Development of Connecting for Life Kilkenny. Priority Groups, Risk and Protective Factors

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3 Context for Suicide Prevention International Context National Context Local Context Suicide in Ireland Suicide in Kilkenny Self-Harm in Ireland Self-Harm in Kilkenny Development of Connecting for Life Kilkenny Priority Groups, Risk and Protective Factors National Priority Groups Local Priority Groups National Risk Factors Local Risk Factors National Protective Factors Connecting for Life Kilkenny Strategic Goals, Objectives and Actions Implementation and Monitoring Structure and Roles Monitoring and Evaluation Communication Resourcing Actions

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10 1.1 International Context According to the World Health Organisation (WHO), over 800,000 people die by suicide every year with much more attempting suicide or engaging in suicidal behaviour. See Figure 1 for global suicide facts and figures. Figure 1: World Health Organisation global suicide facts and figures (2) Ireland s overall suicide rate is not high by European comparison. Looking at the total rate of suicide for men and women of all ages in Ireland, the rate in 2014 was per 100,000 population, the 11th lowest rate of suicide among the 32 countries for which 7

11 CONTEXT FOR SUICIDE PREVENTION IN IRELAND AND KILKENNY data was recorded by Eurostat (Figure 2). The highest rate was found in Lithuania (31.51 per 100,000 population) and the lowest in Cyprus (4.5 per 100,000 population). The EU 28 (European Union membership countries) average for 2014 was per 100,000. Figure 2: Suicide rate per 100,000 for males and females, 2014 *1 In Ireland, the suicide rates among young males and females have decreased in recent years. Taking females and males aged years together, the national rate in 2014 was 4.64 per 100,000, the 19th highest suicide rate in this age group across the countries studied (Figure 3). In 2010, Ireland was the 4th highest and in 2013 it was the 6th highest. The highest rate in 2014 was found in Latvia (16.7 per 100,000 population) and the lowest in Liechtenstein. The EU 28 average for 2014 was 4.67 per 100,000 amongst this population age-group. *Death rate of a population adjusted to a standard age distribution. The standardised death rates used here are calculated on the basis of a standard European population (defined by WHO)

12 Figure 3: Suicide rate per 100,000 for males and females aged years by geographic region, 2014 *2 Evidence for suicide prevention, knowledge and awareness In 2014, the Health Research Board (HRB) was asked by the National Office for Suicide Prevention to examine the evidence base for suicide prevention to establish which suicide prevention interventions were successful in reducing suicidal behaviour including suicidal ideation, self-harm, suicide attempts or death by suicide (3). Overall the review found the body of evidence on suicide prevention interventions to be limited. This does not mean that interventions are ineffective, but that there is little evidence of their effect in published papers. However, effective interventions outlined in the HRB review included Cognitive Behavioural Therapy (CBT), Dialectical Behavioural Therapy (DBT) and the restriction of access to suicidal means. Other areas such as telemental health and web-based interventions have only emerged recently so there is not enough evidence to comment on their success. More recently, two major reviews were published in 2016 which synthesise the evidence around suicide prevention: Zalsman et al (2016) and Hawton et al (2016) (4, 5). The outcomes from these studies strengthen the evidence base in several areas of suicide prevention and have been included in *Data presented as the crude death rate from suicide per 100,000 people. Figures should be interpreted with care as suicide registration methods vary between countries and over time

13 CONTEXT FOR SUICIDE PREVENTION IN IRELAND AND KILKENNY the list below. The development of the actions in Connecting for Life Kilkenny has been informed by the findings reported in this systematic review. Taken together, the review of all literature indicated that the following interventions are effective or show promise: Promote public awareness with regard to issues of mental wellbeing, suicidal behaviour, the consequences of stress and effective crisis management Enable early identification, assessment, treatment and referral to professional care of people vulnerable to suicidal behaviour Maintain a comprehensive training programme for identified first responders and frontline healthcare staff (e.g. Gardaí, Emergency Department staff, educators, mental health professionals) Promote responsible reporting of suicidal behaviour by media outlets Promote increased access to comprehensive services, including mental health services and Emergency Departments, for those vulnerable to or affected by suicidal behaviour Provide supportive and rehabilitative services to people affected by suicide/suicidal behaviour Support the provision of therapeutic approaches such as Dialectical Behavioural Therapy and Cognitive Behavioural Therapy to defined population groups e.g. those who repeatedly self-harm Reduce the availability, accessibility and attractiveness of the means for suicidal behaviour Support the establishment of an integrated data-collection system which serves to identify at-risk groups, individuals and situations Allow screening for suicide risk among groups vulnerable to suicide The role of alcohol in suicide and mental health The World Health Organisation (WHO) acknowledges harmful alcohol use as a key risk factor for all types of suicidal behaviour (2). Individuals with a substance use disorder i.e. either a diagnosis of abuse or dependence on alcohol or drugs, are almost six times more likely to report a lifetime suicide attempt than those without a substance use disorder (6). Numerous studies of individuals in drug and alcohol treatment show that past suicide attempts and ongoing suicidal thoughts are common (7, 8). The long term effects of alcohol misuse are likely to be linked to interconnected effects on mood and social processes. Those not actually dependent on alcohol are at risk through the short term effects on mood, cognitive processes and impulsivity. Young 10

14 people appear to be particularly susceptible to alcohol-associated suicidal behaviour and the pattern of drinking especially binge drinking may be of relevance (9). There is substantial evidence in Ireland and internationally of the negative effect of excessive alcohol use on mental health and wellbeing. The My World Survey of young people s mental health in Ireland showed that excessive use of alcohol is associated with poor mental health and wellbeing, with strong links between excessive drinking and suicidal behaviour in young adults (10). A study by the National Suicide Research Foundation (NSRF) of suicides in Cork found that the presence of alcohol and/or drug abuse was confirmed in 60.7% of cases. Among these, 48.6% had abused alcohol, 21% had abused drugs and 27.6% had abused both alcohol and drugs (11). Similarly, Walsh et al (12) found that alcohol consumption had a significant effect on suicide mortality among men in Ireland and is strongly associated with suicide completion in the general population and among young people. In relation to self-harm, the National Self-Harm Registry in Ireland (NSHRI) 2015 found that alcohol was involved in one third of all selfharm cases. Alcohol was associated with more male cases than female cases (34% and 29% respectively) (13). Evidence-based public health policies to reduce the harmful use of alcohol and drugs are required to reduce suicidal behaviour (14). These policies are considered particularly important within populations with a high prevalence of alcohol use, such as Ireland (15). 1.2 National Context The fact that suicide was only decriminalised in Ireland in 1993 says something about a reluctance within the Irish culture to face up to this issue (suicide was decriminalised in Britain in 1961). Since decriminalisation in 1993, there have been significant landmark developments in the area of suicide prevention in Ireland; 1995: A National Task Force on Suicide was established 1998: The Final Report of the National Task Force on Suicide called for the appointment of Regional Resource Officers for Suicide Prevention 2005: Reach Out: National Strategy for Action on Suicide Prevention was published and the HSE National Office for Suicide Prevention (NOSP) was established 2007: The HSE National Office for Suicide Prevention launched the Your Mental Health public awareness campaign 2015: Connecting for Life, Ireland s National Strategy to Reduce Suicide was published, calling for the development and implementation of county-wide suicide prevention plans 11

15 CONTEXT FOR SUICIDE PREVENTION IN IRELAND AND KILKENNY In broad terms, the nature of suicide prevention efforts since 2015 reflects the importance of local communities in nurturing a supportive environment and in responding with compassion and empathy when a death by suicide occurs National Policy Context National policy on suicide prevention guides the delivery and implementation of services. Central to suicide prevention work is the need for evidence-based policies and synergies between and across different areas of policy and practice. Broadly speaking there are three types of policy interventions that address suicide prevention; Universal interventions: these are broad-based policies that directly or indirectly address suicide prevention across the whole population, aimed at improving the health and wellbeing, social and economic inclusion and safety of the population Selective interventions: these are interventions that address specific individuals and groups that are vulnerable to suicide and include the risks associated with alcohol and drugs as well as specific interventions aimed at the training and awareness of front-line responders e.g. professionals who come into contact with vulnerable groups in hospitals and schools Indicated interventions: these are more targeted interventions that focus on specific individuals and groups that have a high risk of suicide because of severe mental health problems and suicidal behaviour These three types of interventions underpin Connecting for Life, Ireland s National Strategy to Reduce Suicide They emphasise different policy approaches aimed at improving the overall health and wellbeing of the population, reaching individuals and groups vulnerable to suicide and providing targeted treatment and programmes for people that are most vulnerable. Connecting for Life, Ireland s National Strategy to Reduce Suicide (16) Launched in June 2015, Connecting for Life is Ireland s national strategy to reduce suicide. It sets out a vision of an Ireland where fewer lives are lost through suicide, and where communities and individuals are empowered to improve their mental health and wellbeing. It is a cross-sectoral strategy with twenty three different lead agencies responsible for actions. Empowering local communities will be key to the success of the strategy. Connecting for Life Kilkenny is the fifth and final local suicide prevention action 12

