Introduction

“On average, one person dies every two hours in England as a result of suicide. When someone takes their own life, the effect on their family and friends is devastating. Many others involved in providing the support and care will feel the impact” (HM Government 2012).

Suicide is a major issue for society. Nationally, the overall trend in suicide and injury undetermined death rates has been decreasing since 1998 until 2008 and has been rising slightly since.  From 2010 the number of reported suicides has gradually increased with highest number of reported suicides occurring in 2014 with approximately 4,707suicides (ONS 2015).

The impact of every suicide can be devastating – economically, psychologically and spiritually – for all affected (HM Government 2012). The cost of a completed suicide for someone of working age in the UK exceeds £1.6 million (CMO 2014). Suicidal thoughts at some point in a person’s life are relatively common: in 2007 16.7% had thought about suicide, 5.6% reported attempting suicide and 4.9% had harmed themselves without suicidal intent (APMS 2007).

The latest three-year average data shows a national increase of 15.9% in the rate of suicide and injury undetermined deaths from the 2001-2003 baseline (to a rate of 8.9 per 100,000). The rate in the East Midlands dropped from a peak of 9.1 per 100,000 in 2001-2003 to an average lowest rate, 8.8 per 100,000 in 2011-2014(ONS 2015).

For Nottinghamshire there has been a slight increase in the average rate of death by suicide or injury of undetermined intention. For the period 2011 -13, the Nottinghamshire age-standardised rate of 8.5 per 100,000 population, increased to 9.2 per 100,000 population in 2012-14, which is slightly above the England average of 8.9 per 100,000 population. However, as the numbers are small statistical significance is not reached.

In Nottinghamshire, for the period 2012-2014 the highest rate of suicide occurred in the 35-64 age group for both males and females, which is similar to the picture nationally. However, for the 65+ age male group, the suicide rate was higher when compared to the national suicide rate. Although none of these differences are statistically significant due to the small numbers.

Nationally more men die of suicide than women, the ratio of male to female suicide deaths is 3:1. For Nottinghamshire the gender split in the suicide rate is in line with national suicide rates with men accounting for around three quarters of suicides.

There is a socio-economic gradient in suicide risk. Those in the poorest socio-economic group are 10 times more at risk of suicide than those in the most affluent group. Nottinghamshire has a similar pattern, although due to small numbers we need to be cautious in interpretation of our local data.

Suicide prevention goes hand in hand with addressing self- harm. People who self-harm are at increased risk of suicide. UK studies have estimated that in the year after an act of deliberate self-harm the risk of suicide is 30–50 times higher than in the general population. Non-fatal self-harm leading to hospital attendance is the strongest risk factor for completed suicide (Owens et al. 2002).

In England, self-harm is one of the most frequent reasons for emergency hospital admissions (Royal College of Psychiatrist 2006). It accounts for at least 150,000 presentations to general hospitals each year and those who self-harm have a 1 in 6 chance of repeat attendance at A&E within the year (Runeson et al. 2010). When older people self-harm the risk of further self-harm and suicides are substantially higher. All acts of self-harm in people older than 65 years of age should be regarded as evidence of suicidal intent until proven otherwise because the number of people in this age range who go on to complete suicide following acts of self-harm is much higher than in younger adults (Gunnell et al. 2004) .

For the period 2013-2014, the Nottinghamshire emergency hospital admission for intentional self-harm rate was 207.9 per 100,000 population. Nottinghamshire is slightly higher when compared to the England rate of 203.2 per 100.000 population. However, this is not statistically significant.  

There are a wide variety of factors that can contribute to suicide and self-harm (Gunnell & Lewis 2005). These include historical or familial risk factors (e.g. genetic influences, family history and early trauma) and recent risk factors (e.g. psychiatric disorder, physical illness, relationship breakdown and other life events). Changes in socio-economic environment are important, as is exposure to suicidal behaviour by others, including through the media. Availability of suicide methods can contribute to risk, and the danger of the method will partly determine whether an act is fatal or non-fatal.

Suicide prevention is acknowledged to be a complex challenge and is not the sole responsibility of any one sector of society, or of health services alone. Therefore, prevention largely necessitates a general population approach rather than service-related initiatives. For example, restriction of access to means for suicide, population approaches to prevention of depression, improved detection and management of psychiatric disorders in primary care, and voluntary agency and internet-based support (HM Government 2012)

The greatest impact is likely to result from a combination of preventative strategies directed at potential suicide determinants, which include;

• The factors which increase the  risk of suicidal behaviour in a population; for example, availability of means, knowledge and attitudes concerning the prevalence, nature and treatability of mental disorders, and media portrayal of suicidal behaviour
• Recognised high risk groups - e.g. people with recurrent depressive disorders, previous suicide attempts, people who misuse alcohol, the unemployed, people with certain co-morbid mental and personality disorders (Hawton and van Heeringen 2000) and people recently discharged from psychiatric in-patient care (HM Government 2012).

The suicide and self-harm prevention agenda is cross-cutting and relates most closely to the following JSNA chapters: Mental Health, (Emotional and Mental Health of Children and Young People (2014), Young adults and older people), Domestic and Sexual Violence, Carers, Employment, Asylum Seekers, Refugees and Migrant workers.

Unmet needs and gaps

Recommendations for consideration by commissioners