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Suicide prevention strategies
Suicide and gender
Suicide in young people
Suicide in older people
Suicide and race
Suicide and sexuality
Suicide and substance misuse
Suicide and mental distress
Suicide following deliberate self-harm
Suicide in prisons
Suicide in rural areas
Suicide and the media
Attitudes towards suicide
Attempted suicide
Prediction of suicide risk
The effect of suicide on others
Further reading
Useful contacts


This factsheet is targeted towards professionals and students interested in the subject of suicide and suicide prevention strategies.

Anyone concerned about a friend or relative who may be feeling suicidal should see Mind's booklet How to help someone who is feeling suicidal.

Suicide is a major public health issue in the United Kingdom. There were 5,910 suicides in the UK in 2001. In England and Wales the total number of suicides were 4,865. Around 75 per cent of these suicides were by males.[1] Since the late 1980s suicide has been the most common cause of death for men aged between 15-44.[2]

(For further statistical information, see Mind's factsheet  Mental health statistics no.2 - suicide.)

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Suicide prevention strategies

In 1992, the Government published The health of the nation [3], a White Paper outlining a health strategy for England. Mental health was chosen as one of five key areas in which targets were set for improving people's health.

These targets included the reduction of the overall suicide rate by at least 15 per cent by the year 2000. It also called for the reduction of the suicide rate of severely mentally ill people by at least 33 per cent, by the year 2000.

The targets set out in The health of the nation suggest that health care providers have a key role to play if these reductions are to occur. This assumes that a significant proportion of those who commit suicide make contact with health care services within a short period just before their death. A report by Pirkis and Burgess [4] suggests that, among those who die by suicide, contact with psychiatric services and primary care services is common in the months, weeks and days leading up to the event.

Pirkis and Burgess state that: 'The fact that the vast majority of those who do die by suicide make contact with health professionals within a relatively short time before death suggests that, consistent with international policy documents, clinicians can play an important role in preventing the tragedy of suicide.'

In 1999, the Government published the White Paper Saving lives: our healthier nation.[5] This was an action plan to tackle poor health generally, and to reduce the death rate from suicide and undetermined injury by at least a fifth, by 2010.

The White Paper recognised that there was no single route to achieving this target since the factors associated with suicide are many and varied. Factors include social circumstances, biological vulnerability, mental ill health, life events and access to means. The document recognised that a coherent, coordinated suicide prevention strategy would need the collaboration of a wide range of organisations and individuals.

In 2002, the National suicide prevention strategy for England was published.[6]

Details of this strategy, as they apply to different groups of people, can be found in the relevant sections of this factsheet.


The National Service Framework for Mental Health in Wales (NSF) has been developed following the publication of the Adult mental health strategy for Wales. The standards outlined in the NSF are consistent with guidance from the National Institute for Clinical Excellence (NICE).

Suicide prevention is a priority for services in Wales. It should be addressed by delivering high quality, responsive, effective evidence-based care using relevant NICE guidelines and the recommendations of the National confidential inquiry into homicides and suicides: the Safety First report. [7]

As yet, the Welsh Assembly has not devised or implemented a National Suicide Prevention Strategy for Wales.

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Suicide and gender

There is a disturbing disparity between suicide rates in men and women. Britain and America are the only countries in the world which have diverging trends in male and female suicides. Between 1971 and 1998, the suicide rate for women in England and Wales almost halved, while in the same period the rate for men almost doubled.[8]

At the beginning of the twenty-first century, men appear to be more vulnerable to death by suicide than ever before: suicides by men make up 75 per cent of all suicides in the UK. Suicide rates for men are higher than for women across all age groups. In the 25-44 age range, men are almost four times more likely than women to kill themselves, while men aged 45 and over are more than twice as likely to commit suicide as women in the same age range.[9] What is causing this divergence in male and female suicide rates?

The precipitating life events for women who attempt suicide tend to be losses or crises in significant social or family relationships.

As with men, suicide is more common among women who are single, recently separated, divorced or widowed, however, women are more likely than men to have stronger social supports, to feel that their relationships are deterrents to committing suicide, and to seek psychiatric and other medical intervention.[10]

There is a tradition of men being reluctant to talk about problems or express their feelings: men are less likely than women to go to their GP with psychological problems and are more likely to present with physical problems which may not be recognised as a manifestation of mental distress.

The breakdown of traditional gender roles and the concept of the 'new man' has left many men feeling uncertain as to what is expected of them, particularly in terms of significant relationships. The increase in the proportion of unmarried young men may be another factor. Research suggests that marriage is a protective factor against suicide in men, and that half of the increase in young male suicide might be due to the smaller proportions of young men that are married.[11]

Men have suffered more severely than women in the shrinkage of traditional manufacturing jobs. It has also been noted that men in unskilled employment are twice as likely to kill themselves compared with other men in the general population.[12] Unemployed men are two to three times more at risk of suicide than the general population, and although no direct link has been shown between unemployment and young male suicide, there may be an indirect link from the effects of unemployment, such as poverty.

Young men are doing less well than young women at school and in further education.

In recent years there has been an increase in drugs misuse amongst young men and this is likely to have contributed towards the rise in suicide rates in that category

Strategies to help
The National Suicide Prevention Strategy for England recommends that the prevention of suicide in young men would be aided by:

  • improved risk management skills in frontline clinical staff
  • measures to reduce alcohol and substance abuse
  • availability of support at times of crisis
  • promoting the recognition of suicide risk in primary care
  • supporting the management of depression in primary care.

The National Institute for Mental Health in England (NIMHE) is working closely with schools, colleges and universities to develop a health promotion strategy to:

  • promote the mental health of students
  • support the development of internal counselling services
  • extend risk assessment training into college counselling services.

The Department of Health Research and Development Directorate will commission a review of the evidence on how health promotion measures can successfully reach young men. NIMHE will draw on the findings of this review to establish a mental health promotion pilot targeting young men. This will be evaluated and, if successful, will become part of NIMHE's national mental health promotion work.