16 plan to be completed for the South East region, following Wexford, South Tipperary, Waterford and Carlow. The strategy follows on from Reach Out: National Strategy for Action on Suicide Prevention The National Office for Suicide Prevention was set up in 2005 within the HSE to oversee the implementation, monitoring and coordination of the Reach Out strategy. Since 2005, there has been extensive national and international research in relation to suicidal behaviour and effective interventions, while the range of services available to people in emotional distress have developed in terms of access and quality. Despite this progress, since 2005 Ireland s suicide rates remain relatively high and there are particular population groups experiencing significant distress as reflected in rates of both suicide and self-harm. It is likely that the economic recession from 2008 onwards has had an influence on rates of suicidal behaviour. Connecting for Life takes account of the changed landscape in Ireland in relation to mental health and suicide and it provides a comprehensive, cross-sectoral, practical plan that can make a positive difference to the lived experience of people from all population groups in Ireland over the coming years. The successful implementation of Connecting for Life will be underpinned by clear and practical local plans such as this plan for Kilkenny. Connecting for Life will depend on the effective delivery of a broad range of health and social policies and strategies including: A Vision for Change: Report of the Expert Group on Mental Health Policy 2006 (17) A Vision for Change (AVFC) details a comprehensive model of mental health service provision for Ireland. It describes a framework for building and fostering positive mental health across the entire community and for providing accessible, community-based, specialist services for people with mental illness. AVFC builds on the approaches to mental health service provision recommended in previous policy documents. It proposes a holistic view of mental illness and recommends an integrated multidisciplinary approach to addressing the biological, psychological and social factors that contribute to mental health problems. It advocates for a person-centred treatment approach that addresses each of these elements through an integrated care plan that reflects best practice and is agreed with service users and their carers. 13

17 CONTEXT FOR SUICIDE PREVENTION IN IRELAND AND KILKENNY Better Outcomes, Brighter Futures: The National Policy Framework for Children and Young People (18) The purpose of Better Outcomes, Brighter Futures (BOBF) is to coordinate policy across government and to identify areas that, with focused attention, have the potential to improve outcomes for children and young people (0-24 years) and to transform the effectiveness of existing policies, services and resources. The commitments in the framework are drawn from all of government with many current commitments and others that are new. The framework provides a means of ensuring their effective and coordinated delivery. The framework is recognition by government of the need to connect nationally and locally, if we are to effectively use all of the resources available to support our vision for children and young people and recognition that we also need to do more within the resources available. Healthy Ireland A Framework for Improved Health and Wellbeing (19) Healthy Ireland is the national framework for action to improve the health and wellbeing of the people of Ireland. Its main focus is on prevention and keeping people healthier for longer. Healthy Ireland s goals are to: Increase the proportion of people who are healthy at all stages of life Reduce health inequalities Protect the public from threats to health and wellbeing Create an environment where every individual and sector of society can play their part in achieving a healthy Ireland Healthy Ireland takes a whole-of-government and whole-of-society approach to improving health and wellbeing and the quality of people s lives. Reducing Harm, Supporting Recovery - a health led response to drug and alcohol use in Ireland (20) Following on from the National Drug Strategy , Reducing Harm, Supporting Recovery lays out the direction of government policy on drug and alcohol use until The strategy aims to provide an integrated public health approach to drug and alcohol use, focused on promoting healthier lifestyles within society. The vision of the strategy is to create a healthier and safer Ireland and its actions will contribute towards improving the health and wellbeing of the population of Ireland in the coming years. It refers to the link between addiction and recurring mental health problems, particularly 14

18 in young people. It seeks to improve the quality and relevance of service provision for those at higher risk of harm resulting from substance misuse, including those with mental health issues. Recommendations include the development of joint protocols between mental health services and drug and alcohol services to improve outcomes for those with co-morbid addiction and mental health difficulties. Actions in Reducing Harm, Supporting Recovery are closely aligned to Connecting for Life, Ireland s National Strategy to Reduce Suicide The National Traveller and Roma Inclusion Strategy (21) According to the National Traveller and Roma Strategy that has been developed by the Department of Justice and Equality, Travellers and Roma are among the most disadvantaged and marginalised people in Ireland. The strategy states that there is a need for State recognition of Travellers as an ethnic group of the Irish nation, investment by the State is required to implement community based support mechanisms for Travellers and Roma and investment to promote knowledge of and pride in Traveller culture and heritage. The State needs to reinvigorate efforts to ensure that Travellers and Roma interact fully with the public health sector to address some of the underlying health issues that are affecting those communities. The strategy has ten strategic themes including health, where the actions are closely related to those in Connecting for Life, Ireland s National Strategy to Reduce Suicide The suicide rate among Travellers is almost seven times higher than the national rate. This strategy names the following as issues for Travellers and Roma that require action; Dual diagnosis Poor mental health and suicide ideation Culturally appropriate services to respond to mental health needs Targeted interventions and educational materials Communication campaigns to address stigma Evaluation of existing Traveller specific programmes Research into suicide and self-harm in the Traveller and Roma community Availability of suicide prevention programmes e.g. safetalk and ASIST 15

19 CONTEXT FOR SUICIDE PREVENTION IN IRELAND AND KILKENNY 1.3 Local Context Key demographic information for Kilkenny (22) Figure 4: Map of Kilkenny County Kilkenny is a medium-sized county located in South Leinster, covering just less than 2,100 square kilometres. County Kilkenny is part of the southern region and is located within the southern half of the country. The county has direct access to the Irish Sea, through Belview Port on the River Suir and through New Ross on the River Barrow. The River Nore runs through Kilkenny City and the Rivers Barrow and Suir are natural boundaries to the East and the South of the county respectively. Kilkenny City is the largest town in the county and dominates the local economy. It is close to Dublin Airport and other urban centres including Cork, Limerick and Waterford. As part of the local government reforms, County Kilkenny has been divided into four electoral areas and three Municipal Districts, namely Castlecomer, Kilkenny City and Piltown. Kilkenny City is designated as one of nine hubs in the National Spatial Strategy for Ireland As a hub, Kilkenny City is a supporter of gateway growth and a driver of sub-regional development. The population of County Kilkenny in 2016 (based on preliminary data from the Central Statistics Office) is 99,118 with a male and female balance. This shows a population 16

20 growth of 3.9% from the 2011 Census figures where the population was 95,419. Kilkenny as a county enjoys a status of relative affluence. The areas of Kilkenny which have the highest deprivation ratings taken from the Pobal HP Deprivation Index (2011) are Urlingford, Ferrybank, Freshford, Graiguenamanagh, Clogh, Castlecomer, Callan and some areas in Kilkenny City. Overall and to date, targeted work in Kilkenny has been prioritised by taking account of the above data on deprivation. The main industry in Kilkenny comprises wholesale and retail, accommodation, food and manufacturing. Agriculture is also an important sector to the local economy with almost twice the labour force employed in this sector compared to the national average. Tourism is currently a major revenue generator for County Kilkenny and the county has been consistently named as Ireland s second most popular domestic short break destination. The unemployment rate in County Kilkenny is 12.7% compared to the national rate of 12.9 % (CSO 2016), this is a significant improvement on the 2011 rate of 19%. Figure 5: SWOT Analysis for County Kilkenny (Source: Kilkenny LECP) 17

