I welcome the representatives from the National Suicide Research Foundation, Dr. Ella Arensman, director of research, Mr. Paul Corcoran, senior statistician and deputy director, Ms Carmel McAuliffe, research psychologist and project co-ordinator, and Ms Eileen Williamson. For their information, the members present are Deputies Neville and O'Connor and Senator Browne. We will be joined later by two other members of the sub-committee. Dr. Siobhán Barry, the sub-committee's consultant, is also here. I ask the delegation to commence its presentation on the high levels of suicide in Irish society.
High Levels of Suicide: Presentations.
Dr. Ella Arensman
I thank the Chairman and members for inviting us to give a presentation on the high levels of suicide in Ireland. This initiative is timely in light of the large increase in suicide rates, particularly among young men, in the past five years. It is also timely because Reach Out — A National Strategy for Action on Suicide Prevention for the next ten years, was launched in September.
I wish to give a brief outline of the objectives of the work of the National Suicide Research Foundation, a brief overview of some relevant and recent research findings and a synopsis of some of the foundation's priorities, which, to a large extent, mirror those of Reach Out.
I apologise on behalf of Dr. Margaret Kelleher, the medical director of the National Suicide Research Foundation, and Professor Ivan Perry, director of the National Parasuicide Registry, neither of whom could be here today.
The National Suicide Research Foundation was established by Dr. Michael Kelleher ten years ago. Dr. Kelleher was a pioneer in Ireland in terms of initiating the first research projects to determine the extent of the problems of suicide and deliberate self-harm. The National Suicide Research Foundation also researches risk factors and protective factors with regard to suicidal behaviour. In recent years we have expanded our work to research the efficacy of intervention and prevention programmes for suicide and deliberate self-harm.
Since 1995, the National Suicide Research Foundation team has been multidisciplinary and includes psychologists, psychiatrists, biostatisticians and epidemiologists. This is very important in the area of suicidal behaviour because it is clear that answers to the problem will not come from a single discipline. Collaboration and integration are very important in that regard.
The foundation has close links with relevant health care and community services. For example, we recently began a four-level community-based intervention programme that addresses all the important services in the area. There are 22 community and health care organisations on our advisory panel.
I have circulated recent reports and publications to members of the sub-committee. At the end of this presentation, members can find an overview of all of the projects in which the foundation is involved. I do not have time to go through all of them today but we are currently involved in approximately 17 different projects.
In the past ten years the National Suicide Research Foundation has developed an advisory role vis-à-vis the Government. This is reflected in the fact that Mr. Paul Corcoran and I were part of the group that wrote the Reach Out national strategy. We have also made contributions to the mental health policy framework for the next ten years. In addition, the foundation is also involved, almost on a weekly basis, in delivering awareness and skills training, as well as supervision for trainee general practitioners and trainee psychiatrists.
This is an important period in the history of suicide in Ireland. Research into and prevention of suicidal behaviour in Ireland is relatively young. One of the main reasons for this is that suicidal behaviour was criminalised until 1993. Ireland was the last country in Europe to decriminalise suicidal behaviour and Deputy Neville played a crucial role in that process.
The establishment and involvement of so many organisations in this area in the past ten years is a good reflection of their commitment. However, we have reached the point where there is a need for co-ordination at national level to avoid fragmentation or duplication in our work.
I will present the relevant findings on levels of suicide, some of which will not be new to the sub-committee. On average, almost 500 suicides — approximately 80% of them involving men — occur in Ireland each year. The average national annual suicide rate is 13 per 100,000 in all age groups. The latter is similar to the EU average. The gender and age distribution figures show that peak rates of suicide occur among males in the age group 20 to 29. Men under 50 years of age account for 40% of all suicides. Ireland ranks seventh in the EU in peak rates of suicide among young men. Members will see from the slide that the rate among women is significantly lower. However, suicide rates among women, particularly young women, have doubled since the beginning of the 1990s. The latter must, therefore, be treated as a priority area.
Although the reliability of the statistics has improved, there are still clear indications of under-reporting. This is largely due to single road traffic accidents because they commonly involve young men in those age groups. Mr. Corcoran is preparing a report on the reliability of suicide statistics in Ireland, which is due to be published in approximately two months.
The next category of statistics relates to non-fatal suicidal behaviour, which we refer to as deliberate self-harm. A great variety of motives exist for that category of behaviour, such as seeking attention, self-punishment and revenge. Findings from the national parasuicide registry show that annually some 11,000 deliberate self-harm cases present to accident and emergency departments. Of these, almost 60% are women and the national average rate is 200 per 100,000. I was not able to bring the recent European statistics but the figures from a couple of years ago show these rates to be high for all ages.
The next slide shows the most recent available findings of the national parasuicide registry. The data from 2004 will be published in a month. They clearly show that peak rates for deliberate self-harm occur among young women, particularly in the age group 15 to 19, and among young men between the ages of 20 and 24. When comparing the findings, it is important to ask if those young men who engage in non-lethal suicidal behaviour are the same as those who commit suicide six months or a year later. We do not know yet because we cannot link the information from the national parasuicide registry to information from the coroner service or the CSO. That step should be taken as a priority.
Another slide with data from the national parasuicide registry is on care recommended to deliberate self-harm patients following treatment in accident and emergency departments. I refer to two different issues. It is clear from the level of referrals across the different HSE areas that there is variety in how and where deliberate self-harm victims are referred, which shows an important discrepancy. For example, 25% of patients in the eastern region are referred on the basis of a general appointment or admission which compares with 74% in the south-eastern region. Another important issue is that almost half of the deliberate self-harm victims are not admitted at all. When one considers the national level of referral, there is not a standardised procedure and that is a priority for us in the near future.
I will move on to the recent findings of a large school-based survey we conducted in the southern area. A report on the survey, including all the descriptive findings, is included in the pack I circulated. We found that at least 9% of the adolescents involved in the study — which was anonymous and involved filling self-report questionnaires under the guidance of the researchers — engaged in deliberate self-harm in the past year. In line with the registry, we found that the prevalence was higher among girls compared with boys. An important finding, which was beyond our expectations, was that almost half the young people had repeated this behaviour at least once. It is important to take that into account, particularly at that age.
The same school-based survey found that only a minority of the students who reported one or more cases of deliberate self-harm had been in contact with professionals in the health services, which could include a general practitioner, counsellor or physchiatrist. An important message to take from this is that a large proportion of the deliberate self-harm adolescents remain hidden from the services and, for example, teachers. Mr. Corcoran and I examined the possibilities of using this information to estimate how many adolescents could engage in deliberate self-harm nationally and who, at the same time, would be hidden from the services. In our extrapolation, which is even a little conservative, we came to a figure of another 10,000 cases nationwide on an annual basis, which is considerable.
I refer to a summary of what we do and do not know, which also reflects in a condensed way what are our main priorities for the next few years. We have a relatively clear picture of the extent of the problem of suicide in Ireland but we do not have systematic information on the risk factors associated with suicide. We know from anecdotal evidence that there is a relationship with alcohol abuse and depression but we also know most people who are depressed do not die by suicide. What, therefore, is the specific profile of young men who die by suicide? At the second level, based on the findings I highlighted, we need to prioritise the standardisation of the assessment of deliberate self-harm patients and treatment referral following their contact with accident and emergency departments. We are obtaining additional information regarding, for example, what happens to patients who are not admitted but who receive an outpatient referral. At the final level, which is not surprising following the findings I highlighted, a great deal of effort must be put into programmes and interventions to make the hidden young people visible to the services and other relevant people in the community. Our aim is to put a priority on evidence-based mental health promotion, which is also in line with Reach Out.
I will give some details on how we would like to achieve those objectives at each of the three levels. At the first level, we wish to combine the data held by separate statutory organisations, such as the national parasuicide registry, the CSO, the coroner services and in-patient hospital service databases. We have already made some preparations for this. We would also like to include information obtained from interviews with family and friends of victims.
We would also like to see a national confidential inquiry system established. We have examined the national system put in place in the UK in the past ten years, which shows that such a system facilitates the early and effective provision of information for people who are bereaved and who need support and information. It also leads to reduced rates of suicide. The UK system was established in 1995 and is still running. The expected outcomes of a national inquiry service would be improved identification of groups at high risk of suicide, informed and targeted preventative initiatives and reduced rates of suicide.
Our priorities at the second level are to standardise assessment procedures in accident and emergency units and in follow-up care to improve referrals for deliberate self-harm patients. We would like to link up with the national parasuicide registry and other partners such as the network of service providers and the National Office for Suicide Prevention, which co-ordinates work at national level. Expected outcomes are improved assessment and care of deliberate self-harm patients, improved compliance with treatment and reduced rates of repeated suicidal behaviour.
I refer to the third level as the level at the bottom of the iceberg, which includes hidden cases and cases about which we do not yet know. We support a review at national level to examine the efficacy of available mental health promotion programmes. Perhaps all of the members are aware of examples of mental health promotion initiatives. That is good but we do not know the extent to which those initiatives contributed to the reduction of suicidal behaviour. If we had more information, we could facilitate standardised delivery in schools and youth organisations or clubs. We envisage achieving this objective through working closely in partnership with a network of statutory and academic departments in schools under the umbrella of the National Office for Suicide Prevention.
