RESPONSE TO SCOTTISH GOVERNMENT SUICIDE STRATEGY | RCPSYCH | MAY 2013 |
V1.2
RESPONSE FROM:
The Royal College of Psychiatrists in Scotland
RESPONSE TO:
Engagement Paper on the Prevention of Suicide
and Self-Harm
DATE:
28 May 2013
The Royal College of Psychiatrists is the leading medical authority on mental
health in the United Kingdom and is the professional and educational
organisation for doctors specialising in psychiatry.
We are pleased to respond to this consultation. This consultation was prepared
by the Royal College of Psychiatrists in Scotland. For further information please
contact: Karen Addie on 0131 220 2910; e-mail kaddie@scotdiv.rcpsych.ac.uk
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1. Summary of Recommendations
A. There should be a reconsideration and re-examination of the balance
between ‘high risk’ groups and ‘population-level’ approaches, particularly with
regards to the social determinants of health. For example: a recognition that
factors such as the economy, unemployment, and inequality may have much
greater effects on suicide rates within a population than some of the other
factors (e.g. sexuality).
B. There should be a number of properly-evaluated pilots of specific
interventions (e.g. postcards) that might reduce self-harm. These should be
funded by the Scottish Government and evaluations should ensure that the
impact upon key outcomes (such as completed suicide and self-harm) is
assessed.
C. Given the associations between anxiolytics and hypnotics and suicide (63.9%
of deaths) and drug-related deaths (81.4% of deaths), patients on this group
of drugs should be considered a target for assessment for the presence of
treatable mental disorders and associated risk factors for self-harm and
suicide.
D. The recommendations of the Adebowale Report and the implications for
police and other statutory services with regards to responses to mental
illness and suicidal behaviour should be considered by the Scottish
Government.
E. There should be a renewed focus on suicidal behaviour and self-harm
presentations to A&E, and a review of the experience of such patients
presenting to front-line services. Closer liaison between A&E and mental
health services, along with placing greater mental health expertise in A&E
departments should be considered.
F. Guidance on managing intoxicated patients with suicidal behaviour and selfharm should be developed so that such patients are less likely to fall through
the gaps. Novel solutions such as short-stay self-harm units should be
considered. These may facilitate signposting and earlier referral for patients
with repeated presentations with self-harm and substance-misuse problems.
G. Choose Life should conduct work looking at the pathways that individuals
with suicidal behaviour and self-harm take within the NHS. It is highlyprobable that there is significant variation across the NHS and this leads to
uncertainty about the most appropriate way of managing such presentations.
H. The Scottish Government should ensure that the Health and Social Care
Integration agenda remains cognisant of suicide prevention and that suicide
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and self-harm don’t get overlooked during major reorganisations of key
bodies.
I. Support lines, and support for those at risk of suicide should be targeted in
areas where it might be possible to reach those with greater vulnerability (for
example, in the analgesic aisles of supermarkets).
J. It would be helpful if the suicide strategy acknowledged that better
recognition and treatment of mental disorders formed an important strand of
any population-based suicide prevention strategy.
2. General comments

Under ‘Progress’, there is a claim that the Scottish Government has achieved
a 17% reduction in suicide. However, similar trends have been observed in
most of the developed world and Western Europe, and rates were declining
from 2000 onwards. Further, rates in females have increased in Scotland in
recent years.
SDR, suicide and self-inflicted
injury, all ages per 100000, male
SDR, suicide and self-inflicted
injury, all ages per 100000, female
40
9
8
30
7
6
United Kingdom
European Region
Scotland
20
United Kingdom
European Region
Scotland
5
4
10
3
0
1990
2000
2010
2
1990
2000
2010
3-year moving averages. Data From WHO, 2012. http://www.euro.who.int/en/what-wedo/data-and-evidence/databases/european-health-for-all-database-hfa-db2

This has important implications for suicide prevention over the next few
years, particularly since there is evidence that the worldwide economic crisis
has had an adverse effect on suicide rates (Barr, Taylor-Robinson, ScottSamuel, et al, 2012; Barth, Sögner, Gnambs, et al, 2011; Corcoran &
Arensman, 2011; Kondilis, Giannakopoulos, Gavana, et al, 2013; Nandi,
Prescott, Cerdá, et al, 2012; Stuckler, Basu, Suhrcke, et al, 2011). It is likely
that suicide (and self-harm) rates over the next few years will increase rather
than decrease (Reeves, Stuckler, McKee, et al, 2012).

The recognition that “increased attention in primary care to depression and
higher treatment rates have been linked to falls in the suicide rate” is
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important because there is compelling evidence that better recognition and
treatment of depression can reduce suicide rates (Mann, Apter, Bertolote, et
al, 2005).

The reference to ScotSID suggests that, “…those who die by suicide tend to
have had quite extensive contact with health care services…” but this
comment isn’t necessarily correct:
o
Only 19.5% of patients had had a psychiatric outpatient appointment
in the 12-months prior to death. One third of suicide deaths had had a
general hospital admission in the 12-months before death (Information
Services Division, 2012). This isn’t really “extensive” contact with
services.
o
This means that opportunities for suicide prevention lie in a variety of
places, and that the traditional focus of mental health might have high
prevalence but low numbers – i.e. lots of suicides have mental health
problems, but only a small total number of people with mental health
problems will die by suicide.
o
The key issue is how to access those at greatest risk who don’t come
into contact with services.
3. Answers to specific questions
3.1 Are the six objectives for Choose Life Programme still valid (page 4)?
If so, what should be prioritised under each of the objectives? Are
there other objectives we should set?
3.1.1 Objective 1: High Risk Groups
Identifying high-risk groups is laudable, but the majority of suicides are less
likely to occur in specific high-risk groups. Only 1-in-5 suicides were seen by
mental health services in the 12-months before death so 80% of suicides
occurred in people who did not have a clearly-identified need for mental health
services. We know that mental illness is likely to be present in perhaps 90% of
completed suicides (Cavanagh, Carson, Sharpe, et al, 2003), but we do not
appear to be good at identifying (and consequently treating) it.
Many high-risk groups are actually quite small, and one possible consequence is
that disproportionate amounts of time and effort are devoted to groups which
actually contain only a small proportion of the overall population suicide risk.
The current Choose Life strategy would benefit from being more explicit about
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‘high-risk’ approaches and ‘population-level’ approaches, taking into account the
‘prevention paradox’ (Rose, 1981).1
Targeting high-risk groups has the unintended consequence of taking focus away
from population-level factors affecting suicide rates, namely: employment rates;
economic conditions; and societal and financial inequalities. These are almost
uniquely under governmental control; and health services, local authorities, and
social enterprises are frequently unable to address some of these bigger factors
at a level that might affect population suicide. Changes in inequality in the last
1-2 decades in Scotland have been slow, and median incomes have fallen in
recent years (National Statistics, 2012).
The Scottish Government has set a target to reduce the rate of suicide by 20%.
However, in Greece in recent years, suicide rates have increased by 22.7%
between 2007 and 2009 as spending on health decreased by 23.7% (Kondilis,
Giannakopoulos, Gavana, et al, 2013). Any serious attempt to reduce population
suicide has to recognise the importance of economic stability and healthcare
spending on suicide rates.
3.1.2 Objective 3: evidence-based interventions
There is emerging evidence that some interventions (e.g. postcards) may be
beneficial in reducing rates of repetition of self-harm (Carter, Clover, Whyte, et
al, 2013). Scotland (due to its size and capability of linking health datasets) may
be ideally-placed to build on such evidence by supporting well-conducted and
well-evaluated pilot projects to develop interventions that may contribute to selfharm reduction.
3.1.3 Objective 4: Support for those affected by suicidal behaviour
Some clarity on this objective is required. It isn’t clear if this is about supporting
carers and relatives affected by suicide or whether it relates to postvention.
There is very little evidence to guide postvention approaches (Szumilas &
Kutcher, 2011), and any such schemes undertaken in Scotland should be
properly evaluated. Approaches to support relatives, carers and staff affected by
suicide would be welcomed.
A good example is if you want to reduce the number of heart attacks in a population, you don’t just focus on
those people who are overweight and hypertensive: you disincentivise poor diet; you reduce the number of
people who smoke (perhaps by raising prices); and you encourage people to exercise. In mental health, we
have very poor predictors of suicide and the challenge is compounded by suicide being a rare event (incidence
is 0.02% for suicide compared to 0.25% for heart attacks). With suicide, the proximal risks (e.g. agitation,
symptoms, distress) are probably greater whereas the distal risks (e.g. obesity, smoking, hypertension, etc.)
are more significant for heart attacks. The opportunities to reduce the risk of heart attacks are much, much
greater. This needs to be recognised in any population-level strategy.