21 CONTEXT FOR SUICIDE PREVENTION IN IRELAND AND KILKENNY Local Policy Context County Kilkenny is part of the HSE Community Health Organisation (CHO) 5, which was established in 2015 as part of the HSE s reorganisation of the country s community health services. Based on the 2016 National Census, the area covered by CHO 5 has a population of 511,070 and includes the counties of Kilkenny, Carlow, South Tipperary, Waterford and Wexford. Integrated primary care, social care, mental health and health and wellbeing is the foundational building block to providing health care in the area with effective clinical pathways and links to other specialist services (substance use, chronic disease, palliative care etc.). Our Community; Our Conversation (23) Our Community; Our Conversation, County Kilkenny s Action Plan for Suicide was County Kilkenny s first action plan for suicide prevention. The plan arose from concerns in the community surrounding the number of suicides that happened in Kilkenny over the previous five years. It was the first time that organisations, individuals and urban and rural communities came together to collaboratively tackle the issue of suicide that was impacting all concerned. The plan was developed using a community based, holistic approach to address environmental factors related to public mental health, known risk factors for suicidal behaviour and how the community responds to suicide. Our Community; Our Conversation was developed in direct consultation with local communities and organisations, local service providers and key organisations with responsibility for mental health. The consultation was meaningful and participatory and aimed to develop appropriate responses to the needs identified by those who have experienced the devastating impact of suicide first hand. The plan was based on four strategic areas; prevention, intervention, postvention and implementation with a number of key objectives under each strategy area. Our Community; Our Conversation is still very relevant and Connecting for Life Kilkenny draws from the learning in the plan. Many of the actions named in the original suicide prevention plan are ongoing and accurately reflect the current landscape in County Kilkenny in relation to suicide prevention. Actions that will continue to be developed and implemented and that are highlighted in both documents include: Dissemination of positive mental health promotion campaigns including public events and seminars Encouragement of open dialogue to reduce stigma Enhancement of relationships with media outlets 18

22 Widespread distribution of information on supports and services Increased availability of mental health promotion programmes for the whole population and priority groups (young people, LGBTI, Travellers, older adults) Accessibility to suicide and self-harm prevention training programmes Ongoing partnerships in relation to mental health with all community, voluntary, private and statutory agencies including schools, third level, Government departments, local businesses, FRCs, youth organisations etc Improved access to supports and services Implementation of emergency/crisis response policies and procedures Enhanced links between communities and primary care and mental health services Better data collection and research related to suicidal behaviour Promotion of existing services and development of new bereavement supports for individuals, families and communities Kilkenny Local Economic and Community Plan (22) The Local Government Reform Act 2014 provided for significant change in the role and structure of local government, particularly in relation to local, economic and community development. The underlying principles of the Kilkenny Local and Economic Plan (LECP) are the promotion and mainstreaming of equality, sustainability of a more resource efficient and inclusive economy, maximising returns, participative planning and community consultation to address social exclusion and the provision of support for the most marginalised. The vision of the LECP is that Kilkenny is a great place to live, work and play; offering its citizens dignity, security and the capacity to participate to their maximum potential. The LECP creates the framework in which this vision can be realised. The framework includes thirteen high level goals, eight are related to economic elements and four relate to community, while one goal straddles both elements. Connecting for Life Kilkenny sits within Goal 13 which is to improve health and wellbeing but it is also relevant to Goals 10, 11 and 12 as these goals address area-based poverty and disadvantage, social exclusion and enhanced community facilities and participation. Goal 13 has two strategic objectives and 21 actions. The strategic objectives are: To ensure the health and wellbeing of all Kilkenny s citizens is maximised To place particular focus and attention on improved health and wellbeing in relation to people with a disability, substance misuse, mental health and suicide, Travellers, ethnic minorities, homelessness and LGBTI 19

23 CONTEXT FOR SUICIDE PREVENTION IN IRELAND AND KILKENNY The Kilkenny LECP names and supports the implementation of a county strategy for suicide prevention to achieve improved awareness of mental health issues, increased uptake of mental health services and enhanced promotion of positive mental health thus reducing the incidence of suicide and self-harm in County Kilkenny. Social Inclusion Community Activation Programme (24) Kilkenny Leader Partnership (KLP) has responsibility for the Social Inclusion Community Activation Programme (SICAP) from The aim of SICAP is to reduce poverty and promote social inclusion and equality in Ireland through supporting communities and individuals using community development approaches, engagement and collaboration. The themes that are central to SICAP are the promotion of an equality framework with a focus on gender equality and anti-discrimination practices, application of community development approaches to achieve participation of disadvantaged and marginalised communities and collaboration with stakeholders to improve how mainstream policies and programmes are delivered to impact more positively on the socially excluded e.g. Connecting for Life Kilkenny. The SICAP goals are very relevant to Connnecting for Life Kilkenny as are the priority groups that are targeted under SICAP by Kilkenny Leader Partnership. Goal 1 is to support communities and target groups to engage with relevant stakeholders in identifying and addressing social exclusion and equality issues, developing capacity of local community groups and creating more sustainable communities. Goal 2 is about supporting disadvantaged individuals to improve the quality of their lives through the provision of lifelong training and labour market supports. In relation to SICAP, the priority groups are named as disadvantaged children and families, young people and women, lone parents, low income households, people with disabilities, Travellers, Roma and the unemployed. South East Traveller Health Unit Strategic Plan (25) The HSE s South East Traveller Health Unit has been delivering services in partnership with community and men s health projects, the voluntary sector and the South East Regional Traveller Health Network since The strategic plan takes a holistic approach to health and emphasises that Traveller health, including mental health, must be considered with reference to the social determinants of health, such as housing, education, employment and access to services. A specific objective of the plan is to bring about change for the better for members of the Traveller community in relation to both mental health and suicide. Its goal is that increased suicide awareness and 20

24 innovative responses supported by the Traveller Men s Health Projects will reduce rates of male suicide by 10%. The strategy goes on to name sixteen actions specifically aimed at men s health and suicide prevention through targeted services, information, referrals, signposting, cultural capacity, empowerment and self-esteem. The National Traveller and Roma Inclusion Strategy, the Traveller Health Unit Strategic Plan and Connecting for Life Kilkenny form a trio of complementary documents that inform and respond to the complex mental health issues experienced by the Traveller community in Kilkenny. The Rainbow Report: LGBTI Health Needs and Experiences and Health Sector Responses (26) The 2015 Rainbow Report explores the experiences of LGBTI (Lesbian, Gay, Bisexual, Transgender and Intersex) people when engaging with the health services in the South East. The report points out that the naming of LGBTI people in health policy in Ireland is still only emerging and developing as a coherent practice. However, it has been sufficient to allow a significant targeting of LGBTI people by services in some instances. Policies in relation to children and in the areas of suicide prevention, mental health, sexual health and drugs have usefully named LGBTI people as a priority group. Practical recommendations in the Rainbow Report complement actions outlined in Connecting for Life Kilkenny in terms of supporting young people who may be vulnerable to experiencing mental health difficulties. Kilkenny Recreation and Sports Partnership Strategic Plan (27) The vision of the strategic plan for Kilkenny Recreation and Sports Partnership (KRSP) is an active, vibrant community vitalised by sports and recreation opportunities that are accessible to all. This will be achieved by working collaboratively with others to empower people and communities across Kilkenny to create an environment that supports lifelong participation in sports and recreation. The guiding principles of this strategic plan are similar to those of Connecting for Life Kilkenny including partnership working and collaboration, inclusion and equality, honesty, integrity and accountability, a strong evidence base, empowerment of communities and maximisation of resources. KRSP strategic plan recognises sport, recreation and physical activity as protective factors for mental health and it also recognises that sport and recreation needs to be accessible to all, particularly those individuals and/or groups that may be at risk in the community. Priority groups identified in the plan include people with disabilities, rural communities, young people, new communities and older adults. 21