The expected outcomes are improved mental health and well-being in young people, reduced stigma associated with mental health problems and help-seeking behaviour, including suicidal behaviour. The problem regarding stigma was an important aspect that came out of the school-based study. Another expected outcome is the eventual reduced rates of suicidal behaviour.
I must also mention, from my varied experience gained through working in this field for the past 15 years, that if we operated at only one of the three levels, we would not be successful in greatly reducing the rates of suicidal behaviour. The need to operate at the three levels at the same time is an extremely important aspect.
The collaboration and co-ordination of all relevant organisations in Ireland will be crucial to achieving this. The National Office for Suicide Prevention could be an important mechanism. I thank the sub-committee and my colleagues and I will be happy to answer any questions that members may wish to pose.
I welcome the representatives from the National Suicide Research Foundation and thank them for coming before the sub-committee. I have known all of them for many years and I am aware of the excellent work they do. Members were anxious the foundation would have an input into our report and, in that regard, we welcome them and thank them for coming.
The work the foundation is doing in the area of deliberate self-harm is very important. Figures show that 10% of those who self-harm are likely to go on to complete suicide. If one assumes that 8,000 people deliberately self-harmed last year, does that mean that 800 of those can be expected to take their own lives? The statistics on self-harm apply to those admitted to accident and emergency departments. It is extraordinary that 11,200 incidents of self-harm — when one takes into account the number of repeat attempts, these probably involved approximately 9,000 individuals — occurred last year and that 900 of those involved are likely to take their own lives.
The opportunity the area of self-harm represents, in terms of reducing the levels of suicide, is only beginning to be recognised by the health services. However, the resources in this area are inadequate. I appreciate time is needed to build up supports for people who deliberately self-harm, both in hospital and after they are discharged. Some psychiatric nurses have been introduced into accident and emergency departments to deal with and evaluate those who deliberately self-harm. Do the representatives have any idea of the extent to which support is being built up and the adequacy of what is already in place? The support systems are in their early days and we need to emphasise the opportunity that is there if the facilities and investments are put in place. In effect, such support services could touch at least 900 people who have self-harmed and who, according to statistics, are likely to go on to take their own lives.
The number of people who self-harm, according to the representatives, is approximately 21,000 every year. Of these, 11,200 are identified in accident and emergency departments, with an additional 10,000 not attending hospital. However, in a survey conducted by the foundation, only 11% of young people had been to hospital as a result of having harmed themselves. This suggests that 90% of those who engaged in self-harm did not go hospital. Would it not be correct, therefore, to suggest that the figure of 10,000 is too low? On the basis of the survey, it could be between 80,000 or 90,000. I do not believe it is necessarily that high but it has been suggested that as many as 70,000 may self-harm every year. On the basis of the group's survey, 90,000 would have self-harmed.
If resources were available to the foundation, could it move into the area of self-harm and research the true situation with regard to those who do not seek help and do not present at accident and emergency departments? If the representatives had the necessary resources, what type of research would they conduct to evaluate the extent of self-harming, apart from those who present to hospital? Are there programmes in existence which could be evaluated in terms of supporting these people and encouraging general practitioners to move them further on into the health care system, bearing in mind that one in ten of them will probably take their own lives? Perhaps the foundation could deal with general practitioners, who meet people who self-harm but who do not refer them on to other areas of the health care system or even feel there is a need to do so. GPs have an opportunity to help reduce levels of suicide by seeking help for those people. A large number do not seek help at all, either from a GP or the other health services. They are the most difficult cases because they suffer from the stigma and the consequent reluctance on the part of families to seek help. On one hand, this represents an opportunity but, on the other, it highlights the neglect on the part of the State and the system of those who self-harm.
Dr. Arensman
I will answer the first question, Mr. Corcoran will answer the second and Ms McAuliffe will answer the third.
I was not able to show members a slide giving peak rates of self-harm for specific ages of adolescence. The figures for the 15 to 19 age group peak at ages 16 and 17. One explanation may be the lack of resources and support available in hospitals for assessing and caring for deliberate self-harm patients. We are working closely on that issue with Dr. Helen Keely, consultant child and adolescent psychiatrist. From our work with Dr. Keely, we have discovered that it is difficult to refer an adolescent boy or girl to the services, particularly at weekends.
Lack of services is not the only issue. The work I have been doing with the foundation in past two years leaves me unconvinced that if we solved the problem of lack of services tomorrow — some hospitals already have excellent services and capacity — there would be a reduction in suicidal behaviour in the next year or two. However, awareness and skills training among accident and emergency nurses, even crisis nurses, is inadequate. For the past year we have been involved in a pilot study in the south east, where accident and emergency nurses have received training to improve their awareness of deliberate self-harm. We do not yet have the findings but we are aware that their job satisfaction has increased substantially. Facilitating the work of crisis and psychiatric nurses is very important. They greatly appreciate that support because it is difficult for anybody to work in isolation with somebody who is at high risk of dying by suicide. The two issues are capacity and the quality of services, including the attitudes of people involved in delivering them. We will include those issues in the measurement of the progress we make at level two in improving assessment and treatment referral. By the middle of next year, we will have more detailed information on how many deliberate self-harm patients are referred to specific services in hospitals and on the types of assessment they receive. Following that, we will make recommendations for a standard protocol.
Mr. Paul Corcoran
I will answer the question regarding the scale of the problem of deliberate self-harm. To do so, we must cast the net wider than merely considering those cases which present in hospitals. The survey we carried out related to 15 to 17 years olds and showed that only approximately 10% of those who self-harmed presented at hospital. Through the registry, we are aware that between 1,000 and 1,500 adolescents who self-harm present at hospitals. Approximately 10,000 in that age group do not present at hospitals. Deputy Neville is correct that the figure is much greater when all the age groups are included. The ratio is not the same for all age groups. It is not the case that only 10% of self-harm cases in the middle age group present at hospitals, the figure is probably far closer to 50%. However, this implies that the registry of accident and emergency departments see a minority. There are far more cases of deliberate self-harm not turning up at hospitals, particularly in the case of young people who were surveyed. We do not know the proportions——
How many actual presentations have there been at accident and emergency departments?
Mr. Corcoran
There have been 11,000 presentations——
Actual.
Mr. Corcoran
——with deliberate self-harm.
The figure floated is between 50,000 and 60,000. Could that be correct?
Mr. Corcoran
Yes, it is possible. Adolescents alone would add at least 10,000.
Therefore, a figure of between 50,000 and 60,000 would not be unreasonable.
Mr. Corcoran
Yes, it is possible that there could be that many.
It is an enormous figure. It is shocking that the level of services to destigmatise, encourage and promote positive mental health is neglected.
Dr. Arensman
Before the findings of the school-based study emerged, I would have estimated that approximately 50% to 60% of young people would be seen by the services. That 85% were not seen by anybody in the services shows an extreme situation.
Ms Carmel McAuliffe
In response to the third question on how to reach young people who do not present for help from the recognised services, the findings from the survey to which Dr. Arensman refers tell a good deal because their preferential source of help was among friends and family. A number of international studies have been carried outand there are programmes that involved what is called a “gatekeeper” approach. One such programme is ongoing at the National Suicide Research Foundation and is part of a larger European study. The aim of these types of programmes is to develop skills in those people who are not automatically recognised as being in the front line of health services and among peers, family members, friends, relatives or people in the community who are likely to come in contact with young people. It is clear from the findings that the majority of young people who would self-harm do not come to the attention of the services; they come instead to the attention of teachers, other community members, family members and friends. One approach is to try to develop skills and to enhance the awareness of those individuals to be able to respond and bring those young people into contact with the services that can assist them.
I welcome the delegation. Its first point about the need to avoid duplication and fragmentation is apt. I am amazed — as a result of the sub-committee's hearings — by the number of different groups all doing important work. There is a clear need to co-ordinate that work.
I wish to ask four or five questions. The delegation said that the suicide rate among young women has doubled since the 1990s. Is there a particular reason for this trend? Does it reflect a more affluent society? Does it reflect a drinking or binge drinking culture? Has research been carried out on the reasons the rate among women has doubled during the past ten years?
On the issue of deliberate self-harm, what type of injuries are involved? Would it be worth doing a publicity campaign in respect of it? Most people would be shocked to learn that 60,000 people deliberately self-harm. It almost implies that at least one member of every family has tried to deliberately self-harm. I am sure many family members would not recognise the symptoms but perhaps they might recognise the obvious ones. Those we do not recognise are slipping through the net. Perhaps a publicity campaign about the rate of deliberate self-harm, explaining what it is and what to look out for, might prevent further self-harm and possibly further suicide. The figures we are hearing, not only those referred to here but also those provided at previous meetings by other groups, are staggering. When Gareth O'Callaghan appeared before the sub-committee along with the delegation from Aware, he referred to a figure of 100,000. In reality we do not know the actual number. We know that 11,000 cases are presenting at hospitals and that this might only represent 10% of the total. The issue needs to be highlighted and explained.
Another graph that shocks me is the one showing the huge variation in the care level in the different Health Service Executive areas. Has the creation of the HSE been a help or a hindrance? Is it better to have one authority rather than 11 health boards? Have the witnesses seen an improvement since the establishment of the HSE? A very interesting point was made earlier in that there is no direct link between reports of deliberate self-harm and subsequent suicides. It would make sense that these data should feed into one database. How could issues of privacy and confidentiality be overcome in this regard? It would be vital for people to have research on that area.
