Suicide: the preventable crisis ALAMY
Educating health professionals in how to talk to people at risk of suicide could reduce this common cause of death, says Jennifer Trueland
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SUMMARY
There’s an old story about a man visiting a doctor saying he is depressed, he can’t sleep and life isn’t worth living. The doctor thinks for a moment and then suggests a solution. ‘The great clown Pagliacci is in town,’ the doctor says. ‘Go and see him tonight, and I’ll guarantee you leave with a smile on your face.’ ‘But doctor,’ the man replies, bursting into tears, ‘I am the great Pagliacci.’ This tale spread quickly on social media after the death last month of the comic actor Robin Williams. The familiar ‘tears of a clown’ theme was given an extra resonance by the suicide of the star of Mrs Doubtfire, Aladdin and Mork and Mindy. Extensive media coverage alluded to the actor’s problems with drugs and alcohol, his money worries and, most recently, his diagnosis of Parkinson’s disease. Despite all this, there somehow was an irony in the fact that a man who made so many people laugh was so unhappy himself. ‘The death of Robin Williams was very sad,’ says Annessa Rebair, senior lecturer in mental health at Northumbria University’s faculty of health and life sciences. ‘He was loved by a lot of people who had enjoyed his films. ‘But this is happening every day – people are losing members of their family, or friends, to suicide and the impact of that loss ripples out, affecting many of us.’ Far from being a rare tragedy, suicide is an all too common cause of death (see box), and an important public health issue. There were 5,981 suicides in the UK in 2012, and it is the leading cause of death in men under 35.
Suicide – the crucial figures There were 5,981 suicides in the UK in 2012 – 4,590 men and 1,391 women. In the UK, the age group with the highest suicide rate in men was 40-44 years; for women, 50-54 years. (Source: Samaritans, tinyurl.com/nda43nu) Suicide is the leading cause of death in men under 35 in the UK, according to the Mental Health Foundation (tinyurl.com/peykv2d) Worldwide, there are more than 800,000 deaths from suicide every year – one every 40 seconds. Suicide is among the three leading causes of death in those aged 15-44 in some countries and the second leading cause of death in the 10-24 age group. (Source: WHO, tinyurl.com/949ze)
Suicide is increasingly recognised as a significant cause of preventable premature mortality. Nurses in all settings come into contact with people who are at risk. Experts say it is vital that nurses have the confidence to ask patients if they are having suicidal thoughts, and refer them on to appropriate support. Author Jennifer Trueland is a freelance journalist
Ms Rebair believes passionately that nurses have an important role to play in helping to prevent suicide. At this year’s RCN congress she won members’ backing for a resolution that suicide prevention should be included in the undergraduate nursing curriculum for all nurses. Research backs up the case for prevention, but there is also evidence that people find it hard to intervene when they suspect that someone is at risk. A study reported in the BMJ in 2011 (Recognising and responding to suicidal crisis within family and social networks: a qualitative study (BMJ 2011: 343;bmj;d5801)) revealed that the friends and relatives of people who committed suicide had found the warning signs hard to interpret and had been reluctant to act. They had believed their loved ones’ assurances that they were all right, and were unwilling to intrude. The authors pointed out that health professionals can feel similarly inhibited. Ms Rebair argues that undergraduate training in suicide prevention would give nurses the skills they need to get involved. Since congress, RCN has started work to take this forward. So far, says RCN mental health adviser Ian Hulatt, this has involved a literature search, conversations with relevant stakeholders such as Public Health England, and preliminary exploration of how training could be tried out in a university setting.
In his view, the move fits with a growing willingness to talk about mental health issues more widely. ‘There’s greater openness to discussing the issue that you can’t have good health without good mental health,’ he says. ‘But suicide is still a difficult area to address with someone, even with a person who has self-harmed.’ He adds: ‘It is not just about awareness; it’s also about services – crisis services are already struggling in the NHS. There’s still further work to be done.’ Ms Rebair, who also works with Papyrus (Prevention of Young Suicide), believes nurses are keen to improve their skills and awareness in suicide prevention. ‘I wasn’t prepared for the response when I spoke at congress,’ she says. ‘I had people coming up to me afterwards, telling me their stories about how they had been affected by suicide. The response was moving.’
Targeted training
Ms Rebair says suicide prevention training would benefit qualified nurses as well as students, and cites nurses working in accident and emergency, in general practice and the community. Alistair Grant, a senior charge nurse in mental health with NHS Grampian in Scotland, believes that public and NHS staff attitudes have changed towards suicide over the past decade, and that stigma generally is beginning to lessen. ‘All my career has been in acute settings and obviously we see people who self-harm, and who might be at risk of suicide,’ says Mr Grant. ‘But I can see that there has been a change more generally. Other people [in different parts of the health service] are taking more of an interest – there’s a greater understanding and nurses are able to signpost people or refer them for help.’ He adds that it is also important to support people in the voluntary sector working with isolated individuals who might be at risk. As a mental health nurse, he is acutely aware that high-profile suicides, like that of Robin Williams,
NURSING :: vol 29without no 4 :: permission. 2014 21 DownloadedSTANDARD from RCNi.com by ${individualUser.displayName} on Nov 21, 2015. For personalseptember use only. No24 other uses Copyright © 2015 RCNi Ltd. All rights reserved.
