The public health approach to suicide prevention in Ireland

Abstract

This article provides an overview of the public health approach to suicide in Ireland. The authors provide detail on the current suicide prevention strategy in Ireland, Connecting for Life, which is a whole-of-government, systemic, multicomponent national strategy. As the strategy enters its final extended phase of implementation over the period 2020–2024, the public health elements of Connecting for Life are presented, including the population level and more targeted approaches. The findings of an interim review of the strategy are discussed, in addition to the local and national implementation structures which are in place to assist implementation and monitoring of the strategy.

Introduction

Suicide and attempted suicide is a global pressing public health concern, with the World Health Organization (WHO) reporting that it accounts for 800 000 deaths worldwide annually (WHO, 2019). For those who die by suicide, there are also many more attempted suicides, all causing considerable distress for individuals, families and communities. Suicides are observed in all stages of life, from childhood to adolescence, adulthood to old age.

Suicide prevention is defined as the practice of identifying and reducing the impact of risk factors associated with suicidal behaviour and strengthening protective factors against suicidal behaviour (Connecting for Life Research Advisory Group, 2014).

The WHO has been a major driver of global responses to suicide prevention, with the Global Mental Health Action Plan 2013–2020 being adopted by all 194 WHO member states in May 2013, to formally acknowledge the importance of mental health. This ambitious action plan adopts a life course approach, with prevention at its core. The action plan puts forward four primary objectives: more effective leadership and governance for mental health; community-based integrated services; implementation of approaches focused on prevention and mental health promotion; and better research, data and information systems (WHO, 2013).

Following on from this, the WHO published Preventing Suicide: A Global Imperative in 2014 and this took the action plan further, to take WHO member states from, as Arensman (2017, p. 1) puts it, ‘agreement to action’ in relation to suicide prevention. This publication raised awareness of suicide and suicide attempts and how pervasive it is globally. It provided practical, actionable steps for countries to work towards more effective suicide prevention efforts (WHO, 2014). It encouraged the development of multisectoral public health approaches to suicide prevention and has undoubtedly been an influence on the policies and strategies developed and implemented since its publication.

There are an increasing number of countries globally which have developed and implemented national suicide prevention strategies. A global survey carried out by the International Association for Suicide Prevention (IASP) and the WHO reported that 31% of countries currently have a suicide prevention strategy or action in place, and among those that did not, just over half were implementing some form of suicide prevention activity (as cited in Arensman, 2017). National suicide prevention strategies are a way of developing a comprehensive and integrated national public health response to suicide and a structural framework to support prevention activities and evaluation (Platt et al. 2017). According to the WHO (2014), there are generally three types of suicide prevention approaches, a combination of which are often adopted in national strategies and policies:

• Universal strategies: These strategies are constructed to reach the entire population and improve access to mental health services, increase awareness of mental health and suicide and encourage more responsible media reporting of suicide.

• Selective strategies: These strategies target vulnerable groups such as those who have been exposed to trauma and those bereaved by suicide. It also focuses on ‘gatekeeper’ suicide prevention training to tackle suicide at a community level.

• Indicated strategies: These are the most targeted strategies and are aimed at supporting those with mental health disorders, support for health and mental health care personnel and improved assessment and identification of mental health disorders.

Generally, there is good evidence for the various elements of suicide prevention strategies. A systematic review of over 1700 studies published in the Lancet in 2016 (Zalsman et al. 2016) concluded that there is strong evidence for the restriction of access to lethal means, such as restrictions implemented in Ireland around the sale of paracetamol. Restricting access to areas that can be ‘hotspots’ for suicide attempts is also included here, such as railway lines and high places. School based awareness programmes were also reported to be effective. There was less substantive evidence for other elements of suicide prevention strategies such as general public communication campaigns and media guidelines; however, it should be kept in mind that these more preventive interventions are more indirect in nature (i.e. targeting those who may come into contact with a suicidal individual as opposed to the individuals themselves). This can make assessment of the attribution of these interventions, to policy outcomes, challenging.

