Suicide in Australia EXTENSIVE ARCHIVE HERE
A dying shame
Suicide Prevention Week (6 - 10 November 2000)
Read Wesley Mission's Vision and Values Statement
This Report was prepared by the Strategic Planning and Development Department in conjunction with the LifeForce Suicide Prevention Program.
We acknowledge the contribution of Randall Pieterse (LifeForce), Bernard McNair (Senior Manager Wesley Health & Counselling), Dr Keith Suter (Social Policy Consultant), David McGovern (Manager Public Relations), Lyndal Parker (Graphic Designer), Sharon Hoogland and AnneMarie Maizey (Strategic Planning and Development) and Kathy Moir (for Research Assistance).
For further information contact Sharon Hoogland on (02) 9263 5555.
(Biographical details. Authors: Sharon Hoogland, Randall Pieterse. 2000. Pub: Wesley Mission, Sydney.)
Suicide in the U.S.: Statistics and Prevention
Registrar General for Scotland
Deaths Time Series Data
Office for National Statistics
Mortality Statistics: General - DH1 DH1 - Annual review of the Registrar General
on deaths in England and Wales, Contains key statistics of deaths and death rates
in England and Wales by age, sex, marital status, place of death, birthplace and
coroner involvement for the reference year. Since 1993 this volume has
included some tables previously included in Mortality Statistics: Area (Series DH5).
NISRA Northern Ireland Statistics and Research Agency
The Republic of Ireland are provisional at the time of publishing,
obtained from Central Statistics Office, Cork
|KEY FACTS ABOUT SUICIDE FROM MIND
There were 20,927 suicides in England & Wales between 1996-2000140,000 people attempt
suicide each year in England and Wales aloneEstimates suggest the true suicide rate
is 50-60% higher than the official rate75% of suicides in the UK are by males.
Suicides in young men aged 15-24 are now 67% higher than in 1982.
Suicide figures are double the death toll from road traffic accidents.
The overall UK suicide rate has been slowly declining since the early 1980s.
Between 1971 and 1996 the suicide rate for women in the UK almost halved.
Between 1971 and 1996 the suicide rate for men in the UK almost doubled.
Men aged 25-44 have the highest suicide rates.
Suicide rates are higher among people with mental health problems.
Research suggests up to 70% of suicides are by people with depression.
Drug and alcohol misuse both increase the risk factor for suicide.
The suicide rate in male prison inmates is six times the male average.
Overdosing accounts for 50% of female suicides and 25% of male suicides.
10-15% of people who make a suicide attempt will later die by suicide.
Young women 15-19 are at the highest risk of attempted suicide.
16% of suicide inquiry cases in England & Wales were psychiatric in-patients.
The suicide rate among homeless is 35 times that of the general population
Suicide and Gender
Suicide in Young People
Suicide in Older People
Suicide and Race
Suicide and Occupation
Suicide and Unemployment
Suicide and Substance Misuse
Suicide and Mental Distress
Suicide in Psychiatric Hospitals
Suicide in Prisons
Suicide in Rural Areas
Attitudes Towards Suicide
Prediction of Suicide Risk
The Effect of Suicide On Others
Twelve Points to a Safer Service
Suicide is a major public health issue in the United Kingdom. There were 20,927 suicides and probable suicides in the UK in the four years from 1996, 75% of these suicides were by males. These figures are more than double the death toll from road traffic accidents and twelve times the number of deaths from homicide. Of the total figure, 24% were known to be in contact with mental health services in the year prior to death.
Suicide rates in the UK have been slowly declining since the early 1980s. Although the overall suicide rate has been dropping for over a decade, until recently there was a great deal of alarm over dramatic increases in the suicides of young men in the 15-24 age group. This trend now appears to have reversed with the young male suicide rate dropping for the third year in succession, however, it is still 67% higher than it was in 1982, and 25% higher than the overall suicide rate for all men.
