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PART ONE INTRODUCTION, AIMS, OBJECTIVES AND METHODOLOGY

CHAPTER ONE INTRODUCTION

1.1 Suicide in Scotland: international comparison and temporal trends

Over the past 50 years suicide incidence in Scotland has not been exceptionally high by international standards. In the mid-1990s the male suicide rate (defined as intentional self-harm only, i.e. excluding 'undetermined' deaths) was about the average for 17 Western European countries ¹, while the female suicide rate was below the average for these same countries. Figures 1.1 and 1.2 illustrate Scotland's suicide incidence (illustrated by a line with markers for each year) in the context of minimum, maximum and average rates for these 17 countries over the period 1950-2000, among men (figure 1.1) and women (figure 1.2) aged 15-74 years.

Nevertheless, there had been a pronounced and dramatic increase in suicide among men in Scotland, with the rate more than doubling over the last 30 years (while the trend among women has been downwards over the same period) (see figure 1.3). The sharp drop in male suicide in 2003 should, therefore, be noted with considerable interest. Although there was an increase in 2004, the crude male suicide rate was still below the 2002 peak (in fact, at its lowest level since 1996). Whether or not the 2002 peak turns out to be a turning point in suicide incidence among men in Scotland will not be known for several years.

In both sexes there has been a dramatic shift over time in the age-related pattern of suicide, with younger age groups now showing the highest risk (figures 1.4 and 1.5). Among young-mid aged adults suicide constitutes a far more significant cause of death than was previously the case. Male suicide rates have approximately tripled in the 15-34 year age groups. While suicide incidence is considerably lower among women, there has been a marked increase in rates among 15-24 year olds (by over 200%). Compared to England & Wales, suicide rates in Scotland are now about twice as high among all adults aged 15+ years, with an even more pronounced risk in the 15-24 age group.

Figure 1.1 Suicide mortality age standardised rates among men aged 15-74 years, 1950-2000, Scotland and 16 other Western European countries

Source: Leon et al (2003).

Figure 1.2 Suicide mortality age standardised rates among women aged 15-74 years, 1950-2000, Scotland and 16 other Western European countries

Source: Leon et al (2003).

Figure 1.3 Crude suicide rates per 100,000 aged 15+ years, Scotland, 1971-2004

Source: General Register Office (Scotland)

Figure 1.4 Crude suicide rates per 100,000 by age group, males, Scotland, 1971-3 and 2000-02

Source: General Register Office (Scotland)

Figure 1.5 Crude suicide rates per 100,000 by age group, females, Scotland, 1971-3 and 2000-2002

Source: General Register Office (Scotland)

1.2 The cost of suicide

The impact of suicide can be immense. The cost of suicide falls on everyone in society and can be substantial. Most obviously there are direct costs arising from demands placed on the emergency services, potential life saving interventions to be delivered within the health care system, investigations to be carried out by the police and coroner, and of course costs associated with funerals. For those individuals who survive suicide attempts, lengthy physical and psychological rehabilitation may follow.

There are also what economists call indirect costs. As a result of premature death, individuals lose the opportunity to contribute productively to the national economy, whether this be through paid work, voluntary activities, or family responsibilities such as looking after one's children or parents. The most fundamental impact of all, of course, is the loss of the opportunity to experience all that life holds as a result of suicide. The pain and grief that suicide can have on immediate family members and friends can be immense and long lasting. These very personal impacts are known by economists as ' intangible costs' because they are often hidden and difficult to value.

As part of this study, an estimate has been made of the costs of suicide in Scotland, informed by a review of previous studies worldwide (annex 1). This review indicated that few international studies have estimated the costs of suicide. Costs here have been converted to £ sterling and use 2005 prices. Available estimates include one from the Canadian province of New Brunswick where the average direct and indirect costs of each suicide in 1996 were estimated to be £443, 076 (CAN$1,019, 210) (Clayton and Barceló, 2000). In New Zealand another estimate from 2002 including intangible costs was £1,158,768 (NZ$ 3,094, 243) (O'Dea & Tucker, 2005). In Ireland, using a similar methodology, costs in 2002 were estimated to (£1,402, 438 (€1,982,667) per suicide. (Kennelly et al, 2005)

We have undertaken an incidence-based costing study - that is, we have estimated the total lost lifetime costs for all suicides in Scotland that occurred in one year, 2004. The results are shown in table 1.1. (The methodology and detailed results, broken down by age and gender, are available in annex 2.) In total these costs are estimated to be £1.08 billion, with 75% of the estimated costs accounted for by male suicides. This represents an average cost of £1.29 million per completed suicide and is similar to estimates produced using comparable methods in Ireland and New Zealand. The estimate is conservative as it does not take account of additional suicide attempts that did not result in death. It is important to note our assumption that those who complete suicide are as productive as the general population, but only 97.5% as likely as the general population to be in employment.