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Suicide in young people

Suicide accounts for 20 per cent of all deaths amongst young people aged 15-24 and is the second most common cause of death amongst young people after accidental death.[13] Around 19,000 young people attempt suicide every year and about 700 of these die as a result.

Within these statistics there is a marked gender division; young women aged between 15 and 19 years are the group most likely to attempt suicide, however, young men are much more likely to die as a result of their suicide attempt. The suicide rate in young men has doubled since 1985, making them second only to men in the 25-44 age range for suicide.

There appears to be a reluctance to acknowledge suicidal feelings in the very young and this reluctance infiltrates youth suicide statistics. For every suicide recorded in the 1980s among 10-14 year-olds in the UK, three other children were deemed to have died from 'undetermined' causes or 'accidental' drugs overdoses.[14] It has been pointed out that 'a tendency towards minimising, denying and mythologising suicide occurs in most cases of suicide, but even more so in children and adolescents'. [15]

Substance abuse is thought to be a significant factor in youth suicide. Alcohol and drugs can affect thinking and reasoning ability and can act as depressants. They decrease inhibitions, increasing the likelihood of a depressed young person making a suicide attempt. American research has suggested that one in three adolescents were intoxicated at the time of their suicide attempt.

Academic pressure, family break up and relationship problems are all causes of mounting stress and anxiety for young people. Young people who have been physically or sexually abused are often at increased risk of suicide or deliberate self-harm.

The Suicide in Avon study[16] found that 80 per cent of young male suicides had had no contact with their GP, psychiatrist or other support agency in the four weeks before death. The study found that a quarter of young male suicides were related to interpersonal stresses in the 72 hours prior to death, giving the impression that many of these suicides were impulsive.

American research has found that young people who commit suicide are more likely than their peers to have had a friend or relative who died through suicide.[17]

Kate Hill states that: 'The aftermath of a suicide appears to be a dangerous time for those in close proximity, who identify with the victim and are already vulnerable. The emotional furore that follows a death may loosen internal restraints against self-destruction.' [18] Research suggests that, 'Exposure to suicide or suicidal behaviour of relatives and friends appears to be a significant factor influencing a vulnerable young person to suicide.' [19]

Strategies to help
Work has been commissioned through the Department for Education and Skills to map current national initiatives to promote mental health in schools and to identify further opportunities, such as the new National Curriculum on citizenship and the National Health Schools Standard.

The National Institute for Mental Health in England intends to consult with those preparing the National Service Framework for Children on measures to improve the identification and clinical management of depression and to address the mental health needs of young people coming out of care.

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Suicide in older people

Although suicide rates in older people of both sexes have dropped considerably since the 1950s, they are still high, with older men showing the highest rates. Suicide in older people is strongly associated with depression, physical pain or illness, living alone and feelings of hopelessness and guilt. Community surveys suggest that from 10 per cent to over 20 per cent of older people may be experiencing depression, but that only a fraction of these may be known to GP and psychiatric services.[20]

Most suicides in older people occur in the community, and most have had no contact with old age psychiatry services. Cattell & Jolley's research found that community old age psychiatry services were seeing less than 25 per cent of older people with depression who later went on to kill themselves, and most of these people had not seen their family doctor within the month prior to suicide.[21]

Strategies to help
The National Service Framework for Older People[22] seeks to promote good mental health in older people and to treat and support those with dementia and depression by:

  • ensuring access to integrated mental health services
  • effective diagnosis
  • treatment and support for them and their carers.

The National Institute for Mental Health in England (NIMHE) will work with leaders of services for older people and primary care to identify ways of enhancing the assessment and clinical management of depression in older people, especially those suffering from physical illness.

NIMHE aims to consult with voluntary service providers on the resourcing and development of services for vulnerable older people. Regional collaboratives for older people and mental health have been established in some parts of the country, supported by the Modernisation Agency; NIMHE will consult with them on actions to be taken on suicide prevention.

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Suicide and race

Race and cultural background can be major influences on suicidal behaviour. Patterns of suicide amongst Black and Asian people in the UK are not congruent with patterns of suicide amongst white people. For example, one study of young people of Asian origin in the UK found that the suicide rate of 16-24 year old women was three times that of 16-24 year old women of white British origin.[23] This contrasts sharply with the suicide rates of young Asian men who appear to be far less vulnerable to suicide than young men from white British backgrounds. Asian women's groups have linked the high suicide rates amongst young Asian women to cultural pressures; conservative parental values and traditions such as arranged marriages may clash with the wishes and expectations of young women themselves.[24]

Little is known about suicide rates amongst Black people in the UK. This is due, in part, to the fact that British death certificates do not record any details of an individual's racial or cultural identity, unlike the United States, where these details are routinely recorded.

One British study of attempted suicides found that young Black women appeared particularly vulnerable to suicide and that suicide attempts amongst young Black people increased more rapidly than in young white people during the late 1970s.[25]

Recent statistics from Samaritans suggest that there has been a 22 per cent increase in suicide amongst Irish and Scottish people in recent years.[26]

Strategies to help
The Department of Health is due to publish a strategy for consultation for the mental health care of Black and minority ethnic groups. The National Institute for Mental Health in England (NIMHE) is also developing a toolkit on health promotion for people from Black and minority ethnic groups.

NIMHE will ask the Coroners Review Group, as part of their consultation process, to consider routinely recording ethnicity to allow for accurate monitoring.

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Suicide and sexuality

There is strong evidence to suggest that gay men and lesbians have higher rates of suicide and attempted suicide than the general population. Young gay men and lesbians are particularly at risk of suicide.[27] In 1993, the Department of Health published the Health of the nation key area handbook: mental illness, which makes reference specifically to lesbian and gay mental health issues. A Department of Health leaflet says that those at increased risk of suicide include people 'whose sexual orientation brings them into conflict with their family or others'.[28]

Gay people generally, and young gay people in particular, may face a number of pressures due to their sexuality. Many can feel isolated, they may have difficulties coming to terms with their own sexuality, problems arising from society's attitude towards them, direct experience of facing discrimination and being stigmatised. Added to this, levels of substance abuse in the gay population are high. American statistics suggest that alcoholism affects the gay community at a rate of 20-33 per cent which far exceeds the general population at 10 per cent. [29] Reasons suggested for this include the problems of dealing with societal oppression, using alcohol and drugs as a means of coping with depression, and the pivotal role of bars in gay social networks.

