Depression, suicide, and the national service framework
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7301.1500 (Published 23 June 2001) Cite this as: BMJ 2001;322:1500All rapid responses
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Davies et al are sceptical about the intention to reduce suicide set
out in the National Service Framework on Mental Health, mainly because
they regard suicide as rare. In fact, there are around 5,000 suicides per
year in England. This is more than the number of road accident deaths and
more than ten times the number of cot deaths. Should we therefore give up
on road safety? Should we stop advising parents about smoking or sleeping
position? The number of cases may make it difficult for research to use
suicide as an outcome but that is a different issue.
Davies et al quote a finding from the National Confidential Inquiry
into Suicide and Homicide by People with Mental Illness (one of my own
projects), that few suicides under mental health care have been seen by
clinicians as being at high immediate risk in the days or weeks before
death. They argue that improving risk assessment by staff would not
therefore be worthwhile. This is not what the finding means. The Inquiry
figures show that to prevent suicide in clinical practice we need to
strengthen services as a whole rather than focus only on the care of
people known to be at high risk. This is particularly true in areas where
services are conspicuously weak - for example, in dealing with non-
compliance or loss of contact or in providing early follow-up after
discharge from hospital.
Suicide is the commonest cause of death in young men in England and
the main cause of premature death in psychiatric patients. To reduce
suicide we need a broadly-based strategy, incorporating public health and
clinical interventions, targeting key groups such as young men and
restricting access to common methods of suicide such as overdose. A
national suicide prevention strategy is now in preparation.
Yours faithfully,
Professor Louis Appleby
National Director for Mental Health
Competing interests: No competing interests
I am writing to correct several misleading errors in today’s
editorial by Davies, Naik and Lee. I take issue with the take home message
which is that “suicide is rare and the only worthwhile strategy is to
target people at high risk”. The problem here is that whilst high-risk
strategies offer something for individuals, they are largely ineffective
for the population as a whole. Using the authors preferred example of
“readmission” to identify people at high risk would immediately exclude at
least three quarters all people who die through suicide who have had no
recent contact with psychiatric services. Even if one considers people who
have had contact with mental health services, the authors suggest that 22%
will have had five or more admissions, but an even greater number (33%)
will have had no previous admissions and therefore will be overlooked
using the proposed high-risk strategy.
Davies et al. report that every week one in 10 people with depression
admit to suicidal thinking. I find this misleading. Perhaps 1 in 10
spontaneously volunteer suicidal thoughts, but studies have found that up
to 50% will admit to suicidal thoughts if asked (Skoog et al, 1996 Am J
Psychiatr 153, 1015-1020). This is reminiscent of the reason depression is
often overlooked in general practice and in medical inpatients. The
authors mention the widely quoted figure of 15% for the lifetime risk of
suicide in depression after Guze & Robbins’ well-known paper. However,
close examination of the original publication suggests their figure
actually refers to the standardized mortality ratio for suicide in
depression (the proportion of deaths that are due to suicide in this
condition).
The authors go on to mention the evidence for psychotherapy in
preventing recurrence of depression and state that such interventions are
not routinely available in British clinical practice. This could be
interpreted as meaning no intervention to prevent relapse is available
routinely – a statement that overlooks conventional antidepressant
treatment. Whilst it is no doubt true that good long-term studies on
maintenance treatment of depressed patients in remission are rare, they do
exist (Thase 1999 J Clin Psychiatry 60, 15-19 and Davies et al, 1999 Acta
Psychiatrica Scand 100(6), 406-417 and Hochstrasser et al, 2001 Br J
Psychiatr 178, 304-310). Thus clinicians should be aware there is more to
the treatment of depression than getting patients well, there are also
effective strategies for keeping them well.
In case I am being too negative, I would like to make a positive
suggestion to the debate about suicide prevention. That is to go back to
first principles and ask the authors to look again at the association
between depression and suicide. I agree that thankfully suicide is not a
common complication of depression, but depression remains the most
important single risk factor for suicidal thoughts, attempts and completed
suicides. This has been shown by several groups, including Goldney and
colleagues at the University of Adelaide (Goldney RC et al. 2000 Aus NZ J
Psychiatr 34, 98-106). In a telephone survey of 2501 Australians they
calculated the population attributable risk for suicidal thoughts (the
proportion of a disease associated with a risk factor that would be
eliminated if that factor was removed). 46% of suicidal ideation was
attributed to clinical depression, 38% to the experience of traumatic
events and 15% to having low income. In a related case-control study of
302 consecutive individuals who made serious suicide attempts compared
with 1,028 randomly selected controls, Beautrais and colleagues (Beautrais
AL, et al 1996 Am. J. Psychiatr. 153, 1009-1014) found that the risk of
suicide attempts attributable to depression alone was approximately 70%.
