Response to the Draft Report Challenging Assumptions; a Purposeful Conversation

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Clifford Stanley
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Response to the Draft Report Challenging Assumptions; a Purposeful Conversation Dear Members of the Oireachtas Committee on Health and Children on Suicide Prevention, I would like to thank the

The National Suicide Research Foundation (NSRF) in Ireland was founded in 1994 by the late Dr. Michael J Kelleher.

1 Response to the Draft Report Challenging Assumptions; a Purposeful Conversation Dear Members of the Oireachtas Committee on Health and Children on Suicide Prevention, I would like to thank the members of the Joint Oireachtas Committee for addressing the issue of suicide prevention and for inviting me to comment on the report prepared by the Rapporteur, Senator John Gilroy. The National Suicide Research Foundation (NSRF) in Ireland was founded in 1994 by the late Dr. Michael J Kelleher. The NSRF is recognised as a major centre of expertise in research into suicide, self-harm and related mental health aspects, both nationally and internationally. The NSRF currently co-ordinates 22 research projects in the area of suicide, self-harm and related mental health issues, including the National Registry of Deliberate Self-Harm, which is funded by the National Office for Suicide Prevention (NOSP). The NSRF works in partnership with the NOSP and other key stakeholders in implementing evidence informed actions at regional and national level, such as the national implementation of Dialectical Behaviour Therapy for people with frequent patterns of repeated self-harm, guidelines for assessment and management of self-harm in Emergency Departments, restricting access to lethal means, and the implementation of guidelines on media reporting of suicide. This report and the discussion to follow from it are timely considering that currently, the National Strategy for Action on Suicide Prevention, Reach Out, is being reviewed, and that plans are in preparation for the next phase of suicide prevention in Ireland, which will be launched by the NOSP later this year. Even though the report does not specify recommendations, I would like to take the opportunity to provide comments as well as recommendations. 1

2 Accuracy of suicide statistics I am pleased to see that the report addresses the need to achieve greater accuracy of suicide statistics in Ireland. Over the years, there has been growing evidence that a certain number of deaths by suicide are recorded under other categories of external causes of death, such as undetermined deaths, accidental drowning and accidental poisoning (NSRF, 2007; Arensman et al, 2012). I therefore would support the proposal to conduct a national survey or a nationally representative survey of Coroners records to establish which deaths might be attributable to suicide, but do not meet the legal standard of proof required at the inquest. It is exactly for these reasons that in recent years the NSRF has piloted the Suicide Support and Information System (SSIS) in Cork city and county with the pilot study being funded by the NOSP. Within both the national and international context, the SSIS can be considered innovative, as this system combines a number of key objectives, such as facilitation of support for people bereaved by suicide, access to real-time information on the incidence of suicide and associated risk factors, and identification of emerging suicide clusters (Windfuhr, 2010). Outcomes of the SSIS revealed that the characteristics of people who died prematurely and were classified by the Coroner as open verdicts were found to be more similar than dissimilar to confirmed cases of suicide (Arensman et al, 2012; 2013). In recent months, the NSRF has also started a review of all external cause of death verdicts in the Dublin region over a period of 2 years (2012 and 2011), in collaboration with Dr Brian Farrell, the Dublin Area Coroner. We are using internationally validated screening criteria to detect probable suicide cases based among the external cause of death verdicts, and these criteria will be further enhanced. This approach could be expanded to Coroners services in other regions in Ireland. In line with recommendations from the World Health Organisation (WHO, 2012), improving national data systems for surveillance of suicide and access to real-time data are fundamental requirements for national suicide preventions strategies. 2

