) conclude that Cognitive Behaviour Therapy (CBT)-based psychological therapy can result in fewer individuals repeating self-harm. In a study by Birkbak et al (2016), psychosocial therapy after deliberate self-harm led to reduced deaths, including deaths by suicide.

Goodpractice point

All localities should have a treatment pathway for people who self-harm. The absence of this can unintentionally promote some individuals to escalate their self-harm to access care. A minority of people self-harm as an alternative to suicide, as if they were buying off acting on suicidal urges via a lesser action. These individuals usually have complex mental health needs and should be screened for EUPD and, if indicated, offered a more comprehensive evidence- based treatment such as DBT.

Substance use and suicide

Alcohol dependence and alcohol intoxication are important risk factors for suicidal behaviour (Padmanathan et al 2020). Harris and Barraclough (1997) found those who had abused alcohol were at six times greater risk for dying by suicide than those who had not abused alcohol. Forty-five and thirty-three per cent of those who died by suicide in England whilst in contact with services have a history of alcohol or other drug misuse respectively (Oates 2018). The National Confidential Inquiry into Suicide and Safety in Mental Health (2018) estimated the collective figure as 57%.

Although alcohol and drug misuse are implicated in a high proportion of suicides, this association is not found in every country (Sher 2006). The inconsistent results of the relationship between alcohol use and suicide in epidemiological studies indicate that multiple socio-cultural and environmental factors influence suicide.

High rates of positive blood alcohol concentrations have been found in 33-69% of people who die by suicide (Hufford 2001; May et al 2002). Alcohol intoxication increases suicide risk up to 90 times, in comparison with abstinence from alcohol if one has suicidal ideation (Hufford 2001). Hufford distinguished the time impact of substance use as a risk factor for suicide. Distal risk factors create a statistical potential for suicide. Alcohol dependence, as well as associated comorbid psychopathology and negative life events, act as distal risk factor for suicidal behaviour. Proximal risk factors determine the timing of suicidal behaviour. The acute effects of alcohol intoxication act as important proximal risk factors for suicidal behaviour among both those who are alcohol-dependent and non-alcohol-dependent.

Alcohol and substance abuse problems contribute to suicidal behaviour in several ways (Padmanathan et al 2020). People dependent on substances often have a number of other risk factors for suicide. They are likely to have social and financial problems and/or be depressed. Substance use can lead to unemployment, social isolation and marginalisation. Alcohol and drug problems disrupt someone’s relationships and social support. The abuse of alcohol or drugs secondary to depression is arguably the most frequent risk factor for suicidal behaviour. The risks increase if Substance Use Disorder (SUD) co-occurs with depression (major depressive disorder) or other mental health disorders such as Post-Traumatic Stress Disorder (PTSD), anxiety disorder, bipolar disorder, schizophrenia and some personality disorders.

Substance use and abuse can be common in people prone to be impulsive or engage in many types of high-risk behaviours that result in self-harm. Substance use can induce negative affect or emotions and influence cognition and behaviour, which may result in disinhibition, impulsivity or impaired judgement and problem-solving skills. Pain, distress and psychiatric disorders increase the likelihood of both SUD and suicide (Esang Sc Ahmed 2018; Bohnert Sc Ilgen 2019). Drugs and alcohol can also be used as a means to ease the distress associated with attempting suicide (Brady 2006). Unlike other risk factors, substance use may respond to interventions (DOH 2012). In light of these specific mechanisms, Padmanathan and colleagues suggest it cannot be assumed that interventions targeting suicide and self-harm reduction in the general population can be applied to people with substance use problems who may need more specific strategies.

Goodpractice point

Because alcohol and drug addiction are leading risk factors for suicidal behaviour and suicide, anyone presenting for one problem should be assessed for the other. The identification of alcohol and drug use and dependence is critical to the proper assessment of suicide risk. Comorbid substance use should always be addressed in the treatment of suicidal patients regardless of severity, as it reduces the threshold for suicidal action or shortens the length of time between the final decision to make a suicide attempt and the act itself, i.e. the presence of alcohol or drug use narrows the window for intervening effectively in a crisis.

This is a helpful document ‘Working with the client who is suicidal: a tool for adult mental health and addiction services (2007). Produced by the Centre for Applied Research in Mental Health and Addiction (CARMHA); and is available at: download?doi=

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