Much of the research into suicide in the gay and lesbian communities comes from the USA. A 1989 report, commissioned by the US Government, concluded that gay and lesbian young people were two or three times more likely to attempt suicide than other young people and that they may account for 30 per cent of youth suicides.[30] Earlier research by the London Gay Teenage Group in 1982 found that, 19 per cent of the young gay and lesbian group had attempted suicide.[31]

A British survey of four thousand lesbians, gay men and bisexuals found that 34 per cent of men and 24 per cent of women had experienced violence because of their sexuality. 32 per cent had been harassed in the last five years and 73 per cent had been called names in the last five years because of their sexuality.[32]

Discrimination, on a number of levels, can create practical problems for gay people which can be stressful and cause material hardship. Same sex relationships are not legally recognised. This can cause problems around issues such as immigration, next of kin, pensions, inheritance rights, taxation, adoption, fostering, housing and employment rights. Being gay can be grounds for exclusion or dismissal from some kinds of employment and there is no legal protection against discrimination on the grounds of sexual identity.

Gay men and lesbians experiencing mental distress may have problems accessing appropriate services such as counselling or psychotherapy, as a number of counselling and psychotherapeutic methodologies pathologise gay sexuality. Recent research reports that between 25-60 per cent of gay people seek counselling at some stage in their lives, and that up to 50 per cent of these individuals report discontent with their experiences.[33]

The Health Education Authority mental health promotion on 'Sexual Identity' stated that: 'Some gay people internalise negative attitudes towards their sexuality and experience feelings of self-hatred, shame and low self-esteem. Some studies have suggested that internalised homophobia is a risk factor for alcohol and drug dependency. Anxiety, depression, self-harm, suicide and attempted suicide have all been linked with the combined effects of the experience of prejudice and discrimination and internalised negative feelings.'

Strategies to help
The National Suicide Prevention Strategy for England does not specifically target gay, lesbian, bisexual or transgender people. The document describes, in general terms, the promotion of the mental health of socially excluded groups.

The suicide prevention programme will work closely with the National Institute for Mental Health in England equalities programme, which focuses on mental health promotion and social inclusion.

(For further information, please see Mind's factsheet Lesbians, gay men, bisexuals and mental health.)

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Suicide and substance misuse

Substance abuse has long been recognised as a risk factor for suicide and suicide attempts. Alcohol and drugs can affect thinking and reasoning ability and can act as depressants. They can decrease inhibitions, increasing the likelihood of a depressed person making a suicide attempt.

A 1999 report by the Department of Health found that, among suicides outside hospital, 38 per cent had a history of alcohol misuse, and 26 per cent a history of drug misuse.[34]

Estimates suggest that around 15 per cent of people who abuse alcohol may eventually kill themselves.[35] Another estimate suggests that, among people who abuse drugs, the risk of suicide is twenty times that of the general population.[36]

Research suggests that men are nine times as likely to abuse alcohol as women, and men diagnosed with alcoholism are six times as likely to commit suicide as men in the general population. Although women are less likely than men to abuse alcohol, those who do, are at a much greater risk of suicide than men, with a suicide rate twenty times that of the general population.[37]

It has been suggested that the role of alcohol and drugs is of particular significance in those suicides which appear to be impulsive. Alcohol and drugs are particularly implicated in suicides of young men. It has been suggested that the increase in drug use by young people in recent years could be a factor in explaining the dramatic rise in young male suicides in the eighties and early nineties.

Strategies to help
The National Suicide Prevention Strategy for England intends to work closely with the National Institute for Mental Health in England Substance Misuse Programme to improve the clinical management of alcohol and drug misuse, particularly among young men. This includes the development of a risk assessment training package to be used in a range of settings including substance misuse services.

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Suicide and mental distress

Research suggests that, suicide risk is raised for virtually all mental disorders and also some medical disorders related to mental disorder or substance abuse: suicidal thoughts and actions, both past and present, increase risk further. Functional mental disorders such as schizophrenia and depression have, overall, the highest risk, with substance abuse and organic disorders lesser degrees of risk.[38]

Estimates for this differential vary, but average out at around a 15-20 per cent increased risk of suicide for people with recurrent depression, and between 10-15 per cent for those with schizophrenia. These figures may in fact be higher. It is possible that many cases of suicide in the general population may in fact have been experiencing undiagnosed depressive illness. The Mental Health Foundation estimates, through the retrospective examination of information about people who have killed themselves, that 70 per cent of recorded suicides are by people experiencing depression.[39]

A recent study, Aftercare and clinical characteristics of people with mental illness who commit suicide,[40] looked at a 30-month sample of 149 cases of people who had received an inquest verdict of suicide or open verdict in the Greater Manchester area. The study found that those who took their own lives were more likely to have had their care reduced at their final appointment with a health worker because they were deemed to be improving or doing well. This included a reduction in supervision and a cut in drug dosage. Most of these reductions were initiated by the patient. The study found that only a third of cases had an identifiable key worker - a key factor in the Care Programme Approach, introduced in 1991 for vulnerable patients. The conclusion reached was that people with mental health problems may remain at high risk of committing suicide for some time after they appear to be well. The study suggests that, care should not be reduced for up to a year after a person at high risk of suicide is thought to have improved, since this is the period when they are at most danger.

The Manchester study also found that suicide was associated with a history of self-harm, usually overdose, and suicidal thoughts during aftercare. 40 per cent of the cases studied had a major affective disorder such as depression, 24 per cent had a diagnosis of alcoholism, 23 per cent had schizophrenia, 5 per cent were diagnosed with personality disorder and 5 per cent were dependent on drugs.

Depression is often accompanied by thoughts of suicide; indeed such suicidal ideation is seen as an important element in the diagnosis of depression. The deeper the depression, the more likely it is that a person will experience suicidal ideation. However, the physical act of suicide does not appear to be related to the depth of the depression, rather, suicidal acts are more likely to occur when a person is coming out of a depressive episode rather than when the depression is at its most severe. This may be related to energy levels and motivation becoming stronger just as the depression itself is lifting.

In a World Health Organisation study involving the follow-up of a large number of people with symptoms of psychosis, suicide was found to be the leading cause of death in those with schizophrenia.[41]

Depression is generally recognised as a feature of suicide in people with schizophrenia. However, research suggests that the seriousness of suicidal intent is related less to the degree of depression than with one particular aspect of depression - hopelessness about the future.[42] Among people with schizophrenia, despite the occasional dramatic psychotic suicide, the greatest risk for suicide occurs during non-psychotic depressed phases of the illness. [43]

Care and services
Hospital mortality statistics have shown an increase in suicides amongst inpatients in recent years. Approximately one per cent of all suicides in the UK occur within NHS psychiatric hospitals.[44]

A significant proportion of the suicides of people with mental health problems could be prevented every year, according to the National Confidential Inquiry. Their Safety first report found that failings in the care of people with mental illness mean hundreds of people are dying unnecessarily. It found that 17 per cent of suicides were preventable if better care and services had been available.[45]

Four out of ten suicides among people with mental health problems occur while they are psychiatric inpatients or shortly after discharge. A quarter of patients who had committed suicide had been in contact with mental health services in the year before their death, and 23 per cent of people who killed themselves, did so within three months of being discharged from hospital.

Negative staff/patient relationships have also been cited as a factor in other studies looking at suicide among psychiatric patients. Louis Appleby states that 'the feature which most strikingly distinguished suicides was disturbed relationships with hospital staff resulting in premature discharge'. [46] Recent research conducted by the National Schizophrenia Fellowship has found that one in three suicides by people with a mental illness takes place while they are still a hospital inpatient. The NSF's report One in ten analyses 589 cases of suicide that took place between 1991 and 1999. The majority of these cases did not actually happen on hospital wards, but took place away from the hospital, after individuals were allowed to leave the ward unsupervised.

Strategies to help
The National Suicide Prevention Strategy for England has developed an action plan to reduce suicides amongst people in touch with psychiatric services. Local mental health services will be supported by the National Institute for Mental health in England to implement the recommendations made in Twelve points to a safer service (developed from the work of the National Confidential Inquiry, Suicide and homicide by people with mental illness).

The action points are as follows:

  • staff training in the management of risk, every three years
  • all patients with severe mental illness and a history of self-harm or violence to receive the most intensive level of care under the Care Programme Approach
  • individual care plans to specify action to be taken if a patient is non-compliant or fails to attend
  • prompt access to services for people in crisis and their families
  • assertive outreach teams to prevent loss of contact with vulnerable and high-risk patients
  • atypical antipsychotic medication to be available for all patients with severe mental illness who are non-compliant with 'typical' drugs because of side effects
  • local strategies for dual diagnosis covering training on the management of substance misuse services, and staff with specific responsibility to develop the local service
  • inpatient wards to remove or cover all likely ligature points
  • follow-up within seven days of discharge from hospital for everyone with severe mental illness or a history of self-harm in the previous three months
  • patients with a history of self-harm in the last three months to receive supplies of medication covering no more than two weeks
  • local arrangements for information sharing with criminal justice agencies
  • policy ensuring post-incident multi-disciplinary case review and information to be given to families of involved patients.

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Suicide following deliberate self-harm

The term 'deliberate self-harm' is generally used to cover all acts of self-harm, self-injury or attempted suicide. Acts of deliberate self-harm and suicide attempts do not necessarily involve an intention to die. However, there is a strong association between attempted suicide, deliberate self-harm and subsequent successful suicide, so all incidents of self-harm should be treated with extreme care.[47]

Strategies to help
The Royal College of Psychiatrists has produced Guidelines on the management of deliberate self-harm[48]and Managing deliberate self-harm in young people.[49] These documents recognise the fact that, people who deliberately harm themselves, should always be taken seriously. The act of self-harm indicates that individuals may have acute or chronic psychiatric disorders or significant psychosocial problems.

Key messages within the National Suicide Prevention Strategy for England include the development of standards for service provision in the following areas:

  • accident and emergency departments
  • inpatient wards
  • child and adolescent psychiatry.

In addition:

  • Guidance is to be issued by the National Institute for Clinical Excellence (NICE) on the management of deliberate self-harm in accident and emergency departments.
  • A national collaborative is being established for the monitoring of deliberate self-harm. Through this monitoring it will be possible to estimate the number of suicides in the year following deliberate self-harm.
  • The National Institute for Mental Health in England (NIMHE) will support local services in establishing procedures and services for people presenting at accident and emergency departments with deliberate self-harm. These will address the assessment of suicide risk, mental health needs and substance misuse.
  • A risk assessment package will be made available by NIMHE to frontline clinical staff, the prison service, primary care, substance misuse services and college counselling services.

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Suicide in prisons

In 2002, there were 94 suicides in prisons in England and Wales: 85 men and nine women.[50] Prison suicide increased by 40 per cent during the 1990s. The number of self-inflicted deaths in 2002 was the highest in the last 10 years. This rate translates as being over 12 times the total male suicide rate.[51]

Liebling and Krarup conducted the most comprehensive study ever into suicide and self-harm in prison, between 1990 and 1992. Their research report, published in 1993, identified a range of characteristics and background factors associated with prisoners at risk of suicide and self-harm.[52] They found that many prisoners had experienced multiple deprivations prior to their imprisonment, and to this was added the stresses resulting from custody and a range of situational problems. Although all prisoners may be vulnerable at certain times, they found that there were three particularly vulnerable groups: younger 'poor copers', those with mental health problems and adult male serious offenders.

Within the prison population as a whole, young prisoners are the individuals most at risk, particularly those under 21, who make up a third of the remand population. In 1995, 20 per cent of prison suicides were by people under 21, the vast majority being young males.[53]

Liebling and Krarup found that mental health problems were present in approximately one third of prison suicides, however, their research suggests that coping problems and situational factors are more significant than psychiatric explanations.