A number of groups have made presentations to this sub-committee in recent weeks. The consistent theme is the need for co-ordination to avoid fragmentation. Deputy Neville has been to the fore on this matter and knows the issues involved. However, until the sub-committee began these hearings, I was never aware of the number of groups trying to deal with the issue of suicide. Despite all that goodwill and professionalism, we do not seem to have made any improvements. It can be said that, through research, we will see developments in the future. I am concerned that nobody can say why so many young people in their teens, 20s and early 30s are taking their lives by suicide. The National Suicide Research Foundation has today presented figures regarding females. While these are not at the same level as those among males, the level of increase is nevertheless alarming.
People have referred to the amount of Government funding allocated to reducing road traffic deaths and that campaign is quite obvious. However, the same numbers are dying through suicide and we do not seem to be able to get the political imprimatur to advance suicide research. None of us sees this matter as a political issue. The sub-committee represents all parties. It has been suggested that it might be an embarrassment to the Government or the Minister. If that is the case, so be it. In reality, the committee must try to make some kind of input and thereby impress on Government the need to deal with these issues now. It has been suggested that there has been a lack of funding. It was pointed out that the level of funding on suicide research is minimal and will not make an impression. It is more difficult to understand why the funding is not guaranteed each year.
The committee was advised that part of the country's corporate framework, namely, the ESB, is now investing in suicide research. While I had never considered it in these terms before, it was also pointed out to us that the economic deficit created by people taking their own lives is enormous. Perhaps the time has come for us to consider, bearing in mind the loss to the economy, inviting the corporate sector to become involved in funding. Would this approach be too commercial in the view of the National Suicide Research Foundation? Should we be more proactive in involving corporate structures in suicide research, particularly when we cannot seem to find answers as to why so many young people — including many qualified individuals who might be a great loss to the economy — die through suicide? Perhaps the time has come to be far more proactive and not wait for the outcome of a ten-year plan. Someone mentioned that using targets created the wrong impression. Perhaps, however, targets should be set in each HSE area in order that each year's results could be compared by way of success. For instance, I do not propose the erection of signs such as those used by the National Roads Authority outlining the number killed on the roads on a county by county basis but, as legislators, we should be conscious of the number taking their own lives in each county and ascertain whether people should be appointed in each county with responsibility for policy in this area. In addition, should private investment be promoted or encouraged?
Dr. Arensman
I thank members for their questions. I will comment on the first two from Senator Browne, while Ms Williamson will comment on his third regarding the reorganisation of the HSE regions. Mr. Corcoran will respond to the fourth. I would be happy to give information in reply to the fifth but Ms Williamson will also be able to provide answers.
The Senator's first question was related to the reasons for the doubling of the suicide rate among women. We do not have all the answers. That is one of the reasons we would like to prioritise linking information, for example, from the registry, the CSO, the Coroner's Service and other hospital services to find out more about the specific profile of women who have died by suicide in the past five or ten years. Following a number of small-scale studies, we know there is a link between, for example, the increasing rate of depressive disorders and suicide and an increasing trend towards alcohol use and abuse among women, particularly among girls, including a pattern of binge drinking. However, it is important to bear in mind that the majority who are depressed and who abuse alcohol do not die by suicide. The most important question is, what is the specific profile of those young women who have died by suicide in the past five or ten years? We need much more information in this regard. That is what we would like to address at the first level of the inquiry.
The second question was related to the types of behaviour highlighted in the large number of additional cases of deliberate self-harm among young people which came to light in the school-based study. To a certain extent, they showed similar behaviours to those in the cases we saw in the National Parasuicide Registry. One important difference was that the level of self-cutting such as wrist cutting or cutting other parts of the body was higher among young adolescents compared with the slightly older people we see in accident and emergency departments.
An important similarity between young adolescents and adults is the reason they engaged in self-harm. We looked into the specific motives and 61% of young adolescents, whether they were cutting, taking an overdose or harming themselves otherwise, reported a wish to die. We analysed this in more detail but did not find one adolescent who only reported a wish to die because adolescents always reported additional motives, for example, seeking attention, wanting to get help, revenge or self-punishment, which underlines for us the ambivalence of their behaviour, particularly when they make a decision about whether they will take paracetamol or cut themselves. There is great ambivalence. When I do training sessions, I always say that in this ambivalence lies a golden opportunity for them to intervene and change their behaviour. However, there are many similarities in the behaviour of young people, particularly adolescents, and adults, with some slight differences.
Has the research foundation thought about organising a publicity campaign? The figures cited by Dr. Arensman are truly shocking.
Dr. Arensman
Yes.
Suicide has been receiving a great deal of attention in recent times. It is obvious that deliberate self-harm should also be receiving some attention because the figures are far worse.
Dr. Arensman
Yes, I completely agree. We made a start in the HSE southern region by putting in place a community-based intervention programme. The information pack supplied to the sub-committee contains some details of the programme developed for young people, in particular, to inform them about the signs of depression and what could be done when one was depressed, or if someone in one's environment was depressed. The information included in the pack is based on a successful pilot study conducted in Germany some years ago. A similar programme has been rolled out throughout that country. The foundation can pursue a similar project because the European Union has provided funds to pilot such an approach in 14 member states. The HSE southern area is the first part of Ireland to be catered for under the pilot programme.
The information pack contains clear and positive statements such as "depression can be treated" and "depression has many different faces". Many think depression affects only those who are not active anymore — people who stay in their beds. There are many hidden cases of so-called "masked" depression. Although those who suffer from that form of depression have some physical symptoms, nobody in his or her environment thinks he or she has depression. The grave difficulty with assessing depression in adolescents — if we think back to our own adolescence, we will accept that this is the case — is that such persons think the world is a great place one day but think it is dark the next. Many confuse such observations with depression, but they do not constitute depression which is very difficult to assess among adolescents.
The National Suicide Research Foundation is piloting a positive mental health promotion programme. It is also collaborating with the Samaritans on a media campaign.
Does that campaign relate to deliberate self-harm?
Dr. Arensman
Yes, it relates to deliberate self-harm and depression. The foundation decided to pursue such a combined approach because of the important connection between depression and deliberate self-harm. Details of the campaign are available in the information pack supplied to the sub-committee.
Can I ask Dr. Arensman to elaborate further on the pilot programme she mentioned?
Dr. Arensman
Yes.
Will the programme be based on the figures available to the foundation on deliberate self-harm, etc.? The more the sub-committee hears about such matters, the more it becomes aware of the huge issues it needs to address. Mr. Gareth O'Callaghan said during the conference on suicide in County Leitrim and again during his subsequent presentation at a meeting of this sub-committee that more than 100,000 people were diagnosed each year with some form of depression, manic or otherwise. He suggested a further 300,000 with depression did not avail of the relevant services. The sub-committee has been told that 50 people are profoundly affected every time a person takes his or her own life. It also has been suggested 50,000 people go to accident and emergency units every year after engaging in acts of self-harm and that thousands more who engage in such behaviour do not receive medical attention. It is clear there is a need for a proactive campaign based on the startling figures I have mentioned, which create the impression that the problem is out of control, although I appreciate that is not the case. As the figures continue to increase, we are bordering on a situation which is out of control. I hope Dr. Arensman can explain what the pilot programme consists of and how the research foundation intends to select an area for the programme.
Dr. Arensman
When it was selecting the area for the pilot programme, the research foundation was limited by the amount of funding given by the European Union, as well as the additional funding it received from the Health Research Board. It was decided at EU level two years ago to initiate a pilot programme in each member state in the same way the German programme was started in Nuremburg many years ago. If there were no beneficial outcomes, it would be a waste of time at a certain level. The foundation is entering its second year of conducting the pilot programme, the intervention region of which for Ireland's purposes is the southern region of the HSE. The regions which have been chosen for the purposes of comparison where the programme is not being implemented are the south east and mid-west regions of the HSE.
The pilot programme has four main aspects. At the first level it supports general practitioners in their work with depressive and suicidal patients by delivering training. The research foundation has not yet started this aspect of the programme but has been given permission to do so by the Irish College of General Practitioners. It has obtained additional funding from the college to help it to include the training programme in the general practitioner curriculum.
At the second level we have started to organise train the trainer programmes for a wide range of community facilitators, including nurses, social workers, gardaí, members of youth organisations and the clergy. I recently conducted a one day gate-keeper training programme for 45 bishops and priests. It is clear when we speak to such persons that they need information and support on how to communicate with those who may be depressed and suicidal. We conduct train the trainer workshops to prepare people to train others in these programmes within their own organisations. As part of the pilot project in Germany, 2,000 community facilitators were trained over a period of two years. A majority of general practitioners were also trained during that time.
Level three training involves providing support for those working directly with deliberate self-harm patients in accident and emergency departments or other relevant services. Some projects are already running in the southern region of the HSE. For example, there is a crisis nurse service in Cork University Hospital. Anywhere such services can be improved, we will endeavour to do so.