These official statistics, however, only tell part of the story. The official figures are almost certainly a considerable underestimate of the actual number of suicides. The main reason for this disparity is that official suicide statistics in the UK are based on coroners’ verdicts. In the case of a suspected suicide an inquest will be held, but the victim’s intention to commit suicide must be definitely proven. In the absence of any clear proof of intent, the verdict is unlikely to be suicide. Such deaths are likely to be classified as “death by misadventure”, “accidental death”, or there will be an “open” verdict. Estimates of the true rate of suicide in the UK suggest that the actual rate is likely to be in the region of 50-60% higher than the official statistics report.
In her book “The Long Sleep” Kate Hill makes the following point:
“For all practical purposes officially recorded suicide figures are now defunct. The UK Department of Health’s own calculations confirm this. In 1992 the Secretary of State for Health made a commitment to reduce the suicide rate in England and Wales by 15% by the end of the century. The “suicide rate” in question turned out to be the combined death rate from suicide and undetermined causes.” The number of suicide notifications in fact continued to rise until 1998, however, it has fallen in most three-month periods since the beginning of 1998.
A footnote in “The Health of the Nation” key area handbook on mental illness explains that: “Coroners vary in their criteria for recording a suicide verdict. Including the category of undetermined deaths reduces the variation considerably. Most undetermined deaths are suicides.”
The group of people with the highest incidence of suicide in the UK is the homeless. Suicide amongst homeless people is 35 times more likely than in the general population.
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 1996 the suicide rate for women in the UK almost halved, while in the same period the rate for men almost doubled.
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% 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.
What is causing this divergence in male and female suicide rates? There is no easy answer, it is probably a combination of factors: 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; they are more likely to present with physical problems which may not be recognised as a manifestation of mental distress. Men have suffered more severely than women in the shrinkage of traditional manufacturing jobs. 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. The breakdown of traditional gender roles and the concept of the “new man” has left many men feeling uncertain 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. 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 young men.
Men still predominate in “high risk” professions such as vets, doctors, dentists, pharmacists and farmers, all of whom have easy access to poisons, and farmers in particular often have access to firearms. The methods of suicide adopted by men may explain part of the divergence. Men are more likely than women to adopt violent methods of death, for example, hanging, shooting or jumping, all methods of suicide where there is less possibility of recovery than overdose which is the preferred method of women.
Men are at a higher risk of suicide if they are single, recently separated, divorced or widowed. 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.
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.
Suicide in Young People
Suicide accounts for 20% of all deaths amongst young people aged 15-24 and is the second most common cause of death amongst young people after accidental death. Around 19,000 young people attempt suicide every year and about 700 of these succeed. 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 succeed in 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. 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.”
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 was 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 found that 80% 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.
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.” 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.”
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 as many as 16% of older people may be experiencing depression, but that only a fraction of these may be known to GP and psychiatric services.
Most suicides in older people occur in the community, and most have had no contact with old age psychiatry services. Cattell & Jolley’s recent research found that community old age psychiatry services were seeing less than 25% 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.
The most common means of suicide in older people are overdose of prescribed and over-the-counter drugs and hanging, the latter being far more frequent in older men.
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. 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. Highly dangerous suicide methods such as self-burning are more common amongst young Asian women than other groups. Self-burning is a common method of suicide amongst women in India, having its origins in the traditional practice of Hindu widows burning themselves on their husband’s funeral pyre - a practice known as “suttee”.
Little is known about suicide rates amongst Black people in the UK. This 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.
Recent statistics from the Samaritans suggest that there has been a 22% increase in suicide amongst Irish and Scottish people in recent years.
Suicide and Occupation
The Office for National Statistics has analysed the suicides of people in different occupations using the Proportional Mortality Ratio or PMR. This uses the proportion of total deaths due to suicide in a particular group and compares this figure to an average for the overall population. The figure for the PMR gives an indication of suicide risk in a particular group. The average figure is 100, therefore a PMR of 200 indicates twice the average risk.
The numbers of suicides in some occupational groups, particularly for women, are very low, resulting in extreme figures for Proportional Mortality Ratios. However, when taking the low numbers into account it can be seen that the caring and agricultural professions show the highest risks of dying by suicide.