3 Suicide and the economic recession The report covers new outcomes of research recently conducted by the NSRF. While suicide in Ireland showed a decreasing trend between 2003 and 2007, a significant increase in suicide rates was observed between 2007 and 2011 (14%), which was due to an increase in male suicides. We tested if the recession had impacted on the level and the trend of suicide and self-harm between *. We compared the recession-affected rate first with the rate that would have been observed if the pre-recession trend continued and then with the rate that would have been observed if the pre-recession trend levelled off. The number of extra suicide cases ranged from 305 to 560. For self-harm, there was an increase of 12%, and again with the highest increase in men (20%). The number of extra self-harm presentations ranged from 6,464 to 8,862 cases. Further evidence for the impact of the recession on suicide is provided by the SSIS, which shows that among 307 suicide cases examined, 35.8% were unemployed at time of death and 41.6% had worked in the construction/production sector, which was strongly affected by the recession. However, the SSIS also found that among those who had died and who were unemployed at the time of death, nearly half had a history of alcohol and/or drug abuse, and 42% had a history of selfharm (Arensman et al, 2013). Comparing trends in suicide in Ireland to other neighbouring countries, remarkably, Scotland is the only neighbouring country which has not seen a significant increase in suicide during the recession. In fact, suicide rates in Scotland have decreased by 18% between 2002 and 2012 (Scottish Government, 2013). In this context, I would propose to undertake a comparative study involving experts in suicide research and prevention from the 5 nations (Republic of Ireland, Northern Ireland, England, Wales and Scotland), to compare suicide trends, characteristics of the recession, and austerity measures implemented by the different Governments. Austerity measures that may have contributed to increased suicide rates include, reduced access to mental health and community services, not being able to afford treatment, restriction to sickness and disability support etc. Mapping of suicide and self-harm using geo-spatial analysis I am pleased to see that the report underlines the importance of using geo-spatial analyses, such as SaTScan to identify emerging suicide clusters at the earliest stage possible. 3

4 The SaTScan technique has frequently been used to identify clustering and contagion of infectious diseases (Kuldorff, 1997). Last year, we applied this technique for the first time to suicide data obtained through the SSIS and we identified 2 significant clusters of suicide. Applying the SaTScan technique to real-time suicide mortality data from Coroners or An Garda Siochanna based on the information of each suicide cases recorded on Form 104, will facilitate suicide prevention in many ways: 1. Improving early identification of clustering of suicide and self-harm, 2. Identifying geographic areas in Ireland with recurrent suicide and/or self-harm clustering, 3. Identifying area-level and individual factors associated with clustering of suicide and self-harm. Because of the significant and consistent association between trends in non-fatal self-harm and trends in suicide among men, I would also recommend applying SaTScan to the Registry of Deliberate Self-Harm data nationally in order to enable possible prediction of suicide clustering among men in certain areas. Establishment of a national registry of all organisations providing services relating to suicide I fully agree with the proposal to enhance co-ordination and collaboration, and ensure best practice among the organisations working in suicide prevention. The NOSP is currently compiling a directory of quality assured services in suicide prevention and the Irish Association of Suicidology and representatives from the University of Ulster are currently developing guidelines for the accreditation of organisations working in suicide prevention, commissioned by the NOSP. Re-positioning and re-configuring the NOSP at the Department of An Taoiseach and allocated its own budget Considering the importance of multi-sectoral partnerships and collaboration in suicide prevention nationally, there may be benefits in re-positioning the NOSP at the Department of An Taoiseach. Even though the Department of Health has and should maintain a fundamental role in suicide prevention, more prominence of and collaboration with other Departments, such as the Departments of Education, Justice, Social Welfare, Transport and Agriculture is required. This approach would be in line with the WHO Public Health Action for Suicide Prevention (WHO, 2012). Other benefits of re-positioning NOSP at the Department of An Taoiseach include greater autonomy and enhanced political prioritisation of suicide prevention in Ireland. 4

5 Notes: - * The number of suicides and rate per 100,000 for the year 2012 is based on provisional data from the CSO. The final figures for suicide in 2012 have not yet been published by the CSO and are likely to be higher than the provisional figures. - Page 12: Due to significant fluctuations of suicide in small areas, it would not be recommended to calculate suicide rates per 10, Page 22: Replace Form 105 by Form 104 Professor Ella Arensman Director of Research, National Suicide Research Foundation, Adjunct Professor, Department of Epidemiology and Public Health, University College Cork, President, International Association for Suicide Prevention; earensman@ucc.ie 11 th March

Annual Report 2011 National Registry of Deliberate Self Harm

Annual Report 2011 National Registry of Deliberate Self Harm Forum Discussion based on Dr Helen Keeley, Dr Siobhan MacHale, Ms Joan Freeman, Dr Daniel Flynn Facilitator: Ms Susan Kenny Rapporteur: Professor