Suicide, mental health and wellbeing: Taking a population approach

Suicide, mental health and wellbeing: Taking a population approach Dr Jonathan Campion Visiting Professor of Population Mental Health, University College London Director of Public Mental Health, South London and Maudsley NHS Foundation Trust East of England Managed Clinical Network 15 th October 2013

Overview Policy context Population mental health approach to suicide/ self-harm Levels of suicide and self-harm Risk and protective factors for self harm and suicide Higher risk groups Interventions to prevent mental disorder and promote wellbeing also reduce suicide/ self-harm Assessment of local provision of public mental health interventions ti at primary, secondary and tertiary ti levels l Summary

Some policy context

Policy context of suicide prevention Cross-Government suicide prevention strategy HMG, 2012) highlights improvement of mental health of whole population with a universally proportionate approach facilitating greater access to interventions for higher-risk groups Emphasises: reducing suicide risk in high risk groups improving mental health in specific groups reducing access to lethal means

Policy context of mental health and wellbeing Public Health White Paper (DH, 2010) places mental health and wellbeing 'at the heart' of new system and highlights key role of DsPH in public mental health Current mental health strategy (HMG, 2011) adopts twin track approach to: Promote mental wellbeing and prevent mental disorder to the whole population Offer early treatment to people with mental disorder

A population approach to suicide and self harm which integrates mental health and wellbeing

Population mental health approach Outlined in JCPMH public mental health commissioning guidance (Campion & Fitch, 2012) Applied to 700,000 population in East Midlands Information highlights key opportunities for action at primary, secondary and tertiary levels of promotion and prevention

Population mental health approach to suicide and self-harm 1) Intelligence on population level of suicide and selfharm 2) Intelligence on population levels of risk factors for suicide id and self-harm including levels of mental disorder and wellbeing numbers from higher h risk groups protective factors against suicide and self-harm including levels of mental wellbeing 3) Intelligence on coverage of interventions to prevent suicide/ self-harm at primary, secondary and tertiary levels

1) Local levels of suicide and self-harm

Levels of suicide and self-harm Important to measure at local level Varies according to level of risk factors and higher risk groups Informs the required level of coverage of interventions

National levels of self-harm 7% among 11-16 year olds have tried to harm, hurt or kill themselves (Green et al, 2005) 5.6% of adults attempt suicide during their lifetime (McManus et al, 2009) 4.9% of adults have self-harmed 16.7% of adults thought about committing suicide at some point in their life

National levels of suicide 10 th leading cause of death worldwide 1.5% of all deaths (Hawton et al, 2009) 6045 suicides occurred among adults aged 15 and over in 2011 (11.8/100,000) (ONS (2013) 4,552 males 1,493 females) Highest suicide rates in men and women 30-44 year old men (23.5/ 100,000) 45-59 year-old women (7.3/ 100,000)

Regional variation in suicide (ONS, 2013) Highest in North East (12.9/100,000) Lowest in London (8.9/100,000) Over past 10 years: Men Highest in NE/NW Lowest in London/ East Women Highest in NW/SW Lowest in Yorkshire & Humber/ West Midlands

Changes in levels of suicide (ONS, 2013) Substantial decrease in rates over past decades But significantly higher in 2011 (11.8/100,000 compared to 2010 (11.1/100,000) - highest since 2004 Suicide rate in 45-59 year old men increased significantly between 2007 and 2011 (22.2/100,000) 2/100 000) Rose in 7 regions (21% increase in Yorkshire and Humber) in 2010/11 Fell in 2 regions (West Midlands and London)

2) Local risk and protective factors for suicide and 2) Local risk and protective factors for suicide and self-harm

Risk and protective factors Population approach recognises importance of upstream approach to risk and protective factors Both size of impact of factors and numbers affected are important to consider Identification of local l levels l of such factors facilitates t coordinated action to address such factors Results in prevention ention of self-harm and suicide E l f d ti i bl d Example of reduction in blood pressure across a population to reduce CVD events