Suicide and Unemployment
Employment is generally believed to have a positive effect on the well-being of those of working age. Research has shown that “earned income enhances self-esteem and a sense of mastery which, in turn, increases overall well-being”.
The magnitude of this effect increases with the extent to which individuals identify their own self-esteem in terms of bread-winning roles and responsibilities.
There has been much debate over the role of unemployment in suicide and causal links have not been established, however, the rate of attempted suicide amongst the unemployed has been shown to be 10 times as high as for people in work.
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.
The 1999 report “Safer Services: national confidential inquiry into suicide and homicide by people with mental illness” found that among suicides outside hospital, 38% had a history of alcohol misuse, and 26% a history of drug misuse.
Estimates suggest that around 15% of people who abuse alcohol may eventually kill themselves. Another estimate suggests that among people who abuse drugs the risk of suicide is twenty times that of the general population.
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.
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.
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. Suicide risk is particularly high at the inception of treatment and at its end, declining thereafter.
Suicide rates are substantially higher amongst people diagnosed with mental health problems, particularly those diagnosed with schizophrenia and affective disorders, and particularly those who experience recurrent depressive illness, than amongst the general population. Estimates for this differential vary, but average out at around a 15-20% increased risk of suicide for people with recurrent depression, and between 10-15% 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% of recorded suicides are by people experiencing depression.
A recent study “Aftercare and clinical characteristics of people with mental illness who commit suicide” 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% of the cases studied had a major affective disorder such as depression, 24% had a diagnosis of alcoholism, 23% had schizophrenia, 5% were diagnosed with personality disorder and 5% 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.
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. Among people with schizophrenia, despite the occasional dramatic psychotic suicide, the greatest risk for suicide occurs during non-psychotic depressed phases of the illness.
Suicide in Psychiatric Hospitals
Hospital mortality statistics have shown an increase in suicides amongst in-patients in recent years. Approximately 1% of all suicides in the UK occur within NHS psychiatric hospitals.
The Bristol Confidential Inquiry looked at the cases of sixteen people who committed suicide while in-patients in psychiatric hospital, four cases of people who committed suicide while on leave agreed by hospital staff and a further six cases who had been discharged from in-patient status and committed suicide in the community between three days and seven weeks of discharge. The authors of the report concluded that: “although suicide risk was recognised in the majority of patients, only six being quite unexpected, its serious significance was recognised in only a minority. The fact that almost two-thirds of those still of in-patient status committed suicide after absenting themselves without permission also underlines this impression.” The authors raise a number of important issues in their findings. Firstly, there was poor clinical appreciation of suicide risk. In only eleven patients were special precautions taken at ward level to prevent suicide. Secondly, too much attention was focussed on the alleviation of symptoms without attention being paid to current everyday problems which patients faced. In twelve of the patients “current problems had remained unresolved. This might be an important pitfall in the management of patients in hospital, removed as they are from the life difficulties which may have played a part in leading to suicidal despair.” They concluded that “suicidal patients should not be discharged until situational factors have been addressed. Mere improvement of symptoms is an insufficient discharge criterion.” The third important factor to emerge was the quality of care management of suicidal patients: “The high numbers of patients who committed suicide after absenting themselves without permission from hospital wards does suggest that current procedures in the day-to-day management of suicidal patients should be looked into further.” Finally, the significance of negative relations between staff and suicidal patients was emphasised: “Patients were often regarded as complaining and/or manipulative, thereby being the subject of critical comments and negative judgements. Altogether fifteen (55%) had become alienated in some way, in the sense that they had clearly lost the support of others.”
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.”
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 in-patient. 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.
Suicide in Prisons
In 1997 there were 70 suicides in prisons in England and Wales, 67 men and 3 women. This is a 40% increase since 1990 and a huge 159% increase since 1983. This rate translates as being over six times the total male suicide rate. 39% of those who committed suicide were on remand.
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. 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 serious adult male 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% of prison suicides were by people under 21, the vast majority being young males.
