How can we tackle the rise in self-harm?
Self-harm is an important risk factor for suicide. To combat it we need better public awareness, better suicide information and uniform procedures for assessment and aftercare, writes MICHELLE McDONAGH
A HISTORY of deliberate self-harm is an important risk factor for suicide, which is why new figures showing a significant increase in self-harm, particularly in young Irish men, have raised alarm bells among the country’s top suicide researchers.
The figures from the Registry of Deliberate Self Harm, which is compiled by the National Suicide Research Foundation (NSRF), show that the number of deliberate self-harm (DSH) cases presenting to Irish hospitals over the three-year period from 2007 to 2009 rose by 23 per cent in men and 13 per cent in women.
The largest increase in cases of DSH was between 2008 and 2009, as the recession heightened, corresponding with a significant increase in the national suicide figures.
There were 127 deaths from suicide registered with the CSO in the second quarter of 2010 (the most recent statistics available), a small increase on the same period the previous year, and the indications are that this trend has continued into 2011. Deaths from suicide in 2009 reached 527, a 24 per cent increase on the previous year – a record surge – according to CSO figures.
As Dr Ella Arensman, director of research at the NSRF, points out, the latest DSH figures (which are based on people presenting to emergency departments around the country) are only the tip of the iceberg, as many people who engage in self-harm never present to health services. The most common forms of DSH in Irish men and women are deliberate drug or alcohol overdose, and self- cutting.
Since she started working in suicide research back in the 1980s, Dr Arensman has not seen an increase of this scale in DSH over such a short period. The most worrying aspect of the latest figures, she says, is that an increasing rate of self-harm in men is likely to be followed or paralleled by an increasing suicide rate.
In fact, this is already happening, as the significant increase in DSH in Ireland in 2007-2009 was paralleled by a rise in suicide, especially among young men.
We already have the means to tackle Ireland’s growing self-harm and suicide crisis, according to Dr Arensman, and we know what has worked in other European countries.
The solution, she says, is a multiple-intervention approach similar to the very successful German model, which has reduced self-harm and suicide in Nuremberg by 24 per cent over two years and has now been rolled out across that country.
The Nuremberg Alliance Against Depression was a two year pilot intervention programme performed at four levels: training of family doctors and support through different methods; a public relations depression awareness campaign; cooperation with community facilitators (teachers, priests, local media, etc.); and support for self-help activities as well as for high-risk groups. The programme has been extended throughout Germany and in other European countries through the European Alliance Against Depression.
A number of effective, evidence-based interventions need to be implemented concurrently, Dr Arensman says. One of the most important of these is the early identification of people at risk of self-harm or suicide through awareness and skills training for professionals and volunteers working in healthcare and community-based services.
“Uniform procedures for the assessment and aftercare of DSH patients who present to hospitals around the country has to be implemented, and a wider range of effective treatment programmes must be made available for this very vulnerable group following discharge from hospital.
“We also need to inform the general public and relevant help services about the symptoms of depression and warning signs of suicidal behaviour through national awareness and positive mental-health promotion campaigns,” says Dr Arensman.
The Suicide Support and Information System (SSIS), which has been piloted successfully in close collaboration with coroners in Cork city and county since 2008, has examined 183 cases of suicide and deaths of undetermined intent.
The SSIS has identified a very large cluster of 18 suicides of mainly adolescent and young adult males between September 2008 and March 2010 in a small area of Co Cork.
It has also identified specific suicide risk profiles, including undiagnosed and untreated mental-health problems, alcohol and drug abuse, a history of deliberate self-harm, the impact of economic recession as a precipitating factor, recent separation of young men from partner/children and the long-term consequences of sexual abuse in childhood and adolescence.
A major benefit of the SSIS, according to Dr Arensman, is that they can identify suicide cases three years earlier than the CSO.
However, funding has not been extended for this vital system and given the latest increase in self-harm and suicide, the NSRF is very concerned that closing down this system could have a paradoxical effect.
Joan Freeman, founder and chief executive of Pieta House, the centre for the prevention of self-harm or suicide, believes Ireland could lead the way in terms of suicide prevention in Europe if everybody united on the issue.
“We need to stop thinking that suicide is down to psychiatric problems and to start looking at it differently. Behind most suicides is a human experience such as bereavement or marriage break-up.
“The people we see are at the coalface, they have attempted or contemplated suicide, and each person has a different reason for this.
“If we actually looked at the reasons behind each suicide instead of the actual act, then we could do something about it.”
Freeman believes everybody should be able to access a Pieta House service within 100km of their home. It is a unique service in that it provides intensive counselling intervention “up to five times a week if a person is in crisis and needs it”, at no cost, regardless of the client’s financial circumstances.
Dr Tony Bates, director of Headstrong, the National Centre for Youth Mental Health, says “we are living in a time when people are looking for solutions, but they also count suicide and self-harm as legitimate solutions or problem-solving strategies in themselves.
“When I speak to focus groups of 16- to 19-year-olds across the country, I ask them about what they do when they hit a real crisis in their lives, and they have identified suicide as around number six on their list of coping strategies.”
Finding a “solution” to the problem of suicide in Ireland is not a straightforward issue that can be tackled just by providing more acute psychiatric beds, says Dr Bates, as 60 per cent of those who attempt or might take their lives have no contact with the health services at all.
It is a complex, multifaceted issue that requires a fresh approach, and the conversation around suicide needs to change, he says.
Support is available from The Samaritans (samaritans.ie or 1850-609090), Aware (aware.ie or 1890-303302), mentalhealthireland.ie
There were 127deaths from suicide in the second quarter of 2010
There were 527deaths from suicide in 2009, an increase of 24%on the previous year