SCOTS SHOW THE WAY
ISTOCKPHOTO
Signs and support
Annessa Rebair, senior lecturer in mental health at the University of Northumberland, gives the following advice, based on the training company Living Works’ SuicideTALK approach. Signs that someone may be at risk of suicide include: Actions – self-harm, reckless behaviour, withdrawal, giving up hobbies, drug and alcohol misuse. Physical – lack of interest in appearance, lack/change of interest in sex, disturbed sleep, physical health complaints. Feelings – stressful events with feelings of loss, hopelessness, loneliness, worthlessness, anger. Thoughts – such as ‘I just can’t take it anymore’ or ‘everyone will be better off without me’.
Support to offer includes: Tell – the person needs to tell someone about their thoughts and feelings. Ask the person if they feel suicidal – ask directly and clearly. Listen – this might be the first time they have expressed their thoughts and feelings to anyone. Keep safe – help the person explore what needs to be done to keep safe; they may have not fully recognised the danger. Help them commit to a safety plan and explore the inclusion of trusted others.
can have an impact on vulnerable people. He explains that a person’s circumstances can mean they are particularly affected by such cases. Even a storyline in a TV soap opera can make a powerful impression. Some research suggests that reporting of suicides can lead to a ‘spike’ in the numbers of people who take their own life, but Mr Grant says media coverage can also raise more positive awareness and provide an opportunity for troubled people to seek help, which nurses should be ready to provide. In this age of social media, news of celebrity suicides is reported and endlessly ‘shared’. Ms Rebair is
concerned that the attention given to high-profile suicides may trigger ‘copycat’ attempts. ‘It is important to make nurses aware that this might have an effect, so that they can be more vigilant,’ she says. The one thing nurses should never do, she adds, is look the other way. ‘People think “Oh my goodness, it’s a can of worms”. And yes, it’s a complex area. But it’s too important to ignore’ NS Resources Living Works: www.livingworks.net Samaritans: 08457 909090 www.samaritans.org Papyrus (young suicide prevention advice): 0800 068 41 41 www.papyrus-uk.org
In Scotland, the suicide rate has fallen by almost one fifth in the past 12 years – and nurses have been closely involved. At least half of all NHS front line staff were trained in suicide prevention awareness by 2010, with nurses among those training others and being trained themselves. The 19 per cent drop in suicides between 2000-02 and 2011-13 covered the period of Choose Life, a decade-long strategy to tackle suicide, set up as part of a national programme to improve mental health and wellbeing. A new suicide strategy was published last year, and aims to continue to support the downward trend. Alana Atkinson, programme manager with the suicide prevention national programme in NHS Health Scotland, believes that taking a concerted approach has had an important impact. ‘National, and local work in partnership has made a big difference,’ she says. ‘We’ve been very bold in Scotland about talking openly about suicide, and addressing the stigma of suicide to encourage people to come forward for help.’ Training in suicide prevention awareness and skills was targeted at particular groups, including mental health nurses, GPs and people working in accident and emergency. But the work has gone wider than that. ‘It’s an issue for all nurses,’ says Ms Atkinson. ‘We know that while not every person who attempts suicide is in touch with mental health services, many will have been to see their GP, or will have been in a general hospital, in the previous months before their death. ‘When people give cues [that they are vulnerable to suicide] we want all nurses to feel confident in having that conversation, to say “are you thinking about suicide?”, getting to that level of conversation.’ Around 50,000 people have undergone suicide prevention awareness training in Scotland, spreading good practice, she says. Although she believes that awareness about suicide has risen in Scotland, in the health service and the general population, there is still a long way to go. For example, more needs to be done to ensure that people presenting at services who have self-harmed receive support. Other steps have included setting up a suicide information database for Scotland, which provides information about the circumstances of people who die by suicide, and helping health professionals to plan better to prevent it. It is not possible to compare suicide rates across the UK because they are recorded differently, and Ms Atkinson would be the first to say that more still needs to be done in Scotland. But, she adds, a very good start has indeed been made.