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.”
This research and review has led to the Prison service developing a new policy called “Caring for the Suicidal in Custody”. The key elements of the policy are:
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
Suicide in Rural Areas
The facts of rural life belie town-dwellers’ misconceptions of an idyllic country existence. Evidence shows that 25% 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, BSE, the foot and mouth crisis, and the collapse of beef, lamb and milk prices have sent rural incomes plummetting. In 1992 over 14,000 people left the agricultural industry.
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. Women married to farmers have a suicide rate more than 20% higher than the average. There is particular concern at the rise in the number of suicides in rural areas of Wales. The suicide rate generally in Wales is 14.6% higher than in England. Male suicides account for 84% of the suicides in Wales compared with 75% generally.
It is clear that farmers who commit suicide tend to use methods which are readily available to them because of their occupation. Firearms are a common method of suicide amongst farmers, as is hanging. While self-poisoning is less common than in the general population, more than half the poisonings involve the use of agricultural and horticultural chemicals. The Hawton study of “Methods Used for Suicide by Farmers in England and Wales” concludes that the current extensive ownership of firearms by farmers should be questioned. In addition, where a farmer is known to be depressed, or otherwise at risk of suicide, families should be encouraged to limit access to firearms and other dangerous means such as agricultural poisons. Hawton suggests that clinicians treating depressed farmers could clearly have a role in encouraging this as he points out that approximately half of all depressed farmers who killed themselves were receiving treatment for depression.
Mind is to recommend to the Department of Health that access to firearms by farmers is reduced in the hope of lowering the number of suicides in the farming community. It is claimed that the rate of suicide by firearms fell after 1989 as a direct consequence of reduced access to firearms caused by the 1988 Firearms (amendment) Act, therefore, further reducing access to firearms amongst farmers will further reduce the rate of suicide by firearms.
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. The 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. RuralMinds, 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.
For some people the choice of a suicide method is a carefully considered decision while others reach spontaneously for the nearest available means when they reach desperation. Suicides can be divided roughly between what are termed “active” and “passive” methods. Active methods of suicide include hanging, shooting and jumping, methods that tend to be swift and effective and allow little scope for interruption or time to reconsider. Passive methods include overdose, gassing and drowning, methods which are less overtly violent and which may allow scope for intervention, or time to reconsider.
The most commonly used method in suicide attempts is self-poisoning, by both men and women. There has been an enormous rise in the use of paracetamol over the past 20 years and it is now the most common drug, involved in nearly half of all adolescent overdoses and 70% of overdoses by children. Paracetamol overdoses are particularly dangerous in the sense that they are frequently not immediately fatal, and people can believe that they have suffered no ill-effects, but it can cause severe long-term liver damage.
In the 1960s overdose and gassing accounted for 75% of female suicides and 50% of male suicides. Today half of female suicides are a result of overdose compared with 25% of male suicides. Men are more likely to gas themselves, either by domestic supplies or by car exhaust fumes, with 50% choosing one of these methods. There has been a 339% rise in the number of men hanging themselves, compared with a 191% increase in women. Drowning has decreased by about 30% for both sexes. The replacement of barbiturates as sedatives by the less toxic benzodiazepines is partly responsible for the 36% fall in female suicide deaths in the 20 years to 1995, although the number of non-fatal overdoses increased.
Increases in hangings and other suicide methods were found to pre-date the decline in overdose suicides. “This suggests that the social or other problems that underlie recent rises in male suicide rates may also affect women but are not mirrored by increases in suicide rates because the method they favour has become less lethal,” David Gunnell reports in The Lancet.
Self-poisoning is a more common method of suicide used by men and women in health care professions than in the population as a whole, partly due to the fact that they may have more ready access to prescription drugs.
Firearms are a common method of suicide for male farmers, accounting for 38% of farming suicide deaths. Again, farmers often have easy access to firearms.
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 AD 73. 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 (AD 345-430) pronounced suicide to be a “mortal sin” and 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.