Level four involves an intensive awareness campaign. The leaflets and information are contained in the documentation circulated to sub-committee members. The aim is to disseminate the brochures and leaflets across disciplines and settings. As I said, this is the project where we have representatives from 22 health care and community organisations on board. Last night I took one of the last training sessions and a number of people wanted to see all of their personnel trained in this way. We have to start the ball rolling somewhere. I hope more progress can be made.
To return to what we expect to achieve, when we saw the outcome of the German pilot project, the findings were very convincing. Over a period of two years they saw a reduction of 26% in the numbers of those who engaged in deliberate self-harm. The project compared the figures for 2000, the baseline year, with those for 2003 and there was a reduction of 26%. A regional comparison was also made with the region of Wurzberg, where there was a strong increase in the numbers who engaged in self-harm in the same period.
Another important finding was that the lethal nature of the methods used in overdose or self-harm cases had reduced significantly. In Germany there were a lot of people who used guns to harm themselves or to try to die by suicide, many of whom survived. During the course of the pilot project there was a significant reduction in the numbers using this method. Therefore, there were a number of very important changes which could not be explained as coincidence or luck. In fact, the approach taken in the pilot project has been accepted nationally by the German Government. At the last ministerial conference in Helsinki it was accepted as an example of best practice. We must wait another 18 months for the findings from the southern area, but if the evidence is convincing, we will talk with the National Office for Suicide Prevention to see if there are possibilities to roll out the project at a national level.
There are more questions which need to be answered now, but I would like to return to the specific issue of training the trainers later.
Dr. Arensman
That is fine.
Ms Eileen Williamson
I would like to reply to Senator Browne's question on the variations in levels of care and whether the creation of the HSE has been beneficial. This can also be tied in with the Chairman's comments regarding the large number of groups working in the area of suicide prevention.
The HSE is very much in its infancy and Professor Drumm is only a few months in his position. However, the establishment of the National Office for Suicide Prevention is a very significant development. The office has been established under the pillar of the programme for primary, community and continuing care. Its establishment provides an excellent opportunity to ensure the standardisation of services.
The Chairman asked about the levels of suicide in other counties. We do not have resource officers for counties but for the different health board areas. The establishment of the National Office for Suicide Prevention provides an ideal opportunity for resource officers to report to one office. At the launch of the Reach Out strategy in September, the head of the office, Mr. Geoff Day, said the buck stopped with him and that if there are not significant developments in the country with regard to suicide prevention in the next few years, all roads will lead to him. Now that this office has been established, we have the ideal opportunity to deal with the issue.
Dr. Arensman
An important question was posed regarding the possibility of, and possible problems with, linking databases. I will defer to Mr. Corcoran in that regard.
Mr. Corcoran
More than anywhere, confidentiality and privacy are paramount in the area of suicide. The latter has only recently been decriminalised and much stigma is attached to suicide and suicidal behaviour. It is a concern, therefore, that the confidentiality and privacy of people's data are maintained. At the same time, we need to find a balance between maximising the opportunities to find information that will prevent further suicides or further suicidal behaviour. For example, if a person dies by suicide or suspected suicide, gardaí will be involved and they will collect information relating to the events surrounding the death. The coroner will also collect information. The CSO will also be involved and there may also be a pathology report, etc. Several different agencies may be involved in collecting information.
There is limited crossover between the agencies and, therefore, crucial data that would answer some of the questions we have about suicide remains sitting in records around the country without ever being centralised. Coroners keep all their records and there is no centralised mechanism to pool them, while maintaining their confidential nature. If records were pooled and examined, we could see what groups are involved and perhaps discover why young men have high rates of suicide. All we know at present is that the rate of suicide among young men is high but our information is so simplistic that we do not know whether young men living alone, young men in stressful job situations or young men abusing drugs are involved. We cannot combine that information, although we have agencies in place that can find it. Linking databases would make the best possible use of data that has already been collected.
There should also be an opportunity for the bereaved family and friends to contribute information and we should have a mechanism for doing this, either through the coroners or through an inquiry system. Such a mechanism would benefit many of the bereaved by providing them with the opportunity to tell their stories and offer information that could be used to prevent further suicides.
If we are correct about the figure of 100,000, then based roughly on a population of 4.5 million, we are talking about 1 in 45 or 1 in 50 deliberately self-harming themselves, which is truly shocking.
Mr. Corcoran
It is unlikely to be as stark as that. That would, based on the statistics we have collected, be the maximum. People are sometimes surprised when they see the results of surveys of young people asked whether they have ever considered suicide and find that 30% or 40% have done so. Thoughts about suicide and wishing they were dead are relatively common among young people. However, there is a big difference between them and people who go on to engage in suicidal behaviour or who die by suicide. The onus is on us to collect the information that is most relevant to putting prevention initiatives in place and that is how I would prioritise what we should be doing.
Of the 11,000 people who presented to accident and emergency units, how many were repeat or duplicate patients?
Mr. Corcoran
Fewer than 9,000 self-harming patients are involved in presenting to accident and emergency units and approximately 2,000 of those are repeat acts.
To return to what was said about Mr. Day and the buck stopping with him, we all accept that.
I do not accept that. Ms Eileen Wilson put much hope in the new National Office for Suicide Prevention but the national suicide review group was set up on a similar basis after the national task force report. However, it was totally under-resourced and never had an opportunity to do anything. The National Office for Suicide Prevention has been given approximately €500,000 to do its work this year. The National Safety Council, which is the equivalent body with responsibility for road safety, has a budget of €6.7 million. Given that the number of people who die through suicide each year is higher than the number of people killed on the roads, it is clear that the National Office for Suicide Prevention should have at least the same budget as the National Safety Council. We know there is not much chance of the office being given resources of anything like €6.7 million. If it does not receive such funds, however, it will be unable to match the attempts that are made to prevent road accidents. It can be argued that the road accident prevention budget is inadequate in any event because the incidence of road accidents is not decreasing significantly. That is not an argument to be made at this forum. I do not agree with the claim that we can have confidence in the National Office for Suicide Prevention, given that its chairman, Mr. Geoff Day, has been given a budget of just €500,000.
Deputy Neville, as previously, has identified the crux of this issue. I am sure this is frustrating for the National Suicide Research Foundation, which wants to see progress being made. I do not expect the representatives of the foundation to be political or to make political comments. The members of the sub-committee do not have any difficulty with making political comments on these issues. The sub-committee has consistently been told by representatives of professional groups that there is a lack of funding in this area. It is delighted to avail of the expertise of such respected people. It is clear that the various programmes and forms of research depend specifically on the provision of the necessary funds. One of the foundation's representatives referred to the need to train the trainers, which is an excellent concept. However, that scheme is reliant on EU funding.
I received a letter about the issue of suicide last week from a person in County Kilkenny. The woman who wrote the letter explained that she knew of many people who presented through the psychiatric services on foot of some form of self-abuse and, who, unfortunately, later went on to take their own lives. I telephoned her on Saturday to ascertain her level of expertise in this area. I thought she was a medical professional but she told me she was a shopkeeper whose experience in this area relates to her brother, who presented to the psychiatric services but who was not deemed to be at risk. He took his own life some time later by drowning himself in Kilkenny. The sub-committee has heard of many cases of people presenting to the psychiatric services. If I say that such people are failed because the services are not professional, I do not want that to be taken in the wrong context. I mean that the services cannot avail of the necessary financial resources to train people. We depend on funding from the EU and other sources. Five separate groups have argued to the sub-committee that more funding is needed. While I am delighted to hear someone say the buck stops with them — I respect that — it seems that such responsibility will be somewhat limited because of the limited financial resources being made available for the programme.
When the sub-committee was established, its members decided that it should not be just another committee examining the issue of suicide. We are eager to make a firm recommendation after we have completed our hearings. Having listened to the representatives of the National Suicide Research Foundation, the sub-committee would like to state strongly that it will be unable to make any impact on this country's suicide figures unless adequate funding is invested in the HSE regions on a county-by-county basis. It will not even be possible to conduct the research that is needed without such moneys. I mentioned the possibility of corporate funding because the sad reality is that we will not make any impact unless some money is offered by the public or private sectors. If we do not ensure that a level of funding akin to that allocated for research into road deaths and programmes aimed at preventing road accidents is made available, we will continue to hear from the representatives of professional bodies, who are reluctant to get involved in political arguments. It is clear that the level of funding allocated for suicide prevention is not adequate, regardless of the amount of money made available for research.
It has been made clear to the sub-committee that the real way to ascertain the reasons for suicide — such as, for example, why young people take their own lives — is to engage in research involving their families. That is quite obvious to me and everyone else involved in this forum. Adequate finances should be provided to ensure we can learn from the experiences of each family that is prepared to meet professional groups such as the National Suicide Research Foundation on a confidential basis. We can talk about post mortems, etc., after suicides but that will only give us the medical evidence. The high incidence of suicide needs to be considered as a national crisis so that we can deal with it in the way that any national crisis is dealt with, namely, by investing the necessary funding for research and one-to-one meetings with the families involved. Unless we arrive at that point, we will not make an impact.
Ms Williamson
With regard to funding, as Dr. Arensman mentioned, we have been in existence for ten years and every year we have had to go to the Department of Health and Children almost cap in hand with our budget for the upcoming year. The reason I am so optimistic about the national office is that it presents a golden opportunity to co-ordinate all of the services available and even all of the bereavement support groups which——
What resources does the foundation have?
