ulster.ac.uk

Understanding suicide in Northern Ireland: Applying psychology to save livesSiobhan O'Neill Professor of Mental Health Sciences

@ProfSiobhanON

• Around 300 deaths every year.• Highest rate in the UK (approx 16 per 100,000).• Doubled in the last 20 years in NI, whilst England,

Scotland, wales and Ireland have seen a decline (lowest male rate in UK in 30 years).

• Three times as many people as road accidents.• PREVENTABLE.

Suicide in Northern Ireland

@ProfSiobhanON

@ProfSiobhanON

Daniel Somers was an American soldier who took his life in 2013, aged 30. He had been suffering from various health problems including PTSD. His suicide note was published on Gawker. His wife and family have given permission to publish it widely.

A suicide note: Daniel Somers

@ProfSiobhanON

“The illness I have has caused me pain that not even the strongest medicines could dull, and there is no cure.

All day, every day a screaming agony in every nerve ending in my body. It is nothing short of torture. My mind is a

wasteland, filled with visions of incredible horror, unceasing depression, and crippling anxiety, even with all of the

medications the doctors dare give.

Simple things that everyone else takes for granted are nearly impossible for me. I can not laugh or cry. I can barely

leave the house. I derive no pleasure from any activity. Everything simply comes down to passing time until I can sleep again. Now, to sleep forever seems to be the most

merciful thing.”

@ProfSiobhanON

Mental Illness and SuicideA behavioural outcome, not an illness- but it is associated with mental illness.

People with a mental illness

People who die by suicide5%

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Theories of SuicideBackground

Biological factors Psychological factors

Life eventsMental illness

Unbearable Pain

Thoughts

PlanSuicidal behaviour (capability)

CONNECTEDNESS HOPE

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• Loss and bereavement, e.g. the loss of a relationship, or a loss through suicide.

• Isolation and loneliness.• Lack of meaning and purpose (unemployment, failure). • Living in poverty, or in a deprived area.• Low self-esteem and a sense of worthlessness (social

perfectionism). • NI Younger people: relationship breakup/ crisis and

employment/ financial crisis. • NI Older people: bereavement, a loved one’s illness and

physical illness.

Life events & circumstances associated with suicidal pain and hopelessness

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• Suicidal people don’t necessarily want to die.• They don’t want the life they (think) they have ahead.• Behaviour = cry of pain (not cry for help).• HOPE for the future can prevent action.• Mental illness, substances, info about treatments, info about

inevitability of suicide etc… can alter how we see the future.• The urges can “come and go” and vary in strength.• Information about suicide and exposure to suicide can

increase risk of action.• Connectedness with others can prevent action.

Key points about suicide

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• Suicidal thoughts are common (10.6% of women, 7% of men). Plans and attempts are less common. Plans 2.4% & 2.5%. Attempts: 4.3% of women, 2.3% of men.

• A third of men and 41.4% of women with suicidal thoughts made an attempt. ASK ABOUT THOUGHTS & PLANS.

• 57.1% of women who died and 40.7% of men had an attempt. • 62.0% of women and 38.7% of men who made a suicide plan

also made a suicide attempt.• More men die by suicide (75%), more women attempt suicide. • Men are more likely to make one fatal attempt. • Those with conflict-traumas more likely to make one fatal

attempt.

Suicide in Northern IrelandUlster University research

@ProfSiobhanON

• Evidence of alcohol in 41% of those who died.

• Alcohol and drug problems: 7.8% of men and 9.7% of

women.

• 21-40yrs: 10.4% of men and 15.4% of women.

• Area level variation in suicide rates in NI, is accounted for by

deprivation.

• Almost twice the proportion of those who died by suicide lived

in deprived areas, compared with people who had not died.

• In the under 20s, males were more likely to be unemployed

(47.5% males; 17.5% females). Females were more likely to

be students (47.5% females; 28.5% males).

Characteristics of the deceased

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Four Population Groups: Mental Health & Conflict Related Trauma

71.5%

14.6%

9.6%

4.3%

McLafferty, Armour, O’Neill, Murphy & Bunting (2016) Journal of Affective Disorders

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The High Risk Groups

Mental Health Problems (14.6%)

Conflict-Trauma Mental Health Problems (9.6%)

Conflict Multi-Trauma Mental Health Problems (4.3%)

Exposure to Conflict LOW HIGH MODERATEACEs HIGH MODERATE HIGHMental Health Problems HIGH MODERATE HIGHSubstance Use Problems

LIKELIHOOD OFSUICIDALITY

MODERATE

8.965

HIGH

5.359

HIGH

15.375

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• Primary care was the most common service used prior to suicide (half of cases).

• Only 30% of those who died were in receipt of mental health services beyond primary care.