Suicide surveillance and data in Ireland

Suicide prevention efforts, at their core, work to decrease the number of lives lost to suicide. Overall, the rate of suicide in Ireland is below the European average (9.41 per 100 000 in comparison to 11 per 100 000) and the rate of youth suicide is above the European average (at 6.2 per 100 000 in comparison to the European average of 5.6 per 100 000). The rate of youth suicide has reduced significantly in recent years, with Ireland now ranking 13th out of the 31 countries for which data was available (Eurostat, 2021).

However, the accuracy of suicide statistics is a concern across a number of countries globally (Tollefsen et al. 2012). Since suicide is still illegal in a number of countries, and there is still considerable stigma attached to suicide in others, it is very likely that the international data does not capture the true figure, which may be higher. In addition, registering deaths can be a complicated process, and some countries lack a robust death registration process entirely (WHO, 2014).

In Ireland, suicide mortality data is collated and reported on by the Central Statistics Office. This data is gathered by allocating statistical codes to different causes of death, based on information included in official death certificates (HSE National Office for Suicide Prevention, 2014). The classification system used for cause of death is the WHO’s International Classification of Diseases and Related Health Problems (ICD-10). While helpful, there are a number of limitations to Irish data that should be kept in mind.

Firstly, suicide data in Ireland is reported every 2 years via official mortality statistics with limited additional information on those that die by suicide. There are two types of suicide data currently reported by the Central Statistics Office, year of registration (of death) data and year of occurrence (of death) data. Year of occurrence data are more reliable and are the official statistics used by the National Office for Suicide Prevention and government, however there is a 22-month time lag on this data.

Secondly, there is a risk that the current suicide statistics in Ireland are an underestimation of the actual rate of suicide. Any death in Ireland that appears to be from sudden, violent or unexplained causes must be investigated by a Coroner. For a death to be determined a suicide by a Coroner’s inquest, it must be judged beyond reasonable doubt that the cause of death was a suicide. There is a real possibility that this does not capture all deaths by suicide in Ireland, and consequently the official suicide statistics may be higher. Recently, the UK changed the legal requirement for a verdict of suicide from a Coroner’s inquest from ‘beyond reasonable doubt’ to ‘on the balance of probabilities’, accounting for this possibility of underestimation and cases where a death may appear to be a suicide on the balance of the evidence available (Appleby et al. 2019).

Keeping the caveats to the data in mind, since 2016, it appears that suicide rates in Ireland are slightly decreasing, following a peak in suicide rates observed during the recession (Fig. 1). Increases in suicide rates were also reported globally during this recessionary period of 2007–2010, with a 2015 systematic review showing a relationship between suicide and increased unemployment (Oyesanya et al. 2015).

Given the 2 year time lag in suicide statistics, it will take some time to indicate whether the reduction in suicide rates will be sustained in 2020 and beyond. Men are significantly more likely to die by suicide than women, in line with international trends. However the male rate of suicide has been steadily decreasing since 2014, whereas the female rate has remained relatively stable.

There has been an increased interest in suicide statistics in Ireland and indeed globally since the onset of the COVID-19 pandemic, with widespread concerns regarding the potential negative impact of public restrictions and ‘lockdown’ measures on mental health. COVID-19 has acutely highlighted the lack of real-time suicide data in Ireland and indeed other countries. In response to this lack of timely data, the International COVID-19 Suicide Prevention Research Collaboration (which includes Ireland) was established to monitor suicide trends and collect data on suicidal ideation, self-harm and suicide during the pandemic (Gunnell et al. 2020).

Based on emerging data on suicidal ideation, self-harm, suicide and suspected suicide obtained during the first months of the COVID-19 pandemic (March–August 2020), there was either no rise (USA, Australia and UK) or a fall (Japan, Norway) in suicide rates during this period (John et al. 2020). It is not possible to determine if this is the case in low-income countries due to a lack of available data.

