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4. CONCLUSIONS

4.1 Key findings

This report has explored the epidemiology of suicide in Scotland over the period 1989 to 2004, at national and local levels. Among key findings the following should be noted:

• Across the country as a whole male suicide rates increased by 22 percent and female suicide rates by 6 percent over the period 1989-2004 (single years) .
• In about half the local areas suicide incidence over the whole period was not significantly different to national suicide incidence. However, in Glasgow City, the suicide rate was significantly higher than the Scottish average in all years among both men and women. In Glasgow City and a few other local authorities (West Dunbartonshire, Highland, Eilean Siar, Dundee City and Argyll & Bute) all-person standardised suicide mortality ratios ( SMRs) were significantly elevated (compared to Scotland as a whole) . In West Lothian, South Lanarkshire, North Lanarkshire, Fife, Falkirk, East Renfrewshire, East Lothian, East Dunbartonshire, Angus and Aberdeenshire all-person SMRs were significantly lower than the national average.
• There was no clear temporal trend in suicide at the local level. Rates tended to fluctuate or exhibit irregular patterns over time.
• Male suicide rates were approximately three times higher than female suicide rates over the period. There was some variation in the male: female suicide ratio between local areas, with a suggestion that male vulnerability to suicide was greater in the more rural and remote areas of the country.
• Across Scotland as a whole male suicide rates tended to decline with age, whereas among women there was an inverse U-shaped relationship (lower rates in youngest and oldest age groups) . The highest suicide rate among men (40.8 per 100,000) occurred in 25-34 year age group. High rates were also evident among men aged 35-54 years. Among women, the highest suicide rate (11.6 per 100,000) was found in the 45-54 year age group, with high rates also in the 25-44 year age groups. The excess of suicide deaths among males (approximately fourfold) was particularly marked in the younger age groups (15-34 years) . The age-related pattern found at national level is replicated at local level, although there are some anomalous patterns also ( e.g. highest rate in the oldest age group in a few areas) .
• The most common method of suicide among males in Scotland were hanging (7.9 per 100,000) , self-poisoning (6.1) , drowning (3.1) and gassing (3.0) . Among females the most common method of suicide was self-poisoning (4.4 per 100,000) . Hanging suicide rates have significantly increased over time for both men and women, while death rates by gassing (mainly carbon monoxide [car exhaust] poisoning) have significantly decreased. In most local areas the rank ordering of methods and trends over time are similar to what is found at national level. The main difference is the greater popularity of drowning as a method of suicide in Highland and the islands.
• At the national level there was a marked variation in male suicide rates by social class. Differences between rates in the non-manual groups were not statistically significant. However, there were significant differences between rates in the non-manual groups and social class IIIM, between IIIM and IV, and between IV and V. The slope of the social class gradient was more pronounced in 1996-2002 than in 1989-1995. Similar patterns and trends were found in local areas.
• Across Scotland there was a strong relationship between suicide and socio-economic deprivation: the higher the level of deprivation, the higher the standardised suicide mortality ratio ( SMR) . The relative gap between SMRs in the most and least deprived quintiles was larger ('widening gap') in 1996-2002 compared to 1989-1995. The magnitude of the widening gap was similar for men and women. Although the relative gap was higher among people aged 15-44 years than among people aged 45+ years, the widening gap was more pronounced in the older age group than in the younger age group. An analysis of suicide and socio-economic deprivation within local areas reveals evidence of a relative suicide gap in all but a few local authorities and health boards. A widening suicide gap over time was found in 24 (out of 32) local authorities and 12 (out of 15) health boards.
• The suicide rate was found to be significantly higher in class V than in other social classes in all local areas, irrespective of the degree of socio-economic deprivation. In 1989-1995 the patterning of social class differences did not differ markedly between categories of socioeconomic deprivation. This suggests that the main influence on suicide rates is at the individual, rather than area, level. In 1996-2002, however, there is evidence of a trend towards an increase in the social class gradient with worsening level of socioeconomic deprivation: that is to say, the gap between suicide rates in the highest and lowest social classes increases as socio-economic deprivation worsens. However, the compositional effect (the influence of individual social class) is undoubtedly far stronger than the area effect (the influence of the level of socio-economic deprivation in the locality) .

4.2 Implications

4.2.1 Social class and socio-economic deprivation

• The study findings suggest the need to give greater priority to the effects of social class (at individual level) and socio-economic deprivation (at area level) in local and national suicide prevention strategy and action plans.
• Targeted action is warranted in areas with high suicide rates where there is evidence of impact of socio-economic deprivation (eg Glasgow) .
• However, according to the analyses reported here, it is not enough to target suicide prevention activities exclusively on areas of social disadvantage, because this will not meet the needs of people who are in the lowest social classes but who live outside areas of economic deprivation. The analyses indicate that the influence of individual social class is far stronger than the influence of the level of socio-economic deprivation in the area.
• Addressing higher suicide risk in lower socio-economic groups would be consistent with SE's wider strategies on promoting social justice and social inclusion, reducing social inequality and tackling health inequalities
• In addition to considerations of social class and socio-economic deprivation, the ratio of male to female age-adjusted suicide rates indicates a higher level of vulnerability to suicide among men in the more rural and remote areas in the country.

4.2.2 Supporting the national suicide reduction target

• If the recent reduction in suicide incidence is to be sustained in years to come, the public, government, policy makers, agencies, planners, academics, mass media and practitioners need to understand the role that suicide prevention activity in general, and Choose Life in particular, is playing and has played. In this context, it is important to note that in Scotland Choose Life sits in the broader context of health improvement, public health work and wider work on social justice (as part of the Executive's National Programme for Improving Mental Health and Well-being) . Initiatives such as 'Scottish Mental Health First Aid', the 'Breathing Space' telephone line, the 'see me' anti-stigma campaign, work on recovery and social inclusion are all likely to be contributing to the recent reduction in the suicide rate in Scotland. Work on improving health and social care services, such as the recent emphasis on addressing depression and improving the delivery of mental health services (Delivering for Mental Health) may also be impacting on the suicide rate, as well as wider social, economic and public policy factors.
• To support the implementation of Choose Life, more detailed and up to date information about the epidemiology of suicide is needed, both nationally and locally. GROS has collected and collated a considerable amount of information on each suicide (or possible suicide) death in Scotland, but relatively little has been published to date. An in-depth exploration of these data would help to inform planners and practitioners about the suicide situation in Scotland.

4.2.3 Links with the evaluation of the first phase of Choose Life

This study was commissioned as part of a wide programme of research and evaluation to support the implementation of Choose Life. The evaluation of the first phase of Choose Life was published in September 2006 and members of the evaluation team also worked on this project. Findings from this study reinforce several of the recommendations made by the evaluation team. In particular:

• Enhanced focus on inequalities. The evaluation highlighted the omission of socio-economic deprivation and low socio-economic status from priority groups in the Choose Life strategy.
• Targets at local levels. Because the number of suicides and undetermined deaths fluctuates annually, it is not easy to translate a 10 year national target into meaningful local area targets, particularly in areas where the number of suicide deaths per annum is small. To maximise the engagement and continuing contribution of local areas towards the national 10 year target, it may be worthwhile considering the introduction of local targets.
• Possible 'proxy' target. One possible candidate would be non-fatal self harm incidence, operationally defined as admissions to hospital following self-poisoning and/or self-injury, although admissions to hospital and medical or psychosocial 'seriousness' are not perfectly correlated. Many (perhaps even the majority) of those treated in hospital will not represent a high suicide risk, and a small but significant minority of those who do not attend hospital (not referred or refusing to attend) will be high risk and will go on to die by suicide.

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