25 CONTEXT FOR SUICIDE PREVENTION IN IRELAND AND KILKENNY Kilkenny Age Friendly County Strategy (28) The aims of Kilkenny Age Friendly County Strategy are to improve the health and quality of life for older people in the county, to increase the participation of older people in the social, economic and cultural life of the community and to build upon existing services and supports for older people. During the consultation for the strategy the needs listed below were identified by older people, if those needs are not addressed the mental health of older people is at risk. The needs identified below are very relevant to the development and implementation of Connecting for Life Kilkenny, specifically throughout Goal 3 and Goal 4 where older people are named as a priority group. More volunteering opportunities for older people Meeting places for older people to reduce loneliness and social isolation Support for older people to join and participate in community groups e.g. Active Retirement, the ICA, the GAA County-wide consistency which will require improvement of rural transport links Connection to younger people in the community Education and lifelong learning, particularly in relation to communication and technology Improved transport links to national treatment centres Supports in the home to help older people remain in their own homes and clear information available on alternative options Outreach services for older people South East Strategy to Address Adolescent Substance Misuse (29) There is significant evidence that highlights links between mental health concerns (including suicidal ideation) and the misuse of substances such as drugs and alcohol. The National Working Group 3 recommended a four-tier model of service delivery and is accepted by many service providers as the best model for intervention. Similar to the Hardiker model of family support, these services deal directly with vulnerable young people with low to high level mental health needs and risks. Young people are a key target group in Connecting for Life Kilkenny. The model recommended in the working group report is described in Table 1. 3 Report of the National Working Group on the treatment of those under 18 years old presenting to treatment services with serious drug problems in the South East 22

26 Table 1: Four Tier Model of Service Delivery for Intervention 1.4 Suicide in Ireland The number and rate of suicides in the Republic of Ireland for 2015 was 425 or 9.5 per 100,000 population with males accounting for 335 (79%) or 15.2 per 100,000 population and females 90 (21%) or 4.0 per 100,000 population (30). There is more demographic information available from the 2014 figures with a high suicide rate among males aged between 45 and 54 at 28.2 per 100,000, while the greatest increase was among men aged 15 to 24 years (rate of 23.4 compared to 16.1 in 2013). The highest rate among females was also between ages 45 and 54 years at a rate of 6.9 per 100,000. It is therefore imperative that the focus of suicide reduction is not confined to gender or indeed to a particular age group. Figure 6 outlines the suicide rate per 100,000 population by gender for the period (30). The recession in Ireland appears to have had a significant negative impact on 23

27 CONTEXT FOR SUICIDE PREVENTION IN IRELAND AND KILKENNY rates of suicide in men and on self-harm in both men and women. Research conducted by the National Suicide Research Foundation found that by the end of 2012, the male suicide rate was 57% higher than it would have been had the economic recession not occurred, whereas female suicide was almost unchanged. The rate of male and female self-harm was 31% and 22% higher respectively for the same period. Figure 7 shows the breakdown by age group over the period It is well known that suicide has a widespread and devastating effect on people close to the deceased. A study from a next-of-kin perspective in Northern Ireland (31) found that for every death by suicide, 71 other individuals were affected (16 family members, 31 friends, 10 people in the local community, 13 colleagues and 1 health care professional). Figure 6: Suicide rate per 100,000 by gender, * * Rates for 2016 are provisional and subject to change Figure 7: National rates of suicide by age group * *Rates for 2016 are provisional and subject to change 24

28 1.5 Suicide in Kilkenny The Central Statistics Office (CSO) provides data on deaths by suicide by local government area (30). It is customary to use rates per 100,000 of the population in order to map trends and to compare areas. Reporting deaths from suicide at county level can be problematic, with a significant risk that people can be identified in the data, difficulty defining the population of the area and the relatively big swings in rates if numbers change even minimally. Therefore, three-year age standardised death rates have been used to show trends and avoid bias due to annual fluctuations. Figure 8: Three year moving average death rates by suicide per 100,000 population in Kilkenny and the State; * (30) * Rates for 2016 are provisional and subject to change 1.6 Self-harm in Ireland The term self-harm is used to cover various methods by which people harm themselves non-fatally. Research has shown that people who engage in self-harm are at a greater risk of dying by suicide than those who do not engage in self-harm. Data from the National Self-Harm Registry Ireland (2016) indicates that there were 116,174 self-harm presentations to hospitals in Ireland in the past ten years (13). Data held by the National Self-Harm Registry Ireland (13) suggests that there has been a stabilisation and modest fall in self-harm rates. Between 2011 and 2013, there were 25

29 CONTEXT FOR SUICIDE PREVENTION IN IRELAND AND KILKENNY successive decreases in the self-harm rate. An essentially unchanged rate in 2016 indicates a further stabilisation of the rate of self-harm in Ireland since However, the rate in 2016 was still 10% higher than in 2007, the year before the economic recession. The rate was highest among young people, with the peak rate for women in year olds and for men in year olds. Figure 9: Self-harm statistics at a glance (NSRF 2016) 26

30 Nationally, the rate of self-harm remains higher among women than men. The increase in male rates is particularly worrying because self-harm methods among men tend to involve higher lethality leading to a greater risk of suicide following self-harm among males compared to females. In 2016, the national male rate of self-harm was 184 per 100,000, 1% lower than The female rate of self-harm in 2016 was 229 per 100,000, 3% higher than Since 2007, the male rate has increased significantly, by 14%, whereas the female rate is still 7% higher than In 2016, the only significant change in the rate of hospital-treated self-harm by age was among women aged years, where the rate increased by 17% from 289 to 339 per 100,000. Figure 10: Rates of self-harm per 100,000 population by gender, Methods of Self-Harm Intentional drug overdose was the most common method of self-harm, involved in 67% of all presentations registered in Minor tranquilisers, paracetamol-containing medicines and anti-depressants/mood stabilisers were involved in 35%, 30% and 19% of drug overdose acts, respectively. Attempted hanging was involved in 7% of all self-harm presentations. This is a decrease of 3% from 2015, however, between 2007 and 2016, the proportion of self-harm presentations involving hanging increased by 72%. Cutting was the only other common method of self-harm involved in 27% of all episodes. Cutting was more common in men at 28% than in women at 26%, cutting in women 27

31 CONTEXT FOR SUICIDE PREVENTION IN IRELAND AND KILKENNY increased by 8% in Men who cut themselves more often required intensive, medical treatment which reflects greater severity of cutting in males versus females. Alcohol was involved in just under one third of all cases (31%), a slight decrease from Alcohol was significantly more often involved in male episodes of self-harm than in female episodes (34% versus 29%). Presentations peaked in the hours around midnight and almost one-third of all presentations occurred on Sundays and Mondays. Treatment In 2016, three-quarters (76%) of patients discharged from the presenting ED were provided with an onward referral. In 2016, referrals following discharge included the following: In 34% of episodes, an out-patient appointment was recommended as a next care step for the patient Recommendations to attend their GP for a follow-up appointment were given to 18% of discharged patients Of those not admitted to the presenting hospital, 11% transferred to another hospital for treatment Other services e.g. psychological services, community-based mental health teams and addiction services were recommended in 13% of episodes Self-harm patients who have consumed alcohol are at an increased risk of leaving the ED without being seen. Linking the Self-Harm Registry Ireland data with the Suicide Support and Information Systems (SSIS) suicide mortality data revealed that self-harm patients were over 42 times more likely to die by suicide than persons in the general population (11, 13). Repeated Self-Harm There were 8,909 individuals treated for 11,485 self-harm episodes in In 2016, at least five self-harm presentations were made by 143 individuals. The rate of repetition was broadly similar in men and women (14.8% versus 15%). Repetition varied significantly by age. Approximately 13% of self-harm patients aged less than 19 years re-presented with self-harm in The proportion who repeated was highest, at 18%, for years. An analysis of self-harm rates across the country s 32 HSE regions that were measured illustrates the variation in the overall rate of repetition in Dublin North Central, Dublin North and Dùn Laoghaire had the highest rates of repetition and the lowest rates of repetition were seen in Cavan/Monaghan, Louth and Roscommon (13). 28