Judge Tumin, then Chief Inspector of Prisons, was commissioned by the Home Secretary to carry out a review of the Prison Service's policy on suicide and self-harm. This report was published in 1990, and in it Judge Tumin stated: 'Current Prison Service policy fails to communicate the social dimension to self-harm and self-inflicted death. It does not stress sufficiently the significance of the environment in which prisoners and staff are expected to live and work, or the importance of constructive activities in helping inmates to cope with anxiety and stress. Above all, it fails to give weight to the need to sustain people during their time of custody, the importance of relationships between inmates and between staff and inmates in providing support'. [54]

Strategies to help
This research and review has led to the Prison Service developing a new policy called Caring for the Suicidal in Custody.[55] The key elements of the policy are:

  • new suicide screening, care plans and staged risk management systems
  • the implementation of intervention strategies for repeat deliberate self-harm in all prisons
  • improved health screening on reception into custody to assist in the detection of mental disorder, vulnerability to suicide, self-harm and substance misuse
  • prisoner listeners trained by Samaritans, accessible at all times for prisoners in distress
  • primary care - creating a safe environment and helping prisoners to cope with custody
  • special care - identifying and supporting prisoners in crisis and treating them with dignity
  • aftercare - caring for the needs of those affected by suicide and self-harm
  • community responsibility - involving the whole prison community in the awareness and care of the suicidal.

Working with the prison service, the National Institute for Mental Health in England will:

  • investigate ways of improving information sharing into and across the criminal justice system about people known to be at risk of suicide
  • disseminate World Health Organisation Primary care guidelines for prisons, including guidance on suicide prevention.

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Suicide in rural areas

The facts of rural life belie town-dwellers' misconceptions of an idyllic country existence. Evidence shows that 25 per cent of households in rural areas are on or below the breadline, and more farm workers have relied on social security benefits than any other group.

A recent survey of over 500 farmers, conducted by Farmers weekly, found that one in three farmers feel depressed, while nearly two thirds said they feel more stressed than they did five years ago. Long hours, the BSE crisis, and the collapse of beef, lamb and milk prices have sent rural incomes plummeting. In 1992 over 14,000 people left the agricultural industry.[56]

Farmers and farm managers are the occupational group with the fourth highest risk of suicide in England and Wales. In the early 1980s, farmers were the occupational group with the second highest suicide rate, however, in the period between 1982 and 1992, this dropped from 2.05 times the average risk to 1.45 times. However, the actual figures are likely to be substantially higher than this as the percentage of 'open' or 'undetermined' deaths for farmers is very high, and there is substantial evidence that the majority of these are suicides.[57] Women married to farmers have a suicide rate more than 20 per cent higher than the average. There is particular concern over the rise in the number of suicides in rural areas of Wales. The overall suicide rate in Wales is 14.6 per cent higher than in England. Male suicides account for 84 per cent of the suicides in Wales compared with 75 per cent generally.

Strategies to help
The Department of Health has contributed towards the cost of funding rural initiatives as part of their response to the Health of the Nation suicide reduction targets. Samaritans have launched initiatives in Somerset, Oxfordshire, Derbyshire and Gloucestershire to focus public concern on the plight of rural communities and to alert the farming and rural communities to the help that is available. Rural Minds, a partnership between Mind and the Department of Health has been set up to improve the mental health of people living in isolated rural areas.

Helplines have been provided for farmers, by the National Union of Farmers, the Rural Stress Information Network, the Farmers' Crisis Network, Rural Minds and Samaritans.

The National Institute for Mental health in England (NIMHE) will ask the Coroners Review Group, as part of their consultation process, to consider routinely recording occupation to allow monitoring of high risk occupational groups.

The Department of Health and NIMHE have supported the Rural Stress Action Plan. Key aims of the plan are:

  • delivering support to those suffering from stress in rural communities
  • developing regional support networks
  • developing a rural initiative fund
  • NIMHE will work with Rural Minds and through the Rural Stress Action Plan to share identified successful local support initiatives for farmers and their families. An example of this will be to review the dissemination of helpline numbers and explore the possible further development of teleconferencing facilities for farmers
  • NIMHE will liaise with professional organisations to explore how occupational health services can be made more readily available. 

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Suicide and the media

A study has looked at the effects of a drug overdose in a television drama on presentations to hospital as a result of self-poisoning.[58] The study aimed to determine whether a serious drug overdose in the medical drama Casualty altered the incidence of and nature of general hospital presentations for deliberate self-poisoning. The study found that presentations for self-poisoning increased by 17 per cent in the week after the broadcast and nine per cent in the second week. Thirty-two patients, who presented in the week after broadcast and were interviewed, had seen the episode. Of these, 20 per cent said it had influenced their decision to take an overdose, and 17 per cent said it had influenced their choice of drug. A key message from the study is that extreme caution should be exercised about portraying suicidal behaviour on television, and especially about giving details of the method used.

Strategies to help
Both Samaritans and the Presswise Trust have developed guidelines for the media. Key points include:

  • improve the placing of responsible articles on suicide prevention in the media
  • reduce sensationalism and positive tone about suicide in reports
  • promote the inclusion of facts about suicide, and the avoidance of reference to means of suicide in reports
  • improve population awareness of the potential benefits of help-seeking in times of crisis by promoting media portrayal of suicidal people seeking help and gaining benefit
  • influence the training of journalists to ensure that they report issues about mental illness and suicidal behaviour in an informed and sensitive manner.

The Department of Health's Mind Out for Mental Health' campaign has included specific activities targeting suicide reduction:

  • incorporating guidance on the representation of suicide into workshops held with students at journalism colleges
  • discussion sessions between leaders in mental health and journalists
  • a series of roadshows at which frontline journalists discussed responsible reporting
  • a feature on suicide in media journals.

The National Institute for Mental Health in England (NIMHE) will liase with media groups and representatives to explore ways to promote Samaritans' guidelines on media reporting. NIMHE will seek to involve a broad range of agencies in this work, including coroners and the police.

