Can everybody see the presentation? I have handed out copies of the slides. I thank the Chairman and other members of the sub-committee for inviting us here today. We are privileged to be here three years after the first time we presented as part of the consultation round. The objective today is to reflect on the progress made since the launch of Reach Out and since the launch of the important report of this sub-committee. I am joined by Dr. Helen Keeley and Dr. Carmel McAuliffe. Dr. Keeley will also do a brief presentation specifically focusing on youth suicide and deliberate self-harm among adolescents.
I will start by briefly looking at the historical overview or flow of developments in this area in Ireland. I will not go through this in detail but I must highlight that it is not a long time ago that suicidal behaviour was decriminalised in Ireland. In fact, Ireland was the last country in Europe to decriminalise suicidal behaviour. In some of our research, particularly that focusing on stigma and attitudes towards suicide, we see the important impact of this.
In 1995 the late Dr. Michael Kelleher, whom most members will still remember, took up the challenge of setting up the National Suicide Research Foundation in Cork. It was definitely a major challenge in a time in which the stigma was very significant and there was also an absence of reliable data on suicide and self harm. It is unfortunate that by the time Dr. Kelleher achieved the first overviews of and statistics on self-harm, in 1998, he died tragically. That was an important year because the task force was set up as the first cornerstone of suicide prevention.
I will not go through this in great detail but 2005 was a very important year because Reach Out, the ten-year prevention strategy, was launched. I and Dr. Paul Corcoran from the office were involved in writing that publication, together with other members of the writing group, over a period of two years. Another very important milestone was the publication of the report of this sub-committee, which was very timely because there was a need to plan for the future and take on the problem in a comprehensive and structured way.
In most of my presentation today I will focus on specific outcomes in the past three years. I have prepared a pack for members with publications, reports and papers published in peer-reviewed journals, but only with reference to work published in the past three years. The NSRF has had its mission statement for a long time. Why are we doing research? We are not doing it for its own sake but to provide an evidence base to support policy and strategy in this area. In addition, we are a resource, to a large extent, for HSE agencies, and in recent years we have received many requests from community-based services, schools and so on. As I often say in the office, it is a never-ending list.
Historically, Dr. Michael Kelleher started with research in the area of epidemiology of suicide and self-harm, and his main focus was on risk and protective factors. We have obtained much relevant information in this area, but there are still gaps and there are many unanswered questions.
I will end my presentation with an update on these issues with respect to the strategy document and I will describe how we look to the future. It is necessary to have another arm of research when one conducts research in this area. To know the risk factors is to complement the work of the National Suicide Research Foundation. If one knows the extent of the problem, one must then do something about it. However, this is not enough. It is necessary to measure whether what one does about it is effective. For this reason we have established a number of interventions and prevention programmes, especially for young people. Dr. Helen Keeley will report on some innovative projects we have conducted. When one attempts to implement change, attitudes are very important, particularly in light of the history of criminalisation of suicidal behaviour.
Our strategy has changed to a great extent since the launch of Reach Out and the report of this committee. Many of our research priorities are now guided by Reach Out and also by the recommendations in the committee's report. I did not have a great amount of time to prepare this presentation but when I went through the list of 33 recommendations in the committee's report I discovered to my pleasure that all the work we have been doing in the past three years feeds into 16 of the 33 recommendations. Some of these will be illustrated by some of the outcomes that Dr. Helen Keeley and I will present.
Since the start of Reach Out, an increased number of studies has been commissioned by the national office for suicide prevention. A good example is the Garda form 104 report which is in the pack I provided to the members. Trying to discover what lies behind the statistics we receive every year from the Central Statistics Office has proved to be almost a revolutionary type of research in Ireland. That report has been a cornerstone for a new project we are taking on and to which we refer, in house, as the confidential inquiry. Outside, we refer to it as the suicide support and information system.
I am very pleased to tell the sub-committee of an increased number of collaborative studies with Northern Ireland. We established these in the past three years. On World Suicide Prevention Day in September we received an interim report on the first findings of a pilot registry on deliberate self harm in the Derry region. Working with Northern Ireland has been a most useful expansion.
We have also been looking at work outside Ireland because there is never sufficient funding for developmental and new projects. These include an increased number of European collaborative projects under the FP6 framework programme and three new projects under the FP7 programme. Most of the priorities in these studies are in line with the report of this committee and with Reach Out.
Everywhere I go I bring the iceberg diagram now displayed and most sub-committee members will be aware of it. Looking at the most recent findings available from the CSO showing years of occurrence, we see there has not been a significant reduction in suicide. If we take the new findings from the 2006-07 report on the registry, there are still approximately 11,000 cases of self harm coming through accident and emergency departments. We have ongoing evidence from a study we completed in 2004 on a school-based study among adolescents. We found that although a very large number of young people had engaged in self harm, 85% had not been in touch with anybody in the services. If we extrapolate from this to all ages and regions of the country, we find a shocking estimate of 60,000 hidden cases of self harm per year.
We completed a new review-type overview that examined the extent of prior self harm by looking at hidden cases. In the iceberg diagram, members can clearly see that a relatively high proportion of people have already repeatedly self harmed or have a history of repetition, although they remain hidden. If we go further up, we see that an even higher percentage of people seen in emergency departments have a history of previous self harm. At the top, if we examine the history of people who have died by suicide, a possible 82% have repeatedly self harmed or have a history of self harm in the past.
Unfortunately, we can only show the data to 2005 because we are dependent on year of occurrence data issued by the CSO. The pattern we saw years ago continues with a slight increase of suicide rates in the 22-24 age group. An intensified focus on intervention and prevention activities for young people is justified.