Increasing the quality and timeliness of suicide and self-harm data in Ireland is one of the key planks of Connecting for Life. HSE NOSP is currently engaged in a partnership with the Health Research Board to improve our understanding of the characteristics of those that die by suicide in Ireland. This is being achieved through a review of coronial data to capture potential suicides not included in the official Central Statistics Office statistics. The first report from analysis of 3 years of coronial data (2015–2017) will be released in 2022.

Self-harm can often be a precursor to a suicide attempt (Chan et al. 2016), and thus monitoring, treatment and self-harm prevention are integral to a public health approach to suicide prevention. Self-harm data in Ireland is collected by the National Registry for Self-Harm. This national system presents data on individuals that present to Emergency Departments in hospitals across the country following a self-harm incident. It has been in operation since 2000 and had national coverage since 2006, providing valuable data on self-harm. The Registry was one of the first of its kind globally and has been presented as an example of an effective self-harm surveillance system by the World Health Organization (2016). The Registry collects data on individuals that present to Emergency Departments across the country following a self-harm episode (National Suicide Research Foundation, 2020). There is also a National Clinical Programme for Self-Harm which has been in operation since 2014 and runs in 24 Emergency Departments across the country with 24 hour service. Nationally, average self-harm rates have been increasing since 2015, with rates highest among young people, particularly females aged 15–19 years (Griffin et al. 2019). The annual reports from the National Self-Harm Registry play a critical role in monitoring the impact of Connecting for Life, the National Clinical Programme for Self-Harm, and indeed public health efforts to improve mental health more generally.

Mental health and suicide prevention policy and legislation in Ireland

Mental health policy and legislation is required, from a public health perspective, to protect the human rights of some of the most vulnerable in society. In the past, policy and legislation in Ireland has not always achieved this but significant leaps have been made over the last three decades in the development of more progressive, evidence-based approaches regarding suicide prevention and indeed mental health in general.

The landmark legislative reform in Ireland regarding suicide was its decriminalisation in 1993 via the Criminal Law Suicide Act (1993), which provided the catalyst for national and community-based suicide prevention activities. It also paved the way for the creation of important NGOs and research bodies such as the National Suicide Research Foundation in 1995. This was followed by the report on the National Taskforce on Suicide (Department of Health and Children, 1998), which made a series of comprehensive recommendations on the prevention of suicide, service provision, intervention, aftercare and research and evaluation. The National Suicide Review Group was established in the same year, and regional Resource Officers for Suicide Prevention posts were created the following year to co-ordinate local activities.

The early 2000s were punctuated by a series of policy and legislative developments concerning mental health more broadly. The Mental Health Act (2001) made progressive provisions regarding the treatment of detainment of individuals admitted to in-patient facilities, and A Vision for Change was an ambitious national strategy for mental health services which had an overarching goal of reforming mental health service provision towards more community based models of care (Government of Ireland, 2005). While the actual implementation of these legislative and policy instruments took some time to be realised, and some aspects of these instruments yet to be implemented, it was important in contributing to a more open, progressive conversation about mental health in Ireland. Reflecting the long-term and often challenging nature of implementing widespread service reform, the successor to A Vision for Change, titled Sharing the Vision – A Mental Health Policy for Everyone was published by the Department of Health in 2020. Improving suicide data is one of commitments in the policy: ‘The collection and reporting of incidents of suicide should be reviewed and revised, to provide timely data for enhanced and focused suicide prevention actions in the community’. (Department of Health, 2020, p. 80).

The first national study on suicide was published in 2001, which highlighted the epidemiological factors associated with suicide and was the first national study of its kind in Ireland (Departments of Public Health, 2001). The first national suicide prevention strategy in Ireland, Reach Out, was launched in 2005, followed by the establishment of the HSE National Office for Suicide Prevention in 2007 to drive implementation of this strategy (Health Service Executive, National Suicide Review Group and Department of Health and Children, 2005). Reach Out laid the foundations for a collaborative, multidisciplinary, community-focused approach to suicide prevention.