In conclusion, I am suggesting that the identification and treatment of
depression (particularly depression in the community) is a more realistic
target in influencing suicide attempts and completed suicide than
concentrating on psychiatric inpatients with recurrent episodes, although
I would not deny that the later group are very important.
Competing interests: No competing interests
Steffan Davies and his colleagues state that "Proved interventions to
prevent recurrence of depression exist - for example cognitive behavioural
therapy and interpersonal psychotherapy, but these are not routinely
available in British clinical practice". They neglect to draw attention to
the value of continuation chemical antidepressant therapy, a serious and
surprising omission, given the probable superiority of this strategy.
Competing interests: No competing interests
suicide prevention; a wider perspective
Dear Editor
We were interested to read the editorial ‘Depression, suicide and the
national service framework.’ 1 The scope of the authors review is however
unclear. They seem to focus on strategies to deal with interventions in
depressed people in primary care and secondary mental health care
services. This limited review is disappointing as it fails to review a
range of other possible suicide prevention strategies. For instance, a
reduction of access to lethal methods could have a significant effect on
suicide rates.2 Suicide is clearly the end point of a multitude of
factors. Suicide prevention strategies need to address this.
It is clearly of importance that mental health services address gaps
in services and strengthen existing areas to facilitate suicide
prevention. However, the National Confidential Inquiry of Suicides and
Homicide3 found that 76% of people committing suicide have no contact with
mainstream psychiatric services in the year before suicide. Similarly, a
large number of young men are not accessing primary care services prior to
suicide.4 Strategies that focus solely on primary care and secondary
mental health care will not affect suicide rates in those not using the
services; which is the majority of suicides.
In County Durham & Darlington we are attempting to tackle this by
not only addressing mental health services but by looking at a range of
suicide prevention strategies. To help achieve this we have reformed a
suicide prevention task force with multi agency input lead by a Director
of Public Health and a Consultant Psychiatrist. This group includes
representatives from the police, probation, prison, social services,
university, acute medical trusts, MIND, Farming Groups as well as other
potentially interested parties, such as those attempting to tackle social
exclusion in old mining villages. In time we hope to research if suicide
victims have had recent contact with some of these services, an area often
neglected in research. The health authority have been generous enough to
fund a dedicated mental health promotion manager in suicide prevention to
facilitate the work of this task force.
We believe this multi agency approach is necessary, as suicide
prevention strategies will need to come from a variety of sources.
Clearly mental health services have a pivotal role to play but we believe
the National Service Framework for Mental Health Standard 7 places
challenges beyond traditional mental health service provision.
Yours sincerely
*Dr Keith Linsley
Consultant Psychiatrist
County Hospital,
North Road,
Durham
DH1 4ST
Dr John Woodhouse
Director of Public Health
County Durham & Darlington Health Authority
Neil Johnson
Project Manager, Suicide Prevention
County Durham & Darlington Health Authority
* For correspondence
1 DAVIES, S., NAITH, PC., LEE, AS.,
Depression, Suicide and the national service framework. BMJ 2001;
322:1500-1501
2 SCHAPIRA, K., LINSLEY, K.R., LINSLEY, J.A., KELLY, T.P., and KAY,
D.W.K.
Relationship of suicide rates to social factors and availablity of lethal
methods. Comparison of suicide in Newcastle Upon Tyne 1961-1965 and 1985-
1994.
Br J Psychiartry 2001;178:458-464
3 APPLEBY, L., SHAW, J., AMOS, T., et al (1999)
Safer Services. Report of the National Confidential Inquiry into
Suicide and Homicide by
People with Mental Illness. London: The Stationery Office.
4 Young Men and Suicide; Strategy Guidelines for Health Authorities
(2001). The Men’s
Tavistock House, Tavistock Square, London WC1H 9HR
5 DEPARTMENT OF HEALTH (1999) The National Service Framework for
Mental Health.
Modern Standards and Service Models for Mental Health. London:
Department of Health.
Competing interests: No competing interests