Talking it over

“It’s your worst nightmare as a mother. Your door goes at three in the morning and you’re told your son tried to kill himself.

"You take him in but then what?

"Is it OK to talk about it? Is it OK to let him lock the bathroom door? Is it OK to be angry?"

Suicide devastates. This typical mother's feelings of helplessness and confusion as she grapples with how best to broach the topic and support her son forms part of a groundbreaking new multi-media campaign launched last week by the Scottish Association for Mental Health (SAMH). The campaign, which for the first time will see suicide prevention adverts aired before the watershed during carefully selected primetime programming, will seek to help people feel better able to talk more openly about suicide and suicidal thoughts.

Not talking is one of the biggest causes of death in Scotland, says SAMH. Two people a day die by suicide in Scotland - four times as many people than are killed in road accidents. And suicide remains one of the leading causes of death among young people, primarily young men who are three times more likely to die by suicide than women.

The adverts, one focusing on a desperate mother's musings, the other the unspoken thoughts of a young man who despite being enveloped by the love and affection of his family still feels as if he is just going through the motions, are a first for the charity. But suicide is a persistent taboo that it felt it had to help break.

"It still engenders in so many people different reactions - some of them judgemental, some of them angry, some of them from disbelief. And for all those emotional reasons it is still one of the most difficult things to talk about," says chief executive Billy Watson.

"There is something about conversations that would happen naturally after death that still don't really happen after a suicide. And for those people who want to talk about it, [they] find it most difficult - and I'm talking here about the people who are left afterwards - one of the direct aspects of our campaign at the moment is to provide support and networks and peers for those individuals."

As part of the campaign SAMH has created five resources for people who are affected by suicide and has also launched the first of its Community Support Networks in Glasgow.

"We are hoping some of the support we will get from the campaign will let us take that to other parts of Scotland and that is very much about working with individuals, working with families and carers who are supporting people who do at times feel suicidal to put them in touch with the support, to put them in touch with other people who are perhaps in that scenario.

"So it is about awareness but it is also about delivering."

Earlier this year the Scottish Government published its new mental health strategy, which sets out key commitments to deliver faster access to mental health services for younger people, faster access to psychological therapies, work to reduce and prevent suicide, and address stigma and discrimination.

However, following on from this, it is also working to develop a new suicide and self-harm prevention strategy to replace the existing strategy, Choose Life, which comes to an end next year. A working group has been established and over the next few months it will develop an engagement paper that will be put out to consultation in February, with the final strategy expected to be published during the summer.

Choose Life, Scotland's 10-year suicide prevention strategy and action plan was introduced to much acclaim in 2002. It recognised that efforts to tackle suicide as a 'one issue' policy would fail and set the ambitious target of reducing suicide by 20 per cent by 2013. And there is progress to report. The number of deaths by suicide in 2011 was one of the lowest in Scotland since 1991. Overall, the suicide rate has decreased by 17 per cent in Scotland in the period 2000-02 to 2009-11, and the Scottish Government says it is "confident" that it will meet the target by next year.

Suzie Vestri, campaign director of Scotland's national anti-stigma campaign, see me, thinks the strategy has worked well and whether we hit the target or not, a 17 per cent reduction is "a pretty fantastic achievement".

The various strands of Choose Life's work have helped dispel some of the myths around suicide, she says.

"I think that has all contributed towards breaking open some of the myths that there used to be about suicide. So this myth that you couldn't talk about suicide because that just encouraged people. All of that has been broken open by campaigning. But also by solid evidence. And one of the things we've done really well in Scotland is gather evidence about what works in campaigning, what contributes to suicide, who the most at-risk groups are.

"I think Scotland is a world leader in this and I think Choose Life deserve a really big pat on the back."

Stephen Platt, Professor of Health Policy Research, University of Edinburgh, contributed to the development of Choose Life and led an evaluation of the first phase of the strategy. He says the Scottish strategy was a "bold" one.

"I think the idea of having this mix of the central direction but with action devolved to a local level was a brilliant idea. Coming with a ringfenced budget as it did for half of that first period it meant that most of the money that was invested, which is small sums by NHS standards, but compared to what is going on in other countries is quite a substantial amount.

"So what you've got is action at a local level where local areas are able to respond to local need and the picture of suicide in their area."

Platt has been keenly following Scotland's progress and charting it against our nearest neighbours. During the summer he and colleagues published a report of their multilevel study of suicide risk in Scotland and England during 2001-06, which found that Scotland's national suicide rate was an alarming 79 per cent higher.

While he adds the important caveat that there are longstanding problems in comparing data from the two countries, as it is not always like for like, Platt says there are two key stories for Scotland to emerge from their research.

"One is that the rate amongst men having shot up in the 1970s and 1980s, plateaued in the '90s and reached a peak in the early 2000s, and has been coming down. So that is good news.

"The bad news is that the rate in Scotland, which in our article is covering the period up to 2006, showed a rate that is roughly 80 per cent higher. When you look at the more recent figures, which I've done, it is still about that level higher. So in other words, we have come down but so has England and the relative position of Scotland remains something of a concern."

