Suicide Prevention – another casualty in the Stormont stalemate
The latest draft of the Suicide Prevention Strategy known as Protect Life 2 has gone in to abeyance as a result of the fall of the Stormont Executive. Although there were over 100 responses to the draft document and civil servants continue to work on these to recommend a final plan, we are unlikely to see the final document until a new Health Minister is in place.
In Northern Ireland the desire for a plan that reduces the number of suicides has been around since the early 2000s but it is a story characterised by struggle. In the early days when families bereaved by suicide and their activist colleagues lobbied for a strategy not everyone embraced the idea wholeheartedly.
One senior figure in the public health organisation that preceded the current Public Health Agency claimed that a suicide Prevention strategy would divert vital resources from more worthy areas like the care of neo natal babies.
Over the years since there have been attempts by policy makers to merge the suicide prevention strategy with a mental health promotion strategy. It was opposition by members of the Suicide Strategy Implementation Body that saw off the first attempt. Credit for seeing off the second attempt goes to Families Voices Forum with strong support from academics working in the suicide prevention field. There are fears that a plan to merge health promotion and suicide prevention strategies will re-emerge when the final Protect Life 2 document is unveiled.
The concern about merging the strategies come from feelings that suicide prevention would not be given the priority it deserves and that suicide is such an important phenomenon that it required a discrete action plan.
A strategy by definition is about getting us where we are to where we want to be. If we want to see a 10% reduction in suicide deaths, then based on the latest figures (2015: 318) that would bring the deaths down to 276 per year and a 20% reduction would bring the number down to 254.
It should be noted that suicide deaths here are four times the number of road deaths. The current road safety campaign “Sharing the Road to Zero” aims to bring road deaths to an end. There are those who believe that a similar “Down to Zero” approach should be applied to suicide deaths
Suicide however is a taboo subject surrounded by a lot of stigma. Dr Thomas Joiner, an eminent researcher in the area of suicide, has pointed to the two elements of stigma - fear and ignorance. He believes it is essential that we keep the fear that surrounds suicide but shatter the ignorance.
In Scotland direct and open talk about suicide has been encouraged with a campaign that encourages people not to hide suicidal feelings but talk about them. The strategy for suicide prevention in Scotland called Choose Life also includes a campaign to dispel the myths that surround suicide and enable people to have conversations that may seem difficult.
This contrasts with the situation in Northern Ireland where there is no specific suicide prevention public information campaign. Instead the current approach centres around help seeking in the context of mental ill health. Mental illness and suicide are not synonymous and mental illness doesn’t kill people but suicide does.
It seems important that the actual magnitude of suicide is more widely known with attention drawn to the comparison with road traffic deaths. Perhaps if the public fully understood that four times as many people die by suicide here every year there may be a stronger public demand for a more urgent response to this phenomenon.
One key area of improvement is in the GP/Primary care arena. Recent research commissioned by PHARD and carried out by Ulster University has found “widespread acknowledgement that GPS are ill prepared for the management of mental illness” .This was compounded by pressure from the waiting rooms and due to waiting lists alongside the short time - `ten minute rule` in which to see patients like these with complex problems.
Another piece of research from Ulster University published at the same time called for raining for GPs and other practitioners in Primary Care that better enabled the identification and confirmation of suicidal thoughts
A systematic approach to training a GP could meet this need. The time commitment would be two days for two staff and a half day Practice Based Learning session of three hours for the remainder including the GPs. On completion the practice would be skilled to identify and provide suicide first aid to those who present to the surgery. This systematic approach would provide means to identify suicide in a way that builds engagement and trust and are not of the “formulaic” type that GPs in the first study were critical of.
There are further suicide prevention opportunities amongst the people most easily identified as at risk of suicide. These people are those who have lost a family member or friend to suicide and those who have survived a suicide attempt.
Although there are Trust led services in each area to help the bereaved by suicide the uptake of these services varies. In the Belfast Trust it has been found to be 50% uptake.
The attitude of the first responder has, in other countries, been found to be the key factor in whether or not a family accepts the help offered. Perhaps it time to review the Police/SD1 process and consider if another approach would ensure a greater uptake of help.
Many people who survive a suicide attempt are currently being offered care under schemes that are termed self-harm services. Each Trust area has contracted with a provider to receive referrals from their respective Trust mental health services. The term self-harm is misleading in this context. People self-harm for a number of reasons but their intention is to stay alive. To group people who had the intention to end their lives with those who didn’t doesn’t help either group. There is a need to differentiate the response to meet the different needs of both these groups.
Promising approaches for those have survived a suicide attempt include a group work approach called Skills for Safer Living. The approach was developed in Toronto and has also been applied successfully with groups in Dublin.
For workers who work with those previously at risk of suicide a promising new training programme is being offered by LivingWorks Education who also developed the ASIST ( Applied Intervention Skills Training Programme) and safeTALK (Suicide Alertness For Everyone).This new programme is called Suicide to Hope and is set in the recovery milieu
The number of people dying by suicide in Northern Ireland continues to increase year on year despite the efforts of all involved in this field.
One wonders if the political will to treat this phenomenon urgently exists. Suicidal people and those left behind after a suicide are stigmatised and marginalised. They need political champions and courageous advocates.
Recent research conducted here points to the need to train GPs and those in Primary Care in the careful identification and emergency care of the suicidal. Evidence from other places like Scotland suggests that we are not being bold enough in our public information campaigns. There is evidence too that the gatekeeper training which is acknowledged as one of the key factors in reducing suicide, is actually declining in Northern Ireland.
The care of bereaved by suicide and those who survive a suicide attempt need to be reviewed. There is a need to ensure response times are standardised and that the follow up care comes from as wide a range of options as possible.
The new Protect Life2 Suicide Prevention Strategy should set out where we need to get to in terms of suicide prevention and we need to be aiming for zero deaths.
Pat McGreevy is a retired Health Service manager, chair of the Downpatrick Area Suicide Prevention Taskgroup and Secretary of the Suicide Down to Zero charity.
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