The Scottish Government

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CHAPTER ONE: INTRODUCTION

Background

1.1 Scotland has higher age standardised rates of completed suicide than all other parts of the UK, with an age-standardised three year rolling average rate of 15.1 per 100,000 reported for the period 2004-2006 (Scottish Public Health Observatory) compared to a rate of 11.4 reported for the nearest available comparator period in England and Wales (Office of National Statistics, rates for the period 2000-2003). To draw a wider comparison, the 2005 European age standardised rate cited by Choose Life, was 14.6 per 100,000. In line with other parts of the UK, available data show variation in the rates of completed suicide associated with age, gender, level of deprivation and geographic location. The suicide rate for males is around three times that for females, suicide is a leading cause of mortality in those aged under 35 and the risk of death overtly identified as suicide or specified as relating to an act of undetermined intent in the most deprived areas of Scotland is almost double the Scottish average ² .

1.2 Whilst the profile of completed suicide is relatively well-established, with national mortality rates calculated annually and evaluated for broad demographic variation, less is known about the incidence and distribution of attempted suicide, self-harm and suicidal ideation ³. Hospital inpatient admission and discharge statistics, collected separately for England, Wales, Scotland and Ireland, provide figures for the number of admissions and discharges recorded as being the result of 'self-injury' defined by International Classification of Diseases ( ICD) -10 classifications. These data suggest higher rates of non-fatal self-harm in the UK than elsewhere in Europe, and provide some additional comparative information of relevance to the current review. However, inpatient admissions and discharges are likely to be a poor estimate of the absolute prevalence of suicidal behaviour and the figures do not distinguish between attempted suicide and self-harm or provide any indication of the prevalence of suicidal ideation.

1.3 The most recent national survey (Singleton 2001) comparing all three behaviours estimates lifetime self-report prevalence rates for adults to be 4.4% for attempted suicide, 2% for self-harm (without suicidal intent) and 14.9% for suicidal ideation. All three behaviours are reported as more common in women than in men and also as more common in younger than in older people. In contrast to the profile of completed suicide, self-harm and suicidal ideation showed little association with the socio-economic characteristics of survey respondents, although attempted suicide was found to be more common amongst people in lower socio-economic groups. Whilst the survey included respondents from England, Wales and Scotland, prevalence rates are not reported separately and no comparisons are drawn on the basis of location.

1.4 One issue which is of particular relevance to the current review and which has been poorly addressed to date is the association between individual behaviours within the spectrum considered here (completed suicide, attempted suicide, self-harm and suicidal ideation). National statistics and a broad range of research studies have established beyond doubt that people engaging in suicidal behaviours ( see Glossary, Annex J) are at substantively increased risk of completed suicide (e.g. Hawton et al 2003). Several recent studies have also sought to identify the broad characteristics of people engaging in different forms of suicidal behaviour (e.g. Brunner et al 2007) However, there has been little attempt to explore the underlying association between these behaviours more fully. In particular (cf. Whitlock & Knox 2007), there is a need to establish the nature of any causal relationship between suicidal ideation, self-harm, attempted suicide and completed suicide and to establish the factors and mechanisms which result in an individual moving from one form of behaviour to another. This type of holistic approach could contribute significantly to the search for effective interventions.

1.5 The (then) Scottish Executive responded to the significant public health issues outlined above by establishing a National Strategy and Action Plan, Choose Life (Scottish Executive, 2002), which aims to reduce death resulting from suicide by 20% by 2013. This aim mirrors other goals set within the UK (e.g.. Saving Lives, 1999) and contributes at a broader level to national programmes for improving mental health and wellbeing. Choose Life is co-ordinated at the national level by the National Implementation Support Team ( NIST), which promotes and oversees the strategy's objectives, and at the local level by Choose Life co-ordinators who have been appointed in each of Scotland's 32 local authority areas. Working within their Community Planning Partnerships, Choose Life co-ordinators are tasked with agreeing, developing and implementing a local suicide prevention plan. These plans are now being implemented and a major independent evaluation of the first phase of Choose Life has recently been completed (Platt et al 2006).

1.6 A Scoping Study commissioned by the (then) Scottish Executive to support the above initiative identified the need for a set of reviews to provide a comprehensive overview of current knowledge regarding both the determinants (risk and protective factors) of suicidal behaviour and effective interventions for its prevention. The review of interventions which forms the focus of the current report was commissioned and is being published as part of a programme of research in support of the Scottish Government's commitment to suicide prevention, and in taking forward the Choose Life National Strategy and Action Plan - Objective 7 in the strategy related to 'knowing what works' (improving the quality, collection, availability and dissemination of information on issues relating to suicide and suicidal behaviour and on effective interventions to ensure the better design and implementation of responses and services and use of resources). The review serves to inform ongoing work at both local and national levels, and information drawn from the review will subsequently dovetail with a review of risk and protective factors that has also been commissioned by the Scottish Government and with the evaluation of the first phase of Choose Life's implementation (Platt et al 2006).

Aims and objectives

1.7 The remit of the review was to provide a comprehensive overview of the known effectiveness of interventions aimed at preventing suicidal behaviour and ideation both in key risk groups and in the general population. Specific objectives of the review were to:

• Identify the interventions which have been evaluated to date
• Summarise the conclusions which can be drawn from the literature as it stands, taking into account the quality of available data
• Highlight key defining features of the interventions evaluated to date
• Specify the known impact of interventions, taking into account the populations and settings to which these apply
• Address the cost-effectiveness of interventions where such data are available
• Consider the transferability of effective interventions to the Scottish Context and examine the implications for implementation and replication.
• Identify gaps in the evidence base
• Make evidence-based recommendations for the development of national and local policy and practice identifying variations in strategic approach for different key risk groups

Scope of the review

1.8 The review had an extremely broad focus, addressing the evidence available for any and all interventions which have been evaluated for the prevention of suicidal behaviour and suicidal ideation. Issues which were outwith the scope of the review were:

• Postvention
• Interventions for mental illness not including outcomes related specifically to suicide or suicidal behaviour
• Self-harming behaviours lacking the specific intent to self-harm (e.g. alcohol abuse; overwork etc)

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