By far the largest single component of the total costs of suicide (more than 70%) are the intangible human costs experienced by families; indirect lost productivity costs account for 21% of the total costs. For both men and women, these productivity costs are highest for those aged 35-44 years at the time of death. Given these high costs, there are substantial potential economic benefits if the number of suicides can be reduced. Every 1% reduction in the number of suicides could avoid costs of up to £10.7 million over the lifetimes of these individuals. These figures are also broadly in line with the value of a life saved used by the Department of Transport in England.

Table 1.1 Total costs (£sterling) of completed suicides in Scotland in 2004*

* 2005 prices used

1.3 The policy response

There was a rather muted policy response to the adverse trends in suicide rates among young adult males until 1999. In November that year the Centre for Theology and Public Issues at the University of Edinburgh organised a major conference, 'The Sorrows of Young Men'. The intention of the conference was to raise awareness among policy makers and practitioners about suicide in Scotland, particularly recent trends among young to mid-aged adult men, and to explore possible future directions for practice, policy and research. A year later the proceedings of the conference were published (Morton and Francis, 2000). At the time of the original conference and on publication of the proceedings there was a considerable amount of mass media interest, indicating the extent to which suicide was considered to be a priority public health and public policy issue. The Scottish Parliament also signalled its concern during a debate held in April 2000, during which the then Deputy Minister for Community Care articulated the Scottish Executive's determination to "tackle [the issue] through both general and specific measures that are informed - as is appropriate - by the available research" (Scottish Parliament, 2000).

The start of the formal developmental process, guided by the Scottish Executive and intended to lead to the publication of a national framework for suicide prevention, began in November 2000 with a consultative seminar, and continued through 2001, during which a second consultative seminar took place (May 2001). The seminars were attended by over 200 people from a wide range of backgrounds, including health and social care professionals, service providers (from both statutory and voluntary sectors), mental health service users, suicide 'survivors' (family members and others directly affected by suicide), and others with an interest in suicide prevention. Participants fully endorsed the plan to develop a national strategic approach to suicide prevention, highlighting the importance of the goal of reversing the suicide trend in Scotland but also supporting a broader, integrated approach to tackling the determinants of mental health and well-being in its widest sense.

Following the first consultative seminar, a National Planning Group was established to advise on the development of the draft suicide prevention framework. Members came from statutory services, the local government sector, voluntary and user representative groups, and the research community. Drawing on the presentations, discussions and recommendations arising out of the consultative seminars, the National Planning Group prepared a draft 'Framework for the Prevention of Suicide and Deliberate Self-harm' which was issued for formal consultation from October 2001 to January 2002 (Scottish Executive, 2001). A detailed analysis of the 140 written responses to the consultation was undertaken by Scottish Health Feedback (an independent research consultancy) on behalf of the Scottish Executive and published in July 2002 (Scottish Executive Central Research Unit 2002). In a separate, but linked, process, the Scottish Development Centre for Mental Health (SDC) was commissioned by the Scottish Executive to undertake two projects: 'Exploring Experience', a series of discussions with the media about the reporting of suicide and with groups and services affected by suicide and self-harm; and 'Laying the Foundations: Identifying Practice Examples', a compilation of work carried out by statutory and voluntary agencies with those at risk of suicide and self-harm. Reports based on the two SDC projects were published with the main consultation report (Scottish Executive Health Department, 2002a and 2002b)

1.4 Choose Life

Choose Life (Scottish Executive 2002), the national strategy and action plan to prevent suicide in Scotland, was launched in December 2002. The Scottish Executive had established an overall commitment to improving health of the people of Scotland and in shifting the emphasis away from ill health to one that focused more significantly upon prevention and health improvement (Scottish Office 1999, Scottish Executive 2000, Scottish Executive 2003). This commitment was aligned with the Executive's strategies for promoting social justice with a particular focus on tackling health inequalities as the 'overarching aim' of the health improvement agenda (Scottish Executive 2003).