32 1.7 Self-Harm in Kilkenny 2016 self-harm rates for Kilkenny/Carlow are higher than the national rate for men and women, 211 and 267 per 100,000 population for males and females respectively. This equates to 133 males and 164 female presentations in numbers. The majority of presentations occurred in the year age group for men and in the year age group for women. In Kilkenny/Carlow, drug overdose was the most common method of self-harm, involved in 61% (n=228) of presentations. Alcohol was involved in 39% (n=145) of presentations. Self-cutting was the only other common method, involved in 34% (n=126) of presentations. There were 32 presentations (9%) involving attempted hanging and 20 presentations (5%) involving attempted drowning. Fewer than 10 presentations involved poisoning. Overall for residents of Kilkenny/Carlow, 12% of presentations left the ED before a next care recommendation could be made. Following their treatment in the ED, inpatient admission was the next stage of care recommended for 46% of presentations, irrespective of whether general or psychiatric admission was intended. Of all selfharm presentations, 36% resulted in admission to a ward of the treating hospital and 10% were admitted for psychiatric inpatient treatment from the ED. In total, 42% of presentations were discharged following treatment in the ED. Notes, Caveats and Interpretation of Suicide and Self-Harm Statistics This is a brief explanation of suicide and self-harm data and the challenges associated with its interpretation. This is important to consider when reading and interpreting suicide and self-harm data. Suicide figures are collected nationally by the Central Statistics Office. When a person dies by suicide, their death is recorded in the statistics of their actual county of residence. While it can be helpful to know the number of people who died locally from a given cause, it is not helpful to compare the numbers of deaths between counties, due to differences in population sizes. It is effective to use rates per 100,000 of the population when reporting on suicide figures as this takes into account the relevant population sizes. When comparing rates it is also recommended to use a three-year moving average to give a more accurate reflection of the rates due to fluctuations in data and population sizes. 29

33 CONTEXT FOR SUICIDE PREVENTION IN IRELAND AND KILKENNY It can also take time for provisional suicide rates to be finalised and there can be significant differences between provisional and finalised rates. The data from the most recent finalised year should always be used when reporting. The information presented in this plan is reflective of 2015 finalised suicide rates as these are the most recent rates available. All 2016 rates of suicide shown in this section are provisional whereas all 2016 rates of self-harm are verified data is also used as there is more demographic detail available from this year. The National Suicide Research Foundation is responsible for the National Self-Harm Registry Ireland. This is a national system of population monitoring for the occurrence of self-harm, taking data from every Emergency Department in the Republic of Ireland. However, this information is likely to provide a large underestimation of actual numbers of cases of self-harm as many people do not attend an ED for episodes of self-harm e.g. an Irish survey found that only 11.3% of teenagers attended hospital after an episode of self-harm and even fewer sought help elsewhere. Self-harm statistics are collected as the number of presentations, though a breakdown of the number of people presenting at hospital and the number of people repeatedly presenting is also recorded. The types of self-harm method(s) are recorded and reflect all means involved in one episode e.g. one person may have used more than one method of self-harm for one episode of self-harm. Statistics on self-harm are collected by the area of residence of the individual and self-harm figures are also recorded for each hospital group. In this plan, information on self-harm rates for Kilkenny is combined with Carlow. 30

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36 2.1 Development of Connecting for Life Kilkenny The development of a suicide prevention action plan for Kilkenny falls under Action within Goal 2 of Connecting for Life, Ireland s National Strategy to Reduce Suicide This action is to Implement consistent, multi-agency suicide prevention action plans to enhance communities capacity to respond to suicidal behaviours, emerging suicide clusters and murder suicide. The plans will be the responsibility of the HSE Mental Health Division and aligned with Community Health Organisation structure, Local Economic and Community Plans and the Children and Young People s Services Committees County Plans. Kilkenny had a suicide prevention plan in place, Our Community; Our Conversation, from 2014 to 2018 that was developed based on widespread community consultation. Individuals, families, community members, organisations from all sectors, priority groups and service providers were all invited to contribute to the plan and they were reengaged to make submissions to inform the development of Connecting for Life Kilkenny. The information presented below is a summary of the needs identified for Kilkenny in relation to suicide prevention and potential actions that will address and respond to those needs. The submission form was based on six themes and a number of questions were posed to garner information on what the key priorities should be for Kilkenny. The themes were; raising awareness, supporting local communities, priority groups, services, safer communities and research and evaluation. The organisations that made submissions to Connecting for Life Kilkenny are listed in Appendix 1 Raising Awareness Q. What can be done to improve the general public s understanding of suicide, mental health and wellbeing and to reduce the stigma associated with suicide? Targeted campaigns for vulnerable groups based on suicide/self-harm trends in particular areas National campaigns tailored for regional/local needs Healthy eating and alcohol awareness campaigns to address risk factors associated 33

37 DEVELOPMENT OF CONNECTING FOR LIFE KILKENNY with mental health The Little Things campaign and annual mental health promotion festivals/events Links with local media and social media for awareness raising and development of media codes of practice Consistent and constant messaging that mental health is as important as physical health More clarity on it s okay not to be okay Mental health assessment tool/checklist for individuals personal use Information sessions/evenings aimed at the whole population Open dialogue to break down barriers and remove stigma Testimonials from individuals based on their own experience of mental health User friendly directory of services, online and hard copy Information hub or one stop shop for mental health Operational planning in every organisation to include mental health Information sharing on good practice among organisations Explore processes in place in communities in the immediate aftermath of death(s) by suicide Challenge public perceptions on what the mental health services do or fail to do Emphasise the importance of prevention as those who engage in suicidal behaviour often do not come into contact with any health services Explore the possibility of introducing suicide prevention at primary school level Supporting local communities Q. How can local communities be supported to prevent and respond to suicidal behaviour? Mental health services in the community should be provided by the state Avoid duplication of services that causes an over reliance on limited resources Additional funding for community based organisations Information and education for communities including young people, parents and volunteers in community groups Establish community response committees and community critical incident response protocols Toolkit for community based organisations to lead discussion after suicide Manage reactionary responses to suicide in a community by widespread signposting to existing, quality services Widespread delivery of training to community groups, frontline staff and all health 34

38 and social care workers including safetalk, ASIST and Understanding Self-Harm safetalk Trainers in the community Support and resource communities to deliver wellbeing, resilience, health and fitness based programmes Engagement with sports organisations Identify, train and support champions in the community Information on and access to therapeutic services; where, how and what? Access to services that address prevention e.g. addiction, stress/anxiety, isolation, poverty, sexuality, mental health in young people particularly through schools Promotion of therapeutic options available through the GP and Primary Care Forums for mental health organisations to come together on a regular basis HSE responses to suicides in the community Dedicated health and wellbeing staff available in every organisation Priority groups Q. What priority groups could be targeted in Connecting for Life Kilkenny? The priority groups identified in the submission process are detailed in Chapter 3. Services Q. What services are currently available to reduce suicidal behaviour and to improve mental health and wellbeing in Kilkenny? GPs and Caredoc Hospitalisation can often be the only option, the Department of Psychiatry (DOP), St. Luke s Hospital, Kilkenny Volunteer Peer Support Programme in the Emergency Department (ED) of St. Luke s Hospital, Kilkenny The HSE Child and Adolescent Mental Health Service (CAMHS) Adult Mental Health Services and Psychiatry of Old Age 24 hr Mental Health Liaison Service Home Based Treatment Service Mental Health Liaison Nurse for Travellers in Carlow/Kilkenny Psychology drop-in services Counselling in Primary Care (CIPC) The Self-Harm Intervention Programme (SHIP) The Bereavement Counselling Service for Traumatic Deaths 35

39 DEVELOPMENT OF CONNECTING FOR LIFE KILKENNY The HSE Regional Suicide Resource Office The Suicide Bereavement Liaison Service (SBLO) The Involvement Centre for Mental Health Service Users and Families/Carers Kilkenny Consumer Panel for Mental Health Services Kilkenny Mental Health Forum Kilkenny Bereavement Support Service Substance Misuse Services, community based and statutory The South East Recovery College Family Carers Support Service Family Resource Centres Voluntary support groups have a strong presence e.g. Aware, Grow, Samaritans Men s Sheds Community groups e.g. Taxi Watch and the Thomas Hayes Trust Buddy Bench Programme Kilkenny Money, Advice and Budgeting Service (MABS) Youth services including Foròige and Ossory Youth which have a range of groups, projects and initiatives that address mental health and associated issues Services Q. What additional services may be required in Kilkenny? Additional in-patient beds in the Department of Psychiatry After care services for individuals leaving hospital/addiction treatment services Substance misuse liaison service in the general hospital Self-harm and substance misuse social workers External/independent supervision and support for frontline service staff Early intervention services The Suicide Crisis Assessment Nursing (SCAN) Service GPs with specialist mental health/suicide prevention training Availability of the Traveller Liaison Nurse on a fulltime basis in Kilkenny A dual diagnosis clinic and related services There is a gap in services for those engaged in suicidal behaviour who do not have a mental illness diagnosis Access to community based mental health services and supports A more integrated approach in the delivery of services Improved access to services and improved delivery may mean that additional services are not required 36