It also found that young male and female Scots aged 15-44 years have double the risk compared with their English peers. Platt and his colleagues have been attempting to unpick some of the reasons for this, with interesting results. The use of psychotropic drugs, acting as a proxy measure for mental ill-health, and alcohol misuse both made important contributions to the differentials, and so, he says, attempts to reverse the divergent trend in suicide between Scotland and England will require initiatives to prevent and treat mental ill-health and tackle alcohol and drug misuse.

"Those of us working as researchers in suicide prevention have said for a long time that one of the things that would enormously help as a suicide prevention measure would be to try and have better controls over excessive drinking."

He gives the example of minimum pricing, which, subject to legal challenges, will be introduced in Scotland next year and is now also being considered by Westminster.

"This is a suicide prevention measure. It is not billed as such and it is not the primary reason why it would be done, but it will be a suicide prevention measure because anything that can reduce the abuse of alcohol will help to save lives through suicide."

Scotland's ongoing efforts in this regard have not gone unnoticed. The Organisation for Economic Co-operation and Development (OECD) is currently working on a report on mental health in all OECD countries, to be published next June, which will be accompanied by profiles of interesting mental health systems. While it is "very unusual" for the OECD to report on parts of a country, it has decided to feature Scotland as one of the profiles as it says "there seems to be a lot of evidence of interesting and innovative practice from which other countries could learn and draw."

"One of the things we are still working on developing in the profile is Scotland's approach to suicide. Rather than only having a suicide strategy, Choose Life, in addition, Scotland's approaches to mental health across the system are likely to reduce suicide," an OECD spokesperson explains.

"There has been a focus on breaking down the population and looking at groups who are more likely to commit suicide and to try and ensure there are appropriate interventions in place somewhere in the system that might help them. So not necessarily as an explicit suicide strategy, but as part of the wider mental health work. So, for example, increasing access to psychological therapies is likely to have an overall impact on suicide."

Measures to address alcohol misuse would be another relevant example.

"That is exactly the sort of thing we are trying to include in the profile. It is not necessarily explicit for other countries because it is not necessarily as easy to access as a population-targeted suicide strategy like Choose Life, which is written-up and available as a publication. But these other interventions are likely to have an impact on suicide and are interesting for other countries to know about."

The new suicide and self-harm prevention strategy affords an opportunity to build on Scotland's achievements, says Nigel Henderson, chief executive, Penumbra, a Scottish mental health charity that runs a number of community-based self-harm services across Scotland.

While he says there are links between suicide and self-harm, Henderson hopes their differences will also be acknowledged in the forthcoming strategy and says he would also like to see a greater emphasis on increasing understanding of self-harm and tackling the stigma associated with it.

"Part of what the next strategy has to do is find a way that services are more accessible for people so that people do seek help more readily. Some of that is still around the stigma that goes with admitting to having a mental health problem. Some of that is self-perception. But that self-perception comes from the society that we live in."

Various estimates suggest that between one in ten and one in 15 young people in the UK will have at some point considered or acted upon self-harm, which Henderson says makes it a "fairly big public health issue."

"I think it is significant and I think the vast majority of it probably is unseen and happens in isolation. We see a lot of people who have never had contact with formal psychiatric health services but for whom self-harm is for them an important aspect of their life. It is where they get some control in an otherwise chaotic life."

In addition to continuing to link-up with the anti-stigma campaign, Henderson hopes the new strategy will include a greater focus on recovery.

"They are all about the possibility that things can get better. So I think maybe the strategy needs to say something about how the message of recovery and stigma interlinks or is woven into the suicide and self-harm strategy as well." 

Simon Bradstreet, director, Scottish Recovery Network, agrees that given the strong links between the experience of mental health problems and suicide, continuing to promote recovery approaches could "very usefully" be part of a new strategy.

"I think it would be helpful to reference recovery and join-up the existing streams of work that have been going on. The work around recovery in Scotland and the anti-suicide work haven't really been joined-up to a great extent so far. And it is not difficult to see how having a sense of hope for the future, which is a key aspect of recovery, could be a useful component of a suicide reduction strategy."

Peer support could also help individuals talk about their concerns, foster a sense of possibility, and perhaps help them to see a different future, he suggests.

"I think peer support workers, people with their own lived experience of overcoming difficult times and developing coping strategies, are very well placed to fulfil that kind of role in a very authentic and genuine way."

He continues: "Sometimes these conversations are more likely to happen where you've had a shared experience. So, for example, if someone is feeling suicidal that might be something that is more likely to be disclosed to someone who you feel may know what you are talking about. It might be more likely that disclosure comes out and a lot of the work the Scottish Government and Health Scotland have been pursuing is really about encouraging people to talk about it, make it a subject and remove the stigma - because so many people are scared to raise the subject and peer workers may be well placed to do that."

For his part, Watson hopes the new strategy will see a "renewed and sustained" commitment to suicide prevention for the next ten years, adding that he thinks there is much that the Scottish Government has got "absolutely right" in the last decade.

However, he points out that this is not a government-owned issue, and so his ambition for the next strategy would be to see it extend its reach further into the community.

"We know that only 29 per cent of people have been in touch with mental health services in the 12 months before they take their life through suicide. So there is a much wider audience who I think can be involved and have an impact on the suicide preventing agenda."