A Samaritans support sign on Beachy Head, near Eastbourne; others are placed at railway tracks, bridges and buildings across the country
Suicides are startlingly common. Over 5000 are reported in the UK every year, according to the Office for National Statistics—more than double the number of people killed in road traffic accidents. Governments across the world rightly see prevention of suicidal behaviour as an important healthcare target. This autumn has seen World Suicide Prevention Day, international conferences in both Israel and Norway (contrary to popular belief Norway, Sweden and Denmark’s suicide rates are low), the publication of the British government’s prevention strategy report and a study from the Samaritans on the demographics of suicide, which confounded common perceptions of who is most at risk.
In Britain, suicide is dealt with as a medical emergency. This means those who feel they are an immediate risk to themselves—if they check into a hospital’s accident and emergency department (A&E)—will be treated swiftly and often effectively. But the aim is short term: to stop the patient from committing suicide on that particular day.
The problem is that the National Health Service (NHS) often fails to treat the mental health issues that lie behind the patient’s suicidal feelings. If the patient cannot easily describe the illness, practitioners and patients are paralysed; the focus will be on preventing the suicide attempt but may fail to result in long term treatment.
The first challenge is how to encourage suicidal people to ask for the help they need and, once they do, how to assess the risk compassionately. The initial port of call for someone seeking urgent help in Britain is likely to be the NHS Choices website, which advises the suicidal to call the Samaritans or NHS Direct, or to go to their GP or accident and emergency, and talk about how they are feeling. Good advice in theory but, in reality, the hopelessness of suicidal feelings may well prevent those most in need from following it.
For many, treatment comes only in the aftermath of a suicide attempt or an episode of severe self-harm. But it may be a struggle for them to get proper help even then. Stories about patients being “sectioned”—detained at hospital—against their will under the Mental Health Act are commonplace. The experience of patients who have to fight to convince hospital staff that they still need treatment after the suicide crisis is less well known.
A formerly suicidal young woman describes her struggle to get the seriousness of her psychological condition recognised by hospital staff. After attempting to overdose on painkillers, she was found by her mother in the morning and taken to hospital where she had her stomach pumped (now a relatively rare treatment).
“I was in overnight but nobody thought I was much of a risk to myself, so they sent me home,” says the young woman. “I carried on self-harming but no longer wanted to die. Eventually I admitted myself to a psychiatric ward voluntarily, self-harming or taking overdoses whenever they tried to get me to go home.”
In many medical settings “cry for help” suicide attempts are casually dismissed, though research by Dr Thomas Joiner at Florida State University has shown that repeated suicide attempts reduce fear of death and increase the risk of eventually fatal suicide. Suicide prevention organisations across the world believe that too many people with suicidal feelings are misunderstood at the point of contact with medical staff and discharged from care once death is averted.
An on-call medical registrar at a busy London hospital explains the difficulties suicidal behaviour presents to an overstretched NHS. She sees one or two overdoses on every overnight shift and acknowledges that staff quickly weary of the phenomenon.
“They are usually young women who think that taking paracetamol will mean they drift off to sleep and won’t wake up,” she says. “In fact, if you do die it’s of liver failure weeks later. I saw a girl whose liver had failed after an overdose and she was approved for a transplant. After the operation she did it again and there was nothing more we could do when the second liver failed.” The patient died.
“Our job, medically, is to assess the risk of suicide, not to treat the underlying causes,” says the registrar. “The number of people who turn up in A&E and actually die from a suicide attempt is small, so that breeds a culture of ‘oh no, not another one.’ On the other hand, you will be admitted to a ward very quickly if you have a high index of risk; that is, if you didn’t leave a suicide note and have made a very violent attempt.”
Who is at risk? Public perception, partly based on vigorous campaigning by bereaved parents of young suicide victims, might suggest that the young are a particularly vulnerable group. However, the group most at risk in the UK, according to a new report published by the Samaritans, a suicide prevention charity, is working class men aged between 34 and 55.
Salimah Lalji, a spokeswoman for the Samaritans, describes the “forgotten men” who have little emotional support in their lives. “Men depend more on relationships than women do, so relationship breakdown can effect them more deeply,” she says.
Unemployment is also a major factor. Historical suicide rates among those entering the job market at a time of recession are consistently high.
The government’s national suicide strategy, launched in September, concentrates on prevention by removing the means. A study by the Oxford Centre for Suicide Research has proven that this works: people whose method of suicide is removed often do not go on to kill themselves. Suicide rates decreased after laws curbing gun ownership were passed; again when the drug co-proxamol was removed from the market; and again when paracetamol was repackaged.
Lalji says that the Samaritans’ aim is, “to widen the gap between thought and action in that 30 to 60 minute crisis time.”
Once the crisis has passed, resolve is usually diminished. “The biggest example of effective removal of means was when coal gas was replaced by methane in the 1960s,” explains Mark Williams, a professor of clinical psychology at Oxford University. “It had a huge effect region by region as the switch was made. People could no longer put their head in the oven.” However effective this kind of prevention may be in limiting actual deaths, it again does little to address the background causes.
Even when hospitals properly recognise suicidal thoughts in their patients, they are less good than they could be at tackling the deeper questions. There is a “major issue” of “negative attitudes towards this patient population, particularly in doctors and nurses in the general hospital setting,” says Keith Hawton, professor of psychiatry at Oxford University.
A conversation with a psychiatric nurse on an acute ward in south London illuminates this disturbing problem. “There are a lot of young women on the wards who self-harm,” he says. “The sad thing is that if it doesn’t stop before they are 18 it becomes almost a lifestyle; a way of dealing with the world.
“There is unspoken hatred towards them from a lot of staff. I’m not saying it’s right, but if you see the same person being admitted week in, week out, and never progressing no matter what you have to offer,” particularly when hospitals are under such pressure, he says, “you might be able to understand the hatred that gets directed towards them.
“There was a guy a few months ago who walked into A&E asking to be admitted because he was suicidal. The doctors assessed him as not a big risk and sent him home. He left, poured boiling water over his arm, called an ambulance and was assessed and admitted. Now he gets admitted whenever he wants to.”
Others might argue that even though he may not be about to kill himself, this patient is fighting for the help he needs but cannot articulate. Dr Mani Sairam, a psychiatrist and on-call registrar, is understanding about the needs of such patients, which include longer term support. “Often the patients feel more secure when they come in. Out in the community they have no support but in hospital they are being taken care of. A great many people have been saved by services—both with hospital admission and the therapy and support teams afterwards.”
“They say it takes a village to bring up a child,” says Professor Williams. “I’d say it takes a village to support someone who is suicidal. It is important to hold that person through the endings and transitions of treatment and to make sure they continue to be held.”
It is this long term help that is so often neglected in favour of a medical focus on the risk posed by a particular attempt. The NHS must fully address deeper issues of mental health if it wants to help more people who are at risk from suicide.
The Samaritans can be contacted on 08457 90 90 90.