Ms Wiliamson
The Tánaiste and Minister for Health and Children has indicated €3 million will be allocated next year.
The then Minister, Deputy Cowen, allocated that amount in 1998 following publication of the report of the national task force on suicide.
The group's information is important and the sub-committee would like to go with it but, at the end of the day, if each member of the group was asked individually what would make the greatest impact on suicide prevention, he or she would reply research into why people take their own lives. When we make our recommendations, I hope the sub-committee will propose a pilot scheme involving families of the those who have taken their lives in the past year to establish what information can be gathered. If families had the confidence of the professionals involved, they might be more open in what they say about the lead-up to and reasons for a suicide. If a one-year pilot programme was undertaken, the evidence would ensure funding would be provided in subsequent years, particularly given that 444 people take their lives by suicide annually. It would involve a paltry amount. We will make that demand of the Government. Would one-to-one consultation with families be the most important element?
Dr. Arensman
The Chairman has raised a crucial issue which touches the tip of the iceberg. We have a good picture of the number of suicides each year, the number by gender and the age groups affected. However, in terms of specifics, most people who are depressed and most of those who abuse alcohol do not take their own lives. In preparing the plan the No. 1 priority for us is to interview families and friends of the bereaved and to use this avenue to support them. We should not ignore the number of suicides that follow a recent suicide or a case of deliberate self-harm within a family. In the past few years working with the foundation I came across a number of cases where in a short period two or three people in one family took their own lives. This is an extremely high incidence. There is, therefore, an imitation effect. If we had a system such as the inquiry where we could operate through the health service but also engage families and friends, it would ideally be a combination of the two. In some cases, for various reasons, family members would be unable or reluctant to do an interview. The combination of the information available and the information provided by family and friends would give us the greatest insight.
Does Dr. Arensman accept that the most important research tool for the foundation is one-to-one interviews with families? While I have not attended many conferences on suicide, I attended one in County Leitrim. On the evening in question 300 or 400 people were in the room who had been directly affected by a suicide in the family. They spoke spontaneously about their problems but the consistent theme was the lack of after care or support from the professionals and the failure to address the research issue and so on. The brother of one lady, whom I knew coincidentally, had taken his life and she spoke about the effect of hearing news bulletins referring to suicide bombers in Iraq and so on and the continued impact of that description on her family. We take these reports for granted without realising their import. However, if people came forward to professionals such as the members of the delegation who deal with families on a one-to-one basis, we would find out the reasons a person took his or her own life. To my mind, that is how research becomes a real tool.
I welcome the holding of these hearings and have made the point on a number of occasions that the Oireachtas should hear from various groups. The process of Oireachtas joint committees is effective, particularly regarding the business before us today. All of the sessions of the sub-committee have gone well. None of us wants to patronise but the issue affects all of us. I often state I bring my life experiences to politics and I have much experience of this matter. This morning in preparation for this meeting I reflected on the fact that in recent months I had had a great deal of experience involving friends or family members, and my community is no different from any other. It brings the issue home in a definite way to a politician trying to help people. It is challenging.
I am fascinated by the work of the group on statistics, even though I can never get my head around the subject. The suicides I am aware of in recent times include those of a young woman who calmly put her baby to bed and then harmed herself, and an elderly woman who conducted all of her business for her family, locked the door and, to put it delicately, went to her end using several methods. I find one gets involved and is affected. Like professionals, politicians tell themselves not to get too involved and emotional, but one does.
I am happy to support the work done by Deputy Neville and I am in awe of the efforts he makes. If any of us could succeed politically, it would be to help in this area. Colleagues are entitled to make party political points which is fair enough. However, the lack of funding and efforts to provide it reflect the fact that as a society, we do not take the issue of suicide seriously. That is not only true of Ireland. I am glad the Chairman stated the sub-committee would make a strong statement on the question of funding. He pointed out that every night on the news we heard of people happily — if I can use that word — going to their death while doing harm to others. It is an amazing phenomenon.
I wish to ask a statistical question. When we discuss the issue of suicide and listen to presentations, we always consider young people. I have admitted before that I am particularly fascinated by the suicide statistics among the elderly and cannot get my head around the matter. While I do not accept suicide among young people, I have a particular problem in understanding why elderly people do so. A successful meeting was recently organised by the men's group of An Cosan, the educational project in Jobstown, and held in Tallaght in my constituency. Sr. Kathleen from Tallaght Hospital spoke and people shared their experiences. The point on elderly people doing harm to themselves was put to me graphically but I cannot grasp it. I do not suggest I understand or appreciate why young people commit suicide or how they organise it but will the delegation help me to understand how someone who has settled, gone through life and has grandchildren can commit suicide? In any discussion of the issue we consider the pressures on young people. Will the delegation give us some information on the pressures on elderly people?
I hope we succeed — I genuinely mean this — in getting a response from the Government. As a Government backbencher, I believe the service should be properly funded.
How do we combat other problems such as the depiction of suicide bombings? Every day in the media such bombings are depicted. They are now considered normal such that it is no longer a question of if but when such events will happen and how many will be killed. What effect is this having on people's psyches? Suicide is now seen as almost popular or routine.
I hope something positive will come from all of this and that these hearings will not just be seen as a forum for us to discuss the issue of suicide again. Suicide has been identified as a clear problem in Ireland. Action is needed. We must get a positive message across. I hope we will be successful, at least in controlling numbers, although I do not think any of us believes the problem can be solved overnight, if ever. Do the representatives have any views on how educational programmes might be funded?
If people have nowhere to go, what happens? Over the weekend I intervened in a case where a young man in my local area was threatening to harm himself. His family had reached a point where the only way to save him was to have him arrested. He was duly arrested and taken to the psychiatric unit of the local hospital. I am sorry to say he was discharged the following day because the hospital determined that there was nothing wrong with him. I know there is no answer in such a situation but it causes one to despair.
I join my colleagues in welcoming the group represented today. This has been a very interesting session and it is important that we see this work through.
Dr. Arensman
I thank the Deputy for the background information he has given, outlining his own experiences and asking some interesting questions. Mr. Paul Corcoran will be able to answer the first question better than I can. I would like to comment on the issue of suicide bombings. I suggest Ms McAuliffe respond to the question about educational processes.
The issue of suicide among older people is very important and I am glad the Deputy has raised it because sometimes we focus too much on or become biased towards examining suicide among young people. Suicide rates in Ireland among older people are not particularly low in comparison with those in other European countries. The same problem applies. There is also the question of why suicide rates among women have doubled since the beginning of the 1990s. We do not have enough specific information to answer the "why" questions. This is something we would like to develop. In that context, we have proposals regarding interviewing families and combining the information gained with that received from general practitioners, coroners and others involved in the system.
I can make a comparison with what is happening in the Netherlands where I worked for 15 years. Such a comparison underlines the importance of cross-cultural differences because the demographic group with the highest rates of suicide in the past five years in the Netherlands is older people. The highest rate of suicide is to be found among men aged 70 years and over. A study showed that there was a very high level of depression among elderly men and women in the Netherlands. Following these findings, an intervention study was conducted which tested the effects of a psycho-educational approach. A programme was developed under which older people who were depressed attended at least ten sessions and it showed that depression could be treated. There were significant positive outcomes from the study. This is helpful information. While we do not have a specific study in progress in Ireland, it is helpful to know that if there is a high level of depression among older people, there are good possibilities in terms of treatment, if the service is integrated with the health service.
Enough research has not been conducted to answer the question of the growing prevalence of suicide bombings. However, it worries me greatly that I see a parallel between the persons involved in suicide bombings and those who take their own lives in general in that they are disconnected. In addition to my research, I have built up clinical experience over many years in the Netherlands. I asked people at the stage where they were acutely suicidal what their greatest need was and I often received the answer that they no longer had any. That is a reflection of being disconnected, even from the people a person loves most but for whom he or she now has no feelings. I have always wondered how it is possible for a suicide bomber to board an aeroplane and kill thousands of people. We do not know all the answers but the people concerned are disconnected from their loved ones and the rest of the world. This disconnection is a common feature of both ordinary suicides and those who take such actions. I have concluded this from my clinical experience but there is no systematic evidence available.
Mr. Corcoran
As Dr. Arensman said, suicide rates among the elderly are not high compared with those in other countries. Our profile is different, being most similar to that of the United Kingdom where rates are highest among young men. Suicide among the elderly is related more to illness and isolation.
The Chairman referred to the large numbers vulnerable to self-harm who do not come to the attention of the health service and how discouraging it is when somebody who does visit the service receives an inadequate response because of pressure on resources. If the large numbers who engage in self-harm were to visit the service in the next couple of years, it would not be able to actively respond. In terms of resources and funding, it will take years before the service is equipped to deal with the scale of the problem. We must maximise the resources available. We should avoid duplication, streamline functions and collaborate as much as possible to be more cost effective.
What about the Rehab money?
Mr. Corcoran
It is a sizeable amount. However, no one organisation will have the solution and if it is not involved with other agencies, it will not be as beneficial as it should be.
Ms McAuliffe
I will answer the question on how the educational process can make inroads in helping those at risk of self-harm or suicide. There are two areas where this is important and it is an issue of particular of interest to me.