The Koran expressly forbids suicide, and the impact of this injunction still has considerable force in Islamic countries. With the exception of Jordan and Turkey, there are virtually no officially recorded suicides in Islamic nations.
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 an honourable tradition associated with bereaved women, particularly widows, committing suicide.
As recently as the 1950s in Britain, people 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 end of the twentieth 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.
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% of people in contact with healthcare services as a result of their first suicide attempt do eventually die by suicide, 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.
Follow up studies of teenagers who take overdoses show that up to 11% will kill themselves within the next few years.
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 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. People might appear different in some way, for example, appearing unusually cheerful; they may appear more irritable, tearful, or trying hard not to cry. Other signs might include finding it hard to concentrate, appearing less energetic or particularly tired, or eating less (or more) than usual.
People at risk might talk about suicide, they may express a sense of hopelessness, no hope for the future, may see no point in life. They may express feelings of being worthless, 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”)
The Effect of Suicide On Others
The impact on those who witness a suicide can be serious and long-lasting. In 1987 over 300 people died on British Rail tracks, and between 1984 and 1988, deaths on London Underground increased by nearly 50%. Drivers who have witnessed suicides have reported a range of subsequent problems including insomnia, sexual difficulties, recurrent nightmares, and heightened stress and anxiety. The impact of suicide on this group of witnesses has been officially recognised, and train drivers are eligible to claim compensation under the Criminal Injuries Compensation Scheme.
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 such as jumping in front of a train, this reaction is likely to be intensified.” 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…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.”
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 typifed 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 or family, but sometimes there may be a need for some form of professional help..
(For further information see Mind’s “Understanding Bereavement” booklet)
In 1992 the Government published “The Health of the Nation”, 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% by the year 2000. It also called for the reduction of the suicide rate of severely mentally ill people by at least 33% by the year 2000. Recent figures suggest, however, that despite a campaign to educate GPs and other health care professionals, no reduction in the suicide figures has occurred since the publication of “The Health of the Nation”.
Mind commented on the Health of the Nation suicide targets as follows: “Psychiatric treatment at the point of suicidal despair cannot on its own prevent suicide. One study found that most people who had actually committed suicide had already been treated with psychotropic drugs; clearly this had not been enough to stop them. Another study found that when people who felt suicidal were admitted to hospital some improved - but this did not reduce the risk of suicide once they were discharged, unless the social circumstances of their lives had also changed.”
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 recent report by Pirkis and Burgess 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.
Among those in the general population who commit suicide, up to 41% are likely to have had contact with psychiatric in-patient care in the year prior to death, and up to 9% may commit suicide within one day of discharge. Up to 11% are likely to have been in contact with community based services in the year prior to death, and up to 4% in the day prior to death.
Among the general population who commit suicide, a visit to the GP in the period leading up to death is even more likely than contact with psychiatric services. Up to 83% of those who commit suicide visit a GP within a year of death, and up to 20% may do so in the week prior to death.
Pirkis and Burgess state that: “the fact that the vast majority of those who do commit 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.”
Twelve Points to a Safer Service
“Safety First”, the Five Year Report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, presents a series of recommendations that address policy and practice in mental health. The most important clinical recommendations are listed below:
Staff training in the management of risk - both suicide and violence - 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
Individual care plans to specify action to be taken if patient is non-compliant or fails to attend
Prompt access to services for people in crisis and for their families
Assertive outreach teams to prevent loss of contact with vulnerable and high-risk patients
Atypical anti-psychotic medication to be available for all patients with severe mental illness who are non-compliant with “typical” drugs because of side-effects
Strategy for dual-diagnosis covering training on the management of substance misuse, joint working with substance misuse services, and staff with specific responsibility to develop the local service
In-patient wards to remove or cover all ligature points, including all non-collapsible curtain rails
Follow-up within 7 days of discharge from hospital for everyone with severe mental illness or a history of self-harm in the previous 3 months
Patients with a history of self-harm in the last 3 months to receive supplies of medication covering no more than 2 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
Whereas the overall suicide rate in England and Wales has been steadily decreasing since the early 1980s, there has been a 50% increase in attempted suicide since 1991.
Young women in the 15-19 age group are at the highest risk of attempted suicide. However, the sharpest increase has been seen in young men in the 15-24 age group, whose rate of attempted suicide has risen by 118% since 1986. This increase has been particularly sharp since 1992 when the numbers of deaths by suicide within this age group began to decline.
It is estimated that at least 140,000 people attempt suicide each year in England and Wales alone. 1 in 5 people who attempt suicide will try again, of whom 10% will succeed.
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% 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.
A recent study has looked at the effects of a drug overdose in a television drama on presentations to hospital as a result of self-poisoning. The study aimed to determine whether a serious paracetamol 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% in the week after the broadcast and 9% in the second week. Increases in paracetamol overdoses were more marked than increases in non-paracetamol overdoses. Thirty-two patients who presented in the week after broadcast and were interviewed had seen the episode. 20% said it had influenced their decision to take an overdose, and 17% 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.
All Wales Rural Stress Helpline
Telephone: 0800 085 8119
CALM (Campaign Against Men Living Miserably)
Helpline: 0800 58 58 58 (available from 5pm to 3am every day)
The Campaign is operational across Manchester, Merseyside, Cumbria and Bedfordshire. Though anyone can call from anywhere in the country, info is not held about ‘referral agencies’ in any other areas. Aimed at young men aged 15-35 at the start of depression. The campaign operates a free phone helpline, where callers can receive confidential, anonymous and non-judgemental counselling from sensitive and highly trained professional advisers.
Cruse - Bereavement Care
126 Sheen Road
Helpline: 020 8332 7227
MindinfoLine: 0845 7660 163 (outside London)
020 8522 1728 (inside London)
PAPYRUS (Parents Association for the Prevention of Young Suicide)
New Brighton Road
Telephone: 01706 214 449
The Arthur Rank Centre
National Agricultural Centre
Telephone: 01203 414 366
Rural Stress Information Network
Telephone: 0247 641 2916
10 The Grove
Helpline: 08457 90 90 90
Survivors of Bereavement by Suicide
82 Arcon Drive
Telephone: 01482 565 387
Written by George Stewart, Information Officer, May 1999 (Updated June 2001)
Mental Health Statistics 2
Note: The language used in this factsheet reflects the sources referred to. The use of such language does not automatically imply Mind’s acceptance of it.
Notes on Interpreting Suicide Figures
Figures for suicide rates are usually not based solely on those officially classified as having committed suicide. This is because an official suicide verdict has to show beyond reasonable doubt that suicide was intended - reflecting the fact that suicide until recently (1968) was a criminal offence. An alternative verdict of probable suicide or ‘undetermined death’ is given where conclusive evidence is not available and usually these two figures are combined to show suicide rates. This applies to the figures given in this factsheet. Unless otherwise referenced figures are taken from tables sent to Mind by the Office for National Statistics giving rates for England and Wales up to 1998. It is also worth noting that when figures are shown by age and gender it is important that population differences are taken into account i.e. a high rate for young people is not so significant if there are far more young people than other age groups in the population. For this reason figures are taken per 100,000 of that population group -for example in 1979 4 out of every 100,000 women between 15 and 24 committed suicide (yearly rates are given in the tables and charts on pages 3-4)
How many suicides and attempted suicides are there each year?
Although the overall rate of suicide is falling - by more than 12 per cent since 1982, there are around 4,000 suicides in England and Wales each year. Many more suicide attempts are made each year and at least 1 person in every 100 appearing in hospital after a suicide attempt will succeed within a year and up to 5 per cent do so over the following decade.
Which sex is most at risk of suicide?
Suicide rates for men are higher than for women in all age groups and currently men are over three times more likely than women to commit suicide. This gender gap has widened considerably over the past few decades, in 1979 the female to male gender ratio for suicides was 2:3 and in 1998 it was 1:3. This is especially true for young people, with males between 15 and 44 around four times more likely than women to kill themselves.
Which age group is at the highest risk of suicide?
The group at highest risk of suicide was once males aged over 65 years of age, 24 per 100,000 population in 1979 . The group at highest risk today is males aged 25-44. Suicide is the second most common cause of death among people aged under 35 years. In 1979 the suicide rate for 25-44 year old males was 18 per 100,000 and since then it has risen by a third to 24 per 100,000 in 1998.
Which groups have seen the highest rise in suicide rates in recent years?
In males aged 15-24 the suicide rate has risen most over the past two decades from 9 per 100,000 population in 1979 to 14 per 100,000 in 1998, a rise of over 50%.
Have there been any reductions in suicide rates amongst men?
The suicide rate amongst older men has been declining in recent
years. In the 45-64 age range the reductions have been slight,
from 20 per 100,000 population in 1979, to 18 per 100,000 population in 1998. The greatest reductions in male suicide rates have been seen in the over 65s, from 24 per 100,000 population in 1979 to 14 per 100,000 population in 1998.
Which group has the lowest risk of suicide?
Young females are at the lowest risk and suicide rates for this group have remained fairly constant since 1979 at about 3.5 per 100,000 population. In the 25-44 female age range the rates have fallen from 8 per 100,000 population in 1979 to 5 per 100,000 population in 1998.
Which group has seen the most dramatic reductions in suicide rates?
The most dramatic reductions have been amongst older women. In the 45-64 age range the rate has dropped by more than half, from 16 per 100,000 population in 1979 to 6 in 1998. In women over 65 the rate has also dropped considerably, from 15 per 100,000 population in 1979 to 7 per 100,000 in 1998.
What factors increase the risk of a person’s suicide?
The likelihood of a person committing suicide depends on several factors. Social problems, especially those related to family stress, separation, divorce, social isolation, death of a loved one and unemployment, as well as mental and physical illness and access to the means of suicide are all potential risk factors. According to a World Health Organisation working group, there is ample evidence that social conditions which are amenable to change (such as the constant risk of losing one’s job) are among the determinants of suicide.
Marital status affects a person’s risk of suicide. Among men under 45 years the increase in suicides between the early 1970s and late 1980s has been linked to more men remaining single or becoming divorced.
Alcohol and drug use are also factors which can influence suicide risk. Men are known to have far higher drug and alcohol consumption rates than women and the figures are particularly high for younger men.
Suicide and unemployment
Links between unemployment and the frequency of suicide amongst young adults have been clearly demonstrated. In an international study of male suicides in 22 countries between 1974 and 1988, unemployment was found to be a leading factor. According to the Mental Health Foundation an unemployed man is two to three times more at risk of suicide than the general population. Further studies in the UK further confirm the links between unemployment, suicide and attempted suicide.
Suicide and employment
Men in unskilled occupations are four times more likely to commit suicide than are those in professional work.
Certain occupational groups such as doctors, nurses, pharmacists, vets and farmers are at higher risk of suicide. This is partly because of ease of access to the means of suicide.
Suicide and Race
Women born in India and East Africa have a 40 per cent high suicide rate than those born in England and Wales.
The suicide rate amongst young Asian women is twice the national average. Wives who cannot have children or produce only daughters seem to be at greatest risk. Venna Soni, an epidemiologist at Surrey University and the leading expert on Asian suicides states that 1,979 women of all races between the ages of 15 and 34 killed themselves from 1988-1992 in England and Wales. Of these suicides 85 were Asian; this is nearly double their proportion of the population.
Patterns of suicide and attempted suicide among young Black and Asian people in Britain do not reflect those in the wider community. One study shows that suicides in young Asian women in Britain are three times higher than amongst their white counterparts. Although this situation is reversed for young Asian men who seem to be at less risk than young white men of British origin. There is little information about suicide amongst African Caribbean people. Recording of ethnicity in government statistics on health and other areas has recently been introduced in Britain and there are few current official statistics available. A Birmingham study found that young African Caribbean women were at increased risk of attempted suicide and reported rapid increases in the number of Black people committing suicide during the late 1970s. It is, however, not known how many young black people kill themselves and there are no actual figures in the statistics. Note: see Mind’s factsheet and policy on Black and Minority Ethnic Mental Health for further information on context.
