Title: A multi-centre programme of clinical and public health research to guide health service priorities for preventing suicide in England
Funder: Department of Health and Social Care

Abstract: Aims & objectives: Our overall aim is to reduce suicide rates in England by informing the National Suicide Prevention Strategy. We will investigate three issues of importance in the care of people who are at risk of suicide: how best to reduce the impact of the economic crisis on suicide, the care of people who self-harm and reducing the lethality of available suicide methods. Background: Suicide is a major cause of premature mortality, with around 4,500 suicides and 200,000 hospital attendances for self-harm every year in England. Previous self-harm is one of the strongest risk factors for suicide; unemployment and easy access to high lethality suicide methods are the most potent influences on suicide rates. Research plans: The complex antecedents to suicide and challenges to intervening appropriately require a programme of linked, mixed methods research studies: a) The recession and suicide risk: we will i) analyse national & local data on suicide and self-harm to determine who is at greatest risk during the recession and ii) carry out qualitative interviews with 30-40 people whose self-harm was precipitated by job loss or economic difficulties to understand how recession can influence self-harm. b) Improving self-harm services: we will i) investigate the effectiveness and cost effectiveness of different forms of risk assessment in preventing repeat self-harm by comparing outcomes using cross sectional and cohort analyses across hospital services; ii) systematically review the literature on the management of self-harm patients presenting with advance decisions and, using focus group and expert panels, develop clinical guidance for their management; iii) use qualitative methods to investigate the impact of self-harm by young people on parents to determine their needs and develop helping resources. c) Identifying and reducing access to lethal suicide methods: we will i) study the records of 12 coroners to identify whether the use of new and high lethality methods of suicide by gassing (e.g. charcoal burning, hydrogen sulphide) is increasing; ii) calculate drug-specific fatal toxicity indices using available databases to identify medicines associated with high fatality in overdose. Research team: The co-PIs are leading researchers in suicidal behaviour and members of the National Suicide Prevention Strategy Advisory Group. Three of the team are NIHR Senior Investigators. Co-investigators are managers, clinicians, service users and researchers from the NHS Trusts local to the Universities in Bristol, Oxford and Manchester. Our team has a range of complementary disciplinary backgrounds (psychiatry, public health, nursing, social science) and research expertise (health economics, qualitative methods, biostatistics and epidemiology). Programme Management: The three PIs will have collective responsibility for the programme; each component will be lead by a named centre. The research group will meet annually to present findings and review progress and the PIs and core researchers will meet four times per year to monitor project milestones. Each component will have weekly operational meetings. Research environment: The host and collaborating NHS organizations each currently run over 100 research projects, including several programme grants. The collaborating University Departments were all highly ranked in RAE 2008. Two of the centres are hubs in the Mental Health Research Network. Resources available to the applicants include: data from the National Confidential Inquiry into Suicides and Homicides; the self-harm registers of Oxford (1976-present) and Manchester (1997-present) and an extract of the Hospital Episode Statistics Database. Anticipated outputs, outcomes and impact on the health of patients, public, & the NHS: We will: characterise the people most at risk of recession-related suicide and develop interventions for them; develop guidance on self-harm risk assessment tools and the management of people presenting with advance decisions; develop a Healthtalkonline website and guides for parents of young self-harmers and clinicians; and provide policy advice on strategies to reduce suicides from emerging methods of suicide and medicines associated with high case fatality in overdose. Patient & Public involvement: Users and carers are represented on research steering groups at all centres and contributed to the development of the programme. Ethics: key issues are the potential for patient distress, data security and the risk of raising public awareness of novel methods of suicide. We have experience in these areas and protocols for conducting research on vulnerable people. Justification for resources requested: the main resources requested are investigator and research assistant time. Input from senior investigators from a range of disciplines reflects the multidisciplinary nature of suicide prevention research.

Lay abstract: Suicide is a leading cause of premature death in England. Many suicides follow “crisis points” when the individual cannot see any other way out of their difficulties; so suicide prevention aims to intervene, preventing death, and assisting the individual in resolving their difficulties. There are over 200,000 hospital attendances for self-harm every year in England; half of those who die by suicide have previously self-harmed. Our proposed research aims to collect new evidence and use this to improve the care of people who self-harm. It also focuses on issues likely to adversely affect the number of suicide deaths in the next 5 years namely: (i) the economic recession; (ii) the emergence of new, highly lethal, methods of suicide by gassing (e.g. charcoal burning and hydrogen sulphide gas) – these have already had a large impact on suicide in East Asia; and (iii) the toxicity of medicines commonly taken in overdose. Our research plans were developed with help from clinicians, policy makers, service users and Samaritans. Our group includes leading researchers and has successfully collaborated on suicide prevention research over the last 10 years. Three members of the research team sit on the National Suicide Prevention Strategy Advisory Group. Our studies will include interviews with service users and clinicians, a critical review of the existing research, studies of the best means for assessing risk in people who self-harm, analysis of national and local suicide data and detailed reviews of Coroners’ inquest reports. The research will use a number of unique resources available in our centres including the self harm registers in Oxford and Manchester (collecting information on local patterns of self harm for more than 10 years), our recent (2003 and 2010) national studies of self-harm management in England and Hospital Episode Statistics data. The results of our research will inform the approach taken by UK professional and voluntary bodies to minimise the impact of the economic crisis on suicide, guidance for clinicians on how best to assess and manage patients who self-harm and who present with advance decisions, guidance for parents whose children self-harm, prescribing advice to medicines regulatory bodies and clinicians on medicines associated with high risk when taken in overdose, and advice to Government on how to avert a potential epidemic of suicide by gassing.

Research activity codes: 8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH