Alcohol blamed for high suicide rates in Northern Ireland

The 'Suicide and Homicide in Northern Ireland' report by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCI), which is based in the University's Centre for Suicide Prevention, also shows that the higher Northern Ireland suicide rate is greatest among young people; 332 suicides occurred in people under 25 during the study period (2000 to 2008), with mental illness, drugs and alcohol, previous self-harm and deprivation being contributing factors in the majority of cases.

The NCI report -- commissioned by the Health and Social Care Division of the Public Health Agency (PHA) on behalf of the Department of Health, Social Services and Public Safety (DHSSPS) in Northern Ireland -- also reports:

• A total of 1,865 suicides occurred in the general population in Northern Ireland between 2000 and 2008, equivalent to 207 per year, or 13.9 per 100,000 people per annum. This rate is higher than the UK average but lower than the rate in Scotland.
• During the same period, there were 533 suicides in current mental health patients -- defined as individuals who had had contact with mental health services in the previous 12 months. This amounted to 29% of all suicides and corresponds to 59 patient deaths per year.
• Young people who died by suicide were more likely than other age groups to be living in the poorest areas and they had the lowest rate of contact with mental health services (15%). Young mental health patients who dies by suicide tended to have high rates of drug misuse (65%), alcohol misuse (70%) and previous self-harm (73%).
• There were 142 homicide convictions between 2000 and 2008. This figure, while likely to be an underestimate, equates to 16 homicides per year, or 10.6 per million people per annum, similar to the rate in England and Wales but lower than the rate in Scotland.

"High rates of substance misuse and dependence run through this report and, as we rely on information known to clinicians, our figures are likely to underestimate the problem," said Louis Appleby, Professor of Psychiatry at The University of Manchester and NCI Director.

"Alcohol misuse was a factor in 60% of patient suicides and this appears to have become more common during the course of the study period. Alcohol dependence was also the most common clinical diagnosis in patients convicted of homicide, with more than half known to have a problem prior to conviction.

"In homicide and suicide generally, alcohol misuse was a more common feature in Northern Ireland than in the other UK countries and a broad public health approach, including better dual diagnosis of mental illness and alcohol or drug misuse, health education and alcohol pricing, should be seen as key steps towards reducing the risk of both homicide and suicide. In particular, there needs to be a focus on developing new services for young people with substance misuse problems."

The NCI report, which will be launched at Mossley Hill, Newtownabbey, Northern Ireland, on Wednesday, June 29, also reveals that there was not a single 'stranger homicide' by a patient with mental illness throughout the eight-year study period.

"Stranger homicides are important in mental health because they are assumed to reinforce public prejudice against mentally ill people, the popular assumption being that the killing of a stranger is likely to be associated with mental illness," said Professor Appleby, who is also National Director for Health and Criminal Justice.

"In this report, almost a third of homicides involved the killing of a stranger and the frequency of these cases appeared to have increased in the decade up to 2008. However, these were not associated with mental disorder and we recommend initiatives to combat the stigma of mental illness should emphasise the low risk to the general public from mentally ill patients living in the community."

Additional key findings in the NCI report include:

• The suicide rate in Northern Ireland, both in the general population and among mental health patients, rose in the later part of the report period, in contrast to the rest of the United Kingdom. This period includes the first two years after the publication of the Protect Life suicide prevention strategy, though the authors say it is too early to comment on the effectiveness of the strategy.
• There were 35 in-patient suicides between 2000 and 2008, accounting for 7% of the total patient suicides. Twenty-eight (80%) of these occurred off the ward, including 13 where the patient had left without staff agreement. Eight deaths occurred while the patient was under observation. The report recommends the strengthening of protocols to prevent and respond to absconding, including scrapping the use of intermittent observations of patients. Seven of the eight patients who were under observation at the time of suicide were only monitored intermittently.

Further recommendations include:

• Better care planning prior to hospital discharge, including patient follow-up within seven days, to reduce the risk of post-discharge suicide and homicide by patients: 125 patient suicides (24% of all cases) and nine patient homicides (43%) occurred within three months of discharge from hospital.
• In 129 patient suicides (27%) and 10 patient homicides (53%), the patient missed their final appointment with services. The report therefore recommends the introduction of an assertive outreach function into community mental health services, through staff training, reduced case loads, and new team structures.
• In the majority of both patient suicides (90%) and patient homicides (81%), immediate risk at final contact with services had been seen as low. The report recommends a review of risk-management processes within mental health services and an appropriate balance between identifying blame and recognising the complexities of clinical risk management.