The National Programme for Improving Mental Health and Well-being was established as a key driver of the Scottish Executive's commitment to improve health and achieve social justice. Choose Life was launched as a major strand of the National Programme's contribution towards achieving these twin aims of improving the overall health improvement and in reducing inequalities (box 1.1)

The Choose Life plan is being implemented in phases, with an initial phase of three years (April 2003 to March 2006). A budget of £12 million was allocated by the Scottish Executive over this period to suicide prevention activities. Of this £3 million was allocated to national activities and the remaining £9 million to local area partnerships for suicide prevention work. A further £8.4 million is being invested nationally and locally over the period 2006-2008. Although it has not been possible to 'ring-fence' Choose Life funds at the local level, since they are absorbed into local authority budgets, there has been a clear expectation that this funding should be allocated to support local suicide prevention work.

Box 1.1 National Programme for Improving Mental Health and Well-being²

The guiding principles, overall aim, objectives, priority groups and implications for national/local implementation relating to Choose Life are set out in box 1.2. The strategic approach recognises the importance of investing in partnership working, the need for effective leadership and the value of combining targeted intervention (reducing suicide risk in especially vulnerable groups) with a broader, public health perspective (reducing the risk conditions, e.g. high unemployment, which create more vulnerability in the population).

Box 1.2 Choose Life: principles, aim, objectives and priority groups

Table 1.2 provides a timeline of key national and local events relating to Choose Life, from its launch in December 2002 to the end of phase 1 in March 2006.

Table 1.2 Choose Life timeline

1.4.1 National and local infrastructures established to support implementation

Choose Life identifies the main actions that are required at both national and local levels. Broadly speaking, the responsibility of national actors (e.g. the Scottish Executive and national agencies) is to set out the strategic view, give guidance and provide support (especially, but not exclusively, financial), while local actors (e.g. health sector, local government, voluntary organisations) are tasked with developing and implementing local plans for suicide prevention.

National Implementation Support Team ( NIST)

In comparison to other national strategies, Scotland is well placed in having a designated national team to coordinate and support development and implementation.

The National Implementation Support Team ( NIST) is led by the national head of implementation who came into post in January 2004 (see Choose Life timeline, table 1.2). The team reports to the National Programme for Improving Mental Health and Well-being, which sits within the Mental Health Division of the Scottish Executive Health Department. NIST's core functions include information; operations; training and development; and marketing & communications (see figure 1.6).

NIST's role, as outlined in the strategy and action plan 2002, is to:

• establish and support a national Support and Learning Network involving local agencies
• collect and disseminate information on practice, evidence and research findings and training programmes
• support the development of a national data set of indicators, figures and trends on suicidal behaviour and completed suicide
• support the commissioning of additional research work on suicidal behaviour; and commission a detailed independent evaluation of the national strategy and action plan to report by March 2006.

National Choose Life coordinators

Additionally, three national organisations were funded by Choose Life to appoint national coordinators: Scottish Prison Service ( SPS), ChildLine and the Samaritans. The remits of these posts vary according to each organisation and include developmental work, fundraising and awareness raising (see figure 1.6).

SPS's budget was intended to consolidate work in progress which contributed to the organisation's existing suicide prevention strategy ( ACT). A series of local SPS initiatives, which are overseen by the SPSChoose Life coordinator, has also been funded.

Figure 1.6 National infrastructures for Choose life (March 2006)

Local infrastructures to support implementation

At a local level, key objectives of Choose Life were implemented through suicide prevention action plans, agreed and supported by community planning partnerships ( CPPs). It was anticipated nationally that CPPs, which operate in all 32 local authority areas with a range of partners, would be the most appropriate structure to coordinate and maximise opportunities for joint working, shared responsibility and sustainability of suicide prevention work.

Community planning was given a statutory basis in the Local Government in Scotland Act 2003. The Act placed duties on local authorities to initiate, facilitate and maintain community planning and encourage core partners such as health boards, enterprise networks, police and fire service to participate. In addition, local areas may involve other relevant agencies/organisations, such as further education colleges, business representatives and the voluntary sector. The CPP in each area comprises an overarching partnership which is supported by a number of themed (e.g. health and well-being) and neighbourhood partnerships ³.

In most areas, a Choose Life partnership was established as a sub-group of a CPP. The Choose Life partnerships were responsible for setting priorities for the local suicide prevention action plans and for overseeing implementation of phase one of Choose Life.

Choose Life coordinators

As part of the action planning process, each local area was expected to nominate a key lead/coordinating person with whom NIST could communicate and who was responsible for sharing information with other local planning partners and stakeholders. In some areas, Choose Life coordinators were specifically employed for the task, while in other areas the role of coordination was carried as part of the postholder's existing remit.

Links to NIST

NIST has no direct authority over CPPs or Choose Life partnerships or line management responsibility for coordinators, but issues guidance in order to support and advise local areas.

Local areas provide reports to NIST on expenditure through the NIST performance management structures, typically on an annual basis. The Chair of the CPP is mandated to provide a phase one progress report to NIST by July 2006.

1.4.2 Comparison with other national suicide prevention strategies

Scotland is one of at least 10 countries (the others being Australia, England, Finland, France, Ireland, New Zealand, Norway, Sweden and USA) to have developed a national strategy on suicide prevention. Such strategies are characterised by a set of integrated, multi-component activities that are coordinated by government and intended to promote, support and link inter-sectoral programmes at local, regional and national levels. Choose Life appears to incorporate most, if not all, of the essential core elements of a national strategy, as recommended in United Nations guidelines (United Nations, 1996):

• Coordination and integration to promote cross-sectoral collaboration at all levels, from governmental to community level
• High level political support for strategic aims, to lay the foundation for the strategy and its implementation
• A coherent conceptual framework for suicide prevention that provides a means to understand suicidal behaviour in order to inform suicide prevention activities and to foster relevant research that has practical application
• Community involvement and engagement in formulating, implementing and evaluating programmes
• Objectives that are achievable and measurable, some of which may be expressed as targets for change
• Monitoring and evaluation to inform implementation and the review of strategy.

A review of international strategies undertaken by the national evaluation team highlights points of similarity and contrast between Choose Life and other international strategies (see annex 1). Strategies tend to be focused on action at the population level and share broad goals and priorities, while there is more variation in specific objectives and approaches adopted.

Scotland's suicide prevention strategy is distinctive in the extent to which suicide prevention is embedded in the wider policy agenda as part of a drive towards health improvement, including mental health improvement, and social justice. As an example, Delivering for Health (2005a) sets out a programme of action for the NHS in Scotland. This signals a "move towards a system which emphasises a wider effort on improving health and well-being, through preventive medicine, support for self care, and through greater targeting of resources on those at greatest risk." The Mental Health Delivery Plan (anticipated December 2006) is expected to contain a commitment to enhance mental health services in Scotland in line with the principles of Delivering for Health and to set out a programme for service improvement.

1.4.3 Evaluation of national suicide prevention strategies

There is relatively little knowledge about the types of strategic or programme-level interventions that successfully prevent suicide (Beautrais, 2005) and there has been little attempt to evaluate the impact of a national multi-dimensional suicide prevention strategy. For example, in their review of suicide prevention strategies Mann et al (2005) focused upon effectiveness of interventions undertaken as elements of strategies. In general 'monitoring and evaluation' activities described in national strategies refer to the evaluation of interventions that are the means of delivering the objectives and not to the evaluation of the strategy itself. One exception is Australia where a summative evaluation was undertaken of its national youth suicide prevention strategy. Scotland's commitment to a strategic and national level process evaluation of the strategy's early implementation is highly unusual.

1.4.4 Economic evaluation of suicide prevention strategies

It can be difficult to identify the levels of expenditure on national suicide prevention activities, due in part to a lack of earmarked funding, and also because strategies may be delivered across many sectors, by many different public and private agencies, often funded in completed different manners. Nevertheless, it is clear that substantial levels of funding may be allocated to such strategies - for instance £19.5 million ($A48 million) was invested in suicide prevention in Australia between 2000 and 2004. Economic evaluation, which compares both the effectiveness and costs of one or more programmes or individual interventions, can be a useful aid to policy makers in assessing whether such an investment in suicide prevention activities represents value for money.

We have undertaken a review to assess the extent to which economic evaluation is used in the area of suicide prevention (annex 3). Given the limited knowledge about the effectiveness of national strategies at the programme level, it is unsurprising that no economic evaluations of national suicide prevention strategies were found. Much economic analysis has focused instead on looking at how potential society-wide conditions, such as the state of the economy, might impact on the level of suicide in society (e.g. Berk et al 2006) rather than on interventions to prevent suicide per se. Any future economic evaluation of the Choose Life strategy would almost certainly be one of the first evaluations undertaken of a national strategy.

This is not to say that no economic evaluations of area-based suicide prevention strategies have been conducted, but rather they have been modest in scope. For example, multi-intervention suicide prevention programmes targeted at reservation based, Native Americans (Zaloshnja et al 2003) as well as university students in Florida (de Castro et al 2004) have been assessed. A small number of studies has also looked at the cost-effectiveness of individual interventions (often clinical) for high risk groups - for instance social work interventions in England for children and adolescents who have deliberately poisoned themselves (Byford et al 1999) or the use of cognitive behavioural therapy with people with a history of deliberate self-harm in centres in both England and Scotland (Byford et al 2003).

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