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Attitudes towards suicide

Suicide has occurred consistently throughout recorded history in every cultural and social setting. However, attitudes towards suicide have varied widely in different ages, cultures and societies.

In ancient Greece and Rome, suicide was generally seen as an honourable or heroic form of death. Eleven instances of suicide are mentioned in the Old Testament: these are reported simply and are given no negative connotations. One of the most famous examples of suicide was the mass suicide of Jews at Masada in 73 AD. This was generally perceived to have been an honourable action to avoid falling into the hands of the defeating Roman Army.

In the early years of Christianity, St Augustine (345-430 AD) pronounced suicide to be a 'mortal sin'. A century later, the Christian Church prohibited the saying of masses for the souls of those who died by suicide, and they were denied burial in hallowed ground. The last recorded 'unhallowed' burial of a suicide in Britain occurred as late as 1823.[59]

In Japan, the Samurai had ritual codes for different methods of suicide which would bring them 'death before dishonour'. Even in modern Japan there is little stigma associated with suicide, an example being the suicide of writer Yukio Mishima.

Within the Hindu faith, although there appears to be a general taboo against suicide, particularly among men, the idea of 'altruistic' suicide is acceptable, and there is a historic tradition associated with bereaved women, particularly widows, committing suicide.

As recently as the 1950s, people in Britain were still being sent to prison for attempting suicide. The 1961 Suicide Act repealed the law under which both actual and attempted suicides were held to be criminal acts. England and Wales were the last countries in Europe to decriminalise suicide. The word 'suicide', itself, has the implication of being a criminal act, literally meaning self-murder.

In Britain, at the beginning of the twenty-first century, with suicide no longer considered a crime, church membership at an all time low, a general loosening of moral prohibitions, and an emphasis on personal freedom, suicide or taking one's own life appears to be more socially acceptable than ever before. Certainly, there would appear to be fewer moral and psychological obstacles standing between people and the act of suicide.

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Attempted suicide

It is estimated that at least 140,000 people attempt suicide each year in England and Wales alone.[60] One in five people who attempt suicide will try again, of whom 10 per cent will succeed.[61]

'Attempted suicide', 'parasuicide' and 'deliberate self-harm' are terms which can be used to describe non-fatal acts of self-harm. People who attempt suicide can have differing degrees in their wish to die, and different suicidal acts can involve different degrees of risk to life.

Repetitions of suicide attempts are common, with approximately 20 per cent of people being re-admitted to hospital within a year of a previous attempt. Those who have attempted suicide are at a greater risk of eventually dying by suicide, and the number of repeat attempts made increases the likelihood of eventually dying by suicide.

Common factors associated with attempted suicide are single marital status (including divorced/widowed), unemployment, social deprivation, history of physical or sexual abuse, substance abuse and social isolation.

People usually attempt suicide to block unbearable emotional pain, which is caused by a wide variety of problems. It is often a cry for help. A person attempting suicide is often so distressed that they are unable see that they have other options and better choices they could make. Suicidal people often feel terribly isolated, and because of their distress, they may not be able to think of anyone they can turn to, which can further their feelings of isolation. Many suicidal people give warning signs in the hope that they will be rescued, because for many, they are intent on stopping their emotional pain, not on dying.

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Prediction of suicide risk

A history of past suicide attempts is the most accurate predictor of future risk of suicide. It has been estimated that, between 10-15 per cent of people in contact with healthcare services as a result of their first suicide attempt, do eventually die by suicide,[62] the risk being highest during the first year after an attempt. Thus, for the purposes of suicide prevention, an individual's history of suicidal behaviour is a major help in identifying subjects with particularly high risk of suicide in the future.[63]

There are a number of possible indicators that someone may be at risk of suicide. These include: recent bereavement or other loss; the recent break-up of a close relationship; a major disappointment such as failed exams or a missed job promotion; a change in circumstances such as retirement, redundancy, or children leaving home; or experiencing a physical or mental illness.

People may be at particular risk if they have made a previous suicide attempt, if there is a history of suicide in their family, or if they have begun tidying up their affairs, for example, by making a will or taking out insurance.

Other signs to look out for may be a change in behaviour. This might include the person appearing withdrawn or low-spirited, finding it difficult to relate to others, taking less care of themselves or their physical appearance. They may appear more irritable, tearful, or be trying hard not to cry. They may even appear unusually cheerful. They may find it hard to concentrate, appear less energetic or particularly tired, or eat less (or more) than usual.

People at risk might talk about suicide, express a sense of hopelessness towards the future or see no point in life. They may express feelings of being worthless or a failure; of feeling isolated and alone; of sleeping badly - especially waking early.

(For further information, see Mind's booklet How to help someone who is suicidal)

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The effect of suicide on others

The term 'survivors' has been applied to those friends and family who have been affected by suicide. While survivors of suicide have certain things in common with other bereaved people, some aspects of their bereavement are unique. Like all those bereaved, they are faced with a major loss, and with having to face the fact that the loss is permanent. Anger and guilt are common bereavement reactions, but are often more intense and long-lasting among survivors of suicide.

Alison Wertheimer writes of the experiences of people bereaved by suicide in A special scar:  'Survivors who either witness the person committing suicide or, more commonly, find the body, are left to come to terms with a shattering experience. Memories of the scene are likely to remain with the survivor for many years to come, and may never disappear completely. Even when a person has not actually discovered the body, being told about the circumstances of the suicide can leave the survivor with horrific images of the scene of the death, making it hard for them to think about anything else at first. Where the victim died in a violent manner, this reaction is likely to be intensified.' [64] Trying to understand why someone has committed suicide can preoccupy survivors for months and even years after the event.