The following slide shows an overview of suicide trends matched with trends of deaths by road vehicle accidents during the period 1997 to 2005. It speaks for itself. Deaths by suicide are consistently higher than deaths by road traffic accidents. Although there is a slight decrease in mortality caused by road traffic accidents, there is no significant change in suicide rates.
I thought it worthwhile to bring to the committee an overview of trends in undetermined deaths in respect of men and women during the period 1996 to 2005. Contrary to our expectation, we see that in 2004 the rates of undetermined deaths rose for men and women. From studying work done on the Garda form 104 and from subsequent consultations with coroners, gardaí and other mental health care professionals, we know that a certain proportion of hidden cases of suicide are listed as indeterminate deaths but to date we do not know what the proportion is. We hope to make further advances in this area with the new suicide support and information system in which we will work closely with the coroners.
Most members will be familiar with the next picture which shows the coverage of the national registry of deliberate self harm. In the past two years we were able to cover all general hospitals in Ireland and we now produce data each year showing full coverage. It is important for the committee to see what has changed since the early part of this decade. Initially, we saw a falling rate of self harm among men and women and we were hopeful that with the Reach Out strategy and the priorities laid out in the committee's document, we would be able to push this rate further downwards. Unfortunately, figures for the latest year, 2007, show an increase in deliberate self harm among men and women.
We must make a specific critical note here. In those years, especially 2005 to 2007, inclusive, there was a push with regard to programmes that address stigma and increase awareness of suicidal behaviour. It may be the case that people who engage in self harm but at a low non-lethal level, by superficial cutting, for example, or by taking only a few paracetamol pills or tranquillisers, now move into the accident and emergency departments earlier than some years ago. Although I am very much in favour of setting targets, I believe we must keep a critical eye on this possible hypothesis.
If we look at the final data for the last two years of the registry, there has not been much change in terms of the pattern and the top levels of rates of deliberate self harm. Unfortunately, we still see a very high peak of deliberate self harm in young girls between 15 and 19 years of age. We should not underestimate the relatively high peak of self harm among young adult men. Members will recall the previous slide showing suicide numbers. I do not believe it is coincidence that the peak of deliberate self harm found in men of the 20-24 age group occurs with the highest peak for rates of suicide. The only limitation in our work — and it is fundamental — is that we cannot link the data. That might be a challenge for the future.
Members are probably familiar with the relative distribution of methods used by people who engage in deliberate self harm. The majority take an overdose. In Ireland there is a very high prevalence of people using minor and major tranquillisers, followed by analgesics, especially paracetamol and paracetamol compounds, followed in turn by anti-depressants. Another remarkable issue here is the higher than average rate of self-cutting among men. I refer to this as the Irish phenomenon, because we do not see it in other countries. We have reached a stepping stone to enable us to investigate in more depth this group which engages in self-cutting. We wish to find out if the type of self-cutting is very different and if the lethality is higher than for women. We are at the bridge where we can carry out more research in this area.
There is another very important finding of recent years which the sub-committee should take into account when revising priorities. There is a high prevalence of repeated self harm among younger women following an episode for which they have received treatment in emergency departments. However, there now appears to be an increase in the number of men with a tendency to repeat attempts at deliberate self harm following the first attempt or episode. The majority of studies on effective treatments for such self harm involves women. We do not yet know if men respond in a similar way to cognitive behaviour therapy, CBT, problem solving or to other interventions, which is a new challenge for the coming years.
We should take very seriously the data showing that a majority of people, whether men or women, repeat an attempt at self harm very quickly after treatment in emergency departments. What does that tell us about assessment and after care? Some of the data is very worrying. We examined specifically where there are higher rates of people who repeat attempts at self harm in the first three or six months following treatment. Repetition rates for self harm are relatively high among people who have received psychiatric admission, but this probably reflects the severity of cases associated with that specific group. We all know about borderline patients or people with chronic depression who repeatedly harm themselves. The more there is repeated self harm the more difficult it is for clinicians to intervene in the process. This is the first hypothesis we should consider.
The findings in the next slide illustrate that a relatively high percentage of people who leave hospital unseen, or who refuse an assessment, are likely to return. There is a somewhat lower percentage, although it is still quite high, of readmittance for people who only receive general admission, or who are not admitted at all. We should remain vigilant, improve assessment procedures and bridge the gap between people who leave the hospital after an episode of self harm. There should be a proactive follow up approach in such cases.
This slide shows the iceberg effect again but it refers to different content. Because of time constraints I will not go into detail, but it highlights to the sub-committee that we have used a systematic approach in the research and the intervention studies conducted, to try to address all three levels of the iceberg. Most of the outcomes of this work are available in the pack I provided for the sub-committee, but some of the work is ongoing. I will provide some examples. Since we began working together with the Garda using the form 104 to collect relevant data, we know a little more about the accuracy of suicide statistics in Ireland. We evaluated the impact of restricted availability of paracetamol and the negative news is that we have not seen a significant change in the number of intentional drug overdoses following its restricted availability.
Consider the bottom of the iceberg. Much research has been done to test the effectiveness of depression and suicide awareness training, especially at the level of community facilitators. We have found a significant improvement in people's awareness and attitude following the six hour training sessions on depression and awareness held. Dr. Helen Keeley will elaborate on a new project to increase promotion of positive mental health among adolescents.
When preparing for the committee I tried to learn from the work done in the past three years and I discussed the issues with people in other organisations to find out what new priorities we should take on board in addition to those which have not yet been completely addressed, either by Reach Out or by the recommendations in the report of the committee. Consider that the number of men attempting repeated self-harm now exceeds the number of women. We should further examine the effectiveness of interventions aimed at such men.