The risk factors for suicide are multifarious and thus a multisectoral strategy is required which involves collaboration between health, education, justice and others. This is reflected in the second and current national strategy for suicide prevention, Connecting for Life 2015–2020 (Department of Health, 2015). Published in June 2015, this strategy moved from an emphasis on getting more accurate data on suicide in Reach Out to a setting a clear, explicit target set of reducing suicide in Ireland by 10% by 2020.

There are two clear, primary outcomes for the strategy which provide the overarching motivation for all activities being implemented across government:

1. 1. Reduced suicide rates among priority groups and a general reduction of 10% in suicide rates in the general population by 2020.

2. 2. Reduced self-harm presentations among priority groups and the general population.

This strategy has 69 actions which align to seven strategic goals. In keeping with Connecting for Life being a whole-of-government, whole-of-society strategy, 22 government departments/agencies are named in the strategy as either implementation leads or supporting agents for the 69 actions (see Table 1). This multicomponent, systems approach is in line with the evidence on best practice in suicide prevention, internationally (WHO, 2014). In addition, approximately 23 NGO organisations are funded by HSE NOSP to work in partnership with government to support implementation of the strategy. HSE NOSP provides important cross-sectoral implementation support to the diverse range of strategy partners, in addition to leading on some of the strategy actions. The seven strategic goals show that Connecting for Life is a strategy which covers universal, indicated and targeted strategies (Department of Health, 2015).

As a whole-of-government public health strategy, it was important the monitoring of the implementation of the strategy and a promotion of collective responsibility was established from the outset. The literature indicates this is a critical ingredient of effective whole of government policy (Colgan et al. 2014). At a local county level, there are local cross-sectoral groups established which develop local plans aligned to Connecting for Life. At a national agency level, there is a steering group to co-ordinate activities in the HSE relating to suicide prevention. There is also a national cross-sectoral advisory group that oversees the implementation of the Strategy, which is chaired by the Department of Health. This group meets quarterly, with quarterly monitoring reports produced to assess implementation progress and these reports are published on the HSE NOSP website.

High-level political leadership is provided at the Cabinet Committee level, allowing for a uniquely centralised oversight of the strategy in comparison to other jurisdictions, especially those with federal government structures. This tiered leadership at all levels of the policy system is helpful to communicate the importance of a public health approach to suicide prevention and provide ongoing feedback from the system on implementation as it happens.

In line with best practice, mid-way through the implementation of Connecting for Life an independent interim review on the implementation of the strategy was carried out (HSE NOSP, 2019a). This review concluded that some progress was evident across all seven strategic goals, with good progress highlighted in stigma reduction, self-harm, public health communications, media monitoring, the development of local Connecting for Life plans, early intervention services, the coronial process for suicide death registrations, General Practitioner (GP) prescribing behaviours (regarding benzodiazepines), amongst other strategic areas.

However some areas were highlighted as having limited progress made, including the need for more co-ordinated delivery of suicide prevention training, strategic planning around priority or vulnerable groups, restricting access to means of suicide in public places and evaluating the cost-effectiveness of the strategy.

It is hoped to put this learning into action to inform continued implementation of Connecting for Life and enter a new phase of implementation along with our statutory and non-statutory partners.

Suicide prevention in the community

Supporting and empowering communities to respond to suicide forms a core part of suicide prevention efforts in Ireland and is at the heart of the public health approach. Across the country, community based suicide prevention efforts are a product of the valuable collaboration between local HSE Resource Officers for Suicide Prevention, NGOs and statutory services. In Connecting for Life, suicide prevention at the community level is oriented around:

1. 1. Supporting collaboration in suicide prevention efforts through local community action plans that are strategically aligned to Connecting for Life;

2. 2. Supporting communities to help those in need through community Gatekeeper training;

3. 3. Supporting conversations around suicide and mental health through an awareness raising public communications strategy.

4. 4. Supporting community organisations offering mental health supports and services to the public, including priority groups.