Risk factors for suicide and self-harm

Mental disorder a key risk factor

Mental disorder and adolescent self-harm Adolescent mental disorder (Green et al, 2005) 7% among 11-16 year olds 28% among 11-16 s with emotional disorder (4%) 21% among 11-16 s with conduct disorder (6%) 18% among 11-16 s with ADHD (3.5%) Depressive disorder (OR 11.2) (Meltzer et al, 2001) Emotional disorder (OR 3.4) Other mental disorder (OR 3.9)

Mental disorder and suicide 90% of people who die by suicide have mental illness (Cavangh et al, 2003; Phillips, 2010) 5-15 fold increase risk (Harris & Barraclough, 1999) 25% of people who commit suicide are in contact with mental health services (Winduhr & Kapur, 2011) Self-harm: 30-66 fold increased risk of suicide (Cooper et al, 2005; Hawton et al, 2003)

Different mental disorder and suicide Different mental disorder and suicides 1997-2007 (NCI, 2010) Affective disorder (47%) Schizophrenia/ psychotic (19%) (12 fold higher risk) Personality disorder (9%) Alcohol dependence (8%) Drug dependence (4%) Other (13%)

Other risk factors for adolescent self-harm 5 or more stressful life events (OR 1.7) (Meltzer et al, 2001) Very poor family functioning (OR 1.9) Girls > boys (OR 1.5)

Other risk factors for suicide Child adversity Child sexual abuse (OR 8.5) (Bebbington et al, 2009) Four or more adverse child experiences (OR 12.2) 2) (Felitti et al, 1998) Male: 3 fold increased risk particularly in middle age Physical illness/ epilepsy Socioeconomic inequality: unemployment, occupational social class, poverty Stressful life events such as job loss, bereavement or divorce

Groups at higher risk of suicide, self-harm and mental disorder Higher risk groups benefit proportionately t more from intervention to promote wellbeing, prevent mental disorder and treat mental disorder if it arises Proportionate universalism Need for information about numbers from higher risk Need for information about numbers from higher risk groups and size of increased risk (Campion & Fitch, 2012)

Higher risk groups Children in care 4-5 fold increased risk of attempted suicide 75f 7.5 fold increased risk if in long term foster care (Vinnerljung et al, 2006) Ethnic groups (Bhui & McKenzie, 2008) Men: Black African (OR 2.5) and black Caribbean (OR 29) 2.9) aged 13 24 Women: Black African (OR 3.2), black Caribbean (OR 2.7) and South Asian (OR 2.8) women aged 25 39 Homeless (Eynan et al, 2011) 61% reported suicidal ideation 34% attempted suicide

Offenders Higher risk groups Female prisoners 20-fold increased risk (Fazel & Benning, 2009) Male prisoners 5-fold increased risk (Fazel et al, 2005) Female ex-offenders 36-fold increased suicide risk Male ex-offenders 8-fold increased risk (Pratt et al, 2006) LGB (Chakraborty et al, 2011) Suicide attempt (OR 2.2) Self-harm (OR 28) 2.8) Transgender: 34.4% attempted suicide (Whittle & Turner, 2007)

Local assessment of risk factors and higher risk groups to inform needs assessment Numbers affected by risk factors and degree of increased risk Mental disorder is a key risk factor for suicide and selfharm - important to estimate local: numbers affected by different mental disorder levels of different risk factors for mental disorder Numbers from different higher risk groups and size of g g p increased risk

Protective factors

Mental health and wellbeing overarching protection against mental disorder, suicide and self-harm

Mental wellbeing Number of definitions - combination of (Huppert, 2008) 1) feeling good positive emotions of happiness/ contentment interest, engagement, confidence and affection 2) functioning effectively (psychologically) involving development of one s potential having some control over one s life having a sense of purpose such as working towards valued goals, and experiencing positive relationships

Health impacts of mental wellbeing (Campion et al, 2012) Associated with reductions in and prevention of: Mental disorder in children and adolescents Suicide in adults Mental disorder in adults Physical illness Associated health care utilisation Mortality

Impacts outside health also protect against suicide and self-harm Improved educational outcomes Healthier lifestyle Reduced health risk behaviour - smoking, alcohol, drug misuse, physical inactivity, it diet Increased productivity at work, fewer missed days off work More positive relationships Higher income Reduced anti-social behaviour, crime and violence