• 1 in 5 had presented to services (mostly primary care) in the fortnight before death (18.2% of men and 23.9% of women).

• Four times as many of those in the deceased group had attended the ED in the three months leading up to the death (12.9% compared with 3.3%).

• There is an elevated risk in the six-month period after hospital admission.

Health service contact

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• 70% of the suicide group had prescribed mental health medication in the previous 2yrs, compared with under a quarter in the group who were alive.

• Females and older people were more likely to have a diagnosis and use mental health medication than males and younger people (1 in 3 = more than 3).

• Mental health medication non-adherence rate was 61% (antipsychotics 82.9%).

• Half of those who died received prescriptions for pain medication, compared to 27.7% of the comparison group.

Medication Mental health and pain

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Suicide and PainOther evidence• Extreme stress causes pain. • Pain is a symptom of mental illness (depression, anxiety).• Pain is a feature of loss (hurt, mental pain, torture).• Biological connections:

• Inflammation & depression.• Speed of response to stress & aggression.

• Analgesics can help people with mental illness and life crises.• People with higher pain thresholds are more likely to engage

in suicidal behaviour.

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1. People with a mental health or pain condition, 2. People presenting to services after self-harm/ attempt,3. Those who experienced traumatic events relating to the

NI conflict, 4. People who have experienced ACEs.

Recommendation:We should assess for suicidal thoughts in high risk groups & provide suicide specific interventions

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• People who have difficult life experiences, or who are marginalised and isolated should be targeted in suicide prevention work.

• Staff working in services that have contact with these groups should receive training in suicide intervention skills.

• Schools and colleges should be supported to adopt suicide prevention initiatives.

• Help seeking behaviour needs to be destigmatised, and the disclosure of suicidal thoughts recognised as indicative of a treatable mental health condition.

• Population level initiatives to reduce substance abuse and harm. • Psychological therapies should be widely available as an alternative to, or

along with, medication treatments. The NI Psychological Therapies Strategy (DHSSPS, 2010) should be fully implemented.

Recommendations

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• High rates of post-conflict mental disorders.• Exposure to trauma.• Use of alcohol and substances.• Post conflict legacy and perceived injustice: reduced

connectedness (especially those who have been most affected).

• Exposure to pain à capability, habituation (less fear/ more expertise).

• Legacy of the conflict: deprivation, hate crime, intolerance, racism (high rates among LGBT and Irish Travellers).

Understanding suicide in NI

@ProfSiobhanON

• LEAD: Create a leadership-driven, safety-oriented culture. Include suicide attempt and loss survivors in leadership and planning roles.

• TRAIN: Develop a competent, confident, and caring workforce.• IDENTIFY: Systematically identify and assess suicidality.• ENGAGE: Ensure every person has a suicide care management

plan. Include collaborative safety planning and restriction of means.• TREAT: Use evidence-based treatments that directly target

suicidality. • TRANSITION: Provide continuous support, esp. after acute care.• IMPROVE: Apply a data-driven quality improvement approach to

inform system changes.

Designing for ZeroSuicide in healthcare systems

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• Perception of the future as persistently negative –nothing to live for.

• Negative thoughts, hopelessness, guilt, “I’m a burden”.• Sense of worthlessness. • Emotional pain.• Entrapment, lack of a positive future. • Shame – conflict with religious or spiritual beliefs.• Impulsivity and aggression, esp. in young people. • Exposure to violence and pain, expertise.

Psychology informed suicide mitigation: what to watch out for

@ProfSiobhanON

“The illness I have has caused me pain that not even the strongest medicines could dull, and there is no cure.

All day, every day a screaming agony in every nerve ending in my body. It is nothing short of torture. My mind is a

wasteland, filled with visions of incredible horror, unceasing depression, and crippling anxiety, even with all of the

medications the doctors dare give.

Simple things that everyone else takes for granted are nearly impossible for me. I can not laugh or cry. I can barely

leave the house. I derive no pleasure from any activity. Everything simply comes down to passing time until I can sleep again. Now, to sleep forever seems to be the most

merciful thing.”

@ProfSiobhanON

1. Show you care: connectedness & hope.2. Ask the question: removes the shame and stigma,

provides opportunity to ask for help.3. Call for help.

4. Ask your political representatives what they are doing.5. Educate yourself.

Everyone can play a part

ulster.ac.uk

Thanks to my collaboratorsProf Brendan Bunting, Dr Sam Murphy, Prof Cherie Armour, Dr Margaret McLafferty, Dr Edel Ennis, Dr Byron Graham, Prof Adrian Moore, Dr Colette Corry, Dr Tony Benson, Dr Danielle McFeeters, Dr Finola Ferry.

www.profsiobhanoneill.com@profsiobhanonsm.oneill@ulster.ac.uk