1
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3.1.4 Objective 5: Provide education and training about suicidal behaviour and
promote awareness
The evidence for suicide-prevention training having any meaningful impact upon
suicide rates is weak at best, and some studies have demonstrated no effect
(Gask, Dixon, Morriss, et al, 2006; Morriss, Gask, Webb, et al, 2005). Many of
the programmes (e.g. ASIST) are unsupported by convincing evidence of
benefit2 and LivingWorks (the developers of ASIST) acknowledge that factors
other than suicide training may be difficult to affect (Rodgers, 2010).
Importantly, the evaluations conducted so far are focused on the acceptance of
the policy and training rather than the impact of the training of key outcomes
(such as suicide rates). Many of the conclusions drawn from the ASIST
evaluation are based on asking people whether they thought ASIST had had an
effect on suicide rates in their areas!
Despite this, there is a strong indication that those who are suicidal and those at
risk do not seek help (Bruffaerts, Demyttenaere, Hwang, et al, 2011). Stigma
may be an important factor affecting someone’s willingness to approach sources
of help. Therefore, on-going anti-stigma campaigns (directed at mental illness in
general and suicide/self-harm) should continue. However, we need to know
more about why people don’t seek help. We know a fair amount about the
public’s attitudes towards speaking to someone about suicide (Choose Life,
2011), but this is potentially less relevant to understanding how to reach those
at imminent risk. There is a substantial literature on impaired decision making in
the suicidal (For example, Jollant, Bellivier, Leboyer, et al, 2005) and key
messages might benefit from being tailored to perception and receptiveness in
people with high emotional distress.
Up to now, suicide awareness and suicide prevention training has been targeted
at health service staff. However, ensuring that other key groups (e.g. charity
staff, those that are working with vulnerable groups) are able to access such
training is important.
The evaluations of ASIST, for example, are evaluations of perceptions of training rather than evaluations of
whether ASIST training can influence suicide rates. The Scottish evaluation of ASIST commented that, “…the
extent to which firm conclusions can be drawn about the effectiveness of ASIST from the published literature is
limited.” (Griesbach, D., Russell, P., Dolev, R., et al (2008) The Use and Impact of Applied Suicide
Intervention Skills Training (ASIST) in Scotland: An Evaluation. Edinburgh: Scottish Executive.
http://www.scotland.gov.uk/Publications/2008/05/21112543/0)
2
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3.1.5 Objective 6: Reduce availability and lethality of methods used in suicidal
behaviour
The most common methods of suicide in Scotland are hanging (43.8%) and selfpoisoning (32.4%) (Information Services Division, 2012). There are clear gender
differences in the ratios of these two causes of death which may mean that
some interventions have to be gender-specific. Further information (some of
which may be provided by ScotSID) may help in understanding opportunities for
targeting messaging. For example, if it is found that a significant proportion of
males who die by hanging will purchase the rope beforehand, cards for support
services could be made available in retail outlets (in the same way that many
bridges and spans have plaques for the Samaritans). Similarly, carefully-placed
messages could be placed in supermarkets selling analgesics. Sources of help
could be printed on the bags from pharmacists so that people collecting
prescriptions for benzodiazepines (see elsewhere) or antidepressants would have
greater exposure to sources of support.
Access to firearms is less of an issue in the UK (only 1.8% of suicides in
Scotland) but there is some evidence that better (i.e. more stringent) firearm
legislation is associated with reductions in male suicide rates (Gagné, Robitaille,
Hamel, et al, 2010). Targeting a large number of farmers who own firearms in
order to potentially prevent a small number of suicides will be politically
sensitive, despite some studies suggesting that, “General practitioners, other
clinicians and police should be more proactive in removing guns and, if
necessary, revoking gun licences if there is evidence of suicidal behaviour or
abnormal mental states.” (Malmberg, Simkin & Hawton, 1999)
It is worth noting that farmer’s wives rarely use firearms as a method of suicide
(Kelly, Charlton & Jenkins, 1995) so the risk from guns is probably unique to
males.
3.2 While there has been a move to focus more on those in contact with
services, is there more work that we should take forward at
population level?
3.2.1 Assess the presence of undetected and/or untreated mental illness in
those taking Benzodiapines
Almost two-thirds (63.9%) of completed suicides had been prescribed a hypnotic
or anxiolytic in the year before death (Information Services Division, 2012).