Levels of wellbeing Vary by region and locality and can be measured National adult wellbeing (ONS, 2013) 28.4% have a low happiness score 23.0% adults have a low satisfaction score 19.3% have a low worthwhile score National child/ adolescent wellbeing 10% have low happiness score 5% have low satisfaction score 6% have low worthwhile score

Levels of wellbeing varies across life course Falls during teenage years (proportion with high levels of wellbeing) (Chanfreau et al, 2008) Age 11: 24% Age 12: 18% Age 13: 14% Age 14: 11% Age 15: 8% Dips between ages of 33-54 - corresponds to highest suicide rates

Protective factors for wellbeing

Protective factors for wellbeing Social relationships at every stage of life (Chanfreau et al, 2013) Perception of general health one of strongest predictors of subjective wellbeing in adulthood Lack of mental disorder

Protective factors for wellbeing Young children (Chanfreau et al, 2013) Primary school context/ friendships Home life and family relationships Less deprived neighbourhood School teenage years School environment free from bullying and classroom disruption Feeling supported Sharing meals Adulthood Good employment Conditions of home

Protective factors against suicide (McClean et al, 2008) Good coping skills Meaning/ purpose Social values Good relationships with family Social support Supportive school environments Physical activity Work Access to treatment by a health professional

Risk factors for poor wellbeing School and teenage years (Chanfreau et al, 2013) Substance misuse Excessive computer gaming Disruptive behaviour at school Adulthood Deprivation Fuel poverty Poor housing Stressful employment Mental disorder

Interventions to prevent mental disorder and promote wellbeing also reduce suicide/ self- harm

Public mental health interventions Good evidence exists for a range of interventions to prevent mental disorder and promote mental wellbeing across the life course (RCPsych, 2010; Campion et al, 2012) Important to assess local proportion who receive such Interventions to inform needs assessment

Interventions from a range of organisations including from outside health Highlights g importance of cross-sectoral coordination: Primary and secondary care Public Health service providers Local government Social care service providers Third sector social inclusion providers Education providers Employers Criminal justice services

Local provision of interventions to prevent mental disorder, d self harm and suicide id

Different levels of prevention Primary: Address risk factors across whole populations p including higher risk groups Secondary: Early detection of risk factors/ illness and intervention. Early age of onset of mental disorder Tertiary: People with established mental disorder to promote recovery and reduce risk of relapse Need for targeting of higher risk groups

Primary prevention of mental disorder: Local coverage Prevention of Inequalities and deprivation Maternal smoking during pregnancy (PH outcome) Parental mental disorder Violence and abuse Discrimination and stigma

Prevention of child abuse Adverse child experiences single largest risk factor for mental disorder Child abuse associated with several fold increased Child abuse associated with several fold increased risk of mental disorder, suicide and self-harm

Prevention of child abuse Nationally, 19% of 11-17 year olds estimated to experience severe maltreatment during childhood 3% of women and 1% of men experience sexual intercourse during childhood (Bebbington et al, 2011) Proportion receiving interventions to prevent child abuse Proportion experiencing abuse who receive intervention e.g. CPPs due to physical or sexual abuse

School based prevention interventions Proportion receiving School based social emotional programmes to prevention conduct disorder ( 84) (DH, 2011) School based bullying prevention ( 14) (DH, 2011) School based violence prevention programmes

Other school based prevention interventions Proportion receiving intervention for Domestic D violence (TaMHS) Loss, separation and bereavement Stigma prevention Talk Out Loud Anti Stigma Programme Talk Out Loud Young Person s Website http://talkoutloud.info/ created by young people Ask k Normen Service Gateway www.asknormen.co.uk

Screen time prevention Screen time associated with poor wellbeing Daily average of more than 6 hours outside school (Ofcom, 2012) Encourage no screens in children s bedrooms Advice to parents of younger children to choose screen material with a slower pace, less novelty and more of a single narrative quality Advice to parents should to monitor and control the time their children spend on hand-held computer games/media

Coverage of other prevention interventions Debt advice( 4) (DH, 2011) Work place stress reduction Targeted smoking cessation for people with mental disorder which prevents physical illness and premature mortality

S d d t ti ti f t l Secondary and tertiary prevention of mental disorder and associated suicide/ self-harm