Many people faced with bereavement can rely on support from a variety of people including family, friends and colleagues. However, those faced with bereavement due to suicide may find that they have less social support available to them because: 'suicide is not a socially acceptable way to die under any circumstances and without socially acceptable reasons for the death, how can the loss be socially acceptable? The survivors have no available rationale to ease acceptance, their friends have no socially acceptable words of comfort, no special rituals or ceremonies can be invoked to mobilise support and no tradition helps filter the remembrance. Bereavement from suicide, like the suicide itself, is without social acceptance, without institutional patterns'. [65]

There are certain common features of bereavement which have been developed into a model of the path of bereavement:

  • Numbness - this reaction often closely follows the death of a loved one, particularly if the death was sudden or unexpected. A sense of distance and being removed from one's feelings of grief may be present. It has been suggested that this numbing may be the body's mechanism for protecting itself from being overwhelmed by the shock of the loss.
  • Denial - here, a bereaved individual may have significant difficulty accepting the reality of their loss. In severe forms, this may be expressed as a complete denial of the death, or in less severe forms, the bereaved individual may have lapses in thinking and behave as though the person had not really died.
  • Anger - in this phase, the bereaved person may feel a general anger with the world, fate or God, or a more specific anger towards people in their lives. Behaviour such as trying to bargain with God for the return of the dead person may be part of this phase.
  • Depression - as acknowledgement of the loss grows, sadness and depression may become more present, and there may be a growing awareness of the reality of the situation.
  • Acceptance - the bereaved person comes to terms with the loss, and is able to move on and accept the new life that lies ahead for them. This stage is typified by the absence of extreme emotions which may have been present earlier in the process.

Suicide bereavement has certain features which may prolong the process of grieving. Survivors may get stuck in an endless and fruitless search for a definite answer as to why the suicide occurred; or they may believe that they were somehow responsible for the death and may punish themselves by continuing to grieve. It is important for people to be able to release the emotions of grief. Being able to weep and to express anger and other intense emotions is part of the healing process. If a person gets stuck in a particular stage of the grieving process they may require some support or assistance to move forward. This could be provided by supportive friends and family, but sometimes there may be a need for some form of professional help.

Support for those affected
The Coroners Review Group plan to place the support for people bereaved by suicide at the centre of a reformed inquest process.

As part of their consultation process, NIMHE are highlighting the specific needs of people bereaved by suicide. NIMHE are liaising with support organisations to develop a support pack for people in contact with bereaved families, such as GPs, the police and religious leaders.

(For further information, see Mind's booklet Understanding bereavement)

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Further reading

Factsheet: Statistics no.2: suicide
Crisis services factsheet

How to help someone who is feeling suicidal, Mind 2004
Understanding depression, Mind 2004

Suicide and attempted suicide, Mark Williams Penguin, 2001
Night falls fast: Understanding suicide, Kay Redfield Jamison Picador, 2000.

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Useful contacts

CALM (Campaign Against Men Living Miserably)
Rm 621
Gateway House
Piccadilly South
Manchester M60 7PL
tel: 0800 585 858
website: www.comcarenet.co.uk/trafford/therapy/calm.htm

Cruse - Bereavement Care
126 Sheen Road
Surrey TW9 1UR
tel: 020 8939 9530
fax: 020 8940 7638
email: [email protected]
website: www.crusebereavementcare.org.uk

Cruse Cymru
Ty Energlyn
Heol Las
Caerphilly CF83 2WP
tel: 029 2088 6913
fax: 029 2088 6913
email: [email protected]
website: under construction

London Lesbian & Gay Switchboard
P.O. Box 7324
London N1 9QS
tel: 020 7837 7324
fax: 020 7837 7300
website: www.llgs.org.uk

PAPYRUS (Parents Association for the Prevention of Young Suicide)
Rossendale GH
Union road
Lancashire BB4 6NE
tel: 01706 214 449
email: [email protected]
website: www.papyrus-uk.org

HOPELineUK: 0870 170 4000 (7-10pm Mon to Fri and 2-5pm Sat and Sun), answerphone at other times.
Advice and information for parents, carers, teachers, professionals and friends of young people at risk of suicide.

10 The Grove
Slough SL1 1QP
tel: 08457 90 90 90
email: [email protected]
website: www.samaritans.org.uk

Survivors of Bereavement by Suicide
Centre 88
Saner Street
Humberside HU3 2TR
tel: 0870 241 3337
fax: 01482 210 287
email: [email protected]
website: www.uk-sobs.org.uk

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[1] Samaritans 2003, Information Resource Pack.

[2] Brook, A., & Griffiths. C. 2003, 'Trends in the mortality of young adults in England and Wales, 1961 to 2001', Health Statistics Quarterly 19, ONS.

[3] The Stationery Office 1992, The Health of the Nation, Department of Health.

[4] Pirkis, J. & Burgess, P. 1998, 'Suicide and Recency of Health Care Contacts', British Journal of Psychiatry 173, 462-474.

[5] The Stationery Office 1999, Saving Lives: Our Healthier Nation, Department of Health.

[6] The Stationery Office 2002, National Suicide Prevention Strategy for England, Department of Health.

[7] National Patient Safety Agency 2001, Safety First, National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, five-year report of the National Confidential Inquiry.

[8] Ibid.

[9] Ibid.

[10] American Foundation for Suicide Prevention 1997, Suicide in Women, in Suicide Facts.

[11] Charlton, J. et al. 1992, 'Trends in Suicide Deaths in England and Wales' Population Trends No.69, Office for National Statistics, HMSO.

[12] Drever & Whitehead, eds 1997. Health Inequalities, Office for National Statistics.

[13] Samaritans 1998, Exploring the Taboo, Samaritans.

[14] Office of Population Censuses and Surveys, Mortality Statistics for England and Wales 1979-1990, HMSO.

[15] Shafii, M. 1989, 'Completed Suicide in Children & Adolescents: Methods of Psychological Autopsy' in Suicide Among Youth: Perspectives on Risk and Prevention (ed. Pfeffer, C.R.) American Psychiatric Press.

[16] Vassilas, C.A. & Morgan, H.G. 1997, 'Suicide in Avon', British Journal of Psychiatry 170, 453-455.

[17] Shaffi, M., Carigan, S., Whittinghall, J.R. et al. 1985, 'Psychological Autopsy of Completed Suicide in Children and Adolescents', American Journal of Psychiatry, 142, 1061-1064.

[18] Hill, K, 1995, The Long Sleep: Young People and Suicide, Virago.

[19] Shafii, M. 1989, op cit.

[20] The Stationery Office, The Health Survey for England 2000, Department of Health.

[21] Cattell, H. & Jolley, D.J. 1995, 'One Hundred Cases of Suicide in Elderly People', British Journal of Psychiatry, 166, 451-457.

[22] Department of Health 2001, National Service Framework for Older People, Department of Health.

[23] Raleigh, V.S. & Balarajan, R. 1992, 'Suicide and Self-Burning among Indians and West Indians in England and Wales', British Journal of Psychiatry, 129, 365-368.

[24] Ibid.

[25] Burke, A.W. 1976, 'Sociocultural Determinants of Attempted Suicide among West Indians in Birmingham: Ethnic Origin and Immigrant Status', British Journal of Psychiatry, 161, 261-266.

[26] Samaritans 1998, Information Resource Pack.

[27] Bridget, J. 1994, Treatment of Lesbians with Alcohol Problems in Alcohol services in North-West England, Lesbian Information Service.

[28] Department of Health 1993, Sometimes I Think I Can't Go On Anymore, DoH.

[29] Herbert, Hunt & Dell 1994, 'Counselling Gay men and Lesbians with Alcohol Problems' Journal of Rehabilitation.

[30] Research quoted in 'Victims of a Moral Crusade' by Trisha Leslie in The Pink Paper, 9 March 1993.

[31] Trenchard L. & Warren H. 1984, Something to tell you, London Gay Teenage Group.

[32] Health Education Authority 1998, World Mental Health Day 'Sexual Identity'.

[33] Man, L. 1994, 'Working With Lesbian and Gay Clients', Journal of the British Association for  Counselling, Vol 5, No 1.

[34] The Stationery Office 1999, Safer Services: national confidential inquiry into suicide and homicide  by people with mental illness, Department of Health.

[35] Faulkner, A. 1997, Briefing No.1 - Suicide and Deliberate Self-Harm. Mental Health Foundation.

[36] Ibid.

[37] Harris, C. & Barraclough, B. 1997, 'Suicide as an Outcome for Mental Disorders', British  Journal of Psychiatry 170, 205-228.

[38] Ibid.

[39] Mental Health Foundation 1997, Briefing No.1 - Suicide and Deliberate Self-Harm, MHF.

[40] Appleby, L. et al. 1999, 'Aftercare and clinical characteristics of people with mental illness who commit suicide:a case-control study', The Lancet, Vol 353.

[41] Sartorius, N. et al. 1987, WHO, Course of Schizophrenia in Different Countries in Hafner, H., Gatterz, W.F. & Janzaril, W. eds Search for the Causes of Schizophrenia. Berlin: Springer  Verlag.

[42] Beck, A. et al. 1985, 'Hopelessness and Eventual Suicide', American Journal of Psychiatry, 142, 59-563.

[43] Minkoff, K, Bergman, E., Beck, A.T.,et al.,1973,  'Hopelessness, Depression and Attempted Suicide', American Journal of Psychiatry 130.

[44] Levey, S. 1990, Suicide in Principles and Practice of Forensic Psychiatry, eds. Bluglass, R & Bowden, P. Churchill, Livingstone.

[45] Appleby, L. 2001, Safety First: Five Year Report of the National Confidential Inquiry into  Suicide and Homicide by people with Mental Illness, Department of Health.

[46] Appleby, L. 1991, 'Suicide in Psychiatric Patients: Risk and Prevention', British Journal of Psychiatry 158, 368-374.

[47] Mental Health Foundation 1997, Briefing No. 1- Suicide and deliberate self-harm, MHF.

[48] Royal College of Psychiatrists 1994, Guidelines on the Management of Deliberate Self-harm.

[49] Royal College of Psychiatrists 1998, Managing Deliberate Self-harm in Young People.

[50] Home Office, Prison Statistics England and Wales 2002, Office of National Statistics, Crown Copyright.

[51] Summers, L. 2003, Reducing Self-Harm and Suicide in Prisons: Advice for Prison Staff on Using Safer Cells, Jill Dando Institute of Crime Science, University College London, found at http://www.jdi.ucl.ac.uk/publications/short_reports/safer_cells.php

[52] Liebling, A. & Krarup, H. 1992, Institute of Criminology, Cambridge University.

[53] Samaritans 1998, Exploring the Taboo, Samaritans.

[54] HM Chief Inspector of Prisons 1990, Review of Suicide and Self-Harm.

[55] HM Prison Service 1994, Caring for the Suicidal in Custody - Principles of Prison Service Policy.

[56] Pugh, J. 1993, 'Rural Initiatives', Samaritan News, Spring 1993.

[57] Charlton et al. 1992, 'Trends in Suicide Deaths in England and Wales', Population Trends, 69,  10-16.

[58] Hawton, K. et al. 1999, 'Effects of a drug overdose in a television drama on presentations to hospital for self-poisoning', British Medical Journal, 318, 972-977

[59] Pritchard, C. 1995, Suicide - The Ultimate Rejection, Open University Press.

[60] Samaritans 1998, Exploring the Taboo, Samaritans.

[61] O'Shea, B. et al. 1986, Aspects of Deliberate Self-harm, British Journal of Hospital Medicine, 35, 5, 335-337.

[62] Isometsa, E.T. & Lonqvist, J.K. 1998. 'Suicide Attempts Preceding Completed Suicide', British Journal of Psychiatry 173, 531-535.

[63] Taylor,S. et al. 1997, 'How Are Nations Trying To Prevent Suicide?' Acta Psychiatrica Scandinavica, 95, 457-463.

[64] Wertheimer, A. 1991, A Special Scar, Routledge.

[65] Wallace, S.E. 1977, 'On the Atypicality of Suicide Bereavement', in Suicide and Bereavement, Danto & Kutscher (eds) , New York, MSS Information Corporation.

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Written by George Stewart, Mind Information Officer, May 1999, updated by Inger Hatloy, March 2004.

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