Also, 81.4% of drug-related deaths had diazepam in their bodies at the time of
death (Hoolachan, Hecht, Galbraith, et al, 2013). It is improbable that
benzodiazepines and related drugs are causative (although they may compound
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the CNS-depressant effects of opioids, for example) but they may be a marker
for agitation, anxiety, and distress. Anxiety and agitation have been identified as
potentially-modifiable risk factors for suicide (Fawcett, 2009; Hawton, Sutton,
Haw, et al, 2005).
One recommendation would be that those taking benzodiazepines are screened
for undetected mental illness by the prescriber, and that this is reviewed on a
regular basis. Assessing risk will be of uncertain benefit, but asking about low
mood and suicidal thoughts in those who are receiving anxiolytic drugs may help
to identify treatable risk factors for self-harm or suicide.
3.2.2 Improve the experience and assessment of those presenting at A&E with
self-harm
One-in-five (21.5%) of suicides in 2010 attended A&E in the three months prior
to death (Information Services Division, 2012). People who die by suicide
therefore have more contact with A&E in the last 3 months than they do with
psychiatric services in the 12 months before death. However, A&E departments
may be poorly-equipped to deal with patients presenting with distress,
suicidality, and self-harm (Dowding, 2012).
Developing better services for mental illness presentations at Scotland’s A&E
departments – particularly those that are intoxicated at time of presentation –
may contribute to better recognition of persons at risk, as well as ensuring that
they can access treatment/support more quickly. Ensuring that patients undergo
an appropriate assessment may reduce the risk of further self-harm and
completed suicide (Hickey, Hawton, Fagg, et al, 2001).
It is difficult to know the best way of delivering this since A&E staff and mental
health services are both often stretched, and demand may exceed capacity.
Liaison nurses or members of A&E staff who have additional expertise in postself-harm assessment may be solutions.
3.3 Are the objectives for work on addressing self-harm still valid (page
10)? How should we develop that work further? Is the linkage with
the work on distress (page 11) a good way to take the discussion
forward?
3.3.1 Self-harm
Priority PO3 (“Increase the rate of identification of people who are self-harming,
both through encouraging more people to seek help and through better
recognition of self-harming behaviour by professionals working in different
settings…”) will only be realised if the health service response to self-harm is
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changed to one of support and understanding. There are comments elsewhere
about many people’s experiences of A&E being difficult.
Similarly, PO4 (“…improving people’s experience of care services thus assisting
them in moving towards safe and positive future goals…”), despite being
somewhat imprecise, has to acknowledge that many people’s experience of
health services is not good.
The routes into services (if they exist) are highly-variable and there is significant
uncertainty (and disagreement) about the most appropriate way of managing
self-harm in the NHS. Choose Life should consider undertaking a mapping
exercise, perhaps using a number of standardised vignettes, to understand how
patients with self-harm both access services and how the service responds. This
might help health and non-statutory services to develop more consistent
responses to people ‘in distress’.
The role of self-harm as a proximal (rather than a distal) factor is challenging.
14% of all suicide deaths had had an admission for intentional self-harm in the
five years prior to death (24.5% of all admissions). Whilst only 3.5% of all
suicide deaths had an admission for self-harm in the 30 days prior to death, they
comprised 40% of all admissions (Information Services Division, 2012). This
suggests that self-harm (as a risk factor) may be a stronger proximal predictor
of suicide.
3.3.2 Distress
The focus on ‘distress’ is interesting, but the concept is probably too loose to
permit any meaningful service response. Distress is common: the prevalence is
about 30-50% (Caron, Fleury, Perreault, et al, 2012; Kilkkinen, Kao-Philpot,
O'Neil, et al, 2007; Mitchell, Rao & Vaze, 2011). However, it is largely regarded
as being normal and in the majority of people it will be a transient response to
psychosocial stressors. No intervention is required. Not all people with distress
will have mental disorder and many might be concerned about ‘medicalising’ a
common human experience.
Most mental health services are best-equipped (and resourced) to assess those
people who appear to be exhibiting symptoms of mental illness, and to deliver
effective treatments for diagnosable illness. In order to prevent the assumption
that that mental health services should be managing ‘distress’, there should be
much greater clarity regarding closer working between health services and the
third sector, so that some of the barriers to accessing different areas of care are
lowered. This may have resource implications, however, and it would require the
involvement of primary care.