Adolescents who self-harm presenting to hospital 7% of 11-16 year olds have self-harmed (Green et al, 2005) 12.6% episodes of self-harm presented to hospital (Hawton et al, 2003) Admissions for self harm in under 18s in England is 115.5/100,000 (HES, 2013) - approximates to 0.1% 12-fold local variation in admission rates from 26.0 to 311.9/100,000 000

Adult admissions for self-harm 4.9% of adults have self-harmed (McManus et al, 2009) Directly standardised rate for emergency hospital admission for self harm 207/ 100,000 000 in England (HES 2011/12) 10-fold local variation from 52-543/100,000 114,000 inpatient admissions in England in 2011/12 (HSCIC, 2012) 0.3% of adult population

Early detection and aversion Suicide training courses for GPs to detect suicide risk 44 (DH, 2011) Bridge safety barriers 54 (DH, 2011) not displaced

Intervention for mental disorder

National proportion receiving any intervention for different mental disorder 28% of parents of children with conduct disorder 24% of adults with common mental disorder 28% of adults screening positive for PTSD 81% of adults with probable psychosis received some form of treatment compared to 85% in 2000. 65% of adults with psychotic disorder in past year 14% of adults dependent on alcohol 14% of adults dependent on cannabis only 36% of adults dependent on other drugs Less than 10% of older people with depression receive adequate treatment

Improving early recognition Largest risk factor for suicide and self-harm is mental disorder BUT most with mental disorder no intervention Less than 3% of adults see secondary mental health services Improving recognition of health professionals, teachers and general population p

Children/ adolescents with mental disorder receiving intervention from CAMHS Particularly important gap since early intervention for mental disorder can prevent: Associated outcomes during adolescence and adulthood including suicide and self-harm Large proportion of adult mental disorder (Kim-Cohen et al, 2003)

Local economic impact of secondary Local economic impact of secondary prevention for mental disorder

Savings from early intervention of mental disorder per invested (DH, 2011) Parenting interventions for children with conduct disorder 8 Early detection and treatment of depression at work 5 Early intervention ti for the stage which h precedes psychosis (Clinical High Risk State) 10 First episode psychosis 18 Screening and brief interventions in primary care for alcohol misuse 12

Promotion of mental health and wellbeing

Different levels of promotion Primary: Promoting protective factors for mental wellbeing across whole populations. p Secondary: Targeting groups at higher risk of poor wellbeing Tertiary: Targets groups with poor wellbeing and established health problems to help promote their recovery Different organisations have different roles at different levels

Promotion of wellbeing Promote protective factors Target higher risk groups (secondary promotion) and those with low wellbeing including people p recovering from mental disorder Place based approaches (e.g. schools/ workplace/ nursing homes) Cover a large number of population at one time Improve literacy about mental wellbeing and disorder

Local provision of interventions to promote wellbeing

Social marketing to support action to promote wellbeing Campaigns or social marketing of resources such as 10 Actions for Happiness which outline what people can do to promote their wellbeing School based Talk Out Loud

Wellbeing gpromotion for parents and infants Programmes to support secure attachment with parents and carers Breastfeeding support Supporting good parenting skills Preschool programmes

School based mental health promotion interventions Proportion of schools adopting whole school approaches to mental health promotion Proportion of schools recruited to Targeted Mental Health in Schools Programme (TaMHS)

Building Blocks of Provision for Building Mentally Healthy Schools Targeted Mental Health in Schools Drawing and Talking KS1 4 Emotional Health / Wellbeing Team to support students in KS3&4 Home Focused Practitioner Trained in ASD, 123 Magic, Solihull Approach Parenting More Targeted Programmes or Support Wave 3 focused Peer Support KS1&2 Peer Mentoring KS3&4 CBT based Group Work e.g. Growing Optimism or RESPECT Support for child experiencing Loss, Bereavement, Separation, ADHD, ASD, Selfharm & Domestic Abuse Targeted Programmes or Support Wave 2 focused Building Resilience Peer Massage Whole School Universal Well Being thru: or Behaviour Programmes or Wheels Zippy s Friends KS1 Relaxation Management Approach Support Wave 1 interactive FRIENDS KS2/3/4 Techniques e.g. 123 Magic focused resource County PSHE Prog inc SEAL. Shoe Box & Mental Headteacher & Staff Well Solihull Approach & Solution Focused Mental Health Team or Lead Family SEAL Parent Engagement Essential Foundation Healthy Schools Health being or Protective Approach Person in Best Practice Programmes Anti Bullying Handbook Programmes Behaviours School & Mental Health Stigma Programme (MHSP) inc Participation of Children & Young People Approaches Children s Workforce Core Competencies (from DCSF, ECM 2005) Essential Underpinnings for work with children