40 Pieta House 24/7 crisis support Mapping and signposting to services needs to be clearer More informal drop-in services with professional support attached e.g. Crisis/Happy Cafe A safe space/hub for young people Specialist training for school Guidance Counsellors and resource staff School Counsellor in all post primary schools Jigsaw Youth Mental Health Service Cost neutral service for year olds outside sporting/alcohol circles A crisis line with volunteers that can be with a suicidal person outside of normal working hours Access to low/no cost counselling Improved transport links for those living in rural areas to access supports Services Q. How can vulnerable people be supported to access these services? Improved mapping and signposting tied to a local information campaign Education and information for community workers/leaders Training for personnel in government departments working with priority groups i.e. The Department of Social Protection, County Council Engagement of vulnerable people through a network of agencies Multi-disciplinary team (MDT) approach to the care of the individual Increased availability of outreach services for vulnerable people Satellite services in rural locations and smaller towns/villages Reduced waiting lists safetalk trained family and community members, training in the workplace Culturally appropriate services for minority groups to improve ease of access Collaborative approach to addressing an individual s mental health on release from mental health services to involve mental health supports, GP and community supports Improved access to medical cards 37

41 DEVELOPMENT OF CONNECTING FOR LIFE KILKENNY Safer communities Q. What can be done to reduce and restrict access to means of suicidal behaviour? Visible promotion of services especially services that can address some of the contributing factors for distress e.g. MABS Social media access by young people needs to be monitored and managed by parents Appropriate supports for young people Sale of alcohol restricted and age limits enforced Safe storage of medication, chemicals etc. Monitoring of high risk areas e.g. woodland, waterways etc. Known black spots should be identified and provided with additional lighting and signage Explore the issue of over-prescribing/repeat prescriptions Engagement with agricultural agencies for prevention Gun licensing enforcement More knowledge of local patterns of behaviour in relation to suicide and self-harm Hard factual information on the effects of certain means e.g. hanging, poisons etc Engagement with Funeral Directors Research and evaluation Q. How can monitoring and research relating to suicidal behaviour, mental health and wellbeing be improved? Qualitative research with GPs and Counsellors on their experience in terms of suicide and self-harm Analysis of gaps in services Questions on suicide/self-harm to be added to research tools in health related organisations Strengthening of data collection in Emergency Departments Monitor self-harm and suicidal behaviour across all groups Access to discussion sites/groups managed by a dedicated social media team Access to national and international research on suicidal behaviour to improve learning Evaluation of recovery based initiatives e.g. the Recovery College South East programmes Improved funding for monitoring and evaluation throughout organisations Exit interviews for people leaving services A narrative/case study completed on every death by suicide to identify common characteristics and patterns that will inform the planning and development of services 38

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44 3.1 National Priority Groups Ireland s overall suicide rate is among the lowest in the Organisation for Economic Cooperation and Development (Eurostat 2015), ranked 11th lowest in 35 member countries. However, particular demographic groups have consistently been shown by both national and international research evidence to have increased risk of suicidal behaviour. To inform Connecting for Life, CSO suicide statistics and data from the NSHRI, as well as research on the incidence of suicide in various population groups were examined to profile the groups most vulnerable to suicide in Ireland. These include people with mental health problems of all ages, people with alcohol and drug problems, people bereaved by suicide, members of the LGBTI and Traveller communities, people who are homeless, healthcare professionals and prisoners. There are other groups with potentially increased risk of suicidal behaviour where the research evidence is either less consistent or limited. These include asylum seekers, refugees, migrants, sex workers and people with a chronic illness or disability. Further research is required for these groups. These priority groups may change over time. There is a significant overlap between many of the groups, and it is important to note that even within a group where there is increased risk only a minority will engage in suicidal behaviour. Over the lifetime of Connecting for Life, other population groups may emerge as particularly vulnerable to suicide. This list of priority groups will be reviewed regularly based on the most up to date evidence. 41

45 PRIORITY GROUPS, RISK AND PROTECTIVE FACTORS 3.2 Local Priority Groups There are a number of groups identified as being most at risk of suicide and self-harm in County Kilkenny. The needs of priority groups are addressed in the local policy context in Section 1 and the submissions received through the local consultation process highlighted further groups that are considered to be most at risk in Kilkenny. There are several specific policy documents for targeted groups i.e. Travellers, LGBTI, older adults and those engaged in substance misuse. The other priority groups listed below are mentioned throughout the policy context. Connecting for Life Kilkenny highlights the need for additional supports both through healthcare services and in the community for these priority groups; Young people Men LGBTI Travellers Older adults People with disabilities Those engaged in substance misuse, including those leaving residential treatment or prison Mental health service users and those who support them Those with co-morbid mental health and addiction difficulties Homeless One parent families Unemployed Survivors of abuse Rural communities including the farming community Those engaged in self-harm Health and social care workers 42

46 3.3 National Risk Factors Suicidal behaviour is complex. There is usually no single cause or risk factor that is sufficient to explain a suicidal act. Most commonly, several risk factors act cumulatively to increase an individual s vulnerability to suicidal behaviour and risk factors interplay in different ways for different population groups and individuals. International research has identified some common risk factors at individual, socio-cultural and situational levels, these are shown in Table 2. Table 2: National individual, socio-cultural and situational risk factors (14) Many of these risk factors have been identified as significant in the Irish context, with different risk factors affecting different population groups in different ways. A review of Irish studies by the NSRF also found specific risk factors for different populations such as young people, unemployed people and marginalised groups like men living in rural communities, members of the Traveller Community and survivors of institutional sexual abuse. The complex interplay of factors, which seem to exacerbate the risk for individuals, is not yet fully understood. 43

47 PRIORITY GROUPS, RISK AND PROTECTIVE FACTORS For a more in-depth understanding of the factors associated with death by suicide onceoff or standalone research studies such as the Suicide Support and Information System (SSIS) operated by the National Suicide Research Foundation is used. Risk Characteristics The first report of the SSIS in 2012 (33) based on 178 cases of Suicide and 12 open verdicts (total 190) in Cork, revealed the following information which shines a light on risk characteristics in Ireland generally. Previous suicidal behaviour 45% had a history of self-harm, of those, 52% had engaged in self harm 12 months prior to suicide, 24% less than a week and 12% less than a day Psychiatric diagnosis Among those who had received a psychiatric assessment (31.4%), 61.1% were diagnosed with mood disorder followed by anxiety disorder (12.9%) Drugs and alcohol 51.7% had abused alcohol and/or drugs in the year prior to death, the majority abusing alcohol (78.1%) Contact with health services In the year prior to death, 81% had been in contact with their GP or a mental health service, among those who had been in contact with the GP, the majority (67.4%) had done so 4 times or more during the year prior to death The second report of the SSIS in 2013 based on 307 consecutive deaths by suicide in Cork City and County (11) revealed further information including the following: Employment and occupation 40.6% were in paid employment, 33.1 % were unemployed, 11.4% were retired, 6.8% were fulltime students, 5.0% had a long term disability and 3.1% were homemakers More than two fifths (41.6%) had worked in the construction/production sector, followed by the agricultural sector (13.2%), sales/business development (8.9%), students (8.2%), healthcare sector (6.6%) and education sector (3.9%) 44

48 Physical illness Out of 165 cases for which this variable was known, 57% of cases had a physical illness. A wide range of illnesses was represented including cancer, chronic back pain, chronic neck pain and coronary heart problems. Of those who had a physical illness prior to death, 38% were in physical pain in the year prior to death and 16.5% had reduced physical capabilities in the month prior to death. 3.4 Local Risk Factors Local risk factors for suicide and self-harm in County Kilkenny that were highlighted in the submission process include unemployment, financial hardship, substance misuse and rural and social isolation. 3.5 National Protective Factors While many interventions are geared towards the reduction of risk factors in suicide prevention, it is equally important to consider and strengthen the factors that have been shown to increase resilience and protect against suicidal behaviour. Research conducted by the World Health Organisation; Preventing Suicide, A global imperative (2014) (2) demonstrates that strong personal relationships, religious or spiritual beliefs and a lifestyle practice of positive coping strategies and wellbeing are protective factors against the risk of suicide. Strong personal relationships Suicidal behaviour increases when people experience relationship conflict, loss or discord. Equally, maintaining healthy close relationships can increase individual resilience and act as a protective factor against the risk of suicide. The individual s closest social circle, partners, family members, peers, friends and significant others have the most influence and can be supportive in times of crisis. In particular, resilience gained from this support mitigates the suicide risk associated with childhood trauma. Relationships are especially protective for adolescents and the elderly who have a higher level of dependency. Religious or spiritual beliefs Faith itself may be a protective factor since it typically provides a structured belief system and can advocate for behaviour that can be considered physically and mentally beneficial. Many religious and cultural beliefs and behaviours may also contribute 45