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If ‘distress’ is being highlighted as an area of interest, work is needed to: a)
ensure that there is some form of screening for treatable mental disorder among
those with high distress; and b) a clear pathway for treatment. Most people will
not require mental health services or specialist psychiatric assessment.
Finally, it might be helpful for the Strategy to acknowledge that a substantial
part of ‘distress’ may be due to social factors such as benefits problems, housing
problems, relationship problems, and substance misuse problems. Many of these
individuals may not have a mental disorder and ensuring that such people can
access support from the third sector, local authorities, and the charity sector is
important.
3.3.3 Closer liaison between statutory bodies
It is clear that there is a substantial group of individuals who repeatedly seem to
fall between the gaps. They may intermittently present to A&E with self-harm, or
may be brought to hospitals by the police because of concerns over their mental
state. However, because the individual is intoxicated mental health services
cannot conduct a proper assessment, and the police justifiably consider it
inappropriate that someone deemed to be at risk is returned to custody.
Solutions to this are not forthcoming, but where there is a need (this may only
apply to larger, central, and urban hospitals), opportunities for short-term
assessment units could be explored. This may enable patients presenting with
some form of self-harm or risk to be managed in a safe environment without
them being admitted to a general hospital (for intoxication) or without them
having to sober up in a police cell. There would be resource implications from
such units but pilot schemes could be tested so that such individuals could be
managed in a safer environment.
The Scottish Government should consider the recommendations of the
Adebowale Report in connection with police responses to mental illness in the
community (Adebowale, 2013) and the linkages with other services.
Recommendations 11, 17, 18, and 27 are particularly relevant to the
development of a new Strategy.
3.4 Can we strengthen the linkage with tackling health inequalities, given
that the differences in suicide rates also apply to a wider range of
behavioural health challenges? What might that look like in practice?
Health inequalities are, as recognised, closely related to income inequality which
itself tends to be a product of societies and governments rather than individuals
and communities. They have a powerful effect on suicide and self-harm.
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ScotSID and ISD should be supported to extend their suicide reporting
capabilities into more complex analytical capabilities that could determine if
inequalities exert a potent effect on suicide and self-harm in Scotland.
3.5 Should there continue to be a dedicated Choose Life Programme? If
so what should the priorities for that programme be from 2013? Are
there changes that we should make to the programme?
Probably. There needs to be a national group which provides oversight and
direction for all of the different strands of activity that are occurring in the
statutory and non-statutory sectors. Further, there needs to be liaison and
crosstalk between the different sectors, and Choose Life would seem to be a
reasonable way to do this.
As suggested above, Choose Life may be well-placed to undertake any mapping
work so that there is a better understanding of the pathways needed to manage
distress and self-harm.
3.6 Should there continue to be a national target or targets? If so what
should the target be?
Targets can help to focus attention, but NHS Boards and Local Authorities may
have limited ability to affect many of the distal factors influencing suicide, and
only be able to influence the proximal factors in the cases that are known to
services.
Any targets need to focus on factors that can be changed by the organisation
choosing that target. Choose Life should ensure that national targets (e.g.
suicide rates) are not cascaded down to smaller areas (e.g. local authorities)
where national targets will not be applicable.
All targets should be SMART: Specific, Measurable, Attainable, Realistic, and
Timely. Any national targets need to take into account changes that may occur
outwith the intervention under observation.
3.6.1 Health and Social Care Integration
There is considerable risk that the integration agenda will displace much of the
suicide prevention work that is ongoing and which has been established by coworking. Some of the affiliations that are in place may drop down the agenda as
both organisations work hard to integrate complex and sometimes conflicting
agendas and workstreams.
Many NHS Boards may be able to capitalise on integration to strengthen their
suicide-prevention work, but this should not be assumed; particularly if there are
changes in personnel and roles. The integration agenda should ensure that there
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is an explicit expectation that suicide prevention work will remain an important
part of the integrated service and the Scottish Government may wish to provide
some guidance to organisations on how to achieve this. It will be important to
have mechanisms for coordinating suicide prevention at a national and
regional/Health Board level as well as at a Local Authority level.
4. References
Adebowale, V. (2013) Independent Commission on Mental Health and Policing Report.