To support bottom-up, local implementation of the strategy, there are local area Connecting for Life action plans that are developed across the country. These local plans are developed with the support of the HSE, who help convene Steering Groups to drive the development, launch and implementation of these 4 year plans which provide a roadmap to tackle suicide and self-harm locally. There are currently 16 active local area action plans being implemented across the country (HSE NOSP, 2021).

At a community level, Connecting for Life places a stringent emphasis on the importance of Gatekeeper training for suicide prevention (HSE National Office for Suicide Prevention, 2019). Gatekeepers are those who may come into contact or be able to identify someone who is contemplating suicide or at risk of suicidal behaviour (Isaac et al. 2009). Historically, gatekeepers have been identified as either designated or emergent. Designated are those that are qualified helping professionals (such as doctors, psychologists, social workers) and emergent are those in the community that may not be formally trained but may come into contact with, or be approached by, those experiencing suicidal ideation or intent (Isaac et al. 2009). These emergent gatekeepers can be found across the community, for example clergy, police, teachers and sport coaches have been identified in the literature. As part of Connecting for Life, SafeTALK and ASIST are delivered across the country as training for emergent gatekeepers, and STORM is delivered for designated gatekeepers. As part of the commitment to the delivery of an evidence-informed approach to suicide prevention in Ireland, an independent review and evaluation of the implementation of different models of gatekeeper training being delivered in Ireland has been finalised. This evaluation, which included a literature review, concluded that gatekeeper training is effective in improving participants’ knowledge, skills, self-efficacy and likelihood to intervene when someone is in distress. However, it stated that more studies with a longer-term follow-up is required (Collins, 2021).

There are also a variety of important individual level clinical programmes and interventions which are a critical part of the approach to suicide prevention in Ireland, such as Dialectical Behaviour Therapy (DBT), Collaborative Assessment and Management of Suicidality (CAMS) and the Self-Harm Intervention Programme (SHIP). Evaluations of these programmes have been commissioned by the HSE, which all attest to their efficacy at tackling self-harm and suicidality (Quality Matters, 2016; National DBT Project Ireland, 2018; Centre for Effective Services, 2021).

The role of the Connecting for Life public communications strategy is possibly one of the most recognisable aspect of the public health approach to suicide prevention in Ireland. The ‘Little Things’ campaign was run by the HSE NOSP along with over 20 partner organisations. The public health communications approach of Little Things was sharing simple steps everyone can take to improve their mental health and wellbeing and support others experiencing mental health difficulties. The campaign also involved sharing the personal experiences of a small number of individuals who shared their stories on dealing with mental health difficulties. The public health messages were communicated in visual and print media, social media, video and a website called yourmentalhealth.ie which pulled together resources and signposting information on mental health and wellbeing from across the HSE. Over 30 NGO partner organisations also played a core role in supporting the dissemination of the messages from the Little Things campaign at a community level.

Conclusion

Suicide continues to be a serious public health issues globally, with stigma unfortunately still playing a role in inhibiting prevention efforts in some countries. The challenges posed by COVID-19 have put a spotlight on the limitations of suicide data. There is an acute need for more real-time data on suicide to allow for more timely service and policy responses, and the prevention of suicide contagion.

It is imperative that policies and strategies continue to be implemented that are evidence informed and that those initiatives we implement are robustly evaluated to ensure we know what works, for whom and in what circumstances.

Ireland has come a long way in terms of adopting a public health approach to suicide prevention, since it was decriminalised in the early nineties. In collaboration with statutory and non-statutory partners, the HSE National Office for Suicide Prevention has supported the implementation of a multisectoral, whole of government approach to suicide prevention, recognising that the responsibility for prevention and capacity for intervention lies across society as a whole. As Connecting for Life enters its last phase of implementation, much has been achieved but there is still much to do. A commitment to evidence, right from the genesis of the Strategy, should aid its final evaluation of effectiveness and inform the next steps in Ireland’s public health response to suicide.

Fig. 1. Suicide rates in Ireland 2007–2019 (Central Statistics Office national mortality statistics, 2021)

Table 1. The seven goals of the Connecting for Life strategy Department of Health, 2015