Work place-based cost effective interventions to promote wellbeing Work based mental health promotion programmes result in net savings of 10 for each spent (DH, 2011)

Promotion interventions enhancing social contact Timebanks Adult education Volunteering Mindfulness/ spiritual/ religious

Local levels of physical activity % of 5-16 year old pupils participated in physical activity (England 86.4%) % of physically active adults (England 56.0%) Adult participation in 30 minutes, moderate intensity sport Utilisation of outdoor space for exercise/ health reasons: England 14.0%

Provision of mental health promotion 0.03% of mental health budget spent on mental health promotion (DH, 2012) Lack of coverage of cost-effective interventions Lack of information about level of secondary and tertiary promotion/ higher risk groups

Size and impact of prevention and promotion intervention gap Results in broad range of associated impacts including self-harm and suicide Since majority of life time mental disorder arises by mid 20's, these impacts continue over a large part of life course Note the very small number in UK who benefit from primary promotion/ prevention interventions recent reductions with budget cuts

Interventions from a range of organisations including from outside health at primary, secondary and tertiary levels Highlights ht importance of cross-sectoral coordination: Primary and secondary care Public Health service providers Local government Social care service providers Third sector social inclusion providers Education providers Employers Criminal justice services

Summary

Broad impact of mental disorder and wellbeing Mental disorder and poor wellbeing result in broad range of impacts including suicide and self-harm Almost a quarter of the national population experiences mental disorder and poor wellbeing Self-harm and suicidal ideation relatively common although suicide rare

Risk and protective factors Levels of suicide id and self-harm vary depending di on a range of risk and protective factors Important risk factors for suicide and self-harm include mental disorder, poor wellbeing and adversity Mental disorder is single largest risk factor for suicide Important protective factors against suicide and self Important protective factors against suicide and selfharm include wellbeing

Public mental health interventions Effective interventions can prevent mental disorder and promote mental health at primary, secondary and tertiary levels thereby also preventing suicide/ self-harm Several organisations have key roles in preventing mental disorder/ suicide/self-harm and promoting wellbeing by addressing different risk/protective factors I t ti lt i i i i th Interventions result in economic savings even in the short term

Intervention gap Only a minority who would benefit actually receive interventions Impact and of cost of not intervening Public mental health intelligence is important part of the JSNA to inform unmet need and strategic development

Different levels of prevention Prevention of inequalities - underpin a large proportion of mental disorder, poor wellbeing and associated suicide/self-harm Safeguarding prevention of different forms of abuse and violence particularly during childhood reduces mental disorder and suicide/self-harm Secondary prevention through increased access to Secondary prevention through increased access to treatment particularly in childhood and adolescence

Different levels of promotion Interventions to promote mental health literacy important for both providers and population p Parenting g support and preschool particularly important opportunity to promote and prevent Mechanisms required to mainstream very low cost promotion interventions including timebanks/ adult education/ volunteering/physical activity which target higher risk groups

Coordinated working Schools, workplaces, libraries and older people s residential settings important hubs to facilitate coordination of input across different levels of prevention/ promotion Different organisations can provide interventions at different levels of promotion and prevention Such a coordinated approach results in a broad range of impacts including reduced suicide and self-harm

References and contact Campion J, Bhui K, Bhugra D (2012). European Psychiatric Association guidance on prevention of mental disorder. European Psychiatry 27: 68-80. 80 Campion J, Fitch C (2012) Guidance for the commissioning of public mental health services. Joint Commissioning Panel for Mental Health. www.jcpmh.info Campion (2013) Public mental health: The local tangibles. The Psychiatrist 37: 238-243 Email: j.campion@ucl.ac.uk