49 PRIORITY GROUPS, RISK AND PROTECTIVE FACTORS towards stigma related to suicide due to their moral stance on suicide, which can discourage help-seeking behaviours. The protective value of religion and spirituality may occur from providing access to a socially cohesive and supportive community with a shared set of values. Many religious groups also prohibit suicide risk factors such as alcohol use. While religion and spiritual beliefs may offer some protection against suicide, this depends on specific cultural and contextual practices and interpretations. Lifestyle practice of positive coping strategies and wellbeing Personal wellbeing and effective coping strategies protect against suicide. An optimistic outlook, emotional stability and a developed self-identity assist in coping with life s complications. Good self-esteem, self-efficacy and effective problem solving-skills, which include the ability to seek help when needed, can mitigate the impact of stressors and childhood adversities. Willingness to seek help for mental health problems may in particular be determined by personal attitudes. Due to the fact that mental health problems are widely stigmatised, people, especially males, may be reluctant to seek help. Those who are unlikely to seek help can compound their mental health problems, increasing the risk of suicide that may otherwise have been prevented through early intervention. Healthy lifestyle choices that promote mental and physical wellbeing include regular exercise and sport, sleeping well, a healthy diet, consideration of the impact on health of alcohol and drugs, talking about problems, healthy relationships, social contact and effective management of stress. 46

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73 IMPLEMENTATION OF CONNECTING FOR LIFE KILKENNY 5.1 Implementation Structure and Roles A cross-sectoral Implementation Steering Group (ISG) will have responsibility and accountability for ensuring the actions in Connecting for Life Kilkenny are implemented to agreed timeframes and quality parameters. The ISG will also be responsible for sourcing, allocating and managing additional funding for the action plan. A further Oversight Committee will be formed at Community Health Organisation level to support the development and implementation of county suicide prevention plans across the South East, to encourage links between counties in the region and to facilitate a joined up and efficient approach to the development and implementation of the action plans. Ownership of the plan lies with the CHO Mental Health Lead and project management of the implementation of Connecting for Life Kilkenny will be under the direction of the Regional HSE Resource Officer for Suicide Prevention. Below is the proposed structure for the implementation of Connecting for Life Kilkenny. This structure is flexible and open to change based on emerging needs and trends across Kilkenny over the lifetime of the plan. This implementation structure will inform and influence the plans of other agencies and organisations in Kilkenny. It is important that the ISG includes membership of a broad range of organisations to facilitate a cross-sectoral reporting and monitoring approach. Figure 11 shows the local implementation structure for Connecting for Life Kilkenny. Figure 11: Connecting for Life Kilkenny Implementation Structure 70

74 5.2 Monitoring and Evaluation The Connecting for Life Kilkenny ISG will be accountable for the implementation of the action plan. The monitoring and reporting approach will be aligned to the national system for monitoring and evaluation managed by the National Office for Suicide Prevention. 5.3 Communicating Connecting for Life Kilkenny All communications relating to the implementation of Connecting for Life Kilkenny will be the responsibility of the ISG, supported by HSE Communications and the NOSP where required. There are numerous agencies and organisations involved in the delivery of the action plan as lead and key partners and ensuring that there are clear and consistent messages from and to all stakeholders is essential. 5.4 Resourcing Connecting for Life Kilkenny The actions in Connecting for Life Kilkenny are multi-faceted and their implementation will be the responsibility of the HSE and many other organisations where agreement is reached on lead and partner responsibility. This approach will generate outcomes that may not be otherwise achievable if working in isolation and this will provide for a more effective implementation process and more efficient use of resources. Implementing the actions will involve the improved use of existing resources and the need for additional resources. It will be the responsibility of the ISG to identify and seek sources of funding through the appropriate available government funding streams. Alternative sources of funding will also be explored as required. It is envisaged that Connecting for Life Kilkenny which is based on a whole of society approach will provide a strong case for additional funding when and where required. 71

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77 APPENDICES Appendix 1: Acknowledgements In acknowledgement of the work that has gone into the development of this plan, special thanks are given to: The many agencies that took time to make submissions including Foròige, An Garda Sìochàna, GROW, Kilkenny Involvement Centre, Kilkenny Consumer Panel, Kilkenny Leader Partnership, Lifelinkk, Kilkenny MABS, Ossory Youth, the South East Regional Family Support Network and the Thomas Hayes Trust Contributions from the HSE came from HSE Primary Care, HSE Mental Health Services, HSE Substance Misuse and HSE Traveller Mental Health Kilkenny Leader Partnership for its ongoing support of suicide prevention initiatives in County Kilkenny The National Office for Suicide Prevention and HSE Mental Health nationally for providing ongoing guidance and support The Regional Suicide Resource Office for coordination and administration support Tracy Nugent Resource Officer for Suicide Prevention 74

78 Appendix 2: Explanation of Key Terms Families/friends/communities bereaved by suicide People who have been impacted, directly or indirectly, when someone has died by suicide HSE Mental Health services The HSE provides a wide range of community and hospital based mental health services in Ireland, HSE mental health services are delivered through specialist mental health teams from childhood to old age HSE Primary Care services Primary Care Teams comprise of GPs, Public Health Nurses, Occupational Therapists, Physiotherapists, other HSE staff and community representatives Incidence of self-harm/self-harm rates There is a national registry for self-harm presentations to Emergency Departments in General Hospitals that is managed by the National Suicide Research Foundation Mental health and wellbeing Mental health is defined as a state of wellbeing in which the individual realises his or her own potential, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community Mental health problems Refers to a wide range of mental health conditions that affect mental health and impact on mood, thinking and behaviour Mental health promotion Mental health promotion is any action that aims to promote positive mental health among the population and those who are at risk of experiencing mental health problems Mental health service user A person that uses the mental health services 75

79 APPENDICES Non-statutory and community organisations Community, voluntary and non-government agencies, services, organisations and groups People/groups vulnerable to suicide People/groups that may experience more of the risk factors for suicide People at acute risk of suicide/self-harm People who are at high risk of suicide or self-harm, may experience frequent, intense and enduring thoughts of suicide or self-harm or high distress or have specific plans, people/groups that are vulnerable to self-harm or people/groups who are more susceptible than other people/groups to the possibility of self-harm Priority groups In Connecting for Life and Connecting for Life Kilkenny, priority groups refer to the population groups identified as vulnerable to suicide in Ireland, over the lifetime of the strategy other population groups may emerge as particularly vulnerable to suicide Protective and risk factors In general, risk factors increase the likelihood that suicidal behaviour will develop, whereas protective factors reduce this likelihood, in relation to mental health, protective factors include secure family attachments, having one supportive adult during early years, positive early childhood experiences, good physical health, and positive sense of self, effective life and coping skills, risk factors include physical illness or disability, family history of psychiatric problems, family history of suicide, low self-esteem, social status and childhood neglect Reducing suicide/reducing self-harm Reducing suicide or self-harm means lowering the number of deaths by suicide or the number of self-harm incidents Resilience Resilience is the ability to cope with adverse or challenging circumstances Responding to a suicide attempt A response or intervention to support someone who attempts suicide 76