22 september :: vol 29 no 4by:: ${individualUser.displayName} 2014 STANDARD Downloaded24 from RCNi.com on Nov 21, 2015. For personal use only. NoNURSING other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Educating health professionals in how to talk to people at risk of suicide could reduce this common cause of death, says Jennifer Trueland
20 september :: vol 29 no 4by:: ${individualUser.displayName} 2014 STANDARD Downloaded24 from RCNi.com on Nov 21, 2015. For personal use only. NoNURSING other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
SUMMARY
There’s an old story about a man visiting a doctor saying he is depressed, he can’t sleep and life isn’t worth living. The doctor thinks for a moment and then suggests a solution. ‘The great clown Pagliacci is in town,’ the doctor says. ‘Go and see him tonight, and I’ll guarantee you leave with a smile on your face.’ ‘But doctor,’ the man replies, bursting into tears, ‘I am the great Pagliacci.’ This tale spread quickly on social media after the death last month of the comic actor Robin Williams. The familiar ‘tears of a clown’ theme was given an extra resonance by the suicide of the star of Mrs Doubtfire, Aladdin and Mork and Mindy. Extensive media coverage alluded to the actor’s problems with drugs and alcohol, his money worries and, most recently, his diagnosis of Parkinson’s disease. Despite all this, there somehow was an irony in the fact that a man who made so many people laugh was so unhappy himself. ‘The death of Robin Williams was very sad,’ says Annessa Rebair, senior lecturer in mental health at Northumbria University’s faculty of health and life sciences. ‘He was loved by a lot of people who had enjoyed his films. ‘But this is happening every day – people are losing members of their family, or friends, to suicide and the impact of that loss ripples out, affecting many of us.’ Far from being a rare tragedy, suicide is an all too common cause of death (see box), and an important public health issue. There were 5,981 suicides in the UK in 2012, and it is the leading cause of death in men under 35.
Suicide – the crucial figures There were 5,981 suicides in the UK in 2012 – 4,590 men and 1,391 women. In the UK, the age group with the highest suicide rate in men was 40-44 years; for women, 50-54 years. (Source: Samaritans, tinyurl.com/nda43nu) Suicide is the leading cause of death in men under 35 in the UK, according to the Mental Health Foundation (tinyurl.com/peykv2d) Worldwide, there are more than 800,000 deaths from suicide every year – one every 40 seconds. Suicide is among the three leading causes of death in those aged 15-44 in some countries and the second leading cause of death in the 10-24 age group. (Source: WHO, tinyurl.com/949ze)
Suicide is increasingly recognised as a significant cause of preventable premature mortality. Nurses in all settings come into contact with people who are at risk. Experts say it is vital that nurses have the confidence to ask patients if they are having suicidal thoughts, and refer them on to appropriate support. Author Jennifer Trueland is a freelance journalist
Ms Rebair believes passionately that nurses have an important role to play in helping to prevent suicide. At this year’s RCN congress she won members’ backing for a resolution that suicide prevention should be included in the undergraduate nursing curriculum for all nurses. Research backs up the case for prevention, but there is also evidence that people find it hard to intervene when they suspect that someone is at risk. A study reported in the BMJ in 2011 (Recognising and responding to suicidal crisis within family and social networks: a qualitative study (BMJ 2011: 343;bmj;d5801)) revealed that the friends and relatives of people who committed suicide had found the warning signs hard to interpret and had been reluctant to act. They had believed their loved ones’ assurances that they were all right, and were unwilling to intrude. The authors pointed out that health professionals can feel similarly inhibited. Ms Rebair argues that undergraduate training in suicide prevention would give nurses the skills they need to get involved. Since congress, RCN has started work to take this forward. So far, says RCN mental health adviser Ian Hulatt, this has involved a literature search, conversations with relevant stakeholders such as Public Health England, and preliminary exploration of how training could be tried out in a university setting.
In his view, the move fits with a growing willingness to talk about mental health issues more widely. ‘There’s greater openness to discussing the issue that you can’t have good health without good mental health,’ he says. ‘But suicide is still a difficult area to address with someone, even with a person who has self-harmed.’ He adds: ‘It is not just about awareness; it’s also about services – crisis services are already struggling in the NHS. There’s still further work to be done.’ Ms Rebair, who also works with Papyrus (Prevention of Young Suicide), believes nurses are keen to improve their skills and awareness in suicide prevention. ‘I wasn’t prepared for the response when I spoke at congress,’ she says. ‘I had people coming up to me afterwards, telling me their stories about how they had been affected by suicide. The response was moving.’