London: Independent Commission on Mental Health and Policing.
http://www.wazoku.com/wpcontent/uploads/downloads/2013/05/Independent_Commission_on_Mental_Healt
h_and_Policing_Main_Report.pdf
Barr, B., Taylor-Robinson, D., Scott-Samuel, A., et al (2012) Suicides associated
with the 2008-10 economic recession in England: time trend analysis. BMJ, 345,
e5142. http://www.bmj.com/content/345/bmj.e5142
Barth, A., Sögner, L., Gnambs, T., et al (2011) Socioeconomic Factors and Suicide:
An Analysis of 18 Industrialized Countries for the Years 1983 Through 2007.
Journal of Occupational and Environmental Medicine, 53, 313-317.
http://journals.lww.com/joem/Fulltext/2011/03000/Socioeconomic_Factors_and_
Suicide___An_Analysis_of.15.aspx
Bruffaerts, R., Demyttenaere, K., Hwang, I., et al (2011) Treatment of suicidal
people around the world. British Journal of Psychiatry, 199, 64-70.
http://bjp.rcpsych.org/cgi/content/abstract/199/1/64
Caron, J., Fleury, M.-J., Perreault, M., et al (2012) Prevalence of psychological
distress and mental disorders, and use of mental health services in the
epidemiological catchment area of Montreal South-West. BMC Psychiatry, 12,
183. http://www.biomedcentral.com/1471-244X/12/183
Carter, G. L., Clover, K., Whyte, I. M., et al (2013) Postcards from the EDge: 5-year
outcomes of a randomised controlled trial for hospital-treated self-poisoning.
British Journal of Psychiatry, 202, 372-380.
http://bjp.rcpsych.org/content/202/5/372.abstract
Cavanagh, J. T., Carson, A. J., Sharpe, M., et al (2003) Psychological autopsy
studies of suicide: a systematic review. Psychological Medicine, 33, 395-405.
http://dx.doi.org/10.1017/S0033291702006943
Choose Life (2011) Public attitudes towards having conversations about suicide.
Edinburgh: NHS Health Scotland.
Corcoran, P. & Arensman, E. (2011) Suicide and employment status during Ireland’s
Celtic Tiger economy. European Journal of Public Health, 21, 209-214.
http://eurpub.oxfordjournals.org/content/21/2/209.abstract
Dowding, K. (2012) A&E Treatment of Self-Harm and Suicide Attempts at Royal
Sussex County Hospital. Brighton: Brighton and Hove Local Involvement Network.
http://www.bhlink.org/res/media/pdf/SelfharmandSuicideTreatmentatAE(1).pdf
Fawcett, J. (2009) Severe anxiety and agitation as treatment modifiable risk factors
for suicide. In Oxford Textbook of Suicidology and Suicide Prevention (eds D.
Wasserman & C. Wasserman). Oxford: Oxford University Press.
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Gagné, M., Robitaille, Y., Hamel, D., et al (2010) Firearms regulation and declining
rates of male suicide in Quebec. Injury Prevention, 16, 247-253.
http://injuryprevention.bmj.com/content/16/4/247.abstract
Gask, L., Dixon, C., Morriss, R., et al (2006) Evaluating STORM skills training for
managing people at risk of suicide. Journal of Advanced Nursing, 54, 739-750.
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365-2648.2006.03875.x
Griesbach, D., Russell, P., Dolev, R., et al (2008) The Use and Impact of Applied
Suicide Intervention Skills Training (ASIST) in Scotland: An Evaluation.
Edinburgh: Scottish Executive.
http://www.scotland.gov.uk/Publications/2008/05/21112543/0
Hawton, K., Sutton, L., Haw, C., et al (2005) Schizophrenia and suicide: systematic
review of risk factors. British Journal of Psychiatry, 187, 9-20.
http://bjp.rcpsych.org/content/187/1/9.abstract
Hickey, L., Hawton, K., Fagg, J., et al (2001) Deliberate self-harm patients who
leave the accident and emergency department without a psychiatric assessment:
A neglected population at risk of suicide. Journal of Psychosomatic Research, 50,
87-93. http://www.sciencedirect.com/science/article/pii/S0022399900002257
Hoolachan, J., Hecht, G., Galbraith, L., et al (2013) The National Drug-related
Deaths Database (Scotland) Report 2011. Edinburgh: Information Services
Division, NHS Scotland. http://www.isdscotland.org/Health-Topics/Drugs-andAlcohol-Misuse/Publications/2013-04-30/2013-04-30-NDRDDReport.pdf?34017580748
Information Services Division (2012) The Scottish Suicide Information Database
Report 2012. Edinburgh: NHS Scotland. http://www.isdscotland.org/HealthTopics/Public-Health/Publications/2012-12-18/2012-12-18-ScotSID-2012Report.pdf
Jollant, F., Bellivier, F., Leboyer, M., et al (2005) Impaired Decision Making in
Suicide Attempters. American Journal of Psychiatry, 162, 304-310.