Evidence from a number of studies suggests those who engage in self-harm have difficulty in coping with stressful events. It may be useful to study all those who engage in self-harm, whether they seek the help of the services available, and compare the experiences of those who use the services with those, particularly young people, who do not. Schools are an important vehicle for the delivery of educational programmes and other interventions to ensure we do not just engage in gatekeeping but build coping skills for when young people are confronted with stressful life events. Studies of patients who have engaged in self-harm reveal that one of the most promising areas in terms of treatment is the building of coping skills. There is a possibility to make inroads in those two areas.
Dr. Siobhán Barry
Representatives of the child and adolescent service at the Mater Hospital came before the sub-committee some weeks ago and indicated that they had spoken to young adolescents regarding whom they would find most helpful if they had a problem. The adolescents in question replied that they saw health professionals as being very low in the pecking order in terms of who they would seek out. The foundation's information pack provides the male perspective and my question is addressed to Mr. Corcoran. How representative is the sample of young men? One of the most staggering findings in the survey is that in regard to disconnection, almost 60% of the young men interviewed said they would seek their mother out to confide in her if they had a problem, while 30% said they would seek out their father. Reference was made to providing acceptable input and training the trainers. Has thought been given to training parents or making programmes about active listening and so on available to concerned parents, particularly in view of the fact that, if this sample is representative, 60% of young men will seek out their mothers?
Mr. Corcoran
It was interesting that the study found that young men, if in difficulty or distress, would be twice as likely to talk to their mothers than they would be to talk to their fathers. Two of the researchers and I consider ourselves to be young men because we are in the same age group as those interviewed but the study may be slightly misrepresentative in that the young men were healthy and did not have psychiatric or mental health difficulties when it was conducted. Perhaps their search for help would have been poorer if they were distressed. The study should probably go back to the previous generation.
We studied young adults but contact with parents would again have come through the schools because everybody's children go through the school system and meetings are held with parents. My son, for example, is in first year in secondary school and we have attended the school on a few occasions. These meetings present a great opportunity to engage parents in tackling the difficulties young people may experience — not only in first, second or third year but all the way through second level, including examinations — equip them with information on support services and allow them to pick up on patterns of behaviour young people might exhibit if they are in difficulty. That might be in some ways an education parents can go through because all their children will go through the system and that should equip them not only for the school years but also for the years afterwards.
Dr. Arensman
In the four-level intervention programme, under which we use the train the trainer model, we also plan to organise gatekeeper sessions for parents through guidance counsellors and youth workers connected to schools. The programme will be slightly adjusted but we are involving parents as well.
I thank the delegation. The need for further funding has been highlighted at this and previous meetings. The words "connect" and "disconnect" were mentioned and it is up to us to connect funding to research, which will the sub-committee's greatest priority. The programme to train the trainers will make an impression, particularly as the pilot programme in Germany has been a success in this regard. However, we are still not getting any nearer to discovering why so many young people take their lives and that is a significant challenge for all us. The sub-committee has not been able to get around that, even though many professional groups have appeared before it.
I challenge the corporate sector to become involved in funding research to establish why so many young people take their lives. As Dr. Barry stated, it is one thing to discover that a loved one has died by suicide but it is another for the parents and families to cope. If funding could be secured by the sub-committee for one-to-one counselling with families, it would have a major impact. Professionals could then work with a blueprint of the reality rather than abstract research.
We hope to publish our report soon rather than down the road and the message from everybody will be that substantial funding is required to achieve results, while the most important method in establishing the reason for suicide is to deal with the people who have been directly affected. We have been warned that this might present difficulties because families may not wish to come forward. However, this should be done by means of invitation in the hope that they will do so. Given my limited experience — I have attended only one conference on suicide — I was struck by the number of families that craved recognition and follow up. The most telling theme of the conference I attended in Leitrim was that, similar to Alcoholics Anonymous meetings where people talk about their experiences, families wanted to explain the warning signs to others. That was so apparent at the conference, where members of families who had lost loved ones by suicide and still carried a major burden of pain were more than prepared to enter a room full of strangers to explain what are the warning signs.
We have also experienced a warning sign because people are knocking on the doors of the Government, the sub-committee and the political process to make an impact on this issue. While delegations have acknowledged the timeliness of the sub-committee's action on the issue, we are only playing a small part. However, if that part brings the Government's thinking around to investing substantial funding to create the necessary tools to deal with the issue, we will have done a great deal. I thank the representatives and we look forward to hearing from them again.
Sitting suspended at 3.45 p.m. and resumed at 3.50 p.m.
I welcome Mr. Seán McCarthy from the Health Service Executive's regional suicide office in the south-eastern area.
I thank the sub-committee for inviting me here today and for affording me the opportunity to speak about suicide in Ireland. I welcome the opportunity to outline the role of suicide resource officers and their work in the HSE areas. There is one such officer in every HSE area and their roles are both strategic and operational. I will provide an overview of the work currently under way in my area, the south east, as an example of the developments in which we are involved. I will also provide an analysis outlining what we consider to be the strengths, weaknesses and opportunities attached to our role. Previous contributors have highlighted statistics on suicide and self-harm in Ireland. I will, therefore, address the complex issues of causation in suicide.
I have worked as a regional suicide resource officer for the HSE south eastern area since 1999 and was the first person permanently appointed to such a role in the State. Within the HSE south eastern area, there is an established regional suicide resource office. The function of the office is to support local services in the HSE area through close collaboration with local area teams in issues pertaining to suicide and self-harm. The office also works closely with voluntary and community groups in the development of community-based initiatives aimed at increasing awareness of the issues associated with suicidal behaviour.
The office is the only one of its kind within the HSE nationally and has a number of sections attached to it. At present, clerical and administrative support staff, the regional suicide resource officer — namely, me — and two people working full-time in training and development on issues relating to suicide and self-harm all work within the regional suicide resource office or have their activities either fully or partly funded by it. We fund three liaison clinical nurse specialist posts in the accident and emergency departments in our area and a fourth person will be appointed by the end of the year, thereby providing clinical nurse specialist posts in the four accident and emergency departments in the HSE south-eastern area.
We have, on a pilot basis, a self-referral counselling service in the Wexford area for those at risk of harming themselves or committing suicide. We have contract professional counselling services for people bereaved by suicide and, in addition, we have a project in train which is examining the bereavement needs in the area. The latter is run jointly with the Irish Hospice Foundation. We also employ someone from the National Suicide Research Foundation who is researching self-harm presentations in accident and emergency departments.
In addition to those services, we fund numerous voluntary and community groups working in suicide prevention, intervention or postvention. Particularly close support and working relationships have been established with bereavement support groups in the area. Significant work has also been undertaken with the Wexford County Development Board in finalising a localised action plan for suicide prevention, the first of its kind in the country. Work is currently under way and progress is being made in respect of a similar initiative with the Waterford area partnership for the Waterford city area.
As a regional suicide resource officer, I am responsible for overseeing, at local and regional level, implementation and operation of the action points contained in Reach Out — A National Strategy for Action on Suicide Prevention, which was launched by the Tánaiste in September. It is important to state that this structure in the south-east area is not in place in the other HSE areas.
During the past two years, suicide resource officers have contributed to the preparation of the new national strategy for accident and suicide prevention. We have facilitated consultation days throughout the country, which were attended by over 600 people who submitted recommendations for action. Resource officers are central to ensuring the recommendations of Reach Out are implemented and should be involved in the service planning process, paying due regard to the national policy framework, needs analyses, monitoring mechanisms, quality evaluation and value for money and ensuring that these service plans are in line with the HSE corporate plan 2005-08, Quality and Fairness and Reach Out.
We are involved in different operational areas. Resource officers are involved in the delivery of three broad training programmes. At the general awareness level, we have, in collaboration with our colleagues in Northern Ireland, developed a general suicide awareness training pack that we can use when delivering educational talks to a wide range of target audiences. This allows us to adopt a standardised approach to the material we present on a national basis.
In the past year, we started a skills-based training programme — the applied suicide intervention skills training programme — throughout Ireland. This programme, developed in Canada, is a two-day training programme that uses role play and interactive learning. It teaches participants how to support someone who is suicidal. Training is being offered to all members of the community. We have also delivered this training to men-only groups, ethnic minority groups such as Travellers, members of the deaf community and to pilot primary care services. In our own area, we have had an assistive training programme evaluated by an external evaluator.
To train frontline staff, such as mental health staff and general practitioners, in the assessment and management of suicide risk another standardised, an evidence-based programme is now being delivered in some areas. This programme, known as skills training and risk management, was developed at the University of Manchester. Specialist training is also being delivered through accredited organisations and we offer this to individuals and groups that provide support to those bereaved by suicide.
We work closely with individuals, families and a wide range of community and voluntary groups. We offer suicide awareness and mental health promotion training to parent and community groups that have taken the initiative to learn more about suicide prevention. We are delighted to support and empower such groups and we often continue to work with them in their ongoing development.
We respond immediately to requests for support following a suicide in a school or community by linking with relevant support organisations such as the National Educational Psychological Service, child psychology services and local community support groups. Where services are not available, inappropriate or inaccessible, we are often obliged to negotiate or commission alternative services for people. We are also keen to support vulnerable people, such as those living in remote or isolated areas, within our communities. Specific initiatives have been undertaken where a number of suicides have taken place. In particular, initiatives have been taken in the Wexford area and in Midleton.