80 Responding when someone has died by suicide/postvention Responding to suicide refers to the response or intervention to support relatives, friends and communities after someone dies by suicide Self-harm Self-harm describes the various methods by which people harm themselves, varying degrees of suicidal intent can be present and sometimes there may not be any suicidal intent, although an increased risk of further suicidal behaviour is associated with all self-harm Social exclusion Social exclusion refers to being unable to participate in society because of a lack of access to resources that are normally available to the general population. It can refer to both individuals, and communities in a broader framework, with linked problems such as low incomes, poor housing, high-crime environments and family problems Stigma reduction Stigma reduction refers to the process of minimising negative beliefs associated with different types of mental health problems; it brings about a positive change in public attitudes and behaviour towards people with mental health problems Suicide/die by suicide Suicide is death resulting from an intentional self inflicted act Suicide attempt/attempted suicide/someone who has attempted suicide A suicide attempt means any non-fatal suicidal behaviour, when someone has the intent to take their own life Suicidal behaviour Suicidal behaviour refers to a range of behaviours that include planning for suicide, attempting suicide and suicide itself, for the purpose of this plan, the term suicidal behaviour also refers to self-harm (see above for a full definition of self-harm) Suicide prevention/help prevent suicide Suicide prevention aims to diminish the risk and rates of suicide, it may not be possible to eliminate the risk of suicide entirely but it is possible to reduce this risk 77

81 APPENDICES Targeted approach A targeted approach focuses on identifying the smaller number of people who are vulnerable to suicide and/or self-harm and putting appropriate interventions in place Whole-population approach A whole-population approach focuses on suicide prevention for all members of society and it aims to reduce suicidal behaviour by addressing the risk and protective factors at individual, family, community and societal levels 78

82 Appendix 3: Abbreviations A&E/ED AVFC BOBF CAMHS CAREDOC C&V CBT CfL CHO 5 CIPC CSO CYPSC DAFM DBT DES DJE DoH DoP DSP ETB FRC GP HI HRB HSE HSE Comm. HSE H&W Accident and Emergency/Emergency Department A Vision for Change Better Outcomes, Brighter Futures Child and Adolescent Mental Health Services Out of hours Doctor service Community and Voluntary Cognitive Behavioural Therapy Connecting for Life Community Health Organisation Area 5 (Waterford, Wexford, Carlow, Kilkenny and South Tipperary) Counselling in Primary Care Central Statistics Office Children and Young People s Services Committee Department of Agriculture, Food and Marine Dialectical Behavioural Therapy Department of Education and Skills Department of Justice and Equality Department of Health Department of Psychiatry Department of Social Protection Carlow/Kilkenny Education and Training Board Family Resource Centre General Practitioner Healthy Ireland Health Research Board Health Service Executive Communications Health and Wellbeing 79

83 APPENDICES HSE MH HSE PC HSE THU IAS ISG IT Carlow Kk. Co. Co. KLP KRSP LCDC LECP LGBTI Lifelinkk MABS MDT MECC NCS NEPS NGO NOSP NSHRI NSRF NUI OECD ROSP SAOR SBLO SCAN Mental Health Primary Care Traveller Health Unit Irish Association of Suicidology Implementation Steering Group Institute of Technology Carlow Kilkenny County Council Kilkenny Leader Partnership Kilkenny Recreation and Sports Partnership Local Community Development Committee Local Economic and Community Plan Lesbian, Gay, Bisexual, Transgender and Intersex Kilkenny inter-agency group for mental health and wellbeing Money Advice and Budgeting Service Multi-disciplinary team Make Every Contact Count National Counselling Service National Educational Psychology Service Non Governmental Organisation National Office for Suicide Prevention National Self-Harm Registry Ireland National Suicide Research Foundation National University of Ireland Organisation for Economic Cooperation and Development Resource Officer for Suicide Prevention Alcohol Screening and Intervention Model Suicide Bereavement Liaison Service Suicide Crisis Assessment Nursing Service 80

84 SERDATF SERFSN SHIP SICAP SME SSIS Tusla WHO WIT South East Regional Drug and Alcohol Task Force South East Regional Family Support Network Self Harm Intervention Programme Social Integration and Community Activation Programme Small and Medium Enterprises Suicide Support and Information System The National Child and Family Agency World Health Organisation Waterford Institute of Technology 81

85 APPENDICES Appendix 4: References 1. World Health Organisation (2004). Promoting Mental Health: Concepts, Emerging Evidence, Practice. Geneva. 2. World Health Organisation (2014). Preventing suicide: A Global Imperative. Geneva. 3. Health Research Board (2015). Suicide Prevention: An evidence review. Dublin. 4. Zalsman, G., Hawton K., Wasserman, D., Van Heeringen, K., Arensman, E., Sarchiapone, M., Carli, V., Höschl, C., Barzilay, R., Balazs, J., Purebl, G., Kahn, JP., Sáiz PA., Bursztein Lipsicas, C., Bobes, J. et al (2016). Suicide prevention strategies revisited: 10-year systematic review. Lancet Psychiatry. 5. Hawton, K., Witt, KG., Taylor Salisbury, TL., Arensman, E., Gunnell, D., Hazell, P., Townsend, E., Van Heeringen, K. (2016). Psychosocial interventions following selfharm in adults: a systematic review and meta-analysis. Lancet Psychiatry. 6. National Office Suicide Prevention (NOSP) (2014). Policy Paper on Suicide Prevention: A review of national and international policy approaches to suicide prevention. Dublin 7. Ilgen, M., Kleinberg, F. (2011). The link between substance abuse, violence and suicide. Psychiatric Times. Available at 8. Roy, A. (2001). Characteristics of cocaine dependent patients who attempt suicide. The American Journal of Psychiatry. 9. Brady, J. (2006). The Association between Alcohol Misuse and Suicidal Behaviour. Alcohol and Alcoholism. 10. Dooley, B., Fitzgerald, A. (2012). My World Survey: National Study of Youth Mental Health in Ireland. Dublin: Headstrong and UCD School of Psychology. 11. Arensman, E., Wall, A., McAuliffe, C., Corcoran, P., Williamson, E., McCarthy, J., Duggan, A., Perry, IJ. (2013). Second Report of the Suicide Support and Information System. Cork: The National Suicide Research Foundation. 12. Walsh, B., Walsh, D. (2010). Suicide in Ireland: The Influence of Alcohol and Unemployment. Dublin: Mental Health Commission; Report No.: WP10/ Griffin, E., Arensman, E., Dillon, CB., Corcoran, P., Williamson, E., Perry, IJ. (2016). National Self-Harm Registry Ireland Annual Report Cork: National Suicide Research Foundation. 14. World Health Organisation (2012). Public Health Action for the Prevention of Suicide: A Framework. Geneva. 15. Mongan, D., Long, J. (2016). Alcohol in Ireland: consumption, harm, cost and policy response. Dublin: Health Research Board. 16. Government of Ireland. (2015). Connecting for Life: Ireland s National Strategy to Reduce Suicide Dublin. 82

86 17. Department of Health and Children. (2006). A Vision for Change: Report of the Expert Group on Mental Health. Dublin. 18. Department of Children and Youth Affairs. (2013). Better Outcomes, Brighter Futures: The National Policy Framework for Children and Young People. Dublin. 19. Department of Health and Children. (2013). Healthy Ireland: A Framework for Improved Health and Well-being Dublin. 20. Department of Health. (2017). Reducing Harm, Supporting Recovery-a health led response to drug and alcohol use in Ireland, Dublin. 21. Department of Justice and Equality. (2017). The National Traveller and Roma Inclusion Strategy, Dublin. 22. Kilkenny County Council. (2016). Kilkenny Local and Economic and Community Plan Kilkenny. 23. Lifeline Kilkenny (2014). Our Community; Our Conversation, County Kilkenny Action Plan for Suicide Prevention Kilkenny 24. Kilkenny Leader Partnership (2018). Social Inclusion Community Activation Programme Kilkenny. 25. Health Service Executive. (2015). South East Traveller Health Unit Strategic Plan Ireland. 26. Health Service Executive. (2015). The Rainbow Report: LGBTI Health Needs & Experiences and Health Sector Responses. Ireland. 27. Kilkenny Recreation and Sports Partnership. (2015). Strategic Plan Kilkenny Age Friendly Alliance (2010) Kilkenny Age Friendly County Strategy South East Strategy to Address Adolescent Substance Misuse 30. Central Statistics Office (2017) Retrieved from CSO website: statistics/birthsdeathsandmarriages/ 31. Mallon,S., Galway,K., Leavey, G., Randon-Sulbaran, J. (2015)Towards an understanding of the role of bereavement in the pathway to suicide. European Psychiatry, 41, S293-S OECD (2017) Available at: National Suicide Research Foundation. (2012). First Report of the Suicide Support and Information System. Cork 83

87 APPENDICES Appendix 5: Services in Kilkenny 84

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