Targeted training
Ms Rebair says suicide prevention training would benefit qualified nurses as well as students, and cites nurses working in accident and emergency, in general practice and the community. Alistair Grant, a senior charge nurse in mental health with NHS Grampian in Scotland, believes that public and NHS staff attitudes have changed towards suicide over the past decade, and that stigma generally is beginning to lessen. ‘All my career has been in acute settings and obviously we see people who self-harm, and who might be at risk of suicide,’ says Mr Grant. ‘But I can see that there has been a change more generally. Other people [in different parts of the health service] are taking more of an interest – there’s a greater understanding and nurses are able to signpost people or refer them for help.’ He adds that it is also important to support people in the voluntary sector working with isolated individuals who might be at risk. As a mental health nurse, he is acutely aware that high-profile suicides, like that of Robin Williams,
NURSING :: vol 29without no 4 :: permission. 2014 21 DownloadedSTANDARD from RCNi.com by ${individualUser.displayName} on Nov 21, 2015. For personalseptember use only. No24 other uses Copyright © 2015 RCNi Ltd. All rights reserved.
SCOTS SHOW THE WAY
ISTOCKPHOTO
Signs and support
Annessa Rebair, senior lecturer in mental health at the University of Northumberland, gives the following advice, based on the training company Living Works’ SuicideTALK approach. Signs that someone may be at risk of suicide include: Actions – self-harm, reckless behaviour, withdrawal, giving up hobbies, drug and alcohol misuse. Physical – lack of interest in appearance, lack/change of interest in sex, disturbed sleep, physical health complaints. Feelings – stressful events with feelings of loss, hopelessness, loneliness, worthlessness, anger. Thoughts – such as ‘I just can’t take it anymore’ or ‘everyone will be better off without me’.
Support to offer includes: Tell – the person needs to tell someone about their thoughts and feelings. Ask the person if they feel suicidal – ask directly and clearly. Listen – this might be the first time they have expressed their thoughts and feelings to anyone. Keep safe – help the person explore what needs to be done to keep safe; they may have not fully recognised the danger. Help them commit to a safety plan and explore the inclusion of trusted others.
can have an impact on vulnerable people. He explains that a person’s circumstances can mean they are particularly affected by such cases. Even a storyline in a TV soap opera can make a powerful impression. Some research suggests that reporting of suicides can lead to a ‘spike’ in the numbers of people who take their own life, but Mr Grant says media coverage can also raise more positive awareness and provide an opportunity for troubled people to seek help, which nurses should be ready to provide. In this age of social media, news of celebrity suicides is reported and endlessly ‘shared’. Ms Rebair is
concerned that the attention given to high-profile suicides may trigger ‘copycat’ attempts. ‘It is important to make nurses aware that this might have an effect, so that they can be more vigilant,’ she says. The one thing nurses should never do, she adds, is look the other way. ‘People think “Oh my goodness, it’s a can of worms”. And yes, it’s a complex area. But it’s too important to ignore’ NS Resources Living Works: www.livingworks.net Samaritans: 08457 909090 www.samaritans.org Papyrus (young suicide prevention advice): 0800 068 41 41 www.papyrus-uk.org
In Scotland, the suicide rate has fallen by almost one fifth in the past 12 years – and nurses have been closely involved. At least half of all NHS front line staff were trained in suicide prevention awareness by 2010, with nurses among those training others and being trained themselves. The 19 per cent drop in suicides between 2000-02 and 2011-13 covered the period of Choose Life, a decade-long strategy to tackle suicide, set up as part of a national programme to improve mental health and wellbeing. A new suicide strategy was published last year, and aims to continue to support the downward trend. Alana Atkinson, programme manager with the suicide prevention national programme in NHS Health Scotland, believes that taking a concerted approach has had an important impact. ‘National, and local work in partnership has made a big difference,’ she says. ‘We’ve been very bold in Scotland about talking openly about suicide, and addressing the stigma of suicide to encourage people to come forward for help.’ Training in suicide prevention awareness and skills was targeted at particular groups, including mental health nurses, GPs and people working in accident and emergency. But the work has gone wider than that. ‘It’s an issue for all nurses,’ says Ms Atkinson. ‘We know that while not every person who attempts suicide is in touch with mental health services, many will have been to see their GP, or will have been in a general hospital, in the previous months before their death. ‘When people give cues [that they are vulnerable to suicide] we want all nurses to feel confident in having that conversation, to say “are you thinking about suicide?”, getting to that level of conversation.’ Around 50,000 people have undergone suicide prevention awareness training in Scotland, spreading good practice, she says. Although she believes that awareness about suicide has risen in Scotland, in the health service and the general population, there is still a long way to go. For example, more needs to be done to ensure that people presenting at services who have self-harmed receive support. Other steps have included setting up a suicide information database for Scotland, which provides information about the circumstances of people who die by suicide, and helping health professionals to plan better to prevent it. It is not possible to compare suicide rates across the UK because they are recorded differently, and Ms Atkinson would be the first to say that more still needs to be done in Scotland. But, she adds, a very good start has indeed been made.
22 september :: vol 29 no 4by:: ${individualUser.displayName} 2014 STANDARD Downloaded24 from RCNi.com on Nov 21, 2015. For personal use only. NoNURSING other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