The sub-committee is also aware of the disposal of unused medications programme, DUMP, which provides for the safe disposal and destruction of unused and unwanted medication. In addition to the obvious role of such a campaign in suicide and parasuicide prevention, it hopes to prevent accidental overdoses by young children and to protect the environment.
With regard to service developments, on any given day we are involved in a wide range of work, such as mental health promotion, intervention, training, research and supporting those bereaved by suicide. We work with a wide variety of groups, such as statutory, voluntary and community agencies, as well as families and individuals, over a large and diverse geographical area. We provide an immediate response, if required, when other projects are setting the foundations for work that will have a more long-term impact.
Resource officers have been instrumental in shaping the appointment of crisis nurse liaison and mental health clinical nurse posts for dealing with deliberate self-harm presentations to accident and emergency departments. We are currently aiming for 90% coverage in our hospitals before the end of 2005. While different individual projects may be carried out at local level, much of the core work remains similar for all resource officers nationally.
As resource officers, we believe that our strength lies in the fact that individuals within the group come from a wide range of disciplines. That helps us greatly in the work we undertake as a team. We believe the material we produce has been very valuable and useful and it is very cost effective. A standardised approach to resource development improves public understanding of this difficult subject. We are involved in all aspects of suicide prevention and, as a result, have built up expert knowledge in terms of our understanding of local needs and local support services. We have an ability to channel our knowledge of operational needs into informing strategic planning. We are also effective in working across various disciplines and agencies and have developed links with colleagues in other countries.
Some very worthwhile work is being done throughout the country but our greatest difficulty is that work is not being co-ordinated or systematically rolled out nationwide. If something works well in one area, there is no guarantee that it can be implemented throughout the country. This is a reflection of a number of issues, including the lack of national leadership in the prioritisation and co-ordination of our work, budget allocations being too limited, different priorities being identified in various areas and the health service not offering a consistent, equitable service nationally.
The current figures for base funding available to the former health board regions for 2005, according to the National Office for Suicide Prevention, are €594,000 in the eastern region, €355,000 in the midlands, €215,000 in the mid-western region, €361,000 in the north-eastern region, €310,000 in the north-western region, €355,000 in the south-eastern region, €835,000 in the southern region and €177,000 in the western region. This yields a total——
How do those figures compare in terms of population numbers in the various catchment areas?
The population make-up is different in each region but I do not know the exact breakdown in that regard. The midlands region has a much smaller population than, for example, the south-eastern or southern regions. The population for my area in the south east, which has an allocated budget of €355,000, is over 400,000.
We acknowledge that major financial demands are made on the health services and that resource allocations are unable to meet all needs. However, it is important to note that, due to the great degree of stigma and pain associated with suicide, affected families have not spoken out. As a result, lobby groups for other health services have had a louder voice.
There is a variation in services available in different areas, depending on resources and the commitment of local services. From a political perspective, it was felt in the past that the general public's interest in suicide prevention was low. This is now changing. We are finding a high level of interest from community groups and large numbers are attending public meetings on the issue.
The work and commitment of this sub-committee is very welcome and will hopefully contribute to the amelioration of suicide and self-harm in our communities. In some situations, however, the general public appears to want to find out what the Health Service Executive is doing about the issue, rather than participating in finding a solution. Suicide appears to be seen as something akin to a condition that is recognisable and treatable and, therefore, the responsibility of the health services. This is not helped by descriptions of the increased number of suicides as an epidemic. Further work is needed to reach agreement on how we view suicide and on implementing a national response in which all perspectives are included. We believe this is one of the fundamental roles for the new National Office for Suicide Prevention.
From a personal perspective, the greatest threat to us, as individuals, within the group of resource officers, is the large turnover of staff and the resultant loss of expertise. Since 1999, there has been a significant turnover of staff in this area. One of our greatest concerns is that the Reach Out recommendations will not be translated into action.
I wish to end on a positive note by saying that we, as a group and as individuals, are very committed and have a strong energy and conviction in respect of our work. We are seeking the support of this sub-committee in a number of areas. We need its support at national level to endorse, support and implement the national suicide prevention strategy. Suicide prevention must appear and remain on the political agenda. We require adequate resources in order to begin to implement the recommendations of the national strategy. Not only do we need appropriate funding, we also require skilled personnel who are able to work in this area.
We feel that the time is right to remedy the current situation. The new national strategy, coupled with the health service reform programme, will provide us with a great opportunity to change existing practices and move towards a more effective way of delivering services. It is essential that the newly established National Office for Suicide Prevention be supported in every way. Funding for suicide prevention should be provided through the national office to those responsible for the implementation of the Reach Out strategy. There is also a need to establish, as a matter of urgency, a direct reporting relationship between HSE resource officers and the HSE national office in order to ensure co-ordination of efforts nationally in the implementation of Reach Out. This should ensure that all of us who are working on implementing the national suicide prevention strategy are working together in an integrated and co-ordinated manner. The latter will, in turn, ensure the best use of limited resources and the delivery of value for money, in a national context, in respect of suicide prevention.
I thank the sub-committee for its attention and hope that members found my comments helpful. I also hope that the sub-committee can, in turn, help us.
I thank Mr. McCarthy. Deputy Neville told us, in advance of Mr. McCarthy's attendance at this meeting, that he would be very much to the point and in charge of his brief. He has proved that to be the case.
I thank Mr. McCarthy for his attendance. I have met him at several conferences and am aware of the work he does and the office he set up to try to deal with suicide.
Following the report of the national task force on suicide, many people said that the Government set up the suicide resource officer system. I wish to explore this matter with Mr. McCarthy. He said that his was the first suicide resource office in Ireland. My understanding is that some of the suicide resource offices consist of one person in an office with no support structures. We will not have an opportunity to discuss the situation nationally but it is accepted that the office run by Mr. McCarthy is an example of best practice in this area. I am interested in exploring what is happening elsewhere and I know that Mr. McCarthy has some knowledge of the broader picture. My knowledge is very limited. What is the situation as regards suicide resource offices? Do they consist of one or two people, does it vary from place to place and, if so, how much variation is there?
I will try to respond to that question as accurately as possible. In my area, we have a fully established and resourced office with responsibility for suicide prevention. In other areas, there is one person, working on his or her own, without administrative support.
What percentage of resource officers would be working in the latter scenario?
There are two or three people working in that type of scenario, which represents 20% or 30% of resource officers at present. It is fair to say that the situation has varied considerably from time to time, on foot of changes in the reporting relationships in health board areas following the changeover to the new HSE structure. At various points, changes have taken place and this has been reflected in the priority given to suicide in different regions.
Is there a need to establish the exact role of suicide resource officers and to have consistency across the State in that regard? I am aware of differences in services in each region. When services are discussed nationally, the suicide resource offices and the role they play are often referred to but the latter is different in each of the former health board areas. The situation often changes dramatically when an active suicide resource officer is moved on or promoted. Does Mr. McCarthy agree there is inconsistency?
I agree that the role of suicide resource officers should be reviewed. There needs to be consistency in terms of role and functions across the HSE because, at present, different officers have different job descriptions. Some have mental health promotion roles attached to their job, whereas others do not and there is inconsistency in the resources available to them. A consistent approach needs to be taken to the delivery of suicide prevention initiatives nationally. We hope that the newly established National Office for Suicide Prevention will review this area as a matter of urgency.
Is Mr. McCarthy of the opinion that we should cover this area in our report? What does he suggest that we should recommend? The sub-committee is limited to making recommendations.
We would be happy for anyone to make a recommendation. We need to examine the standard job description and role of resource officers. To support communities and individuals, we need standardisation of delivery. Resource officers are now seen as a first point of contact in many communities for bereaved families, for professionals such as general practitioners and for many frontline responders such as gardaí and probation services seeking advice on and help with cases of self-harm, suicide, attempted suicide and bereavement by suicide. Consistency is crucial if resource officers are to have a role in making operational recommendations.
How does Mr. McCarthy account for the fact that he has a budget of €355,000 to provide the service that we would recommend for every area and that the HSE midland area and others have similar budgets? What is happening?
I can only speak for my area, the HSE south eastern area. It was set up as a stand alone, fully functioning office with its own budget, for which the resource officer is responsible. Since the service planning process in 1999 we have planned in a strategic manner how we use and fund various posts. I cannot comment on other areas because I do not have a working knowledge of them.
However, Mr. McCarthy would have a fair idea. I have been informed that much of the budget is absorbed by the general psychiatric services. I was told that, in one location, some of the money earmarked for suicide prevention was used to repair a lift in the psychiatric hospital. Is that the case?
I cannot comment definitively. I understand that the National Office for Suicide Prevention will examine the funding provided to the HSE areas and consider how it has been spent over the years.
This sub-committee must ask how an operation such as Mr. McCarthy's can have the same budget as a one-person operation. This has happened, although I do not know where. Money has been allocated to suicide prevention but as somebody says that keeping a mental hospital open will reduce suicide, it is moved into the general psychiatric services, for which it was never destined. Such things are covered by the budget for the psychiatric services, not the budget for suicide prevention. They are closely linked and overlap. In any country of which I have experience, however, the budgets are separate. Mr. McCarthy's office exemplifies that the use of a suicide budget dealing with prevention, bereavement, research or whatever is recommended by the HSE. We must query how one person sitting in an office on their own, without even a secretary, can have the same budget. Does Mr. McCarthy agree?