http://ajp.psychiatryonline.org/cgi/content/abstract/162/2/304
Kelly, S., Charlton, J. & Jenkins, R. (1995) Suicide deaths in England and Wales,
1982-92: the contribution of occupation and geography. Population Trends, 80,
16-25. https://www.ncbi.nlm.nih.gov/pubmed/7664129
Kilkkinen, A., Kao-Philpot, A., O'Neil, A., et al (2007) Prevalence of psychological
distress, anxiety and depression in rural communities in Australia. Australian
Journal of Rural Health, 15, 114-119. http://dx.doi.org/10.1111/j.14401584.2007.00863.x
Kondilis, E., Giannakopoulos, S., Gavana, M., et al (2013) Economic Crisis,
Restrictive Policies, and the Population’s Health and Health Care: The Greek Case
[In Press, doi: 10.2105/AJPH.2012.301126]. American Journal of Public Health,
e1-e8. http://dx.doi.org/10.2105/AJPH.2012.301126
Malmberg, A., Simkin, S. & Hawton, K. (1999) Suicide in farmers. British Journal of
Psychiatry, 175, 103-105. http://bjp.rcpsych.org/cgi/reprint/175/2/103
Mann, J. J., Apter, A., Bertolote, J., et al (2005) Suicide prevention strategies: a
systematic review. JAMA, 294, 2064-2074. http://jama.amaassn.org/cgi/content/full/294/16/2064
Mitchell, A. J., Rao, S. & Vaze, A. (2011) Can general practitioners identify people
with distress and mild depression? A meta-analysis of clinical accuracy. Journal of
Affective Disorders, 130, 26-36.
http://www.sciencedirect.com/science/article/pii/S0165032710005094
PAGE | 13
RESPONSE TO SCOTTISH GOVERNMENT SUICIDE STRATEGY | RCPSYCH | MAY 2013 |
V1.2
Morriss, R., Gask, L., Webb, R., et al (2005) The effects on suicide rates of an
educational intervention for front-line health professionals with suicidal patients
(the STORM Project). Psychological Medicine, 35, 957-960.
http://dx.doi.org/10.1017/S0033291705004502
Nandi, A., Prescott, M. R., Cerdá, M., et al (2012) Economic Conditions and Suicide
Rates in New York City. American Journal of Epidemiology, 175, 527-535.
http://aje.oxfordjournals.org/content/175/6/527.abstract
National Statistics (2012) Poverty and income inequality in Scotland: 2010-11.
Edinburgh: Scottish Government.
http://www.scotland.gov.uk/Publications/2012/06/7976/downloads
Reeves, A., Stuckler, D., McKee, M., et al (2012) Increase in state suicide rates in
the USA during economic recession [In Press]. The Lancet.
http://www.sciencedirect.com/science/article/pii/S0140673612619102
Rodgers, P. (2010) Review of the Applied Suicide Intervention Skills Training Program
(ASIST): Rationale, Evaluation Results, and Directions for Future Research.
Calgary: Livingworks Education.
http://www.lifeline.org.au/__data/assets/pdf_file/0004/47047/ASIST_Review_Ap
r_2010_by_Philip_Rodgers.pdf
Rose, G. (1981) Strategy of prevention: lessons from cardiovascular disease. British
Medical Journal, 282, 1847-1851.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt
=Citation&list_uids=6786649
Stuckler, D., Basu, S., Suhrcke, M., et al (2011) Effects of the 2008 recession on
health: a first look at European data. Lancet, 378, 124-125.
http://linkinghub.elsevier.com/retrieve/pii/S0140673611610799
Szumilas, M. & Kutcher, S. (2011) Post-suicide Intervention Programs: A Systematic
Review. Canadian Journal of Public Health, 102, 18-29.
http://journal.cpha.ca/index.php/cjph/article/view/2221
PAGE | 14