Suicide and Young People
. Suicide is now the second most common cause of death amongst young people .As the above tables show the rate for young males has risen by over 50% over the past 20 years.
However, in contrast with suicide itself, suicide attempts are far more common amongst women than men, and this is particularly true for the under 25s. Young
females who attempt suicide outnumber their male counterparts more than at any other age. In her book ‘The Long Sleep’, Kate Hill quotes the results of various studies showing that teenage girls’ suicide attempts have outnumbered boys in a range of different ratios from 2:1 to 9:1. She also says that attempted suicides amongst young men in the 1990s are rising and that the gender gap between the two groups is becoming narrower. Young men who take overdoses are now less atypical of their sex. She quotes a study carried out in Oxford, the results of which were projected to the UK as a whole. The study suggests that there are 29,400 female suicide attempts and 14,530 male suicide attempts annually amongst the under 25s. See Mind’s Children and Young People factsheet for further information on context.
A recent survey of young homeless people revealed that one in three had tried to kill themselves. The study used a representative sample of 161 homeless young adults between the ages of 16-21 comparing them to a similar sample who had homes. The study found the homeless group were five times more likely to have attempted suicide in the year before the study. The study also found that those who were homeless were two and a half times more likely to have a psychiatric disorder than the comparison group.
Young lesbians and gay men are also at a higher risk. Research commissioned by the US Government found that lesbian and gay youth were 2-3 times more likely to attempt suicide than other young people and may account for 30% of completed suicides in their age range. A survey in the UK has given similar results, finding that 19% of young lesbians and young gay men who took part in the study had previously attempted suicide.
Suicide and Mental Health Problems
Safer Services reported that one in four people who subsequently took their own lives, around 1000 people each year, were found to have been in contact with specialist mental health services in the year before death. Of these 16 percent were inpatients at the time of their death, and 24 percent had been discharged from hospital within the previous three months. Many were not fully compliant with treatment when discharged, and in most cases staff perceived the immediate risk of suicide to be low.
Safer Services also recorded that around half of the suicides were committed by people with a history of self-harm and either substance misuse or previous admission to hospital.
Major mental health problems such as schizophrenia and manic depression occur in about 0.4% of the population. People with a diagnosis of schizophrenia are at an increased risk of suicide and this risk increases when they are young. The onset of schizophrenia tends to occur between 17-25 years of age at the same time that many are struggling to establish an adult identity and relationships. The arrival of distressing symptoms at this time along with the stigma attached to the diagnosis increases the risk of suicide. A lifetime risk of up to 10% has been suggested, but even this may be an underestimate and there is growing concern that suicide risk is increasing.
A number of studies seem to show that as many as 90% of all suicides had one or more psychiatric disorders when they kill themselves and that certain diagnosed mental illnesses have increased suicide risks. In one research study, of 44 disorders considered, 36 had significantly higher standardised mortality rates for suicide leading the authors to conclude that virtually all mental disorders increased the risk of suicide except, possibly, dementia and agoraphobia.
Several research studies have suggested that between 20-40% of people with a diagnosis of schizophrenia have a history of attempted suicide, which shows a considerable excess of mortality by suicide in comparison with the general population. In a report on more than 200 deaths of patients compulsorily detained in hospital under the Mental Health Act over a period of two years, 95 deaths were identified as probable suicides. The report also shows that in 60% of cases of probable suicide the individual had a diagnosis of schizophrenia.
In the case of manic depression, studies have shown a risk on average around 15 times higher than the average for the general population. Major depression is also a factor in suicide with the average risk around 20 times higher than for the general population.
Notes on terminology
The language and terminology of psychiatric diagnosis used in this document refers to the original sources used. The use of such language in no way implies Mind’s unqualified acceptance of it. It has been retained for the sake of accuracy.