I do.
We must examine the budgets. The eastern region has budget of €590,000 and the southern area has one of €350,000.
That is boosted by the National Suicide Research Foundation money.
The funding indicated is that made available to HSE areas and is not inclusive of funding to the National Suicide Research Foundation, the Irish Association of Suicidology or the national suicide review group.
The Irish Association of Suicidology only gets €75,000.
A person who headed up a project would have full responsibility for that budget and would know whether part of it was allocated to a psychiatrist. However, it is something we must address.
I was interested to hear that gardaí and frontline services use the suicide resource officer as a first point of contact. We need to get the message across that there is a dedicated contact point to deal with suicide in each HSE area. Mr. McCarthy mentioned the ASIST programme, which targets different groups, such as men's groups, Traveller groups, etc. Does it target professional groups, such as hospital staff and community nurses?
The applied suicide intervention skills training, ASIST, programme is just one of a number of different programmes being delivered throughout the country. In my area, two people work full-time on the development and delivery of training. The ASIST programme is open to anybody who wishes to be upskilled, learn new skills or reaffirm skills and knowledge they previously gained in dealing with people who are suicidal. Up to 24 people may attend a programme and would possess a wide range of skills, knowledge and expertise, whether they be members of parents' councils in schools, accident and emergency consultants, clinical psychologists or consultant psychiatrists. Social workers, psychologists and non-professionals who have an interest in the area and may wish to learn how to deal with a suicidal person may also attend. It is open to anybody. This week, 24 people are partaking in a training programme.
When they have received the training, do they get to use it? Does the feedback suggest that there is a demand for the skills they learn and that they have been able to intervene in cases?
There has been a range of responses. Some have not used the skills six or 12 months after completing the programme. These might be people from a community group and will not, in the course of their day-to-day activities, come into contact with someone who is suicidal. There also have been responses from people working as frontline responders, paramedics, accident and emergency consultants and nursing staff, mental health nursing staff, etc. who, on a day-to-day basis, are using the skills they have either learned or reaffirmed in the knowledge that these have given them a framework within which to respond.
Mr. McCarthy referred to information packs. He stated that, in collaboration with its Northern Ireland counterpart, the HSE has developed a general suicide awareness training pack. I understand that a number of suicide prevention programmes will be jointly launched, North and South, possibly today. What is Mr. McCarthy's view of the impact of the training packs?
Resource officers, North and South, have collaborated on the development of information and training packs. Throughout the country, community groups, parents groups, schools, GAA clubs and sporting organisations are carrying out general awareness training and are seeking basic information. We examined all the information being provided by various people and soon realised that what was being done was very similar. In order to have a co-ordinated and equitable service in information provision, we set out to establish a general awareness training programme with standardisation of information in order that somebody in Letterkenny will get the same information in regard to risk factors, warning signs and intervention in a training programme as would a person in Enniscorthy, County Wexford. What we hope to do with this standardised training pack is to train people in the delivery of general awareness training programmes. The resources and the number of people currently available to do this training is limited. We hope that through a general awareness training programme youth organisations and the Garda Síochána through its training divisions will be able to provide basic information on suicide and self-harm. That is one example of a training pack.
As to whether this is worthwhile, the provision of information is itself a service and there is a huge demand for it. We have a number of packs within the HSE south eastern area and we are returning to the printers two or three times a year. We distribute approximately 4,000 to 5,000 suicide information packs and a similar number on bereavement. That indicates the demand from the general public.
Dr. Barry
What specific impact has the provision of resource officers had in the old South Eastern Health Board area in terms of the numbers of people who have taken their lives or who have deliberately self-harmed?
It would be difficult to say that the provision of resource officers has had an impact on the numbers of people dying by suicide. This has fluctuated from year to year. We had two terrible experiences in the Wexford area of clusters of suicides. It would have been extremely difficult for somebody from mainstream services to take the lead in responding to these clusters and in contracting, for example, counselling services for those who have been bereaved. As resource officers, we were able to pull together all of the necessary resources. Mental health services were able to contribute in their way. The acute general hospital service was able to provide specific services. We were able to bring together people from other statutory bodies and from the voluntary community groups so that there was a community response to suicide. Furthermore, in Wexford we were able to develop, with the county development board, a localised action plan to assist in suicide prevention. Local bodies and groups such as community forums were able to play a role in this regard. People want to play a role in suicide prevention but they also want leadership and require information about how they can contribute. They do not want to take over and replace existing services. Resource officers have a role in providing services and in the co-ordination of services at local level.
It is revealing that Mr. McCarthy's greatest concern is that the Reach Out recommendations will not be translated into action.
Other people are also concerned about that matter. The national task force report has been published since I took up my role. Quite a number of its recommendations have been implemented.
Eight of them were implemented. The Minister of State at the Department of Health and Children, Deputy Tim O'Malley, did not go beyond eight when asked to do so.
Many of the recommendations regarding low threshold, easy access counselling services and the delivery of specific services in accident and emergency departments were implemented. However, their implementation depended on local services prioritising certain recommendations. Many of those recommendations have been repeated in the new action plan. Our greatest fear is that in ten years' time we may still be talking about suicide prevention and services will not have been put in place.
There will be another new report and another new office set up.
We hope the recommendations will be put in place.
It is clear from the presentations that what is required is the implementation of the national suicide strategy. Mr. McCarthy is the first of those to come before us who specifically emphasised that adequate funding must be provided if we are to make any impact in reducing the number of those committing suicide. He also stressed the importance of the national office. The sub-committee has consistently emphasised that regardless of how many professional people come before it to present their cases, what underpins a resolution is adequate resources and funding, research, preventative measures and professional input. I agree that unless there is a change in the situation whereby we are battling on a day-to-day basis for funding, we will be here in ten years' time having made no impact. It is important to secure adequate funding, otherwise the number of suicide deaths will continue to increase and we will have more reports and no results.
Could I make a further comment regarding funding?
Yes.
Funding alone is not the answer. The current employment ceiling often prevents us employing people who can work on the ground dealing with people who present with self-harm or who are bereaved. Services are already extremely stretched. As well as funding, therefore, we need the ability to employ people where necessary and appropriate.
Mr. McCarthy stated earlier that there was a high turnover of staff involved in the delivery of this type of care. How big a problem is that? Can Mr. McCarthy suggest any way of retaining staff? Training in the area of suicide is highly specialised. Staff are trained to a high level and then lost. Are they being promoted through the system or are they unable to cope?
Since I took the post of resource officer, seven or eight people working in similar posts have left.
Is that nationally?
Yes, from ten areas. These are people who would have developed a huge understanding and knowledge of the area. Some move on through promotion. However, it is still the case that some people are not appointed on a full-time basis to the role of resource officer but are seconded into posts. Therefore, the difficulty regarding security of posts, particularly in this area, makes it a difficult one in which to work.
Seconding people on a temporary basis creates difficulties because they do not know whether to get on with the job or use the position as a stepping stone for promotion.
That has been a difficulty.
Can the sub-committee ask the Health Service Executive to indicate the number of people employed in the suicide resource offices in each of the former health board areas and the number who are permanent rather than on secondment? If I table a parliamentary question, it will be six months before I get an answer. Twelve months ago, I would have received that information in four days, whereas now I would be lucky to get it in four months.
I accept that. Mr. McCarthy stated that it is not enough for people to look to the HSE for all the answers. The involvement of community groups is an issue and he mentioned clusters in Wexford. That raises the need for local support groups and the harnessing of voluntary organisations to take a lead in their immediate areas, which requires the funding of facilitators. Sufficient funding should be allocated to provide facilitators in each county to bring people together in an open forum to talk. Between 400 and 500 people attended the conference in Leitrim and talked openly about their fears and their responses after a suicide was committed in their families. More importantly, they referred to how the health services were removed from their daily lives following the suicide. Until people can talk openly and appropriate support and research is provided, an impact will not be made because people will continue to rely on the National Office for Suicide Prevention or the health services for a resolution. It is important that Government and, if possible, private funding should be secured in order that the next step can be taken.
A recommendation should be made that a clearly identifiable permanent suicide resource officer should be appointed in each region. He or she would then be the first point of contact for all the services, such as the Garda and the hospitals, involved. The secondment of people to regions on a temporary basis is not sufficient because permanence is needed. People must be identifiable in these positions because individuals will approach them when they are in need. If the personnel keep changing, people will lose confidence.
Within the hierarchy of the HSE areas, are officers graded differently?
Most of the posts are administrative. They vary from grade seven to eight and other arrangements apply to secondment.
There should be consistency.
There is inconsistency in this regard. The national suicide review group made recommendations on the grading of resource officers.
What did the group suggest?
Grade eight.
I thank Mr. McCarthy. We appreciate his presentation and his frank admissions regarding how we should move from here. We are in the business of making recommendations that will bring about change.
The sub-committee adjourned at 4.40 p.m. until 2 p.m. on Tuesday, 29 November 2005.